The Medicare Handbook
The Medicare Handbook
INCLUDING INFORMATION FOR BENEFICIARIES
ON:
* MEDICARE BENEFITS
* PARTICIPATING PHYSICIANS
AND SUPPLIERS
* HEALTH INSURANCE TO SUPPLEMENT
MEDICARE
* LIMITS TO MEDICARE COVERAGE
ABOUT THIS HANDBOOK
Medicare pays for many of your health
care expenses, but
it does not cover all of them. It is important
for you to know
what Medicare does and does not pay for. This
Handbook will
help you understand how the Medicare program works
and what
your benefits are. You can use the alphabetical
index at the
back of the book to find information on specific
subjects. This
Handbook is also available in Spanish. (See inside
back cover
for how to order.)
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
coinsur-
ance 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.
Care Outside the United States
Medicare generally does not pay for hospital
or medical
services outside the United States. (Puerto Rico,
the U.S.
Virgin Islands, Guam, American Samoa, and the
Northern Mariana
Islands are considered part of the United States.)
If you are planning to travel outside
the United States,
you may want to buy special short-term health
insurance for
foreign travel. If you have other health insurance
in addition
to Medicare, check to see if health care in a
foreign country
is covered under your policy.
There are rare emergency cases where Medicare
can pay for
care in Canada or Mexico. Also, Medicare can sometimes
pay if a
Mexican or Canadian hospital is closer to your
home than the
nearest U.S. hospital that can provide the care
you need. If
you get emergency treatment in a Canadian or Mexican
hospital
or if you live near a Canadian or Mexican hospital,
ask someone
who works at the hospital about Medicare coverage,
or have the
hospital help you contact the Medicare intermediary.
Care in a Christian Science Sanatorium
Medicare Part A helps pay for inpatient
hospital and
skilled nursing facility services you receive
in a
participating Christian Science sanatorium if
it is operated or
listed and certified by the First Church of Christ,
Scientist,
in Boston. (However, Medicare Part B will not
pay for the
practitioner.)
The Prospective Payment System
Medicare pays for most inpatient hospital
care under the
Prospective Payment System (PPS). Under PPS, hospitals
are paid
a predetermined rate per discharge for inpatient
services
furnished to Medicare beneficiaries. The predetermined
rates
are based on payment categories called Diagnosis
Related
Groups, or DRGs. In some cases, the Medicare payment
will be
more than the hospital's costs; in other cases,
the payment
will be less than the hospital's costs. In special
cases,
where costs for necessary care are unusually high
or the length
of stay is unusually long, the hospital receives
additional
payment. But even if Medicare pays the hospital
less than the
cost of your care, you do not have to make up
the difference.
It is important to remember that the
PPS system does not
change your Medicare Part A protection as described
in this
handbook. PPS does not determine the length of
your stay in the
hospital or the extent of care you receive. The
law requires
participating hospitals to accept Medicare payments
as payment
in full, and those hospitals are prohibited from
billing the
Medicare patient for anything other than the applicable
deductible and coinsurance amounts, plus any amounts
due for
noncovered items or services such as television,
telephone or
private duty nurses.
Skilled Nursing Facility Care
Medicare Part A can help pay for certain
inpatient care in
a Medicare-participating skilled nursing facility
following a
hospital stay. Your condition must require daily
skilled
nursing or skilled rehabilitation services which,
as a
practical matter, can only be provided in a skilled
nursing
facility, and the skilled care you receive must
be based on a
doctor's orders.
What is a Skilled Nursing Facility?
A skilled nursing facility is a specially
qualified
facility that specializes in skilled care. It
has the staff and
equipment to provide skilled nursing care or skilled
rehabilitation services and other related health
services.
Skilled nursing care means care that can only
be performed by,
or under the supervision of, licensed nursing
personnel.
Skilled rehabilitation services may include such
services as
physical therapy performed by, or under the supervision
of, a
professional therapist.
