Don’t Miss

 

* The Assignment Method of Payment

 

Many doctors and suppliers have agreed to be part of Medicare’s participating physician and supplier program. They accept assignment on all Medicare claims. If you get your medical services from one of these participating doctors or suppliers, you can often save money. See page 28 for more information about the assignment method of payment, and what you can do to find a participating doctor or supplier.

 

* Your Appeal Rights

 

Pages 35 and 36 explain how to appeal when Medicare does not pay your Part A or Part B claims.

 

* If You Need Financial Assistance to Pay for Health Care

 

Sometimes you can get help paying for Medicare. Look on pages 2 and 3 for more information.

 

* New primary and preventive services

 

Medicare now has a Federally Qualified Health Center benefit. Look on page 24.

 

* New Information About Insurance to Supplement Medicare

 

Some people want to have insurance to pay medical bills Medicare doesn’t cover. See pages 8 and 9 to find out about Medicare supplement 'Medigap' insurance, including a new open enrollment period.

 

* New Benefits

 

Recently added Medicare Part B benefits for cancer screening--mammograms and Pap smears--are described on page 25.

 

* Who Pays First?

 

Medicare is not always the insurer that pays first on claims. For example, some people are employed, or their spouse is employed, and the employer health insurance pays first. For more about who pays first, see pages 10 and 11.

 

* Where to Call or Write

 

Look on the inside front cover to find where to call or write to ask questions about Medicare.

This handbook is meant to explain the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations and Rulings.

Save this handbook for reference. It is revised each year and is available from Social Security, but you will not automatically get a handbook in the mail unless there are major changes in the Medicare program.

 

Contents

 

What is Medicare?

The Two Parts of Medicare Who Can Get Medicare Hospital Insurance Who Can Get Medicare Medical Insurance (Part B)? Buying Medicare Part A and Part B Enrollment in Medicare Your Medicare Card Assistance for Low-Income Beneficiaries Intermediaries and Carriers Peer Review Organizations Your Right to Decide About Your Medical Care Fraud and Abuse Your Rights Under the Privacy Act

Medicare Coordinated Care Plans

What Are Coordinated Care Plans Who Can Enroll in Coordinated Care Plans? Joining a Coordinated Care Plan Ending Enrollment in a Coordinated Care Plan If You Have Problems

Medicare and Other Insurance

Buying Health Insurance to Supplement Medicare When Other Insurance Pays Before Medicare

What Medicare Does Not Pay For

Custodial Care Care Not Reasonable and Necessary Under Medicare Program Standards Services Medicare Does Not Pay For Limitation of Liability

Medicare Hospital Insurance (Part A)

What Medicare Part A Includes How Medicare Pays for Part A Services When You Are a Hospital Inpatient Skilled Nursing Facility Care Home Health Care Hospice Care

Medicare Medical Insurance (Part B)

What Medicare Part B Includes Deductible and Coinsurance Amounts Under Part B Doctors’ Services Covered by Medicare Part B Second Opinion Before Surgery Services of Special Practitioners Outpatient Hospital Services Other Services and Supplies Covered by Medicare Drugs and Biologicals Medicare Payments for Outpatient Treatment of Mental Illness

Medicare Medical Insurance (Part B) Payments

The Assignment Payment Method Participating Doctors and Suppliers When Your Doctor Does Not Accept Assignment Participating Providers Medicare Approved Amounts Submitting Part B Claims

 

Getting the Part of Medicare You Do Not Have

Getting Medicare Medical Insurance (Part B) Getting Medicare Hospital Insurance (Part A) Special Enrollment Period

Events That Can Change Your Medicare Protection

When Protection Ends for People 65 and Older When Protection Ends for the Disabled When Protection Ends for Those With Permanent Kidney Failure

How to Appeal Medicare Decisions

Appealing Decisions Made by Providers of Part A Services Appealing Decisions Made by Peer Review Organizations (PROs) Appealing Decisions of Intermediaries on Part A Claims Appealing Decisions Made by Carriers on Part B Claims Appealing Decisions Made by Health Maintenance Organizations (HMOs) For More Information

Appendices

Charts: Medicare Covered Services Medicare Carriers Medicare Peer Review Organizations (PROs)

Index

 

What is Medicare?

 

The Medicare program is a federal health insurance program for people 65 or older and certain disabled people. It is run by the Health Care Financing Administration of the U.S. Department of Health and Human Services. Social Security Administration offices across the country take applications for Medicare and provide general information about the program.

 

The Two Parts of Medicare

 

There are two parts to the Medicare program. Hospital Insurance (Part A) helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care. Medical Insurance (Part B) helps pay for doctors’ services, outpatient hospital services, durable medical equipment, and a number of other medical services and supplies that are not covered by the Hospital Insurance part of Medicare. Throughout this handbook, Medicare Hospital Insurance is called Part A and Medicare Medical Insurance is called Part B.

Part A has deductibles and coinsurance, but most people do not have to pay premiums for Part A (see page 33). Part B has premiums, deductibles, and coinsurance amounts that you must pay yourself or through coverage by another insurance plan. Premium, deductible and coinsurance amounts are set each year based on formulas established by law. New payment amounts begin each January 1. When amounts increase, you will be notified. For 1993 deductible, premium and coinsurance amounts, see the charts on pages 37 and 38.

 

Who Can Get Medicare Hospital Insurance (Part A)?

 

Generally, people age 65 and older can get premium-free Medicare Part A benefits, based on their own or their spouses’ employment. (Premium-free means there are no premium payments. Most people do not pay premiums for Medicare Part A.) You can get premium-free Medicare Part A if you are 65 or older and any of these three statements is true:

* You receive benefits under the Social Security or Railroad Retirement system.

* You could receive benefits under Social Security or the Railroad Retirement system but have not filed for them.

* You or your spouse had Medicare-covered government employment.

If you are under 65, you can get premium-free Medicare Part A benefits if you have been a disabled beneficiary under Social Security or the Railroad Retirement Board for more than 24 months.

Certain government employees and certain members of their families can also get Medicare when they are disabled for more than 29 months. They should apply at the Social Security Administration office as soon as they become disabled.

Or, you may be able to get premium-free Medicare Part A benefits if you receive continuing dialysis for permanent kidney failure or if you have had a kidney transplant. (People who can get Medicare because of kidney disease may get a copy of Medicare Coverage of Kidney Dialysis and Kidney Transplant Services from the Consumer Information Center. See inside back cover for how to order.)

Check with Social Security to see if you have worked long enough under Social Security, Railroad Retirement, as a government employee, or a combination of these systems to be able to get Medicare Part A benefits. Generally, if either you or your spouse worked for 10 years, you will be able to get premium-free Medicare Part A benefits.

 

Who Can Get Medicare Medical Insurance (Part B)?

 

Any person who can get premium-free Medicare Part A benefits based on work as described above can enroll for Part B, pay the monthly Part B premiums (in 1993, $36.60 for most beneficiaries), and get Part B benefits. In addition, most United States residents age 65 or over can enroll in Part B.

 

Buying Medicare Part A and Part B

 

If you or your spouse do not have enough work credits to be able to get Medicare Part A benefits and you are 65 or over, you may be able to buy Medicare Parts A and B--or just Medicare Part B--by paying monthly premiums. Also, you may be able to buy Medicare Parts A and B if you are disabled and lost your premium-free

Part A solely because you are working. (See page 34 for more information.)

 

Enrollment in Medicare

 

If you are already getting Social Security or Railroad Retirement benefit payments when you turn 65, you will automatically get a Medicare card in the mail. The card will show that you can get both Medicare Hospital Insurance (Part A) and Medical Insurance (Part B) benefits. If you do not want Part B, follow the instructions that come with the card.

The above process also applies when you have been a disability beneficiary under Social Security or Railroad Retirement for 24 months. A Medicare card will come in the mail.

Some people do not automatically get a Medicare card. They must file an application to get Medicare benefits. If you have not applied for Social Security or Railroad Retirement benefits, or if government employment is involved, or if you have kidney disease, you must file an application for Medicare. Check with Social Security if you are able to get Medicare under the Social Security system or based on Medicare-covered government employment; check with the Railroad Retirement office if you are able to get Medicare under the Railroad Retirement system.

If you must file an application for Medicare, you should apply during your initial enrollment period, to avoid late enrollment penalties under Medicare Part B (unless you qualify for a special enrollment period as described on page 33). Your initial enrollment period is a seven-month period that starts three months before the month you first meet the requirements for Medicare. If you do not sign up for Medicare during the first three months of your initial enrollment period, there will be a delay in starting your Part B coverage. Your coverage will be delayed from one to three months after enrollment.

 

If you do not enroll for Medicare Part B at any time during your initial enrollment period, you will not have another chance to enroll until the next general enrollment period. A general enrollment period is held each year from January 1 through March 31 and if you enroll during this period you will not be able to get Medicare until July of that year. You may also be charged a premium penalty for late enrollment (unless you qualify for a special enrollment period as described on page 33).

The enrollment period requirements and penalties for late enrollment described above for Part B also apply to people who buy Part A. (See page 33 for more information about buying Medicare Part A.)

 

Your Medicare Card

 

The Medicare card shows the Medicare coverage you have--Hospital Insurance (Part A), Medical Insurance (Part B), or both--and the date your protection started. If you do not have both parts of Medicare, see page 33 for information on how you can get the part you don’t have.

Your Medicare card also shows your health insurance claim number. Sometimes this claim number is referred to as your Medicare number. The claim number usually has nine digits and one or two letters. There may also be another number after the letter. Your full claim number must always be included on all Medicare claims and correspondence. When a husband and wife both have Medicare, each receives a separate card and claim number. Each spouse must use the exact name and claim number shown on his or her card.

It is important that you remember to:

* Use your Medicare card only after the effective date shown on it.

* Keep your card handy. And be sure to carry your card with you whenever you are away from home.

* Always show your Medicare card when you receive services that Medicare helps pay for.

* Always write your complete health insurance claim number (including any letters) on all checks for Medicare premium payments or any correspondence about Medicare. Also, you should have your Medicare card available when you make a telephone inquiry.

* Immediately ask Social Security to get you a new card if you lose yours.

* Never let anyone else use your Medicare card.

 

Assistance for Low-Income Beneficiaries

 

Federal law requires that state Medicaid programs pay Medicare costs for certain elderly and disabled people with low incomes and very limited resources, described below. The following is a general description only; rules may vary from state to state.

 

Qualified Medicare Beneficiaries (QMB)

 

In general, you must meet these requirements:

* You must be entitled to Medic are Hospital Insurance (Part A).

* Your annual income for 1992 must be at or below $7,050 for one person and $9,430 for a family of two (amounts are somewhat higher in Alaska and Hawaii).* Amounts for 1993 will be slightly higher than those for 1992.

* You cannot have resources such as bank accounts or stocks and bonds worth more than $4,000 for an individual or $6,000 for a couple. Your personal home, automobile, burial plot, furniture, jewelry, or life insurance are not counted, unless those items are of extraordinary value.

If you qualify as a QMB, your Medicare premiums, deductibles and coinsurance will be covered.

* This amount is based on a percentage of the national poverty guidelines plus an income disregard of $240.

 

Specified Low-income Medicare Beneficiaries (SLMB)

 

Beginning January 1, 1993, there is a new program for certain low-income Medicare beneficiaries whose income is above the level to qualify as a QMB, but whose income is below 110 percent of the national poverty guidelines. If you qualify as a SLMB, Medicaid will pay your Medicare Part B premium only ($36.60 per month in 1993).

 

Where to Apply

 

If you think you may qualify for any of these benefits, you should file an application at the state or local welfare, social service or public health agency that serves people on Medicaid. All of these agencies are state--not federal--agencies.