Most nursing homes in the United States
are not skilled
nursing facilities that participate in Medicare.
In some
facilities, only certain portions participate
in Medicare. If
you are not sure whether a facility participates
in Medicare as
a skilled nursing facility, ask someone in the
facility's
business office. If staff at the facility cannot
tell you, ask
Social Security to check with the Health Care
Financing
Administration.
When Can Medicare Pay?
Medicare Part A can help pay for your
care in a
Medicare-participating skilled nursing facility
if you meet all
of these five conditions:
1) Your condition requires daily skilled
nursing or skilled
rehabilitation services which, as a practical
matter, can
only be provided in a skilled nursing facility.
2) You have been in a hospital at least three
days in a row
(not counting the day of discharge) before
you are admitted
to a participating skilled nursing facility.
3) You are admitted to the facility within
a short time
(generally within 30 days) after you leave
the hospital.
4) Your care in the skilled nursing facility
is for a
condition that was treated in the hospital,
or for a
condition that arose while you were receiving
care in the
skilled nursing facility for a condition
which was treated
in the hospital.
5) A medical professional certifies that
you need, and you
receive, skilled nursing or skilled rehabilitation
services
on a daily basis.
All five conditions must be met. Remember,
you must need
skilled nursing care or skilled rehabilitation
services on a
daily basis. Part A will not pay for your stay
if you need
skilled nursing or rehabilitation services only
occasionally,
such as once or twice a week, or if you do not
need to be in a
skilled nursing facility to get skilled services.
Also,
Medicare will not pay for your stay if you are
in a skilled
nursing facility mainly because you need custodial
care.
Skilled Care or Custodial Care?
The only type of "nursing home"
care Medicare helps pay
for is skilled nursing facility 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 the patient with daily living
or meeting
personal needs, and could be provided safely and
reasonably by
people Without professional skills or training.
For example,
custodial care includes help in walking, getting
in and out of
bed, bathing, dressing, eating and taking medicine.
When your stay in a skilled nursing facility
is covered by
Medicare, Part A helps pay for a maximum of 100
days in each
benefit period, but only if you need daily skilled
nursing care
or rehabilitation services for that long.
If you leave a skilled nursing facility
and are readmitted
within 30 days, you do not have to have a new
three day stay in
the hospital for your care to be covered. If you
have some of
your 100 days left and you need skilled nursing
or
rehabilitation services on a daily basis for further
treatment
of a condition treated during your previous stay
in the
facility, Medicare will help pay.
In each benefit period, Part A pays for
all covered
services for the first 20 days you are in a skilled
nursing
facility. During 1993, for days 21 through 100,
Part A pays for
all covered services except for $84.50 a day.
You may be
charged up to this daily coinsurance amount by
the skilled
nursing facility.
Medicare Part A does not cover your doctor's
services while
you are in a skilled nursing facility. Medicare
Part B covers
doctors' services. (A description of Medicare
Part B begins on
page 21.)
Major services covered under Part A when you
are in a skilled
nursing facility:
* A semiprivate room (two to four beds in
a room).
* All your meals, including special diets
furnished by the
facility.
* Regular nursing services.
* Physical, occupational, and speech therapy.
* Drugs furnished by the facility during your
stay.
* Blood transfusions furnished during your
stay. (See page
16 for information about coverage of blood.)
* Medical supplies such as splints and casts
furnished by
the facility.
* Use of appliances such as a wheelchair
furnished by the
facility.
Some services not covered under Part A when
you are in a
skilled nursing facility:
* Personal convenience items that you request
such as a
television in your room.
* Private duty nurses.
* Any extra charges for a private room, unless
it is
determined to be medically necessary.
Rules That Protect You
Skilled nursing facilities cannot require
you to pay a
deposit or other payment as a condition of admission
to the
facility unless it is clear that services are
not covered by
Medicare.
If you are already an inpatient in a skilled
nursing
facility and the staff at the facility decides
you no longer
need the level of skilled care covered by Medicare,
they must
notify you immediately. If you disagree with this
decision, the
facility must submit your claim at your request
to Medicare for
an official Medicare decision on coverage. The
facility may not
require you to pay a deposit until Medicare issues
its
decision. You must pay for any coinsurance while
your claim is
being processed, and for any services which are
never covered
by Medicare.
Complaints and Appeals
If you want to complain about a skilled
nursing facility's
treatment of patients or other conditions that
concern you, you
can contact the state survey agency. Each skilled
nursing
facility can give you the telephone number and
address of the
state survey agency if you ask for it. You can
also look at a
copy of the skilled nursing facility's latest
certification
survey report. The survey report will tell you
the results of
the state survey agency's review of how well the
agency thinks
the facility followed the rules about patient's
rights, safety
and quality of care.
Also, 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).
Home Health Care
If you need skilled health care in your
home for the
treatment of an illness or injury, Medicare pays
for covered
home health services furnished by a participating
home health
agency. A home health agency is a public or private
agency that
specializes in giving skilled nursing services
and other
therapeutic services, such as physical therapy,
in your home.
(A hospital or other facility that mainly provides
skilled
nursing or rehabilitation services cannot be considered
your
home.)
Medicare pays for home health visits only
if all four of
the following conditions are met:
1) The care you need includes intermittent
skilled nursing
care, physical therapy, or speech therapy.
2) You are confined to your home (homebound).
3) You are under the care of a physician
who determines
you need home health care and sets up a home
health
plan for you.
4) The home health agency providing services
participates
in Medicare.
Once all four of these conditions are
met, either Medicare
Part A or Medicare Part B will pay for all medically
necessary
home health services. When you no longer need
intermittent
skilled nursing care, physical therapy, or speech
therapy,
Medicare will pay for home health services if
you continue to
need occupational therapy.
Medicare home health services do not include
coverage for
general household services such as laundry, meal
preparation,
shopping, or other home care services furnished
mainly to
assist people in meeting personal, family, or
domestic needs.
To determine whether you can get services
under the
Medicare home health benefit, ask your physician
to refer you
to a Medicare participating home health agency.
The home health
agency will evaluate your case and tell you whether
you meet
the requirements for Medicare coverage. Home health
agencies
should not charge for this evaluation.
Home health services covered by Medicare:
* Part-time or intermittent skilled nursing
care. (This can
include eight hours of reasonable and necessary
care per
day for up to 21 consecutive days--or longer
in certain
circumstances.)
* Physical therapy.
* Speech therapy.
If you need intermittent skilled nursing
care, or
physical or speech therapy, Medicare also pays
for:
* Occupational therapy.
* Part-time or intermittent services of
home health aides.
* Medical social services.
* Medical supplies.
* Durable medical equipment (80 percent
of approved amount).
Home health services not covered by Medicare.
* 24-hour-a-day nursing care at home.
* Drugs and biologicals.
* Meals delivered to your home.
* Homemaker services.
* Blood transfusions.
Medicare pays the full approved cost of
all covered home
health visits. You may be charged only for any
services or
costs that Medicare does not cover. However, if
you need
durable medical equipment, you are responsible
for a 20 percent
coinsurance payment for the equipment. (See page
26 for more
information about durable medical equipment.)
The home health agency will submit the
claim for payment.
You do not have to send in any bills yourself.
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).
Hospice Care
A hospice is a public agency or private
organization that
is primarily engaged in providing pain relief,
symptom
management and supportive services to terminally
ill people.
Hospice care is a special type of care
for people who are
terminally ill. It includes both home care and
inpatient care,
when needed, and a variety of services not otherwise
covered
under Medicare. Under the Medicare hospice benefit,
Medicare
pays for services every day and also permits a
hospice to
provide appropriate custodial care, including
homemaker
services and counseling.