If you need the telephone number for Medicaid, call 1-800-638-6833. Give the operator the name of your state and explain that you want the Medicaid telephone number so you can get information about these benefits.

 

Intermediaries and Carriers

 

The federal government contracts with private insurance organizations called intermediaries and carriers to process claims and make Medicare payments. Intermediaries handle inpatient and outpatient claims submitted on your behalf by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of services.

You will not usually need to get in touch with intermediaries because Medicare pays most hospitals, skilled nursing facilities, home health agencies, hospices and other providers of services directly. But, if you have a question about your Part A bill, ask someone who works at the facility for help. If you cannot get an answer there, ask someone in the billing office at the facility to help you get in touch with the Medicare intermediary.

Carriers handle claims for services by doctors and suppliers covered under Medicare’s Part B program. If you have questions about Medicare Part B claims, contact your Medicare carrier. The addresses and phone numbers of carriers are on pages 39 to 44.

If you want someone to contact Medicare for you, see 'Your Rights Under the Privacy Act,' (page 5) for more information.

 

Peer Review Organizations

 

Peer Review Organizations (PROs) are groups of practicing doctors and other health care professionals who are paid by the federal government to review the care given to Medicare patients. Each state has a PRO that decides, for Medicare payment purposes, whether care is reasonable, necessary, and provided in the most appropriate setting. PROs also decide whether care meets the standards of quality generally accepted by the medical profession. PROs have the authority to deny payments if care is not medically necessary or not delivered in the most appropriate setting.

PROs investigate individual patient complaints about the quality of care and respond to:

* Requests for review of notices of noncoverage issued by hospitals to beneficiaries; and

* Requests for reconsideration of PRO decisions by beneficiaries, physicians, and hospitals.

The PRO will tell you in writing if the service you got was not covered by Medicare. See page 12 for a discussion of what is not covered by Medicare.

If you are admitted to a Medicare participating hospital, you will receive An Important Message From Medicare which explains your rights as a hospital patient and provides the name, address and phone number of the PRO for your state. If you are not given a copy of the message, be sure to ask for one.

If you feel that you are improperly refused admission to a hospital or that you are forced to leave the hospital too soon, ask for a written explanation of the decision. Such a written notice must fully explain how you can appeal the decision and it must give you the name, address and phone number of the PRO where your appeal or request for review can be submitted. (See page 35 for further discussion of your appeal fights under Medicare.)

 

Beneficiary Complaints

 

PROs are responsible for reviewing beneficiary complaints about the quality of care provided by inpatient hospitals, hospital outpatient departments and hospital emergency rooms; skilled nursing facilities; home health agencies; ambulatory surgical centers; and certain health maintenance organizations.

If you believe that you have received poor quality care from one of these facilities, you may complain to the PRO. The PRO will investigate written complaints from beneficiaries, or their representatives, about the quality of Medicare services received.

Your complaint must be in writing. If you wish, the PRO will help you put your complaint in writing by taking the information from you over the telephone and writing the complaint. If someone other than the PRO makes a complaint for you or on your behalf, you must give written permission for that person to represent you in the complaint.

Medicare PROs for each state are listed on pages 45 to 49.

 

Your Right to Decide About Your Medical Care

 

Under a new Medicare law, when you are admitted to a Medicare hospital or skilled nursing facility, get Medicare home health care, or enroll in a Medicare-approved hospice or health maintenance organization, you must be given written information about your rights to make decisions about your medical care.

Generally, you will be told about your fight to accept or refuse medical or surgical treatment. You will also be told about your fight to make--if you choose--an 'advance directive.' An advance directive contains written instructions about your choices for health care or naming someone to make those choices for you. The instructions are to be used if you are too sick or otherwise unable to talk. (The paper giving your health care choices may be called a 'living will' or 'a durable power of attorney for health care.')

You do not have to have an advance directive. But, if you have one you can say 'yes' in advance to treatment you want if you get too sick to talk to your health care provider. You can also say 'no' in advance to treatment you don’t want.

Laws governing advance directives vary from state to state. Your treatment choices will depend on what is legal in your state. You can ask health care professionals in your state about the state’s rules for living wills or durable powers of attorney. You can also contact your local state’s attorney’s office for this information.

 

Fraud and Abuse

 

Suspected Fraud Should be Reported

 

If you have reason to believe that a doctor, hospital, or other provider of health care services is performing unnecessary or inappropriate services, or is billing Medicare for services you did not receive, you should immediately report to the Medicare carrier or intermediary that handles your claims (see page 3).

The routine waiver of deductibles and coinsurance by doctors or suppliers of durable medical equipment is unlawful. Coinsurance and deductible payments may be waived only after careful consideration of a particular patient’s financial hardship. Therefore, if a doctor or supplier offers to waive coinsurance or deductible payments, without having considered your individual circumstances or when you have not asked to have the payments waived, you should immediately report the. offer to the Medicare carrier or intermediary.

 

Report to the Medicare Carrier or Intermediary First

 

Call the carrier or intermediary first when you suspect fraud. Medicare carriers and intermediaries routinely look into cases of possible fraud and will appreciate your alerting them to your case. The carrier or intermediary will need to know the exact nature of the wrongdoing you suspect, the date it occurred, and the name and address of the party involved. Have this information ready when you call. (The telephone number of the Medicare intermediary or carrier is listed on the notice explaining Medicare’s decision on your Medicare claim. Medicare carriers are also listed on pages 39 to 44.)

 

Calling For Further Help

 

If the Medicare carrier or intermediary does not respond to your report of Medicare fraud or abuse, you may call the Health Care Financing Administration (HCFA) hotline at 1-800-638-6833. There is no charge to you when you call this number. The hotline operator will refer you to the appropriate staff person at a HCFA regional office.

Be prepared to tell the HCFA regional office staff person:

* The exact nature of the wrongdoing you suspect, the date it occurred, and the name and address of the party involved.

* The name and location of the Medicare intermediary or carrier you reported it to, and when you reported it.