Medicare Part A helps pay for hospice
care if all three of
these conditions are met:
1) A doctor certifies that the patient is
terminally ill.
2) The patient chooses to receive care from
a hospice
instead of standard Medicare benefits for
the terminal
illness.
3) Care is provided by a Medicare-participating
hospice
program.
Special benefit periods apply to hospice
care. Part A pays
for two 90-day periods, followed by a 30-day period,
and--when
necessary--an extension period of indefinite duration.
If a
beneficiary cancels hospice care during one of
the first three
benefit periods, any days left in that period
are lost, but the
remaining benefit period(s) are still available,
And, a
beneficiary may disenroll from the hospice during
any benefit
period, return to regular Medicare coverage, then
later
re-elect the hospice benefit if another benefit
period is
available.
Two Benefit Period Examples:
* Mr. Jones cancelled his hospice care at
the end of 59 days
during his first 90-day benefit period. He
lost the 31
remaining days of the first 90-day period.
But if he wants
to, he can choose hospice care again. He
still has a
90-day period, a 30-day period, and the indefinite
extension period.
* Ms. Smith cancelled hospice care during
her final
extension period. She cannot use the Medicare
hospice
benefit again.
There are no deductibles under the hospice
benefit. The
beneficiary does not pay for Medicare-covered
services for the
terminal illness, except for small coinsurance
amounts for
outpatient drugs and inpatient respite care.
The patient is responsible for five percent
of the cost of
outpatient drugs or $5 toward each prescription,
whichever is
less. For inpatient respite care, the patient
pays five percent
of the Medicare-allowed rate (approximately $4.48
per day in
1993). The rate varies slightly depending on the
area of the
country.
Respite care under the hospice program
is a shortterm
inpatient stay in a facility. The Medicare beneficiary's
inpatient stay gives temporary relief--a respite--to
the person
who regularly assists with home care. Each inpatient
respite
care stay is limited to no more than five days
in a row.
While receiving hospice care, if a patient
requires
treatment for a condition not related to the terminal
illness,
Medicare continues to help pay for all necessary
covered
services under the standard Medicare benefit program.
Services covered by Part A when provided by
a hospice:
* Nursing services.
* Doctors' services.
* Drugs, including outpatient drugs for
pain relief and
symptom management.
* Physical therapy, occupational therapy
and speechlanguage
pathology.
* Home health aide and homemaker services.
* Medical social services.
* Medical supplies and appliances.
* Short-term inpatient care, including respite
care.
* Counseling.
The Medicare Part A hospice benefit does
not pay for
treatments other than for pain relief and symptom
management of
a terminal illness. Regular Medicare can usually
help pay for
treatments not related to the terminal illness.
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 right
to appeal
the decision (see page 35).
Medicare Medical Insurance (Part B)
What Medicare Part B Includes
Medicare Part B helps pay for:
* Doctors' services.
* Outpatient hospital care.
* Diagnostic tests.
* Durable medical equipment.
* Ambulance services.
* Many other health services and supplies that
are not
covered by Medicare Part A.
The following sections tell you more about
these different
kinds of care, the services that are and are not
covered by
Medicare Part B, and what part of your medical
expenses
Medicare will pay.
Deductible and Coinsurance Amounts Under Part
B
The Annual Deductible
You must pay the first $100 in approved
charges for
covered medical expenses in 1993. This is called
the Medicare
Part B annual deductible. You need to meet this
$100 deductible
only once during the year, and the deductible
can be met by any
combination of covered expenses. You do not have
to meet a
separate deductible for each different kind of
covered service
you receive.
The Blood Deductible
You must pay any nonreplacement fees charged
for the first
three pints or units of blood and blood components
you use each
year. (The nonreplacement fee is the amount that
some
practitioners and facilities charge for blood
that is not
replaced.) This is called the Medicare Part B
blood deductible.
After you have replaced or paid for the first
three pints of
blood and you have met the $100 annual deductible,
Medicare
will pay 80 percent of the approved amount for
blood, starting
with the fourth pint. (If you have already paid
for or replaced
some units of blood under Medicare Part A during
the calendar
year, you do not have to pay for or replace that
number of
units again under Medicare Part B.)
Coinsurance
After you pay the annual deductible, you
will owe a share
of the Medicare-approved amount for most services
and supplies.
This share is called coinsurance. Usually, your
coinsurance
share is 20 percent of the Medicare-approved amount.
Medicare determines the approved amount
for each service
you receive. If your services were provided "on
assignment,"
you pay only the coinsurance (see page 28 for
an explanation of
assignment).
If your services were not provided "on
assignment," and
the charges for your services were more than the
Medicare-approved amount, you usually owe the
Medicare
coinsurance plus certain charges above the Medicare-approved
amount. (See "Medicare Approved Amounts"
on page 29.) There are
limits on the amount your doctor can charge you.
NOTE: This explanation of your deductible
and coinsurance
amounts describes Medicare's payment system for
most services
covered by Medicare Part B. In cases where payment
for services
is handled in a different way, you will be given
an explanation
along with the description of services covered.
(You will find
more information about how Medicare pays Part
B claims in the
section beginning on page 28.)
Doctors' Services Covered By Medicare Part
B
Medicare Part B helps pay for covered
services you receive
from your doctor in his or her office, in a hospital,
in a
skilled nursing facility, in your home, or any
other location.
Major doctors' services covered by Medicare
Part B:
* Medical and surgical services, including
anesthesia.
* Diagnostic tests and procedures that are
part of your
treatment.
* Radiology and pathology services by doctors
while you are
a hospital inpatient or outpatient.
* Treatment of mental illness. (Medicare
payments for
treatment are limited; see page 27)
* Other services such as:
-- X-rays.
-- Services of your doctor's office nurse.
-- Drugs and biologicals that cannot
be
self-administered.
-- Transfusions of blood and blood components,
-- Medical supplies.
-- Physical/occupational therapy and
speech pathology
services.
Some doctors' services not covered by Medicare
Part B:
* Routine physical examinations, and tests
directly related
to such examinations (except some Pap smears
and
mammograms, see page 25).
* Most routine foot care and dental care.
* Examinations for prescribing or fitting
eyeglasses or
hearing aids.
* Immunizations (except pneumococcal pneumonia
vaccinations
or immunizations required because of an injury
or
immediate risk of infection, and hepatitis
B for certain
persons at risk).
* Cosmetic surgery, unless it is needed because
of
accidental injury or to improve the function
of a
malformed part of the body.
Types of Doctors
Most doctors' services are furnished by
a doctor of
medicine or a doctor of osteopathy. Other "physicians"
that can
furnish some covered services include chiropractors,
doctors of
podiatric medicine (podiatrists), doctors of dental
surgery or
of dental medicine (dentists), and doctors of
optometry
(optometrists).
Chiropractors' Services
Medicare helps pay for only one kind of
treatment
furnished by a licensed chiropractor: manual manipulation
of
the spine to correct a subluxation that is demonstrated
by
X-ray. Medicare Part B does not pay for any other
diagnostic or
therapeutic services, including Xrays, furnished
by a
chiropractor.
Podiatrists' Services
Medicare Part B helps pay for any covered
services of a
licensed podiatrist to treat injuries and diseases
of the foot.
Examples of common problems include ingrown toenails,
hammer
toe deformities, bunion deformities and heel spurs.
Medicare generally does not pay for routine
foot care such
as cutting or removal of corns and calluses, trimming
of nails,
and other hygienic care. But, Medicare does help
pay for some
routine foot care if you are being treated by
a medical doctor
for a medical condition affecting your legs or
feet (such as
diabetes or peripheral vascular disease) which
requires that
the routine care be performed by a podiatrist
or by a doctor of
medicine or osteopathy.