* The name of any intermediary or carrier employee to whom you spoke and what advice that person gave you.

 

Your Rights Under the Privacy Act

 

Under the Privacy Act all federal agencies must safeguard information they collect about the people they serve.

When the Health Care Financing Administration (the agency that administers the Medicare program) asks you to fill out forms giving information about yourself to Medicare, we must:

* Explain why we are collecting the information.

* Tell you whom we plan to give it to.

* Tell you whether you must, by law, give us the information.

When you give Medicare information, the Privacy Act allows you to:

* Review your records for accuracy.

* Make corrections, if you believe there are errors.

* Know exactly what we will do with your records.

The Privacy Act also allows the government to verify the information you give us, using computer matches with other federal or state governments. If we do computer matches, we must tell you that they take place and give you a chance to protest our findings.

We include information about matches on all the forms you fill out. We also put a notice in the Federal Register, which is published by the federal government to notify the public of official actions. Copies are available at many libraries. (A computer-data match using Medicare, Internal Revenue Service and Social Security information is discussed on page 11.)

Medicare Carriers and Intermediaries must follow Privacy Act rules: These Medicare contractors may not discuss personal information about you with your family members or others who write or telephone on your behalf unless you give the contractors written permission.

 

What Are Coordinated Care Plans?

 

More and more Medicare beneficiaries are joining coordinated care plans. These coordinated care plans are prepaid, managed care plans, most of which are health maintenance organizations (HMOs) or competitive medical plans (CMPs). Both HMOs and CMPs contract with Medicare and follow the same contracting rules. In this handbook, HMOs will be used to illustrate the benefits for both.

Many beneficiaries find that coordinated care plans are a good way to get more health care for their dollar. HMOs provide or arrange for all Medicare covered services, and generally charge you fixed monthly premiums and only small co-payments. This means that if you join a coordinated care plan and get all of your services through the HMO, your out-of-pocket costs are usually more predictable. Also, depending on your health needs, those costs may be less than you would pay if you had to pay the regular Medicare deductible and coinsurance amounts.

Coordinated care plans may also offer benefits not covered by Medicare for little or no additional cost. Benefits may include preventive care, dental care, heating aids and eyeglasses.

 

Who Can Enroll in Coordinated Care Plans?

 

Most Medicare beneficiaries are eligible to enroll in HMOs. HMOs cannot screen applicants to decide if they are healthy, or delay coverage for pre-existing conditions. The only enrollment criteria for Medicare HMOs are:

* You must be enrolled in Medicare Part B and continue to pay the Part B premiums (you do not need to be able to get Part A).

* You must live in the plan’s service area.

* You cannot be receiving care in a Medicare-certified hospice.

* You cannot have permanent kidney failure.

If you develop permanent kidney failure after joining a coordinated care plan, the plan will provide, pay for, or arrange for your care. If you choose to receive hospice care after joining a coordinated care plan, the plan must inform you about hospice services available in your area. Staff at the coordinated care plan will explain how the hospice choice affects your plan membership.

 

Joining a Coordinated Care Plan

 

To join a coordinated care plan, contact plans in your area that have a contract with Medicare. All HMOs with Medicare contracts have an advertised open enrollment period at least once a year. Once you join, you may stay with the plan as long as it continues to contract with Medicare. And you may return to regular Medicare at any time.You can find out if there are HMOs in your area that contract with Medicare by calling the Health Care Financing Administration (HCFA) regional office nearest you. Medicare Coordinated Care contact numbers are listed in the box on page 7.

If you enroll in a coordinated care plan you will usually be required to get all care from the plan. In most cases, if you get services that are not authorized by the HMO (unless they are emergency services or services you urgently need when you are out of the plan’s service area) neither the plan nor Medicare will pay for the services.

When you join an HMO, be sure to read your membership materials carefully to learn your fights and coverage.

 

Ending Enrollment in a Coordinated Care Plan

 

To end your enrollment in a coordinated care plan, send a signed request to your plan or to your local Social Security or Railroad Retirement Board office. You return to regular Medicare the first day of the month following the month your request is received by one of these offices. (If you leave a coordinated care plan to return to regular Medicare and buy a Medigap policy, you may have to wait for up to 6 months for the new Medigap policy to cover any pre-existing condition.)

 

If You Have Problems

 

If you belong to a Medicare HMO and you are unhappy with the quality of care, you can:

* Follow your HMO’s grievance procedure, or

* Complain to your Peer Review Organization (PRO). PROs are groups of practicing doctors and other health care professionals under contract to Medicare to review the care provided to Medicare patients (seepage 3).

If you have reason to believe that your Medicare HMO did not give you necessary care, inappropriately ended your enrollment, charged you an excessive premium, or falsified or misrepresented information, you can:

* Write to the Office of Prepaid Health Care Operations and Oversight, Room 4406 Cohen Building, 330 Independence Ave., SW, Washington, DC 20201.

* Describe your problem. The Office will see that your case is reviewed.

If you believe that your HMO has made an incorrect decision on coverage of benefits or payment of a claim, you can appeal--your appeal fights are similar to those provided under traditional Medicare. (See page 36 for more information about appeals.)

NOTE: A new Medicare supplement (Medigap) option is now available in some states. It is a kind of coordinated care plan called Medicare SELECT (see page 8 for more information).

If you need more information about Medicare and coordinated care plans, you can get a copy of Medicare and Coordinated Care Plans from the Consumer Information Center (see inside back cover).

 

Regional Office Coordinated Care Contacts

 

Health Care Financing Administration staff at the offices listed below can tell you if there are HMOs in your area that contract with Medicare.

Boston: (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont) Beneficiary Services Branch (617) 565-1232

New York: (New Jersey, New York, Puerto Rico and the Virgin Islands) Carrier Operations Branch (212) 264-8522

Philadelphia: (Delaware, District of Columbia, Maryland, Pennsylvania, Virginia and West Virginia) Beneficiary Services Branch (215) 596-1332

Atlanta: (Alabama, North and South Carolina, Florida, Georgia, Kentucky, Mississippi, and Tennessee) Beneficiary Services and HMO Branch (404) 331-2549

Chicago: (Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin) Beneficiary Services and HMO Branch (312) 353-7180

Dallas: (Arkansas, Louisiana, New Mexico, Oklahoma and Texas) Beneficiary Services Branch (214) 767-6401

Kansas City: (Iowa, Kansas, Missouri and Nebraska) Program Services Branch (816) 426-2866

Denver: (Colorado, Montana, North and South Dakota, Utah and Wyoming) Beneficiary Services Branch (303) 844-4024 ext 238

San Francisco: (American Samoa, Arizona, California, Guam, Hawaii and Nevada) Beneficiary Services Branch (415) 744-3617

Seattle: (Alaska, Idaho, Oregon and Washington) Beneficiary Services Branch (206) 553-0800

 

Medicare and Other Insurance

 

Buying Health Insurance to Supplement Medicare

 

Medicare provides basic protection against the cost of health care, but it will not pay all of your medical expenses, nor most long-term care expenses. For this reason, many private insurance companies sell supplement (Medigap) insurance as well as separate long-term care insurance. The federal government does not sell or service such insurance.

 

Shopping for Medigap Insurance

 

If you are thinking about buying a new private insurance policy or replacing an old policy to supplement your Medicare protection or cover long-term care costs, you should shop carefully. You can get a booklet, Guide to Health Insurance for People with Medicare, to help you make Medicare supplement decisions. (See box below for more information about the guide.)

 

New Standardized Medigap Policies

 

Most states have adopted regulations limiting the sale of Medigap insurance to no more than 10 standard policies. One of the 10 is a basic policy offering a 'core package' of benefits. These standardized plans are identified by the letters A through J. Plan A is the core package. The other nine plans each have a different combination of benefits, but they all include the core package. The basic policy, offering the core package of benefits, is available in all states.

To find out what standardized policies are available in your state, check with your state insurance department. The telephone number of your state insurance department is probably listed under 'state agencies' in your telephone book. If not, you can get a copy of the Guide to Health Insurance for People with Medicare (see box below).

In most cases, if you already have a Medigap policy, you may keep it but there are a few states where you must convert your policy to one of the standard plans. In all cases, if you buy a new policy, you will be required to choose a standardized plan.

 

Open Enrollment Period for Medigap Policies

 

An open enrollment period for selecting Medigap policies guarantees that for six months immediately following the effective date of Medicare Part B coverage, people age 65 or older cannot be denied Medigap insurance or charged higher premiums because of health problems.

No matter how you enroll in Part B--whether by automatic notification or through an initial, special or general enrollment period--you are covered by the new guarantees if both of the following are true:

* You are 65 or older and are enrolled in Medicare based on age rather than disability.

* The date you get by adding six months to the effective date for your Part B coverage (printed on your Medicare card) is in the future. The date you get tells you when your Medigap open enrollment ends.

NOTE: Even when you buy your Medigap policy in this open enrollment period, the policy may still exclude coverage for 'pre-existing conditions' during the first six months the policy is in effect. Pre-existing conditions are conditions that were either diagnosed or treated during the six-month period before the Medigap policy became effective.

 

Medicare SELECT

 

A new kind of Medigap insurance-available through 1994-has been introduced in 15 states. It is called Medicare SELECT. The difference between Medicare SELECT and regular Medigap insurance is that a Medicare SELECT policy may (except in emergencies) limit Medigap benefits to items and services provided by certain selected health care professionals or may pay only partial benefits when you get health care from other health care professionals.

You can order a free copy of the Guide to health Insurance for People With Medicare from the Consumer Information Center. There is ordering information on the inside back cover of this book. The guide:

* Explains how supplemental insurance works.

* Tells how to shop for Medigap insurance.

* Gives information on the new standard plans.

* Gives information on Medicare SELECT.

* Lists names, addresses and telephone numbers of state insurance departments and state agencies on aging. Some of these offices may have free counseling services available.

 

Insurers, including some HMOs, offer Medicare SELECT in the same way standard Medigap insurance is offered. The policies are required to meet certain federal standards and are regulated by the states in which they are approved. The premiums charged for Medicare SELECT policies are expected to be lower than premiums for comparable Medigap policies that do not have this selected-provider feature.

Medicare SELECT policies are permitted to be offered in Alabama, Arizona, California, Florida, Illinois, Indiana, Kentucky, Massachusetts, Minnesota, Missouri, North Dakota, Ohio, Texas, Washington and Wisconsin. If you live in one of these states, you can ask your state insurance department about the Medicare SELECT policies that have been approved for sale in the state.

 

Employment-related Retiree Coverage Instead of Medigap

 

Some retired people can get health coverage through their former employer or union. This health coverage may supplement Medicare but it is not Medigap insurance and does not have to meet federal and state Medigap requirements. (See below for rules about selling Medigap Insurance.)

Retiree coverage is usually provided free or at a greatly reduced price and may be a good bargain. But the benefits may not be adequate to serve as your supplement to Medicare. Does your retiree plan have an 'escape clause,' so that benefits might be changed? On the other hand, does your retiree plan protect you from the preexisting condition restriction that might be applied during the first six months under a Medigap policy? Check carefully before you decide whether to stay with your retiree coverage or buy a Medigap policy.

 

Medicaid Recipients

 

Low-income people who are eligible for Medicaid usually do not need additional insurance. Medicaid pays for certain health care benefits beyond those covered by Medicare, such as long-term nursing home care. If you have Medigap insurance purchased on or after November 5, 1991, and you become eligible for Medicaid, you can ask that the Medigap benefits and premiums be suspended for up to two years while you are covered Medicaid. If you become ineligible for Medicaid benefits during the two years, your Medigap policy is automatically reinstituted if you give proper notice and begin paying premiums again.

 

Coordinated Care Plans Instead of Medigap

 

Coordinated care plans that contract with Medicare are not Medigap plans, but they can be an alternative to standard Medigap insurance. (See page 6 for more information about coordinated care plans.)

 

There are Rules for Selling Medigap Insurance

 

Both state and federal laws govern sales of Medigap insurance. Companies or agents selling Medigap insurance must avoid certain illegal practices. Federal criminal and civil penalties (fines) may be imposed against any insurance company or agent that knowingly:

* Sells you a health insurance policy that duplicates your Medicare or Medicaid coverage, or any private health insurance coverage you may have.

* Tells you that they are employees or agents of the Medicare program or of any government agency.

* Makes a false statement that a policy meets legal standards for certification when it does not.

* Sells you a Medigap policy that is not one of the 10 approved standard policies (after the new standards have been put in place in your state).

* Denies you your Medigap open enrollment period by refusing to issue you a policy, placing conditions on the policy, or discriminating in the price of a policy because of your health status, claims experience, receipt of health care, or your medical condition.

* Uses the U.S. mail in a state for advertising or delivering health insurance policies to supplement Medicare if the policies have not been approved for sale in that state.

 

If You Suspect Illegal Sales Practices

 

If you suspect that you have been the victim of illegal sales practices, you should report these practices to your state insurance department. States are responsible for the regulation of insurance policies issued within their boundaries. Because federal laws also govern Medigap sales practices, you should also report the practices to the appropriate federal officials.

Your state insurance department may be listed in your telephone book. If not, you can get a copy of the booklet, Guide to Health Insurance for People with Medicare (see box on page 8).

To talk to federal officials about the suspected illegal sales practices, you may call this number: 1-800-638-6833.

 

When Other Insurance Pays Before Medicare

 

If any of the following insurance situations applies to you, please notify your doctor, hospital, and all other providers of services. For more information about any of these insurance situations, ask Social Security for a copy of Medicare and Other Health Benefits. The publication is also available free from the Consumer Information Center (see inside back cover).

 

When You or Your Spouse Continue To Work

 

Medicare has special rules that apply to beneficiaries who have employer group health plan coverage through their current employment or the current employment of a spouse.

Group health plans of employers with 20 or more employees are primary payers and Medicare is secondary payer for workers age 65 or older, and workers’ spouses age 65 or older. Group health plans must offer these people the same health insurance benefits under the same conditions offered to younger workers and spouses. You and your spouse have the option to reject the plan offered by the employer. If you reject the employer’s health plan, Medicare will remain the primary health insurance payer. In that case, the employer’s plan is not permitted to offer you coverage that supplements Medicare covered services. If your employer plan denies you coverage, offers you different coverage, or pays benefits that are secondary to Medicare, notify the carrier that handles your Medicare claims.

 

If You Are Disabled and Under Age 65

 

Medicare is the secondary payer for certain disabled people who have premium-free Medicare Part A and are covered under their employer’s health plan or the employer health plan of an employed family member. This secondary payer provision applies to group health plans of employers that employ 100 or more people. The secondary payer provision also applies to group health plans of employers with fewer than 100 employees if their employers are part of a multi-employer plan in which at least one employer has 100 or more employees.

 

Other Situations Where Medicare is the Secondary Payer

 

If you have a work-related illness or injury, services provided as treatment of that illness or injury should be covered by workers’ compensation or federal black lung benefits. It is important that your Medicare claim form note that the treatment is related to a work-related illness or injury, even if the injury or illness occurred in the past.

Medicare is a secondary payer during a period (generally 18 months) for beneficiaries who have Medicare solely on the basis of permanent kidney failure, if they have employer group health plan coverage themselves or through a family member.

Medicare also serves as the secondary payer in cases where no-fault insurance or liability insurance is available as the primary payer.

Although Medicare benefits are secondary to benefits paid by liability insurers, Medicare may make a conditional payment if it receives a claim for services covered by liability insurance. In those cases, Medicare may pay the claim; then, when a liability settlement is reached, Medicare recovers its conditional payment from the settlement amount.

 

If You Have or Can Get Both Medicare and Veterans Benefits

 

If you have or can get both Medicare and veterans benefits, you may choose to get treatment under either program. But, Medicare:

* Cannot pay for services you receive from Veterans Affairs (VA) hospitals or other VA facilities, except for certain emergency hospital services; and

* Generally cannot pay if the VA pays for VA-authorized services that you get in a non-VA hospital or from a non-VA physician.

Since July 1986, the VA has been charging coinsurance payments to some veterans who have non-service connected conditions for treatment in a VA hospital or medical facility, or for VA-authorized treatment by nonVA sources. The VA charges coinsurance payments when the veteran’s income exceeds a particular level. If the VA charges you a coinsurance payment for VA-authorized care by a non-VA physician or hospital, Medicare may be able to reimburse you, in whole or in part, for your VA coinsurance payment obligation. (If you have Medigap insurance, your Medigap policy may pay the VA coinsurance and deductible obligations, even if Medicare cannot.)

NOTE: Medicare cannot reimburse you for VA coinsurance payments for services furnished by VA hospitals and facilities, unless the services are emergency inpatient or outpatient hospital services. Then, the Medicare payment is subject to Medicare deductible and coinsurance amounts.

If you have questions about whether the VA or Medicare should pay for your doctor or other services covered under Medicare Part B, contact your Medicare carrier. If you have questions about whether the VA or Medicare should pay for hospital or other services covered under Medicare Part A, ask the provider of services to check with the Medicare intermediary.

 

The Data Match

 

In 1989, Congress passed a; law that will help Medicare get back an estimated $1 billion in taxpayer money. The law enables Medicare to get accurate information about beneficiaries’ health insurance.

The law authorizes the Health Care Financing Administration (the agency that administers the Medicare program), the Internal Revenue Service, and the Social Security Administration to share information about whether Medicare beneficiaries or their spouses are working and whether they have employment-related health insurance.

The process for sharing information from other agencies is called the Data Match. The Data Match will help Medicare find cases where another insurer should have paid first on Medicare beneficiaries’ health care claims. A designated Medicare contractor will contact employers to confirm health insurance coverage information. (For information about your fights under the Data Match, see 'Your Rights Under the Privacy Act,' page 5.)

 

What Medicare Does Not Pay For

 

Custodial Care

 

Medicare does not pay for custodial care when that is the only kind of care you need. Care is considered custodial when it is primarily for the purpose of helping you with daily living or meeting personal needs and could be provided safely and reasonably by people without professional skills or training. Much of the care provided in nursing homes to people with chronic, long-term illnesses or disabilities is considered custodial care. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, eating, and taking medicine. Even if you are in a participating hospital or skilled nursing facility, Medicare does not cover your stay if you need only custodial care.

 

Care Not Reasonable and Necessary Under Medicare Program Standards

 

Medicare does not pay for services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury. These services include drugs or devices that have not been approved by the Food and Drug Administration (FDA); medical procedures and services performed using drugs or devices not approved by FDA;* and services, including drugs or devices, not considered safe and effective because they are experimental or investigational.

* Some services are not covered by Medicare even when FDA has approved the drug or device used.

If a doctor admits you to a hospital or skilled nursing facility when the kind of care you need could be provided elsewhere (for example, at home or in an outpatient facility), your stay will not be considered reasonable and necessary, and Medicare will not pay for your stay. If you stay in a hospital or skilled nursing facility longer than you need to be there, Medicare payments will end when inpatient care is no longer reasonable and necessary.

If a doctor (or other practitioner) comes to treat you---or you visit him or her for treatment--more often than is medically necessary, Medicare will not pay for the 'extra' visits. Medicare will not pay for more services than are reasonable and necessary for your treatment.

Medicare always bases decisions about what is reasonable and necessary on professional medical advice.

 

Services Medicare Does Not Pay For

 

Medicare, by law, cannot pay for certain services. These include services performed by immediate relatives or members of your household, and services paid for by another government program. If you have a question about whether Medicare pays for a particular service, ask your Medicare carrier. (See pages 39 to 44 for the name and telephone number of your carrier.)

 

Limitation of Liability

 

Under Medicare law you will not be held responsible for payment of the cost of certain health care services for which you were denied Medicare payment if you did not know or you could not reasonably be expected to know (for example, you had not received a written notice) that the services were not covered by Medicare. This provision is called limitation of liability and is often referred to as a 'waiver of liability.' This protection from financial liability applies only when the care was denied because it was one of the following: Custodial care.

Not 'reasonable and necessary' under Medicare program standards for diagnosis or treatment.

* For home health services, the patient was not homebound or not receiving skilled nursing care on an intermittent basis.

* The only reason for the denial is that, in error, you were placed in a skilled nursing facility bed that was not approved by Medicare.

This limitation of liability provision does not apply to Medicare Part B services provided by a non-participating physician or supplier who did not accept assignment of the claim. However, in certain situations Medicare law will protect you from paying for services provided by a non-participating physician on a non-assigned basis that are denied as 'not reasonable and necessary.' If your physician knows or should know that Medicare will not pay for a particular service as 'not reasonable and necessary,' he or she must give you written notice--before performing the service--of the reasons why he or she believes Medicare will not pay. The physician must get your written agreement to pay for the services. If you did not receive this notice, you are not required to pay for the service. If you did pay, you may be entitled to a refund. (This written notice is not an official Medicare. determination. If you disagree with it, you may ask your doctor to submit a claim for payment to get an official Medicare determination.)

 

Medicare Hospital Insurance (Part A)

 

What Medicare Part A Includes

 

Medicare Part A helps pay for four kinds of medically necessary care:

1) Inpatient hospital care.

2) Inpatient care in a skilled nursing facility following a hospital stay.

3) Home health care.

4) Hospice care.

There is a limit on how many days of hospital or skilled nursing facility care Medicare helps pay for in each benefit period. But, your Part A protection is renewed every time you start a new benefit period. (Benefit periods are described below.)

Skilled nursing facility care is the only type of nursing home care that Medicare covers. Medicare does not pay for care that is primarily custodial. (See pages 17 and 20 for more about custodial care.)

 

Benefit Periods

 

A benefit period is a way of measuring your use of services under Medicare Part A. Your First benefit period starts the first time you receive inpatient hospital care after your Hospital Insurance begins. A benefit period ends when you have been out of a hospital or other facility primarily providing skilled nursing or rehabilitation services for 60 days in a row (including the day of discharge). If you remain in a facility (other than a hospital) that primarily provides skilled nursing or-rehabilitation services, a benefit period ends when you have not received any skilled care there for 60 days in a row. After one benefit period has ended, another one will start whenever you again receive inpatient hospital care.

There is no limit to the number of benefit periods you can have for hospital and skilled nursing facility care. However, special limited benefit periods apply to hospice care (see page 19).

Here are two examples of how the benefit period works:

Example 1: Ms. Jones enters the hospital on January 5. She is discharged on January 15. She has used 10 days of her first benefit period. Ms. Jones is not hospitalized again until July 20. Since more than 60 days elapsed between her hospital stays, she begins a new benefit period, her Part A coverage is completely renewed, and she will again pay the hospital deductible. (The hospital deductible is explained on page 15.)

Example 2: Ms. Smith enters the hospital on August 14. She is discharged on August 24. She also has used 10 days of her first benefit period. However, she is then readmitted to the hospital on September 20. Since fewer than 60 days elapsed between hospital stays, Ms. Smith is still in her first benefit period and will not be required to pay another hospital deductible. This means that the first day of her second admission is counted as the eleventh day of hospital care in that benefit period. Ms. Smith will not begin a new benefit period until she has been out of the hospital (and has not received any skilled care in a skilled nursing facility) for 60 consecutive days.

 

How Medicare Pays for Part A Services

 

Medicare Part A helps pay for most but not all of the services you receive in a hospital or skilled nursing facility or from a home health agency or hospice program. There are covered services and noncovered services under each kind of care. Covered services are services and supplies that Part A pays for.

Hospitals, skilled nursing facilities, home health agencies and hospices are called 'providers' under the Medicare Part A program. Providers submit their claims directly to Medicare--you cannot submit claims for their services. The provider will charge you for any part of the Part A deductible you have not met and any coinsurance payment you owe. Providers cannot require you to make a deposit before being admitted for inpatient care that is or may be covered under Part A of Medicare.

When a hospital, skilled nursing facility, home health agency, or hospice sends Medicare a Part A claim for payment, you get a Notice of Utilization that explains the decision Medicare made on the claim. This notice is not a bill. If you have any questions about the notice, get in touch with the people who sent you the notice.

 

When You Are a Hospital Inpatient

 

Medicare Part A helps pay for inpatient hospital care if all of the following four conditions are met:

1) A doctor prescribes inpatient hospital care for treatment of your illness or injury.

2) You require the kind of care that can be provided only in a hospital.

3) The hospital is participating in Medicare.*

4) The Utilization Review Committee of the hospital, a Peer Review Organization or an intermediary does not disapprove your stay.

* Under certain conditions, Medicare helps pay for emergency inpatient care you receive in a non-participating hospital.

If you meet these four conditions, Medicare will help pay for up to 90 days of medically necessary inpatient hospital care in each benefit period.**

** Medicare pays for only limited inpatient care in a psychiatric hospital (see page 16). The hospital can tell you about these limits.

During 1993, from the first day through the 60th day in a hospital during each benefit period, Part A pays for all covered services except the first $676. This is called the inpatient hospital deductible. (A deductible is an amount you owe before Medicare begins paying for services and supplies covered by the program.) The hospital may charge you the deductible only for your first admission in each benefit period. If you are discharged and then readmitted before the benefit period ends, you do not have to pay the deductible again.

From the 61st through the 90th day in a hospital during each benefit period, Part A pays for all covered services except for $169 a day. This daily amount is called coinsurance. The hospital charges you the $169.

Hospital reserve days (explained below) can help with your expenses if you need more than 90 days of inpatient hospital care in a benefit period.

Medicare Part A does not pay for the services of doctors and certain other practitioners, even though you receive these services in a hospital. Instead, those services are covered under Medicare Part B. (A description of Medicare Part B begins on page 21.)

Major services covered under Part A when you are a hospital inpatient:

* A semiprivate room (two to four beds in a room).

* All your meals, including special diets.

* Regular nursing services.

* Costs of special care units, such as intensive care or coronary care units.

* Drugs furnished by the hospital during your stay.

* Blood transfusions furnished by the hospital during your stay. (See page 16 for information about coverage of blood.)

* Lab tests included in your hospital bill.

* X-rays and other radiology services, including radiation therapy, billed by the hospital.

* Medical supplies such as casts, surgical dressings, and splints.

* Use of appliances, such as a wheelchair.

* Operating and recovery room costs.

* Rehabilitation services, such as physical therapy, occupational therapy, and speech pathology services.

Some services not covered under Part A when you are a hospital inpatient:

* Personal convenience items that you request such as a telephone or television in your room.

* Private duty nurses.

* Any extra charges for a private room unless it is determined to be medically necessary.

NOTE: If you disagree with a decision on the amount Medicare will pay on a claim or whether services you receive are covered by Medicare, you always have the fight to appeal the decision (see page 35).

 

Hospital Inpatient Reserve Days

 

Medicare helps pay for your care in a hospital for up to 90 days in each benefit period. Medicare Part A also includes an extra 60 hospital days you can use if you have a long illness and have to stay in the hospital for more than 90 days. These extra days are called reserve days.

You have only 60 reserve days in your lifetime. For example, if you use 8 reserve days in your first hospital stay this year, the next time you visit a hospital you will have only 52 reserve days left to use, whether or not you have a new benefit period.

You can decide when you want to use your reserve days. After you have been in the hospital 90 days, you can use all or some of your 60 reserve days if you wish.

If you do not want to use your reserve days, you must tell the hospital in writing, either when you are admitted to the hospital, or at any time afterwards up to 90 days after you are discharged. If you use reserve days and then decide that you did not want to use them, you must request approval from the hospital to get them restored.

During 1993, Medicare Part A pays for all covered services except $338 a day for each reserve day you use. You are responsible for paying this $338.

All Medigap plans pay some part of hospital bills after you have used all your reserve days. (See page 8 for more information about Medigap insurance.)

 

Coverage of Blood Under Part A

 

Part A helps pay for blood (whole blood or units of packed red blood cells), blood components, and the cost of blood processing and administration. If you receive blood as an inpatient of a hospital or skilled nursing facility, Part A will pay for these blood costs, except for any nonreplacement fees charged for the first three pints of whole blood or units of packed red cells per calendar year. (The nonreplacement fee is the amount that some hospitals and skilled nursing facilities charge for blood that is not replaced.)

You are responsible for the nonreplacement fees for the first three pints or units of blood furnished by a hospital or skilled nursing facility. If you are charged nonreplacement fees, you have the option of either paying the fees or having the blood replaced. If you choose to have the blood replaced, you can either replace the blood personally or arrange to have another person or an organization replace it for you. A hospital or skilled nursing facility cannot charge you for any of the first three pints of blood you replace or arrange to replace. (If you have already paid for or replaced blood under Medicare Part B during the calendar year, you do not have to meet those costs again under Medicare Part A. See page 21 for an explanation of coverage of blood under Medicare Part B.)

 

Care in a Psychiatric Hospital

 

Part A helps pay for no more than 190 days of inpatient care in a participating psychiatric hospital in your lifetime. Once you have used these 190 days, Part A does not pay for any more inpatient care in a psychiatric hospital.

Also, a special role applies if you are in a participating psychiatric hospital at the time your Part A starts. Social Security can give you more information.