Dentists' Services
Medicare Part B generally does not pay
for care in
connection with the treatment, filling, removal,
or replacement
of teeth; root canal therapy; surgery for impacted
teeth; or
other surgical procedures involving the teeth
or structures
directly supporting the teeth. However, Medicare
does help pay
for services of a dentist in certain cases when
the medical
problem is more extensive than the teeth or structures
directly
supporting them. (If you need to be hospitalized
because of the
severity of a dental procedure, Medicare Part
A may pay for
your inpatient hospital stay even if the dental
care itself is
not covered by Medicare.)
Optometrists' Services
Medicare helps pay for Medicare-covered
vision care,
including the services of an optometrist if the
optometrist is
legally authorized to perform those services by
the state in
which he or she performs them. However, Medicare
will not pay
for routine eye exams and usually will not pay
for eyeglasses.
(Medicare will pay for cataract spectacles, cataract
contact
lenses, or intraocular lenses that replace the
natural lens of
the eye after cataract surgery. Medicare will
also pay for one
pair of conventional eyeglasses or conventional
contact lenses
if necessary after cataract surgery with insertion
of an
intraocular lens.)
Second Opinion Before Surgery
Sometimes your doctor may recommend surgery
for the
treatment of a medical problem. In some cases,
surgery is
unavoidable. But there is increasing evidence
that many
conditions can be treated equally well without
surgery. Because
even minor surgery involves some risk, we recommend
that you
get an opinion from a second doctor to help you
decide about
surgery. Medicare will help pay for a second opinion.
Medicare
will also help pay for a third opinion if the
first and second
opinions contradict each other.
Your own doctor is the best source for
referral to another
doctor. But, if you wish, you can call your Medicare
Part B
carrier for the names and phone numbers of doctors
in your area
who provide second opinions. (Medicare carriers
are listed on
pages 39 to 44.)
Services of Special Practitioners
Medicare Part B helps pay for covered
services you receive
from certain specially qualified practitioners
who are not
physicians. The practitioners must be approved
by Medicare.
Medicare-approved practitioners are listed below:
* Certified registered nurse anesthetist.
* Certified nurse midwife.
* Clinical psychologist.
* Clinical social worker (other than in
a hospital).
* Physician assistant. (A physician assistant
can furnish
certain services in a hospital or certain
other
facilities, can serve as an assistant-at-surgery,
and can
furnish services in any location that is
designated as a
rural health professional shortage area.)
* Nurse practitioner and clinical nurse
specialist in
collaboration with a physician. (A nurse
practitioner can
furnish services in a skilled nursing facility
or a
Medicaid nursing facility in any area. In
addition, a
nurse practitioner or clinical nurse specialist
can
furnish services in a rural area.)
Outpatient Hospital Services
Medicare Part B helps pay for covered
services you receive
as an outpatient from a participating hospital
for diagnosis or
treatment of an illness or injury. Under certain
conditions,
Medicare helps pay for emergency outpatient care
you receive
from a non-participating hospital.
When you get outpatient hospital services,
you are
responsible for the annual Medicare Part B deductible.
In
addition to the deductible, you are responsible
for a
coinsurance of 20 percent of the hospital's charge
above the
deductible.
When you go to a hospital for outpatient
services, you are
sometimes asked how much of your Part B deductible
you have
met. One easy way to answer that question is to
show your most
recent Explanation of Your Medicare Part B Benefits
notice.
From this form, hospital staff can usually tell
how much of the
$100 annual deductible you have met.
If the hospital cannot tell how much of
the $100
deductible you have met and the charge for the
services you
received is less than $100, the hospital may ask
you
to pay the entire bill. The amount you pay the
hospital can be
credited toward any part of the deductible you
have not met. If
you pay the hospital for deductible amounts you
do not owe, the
hospital or the Medicare intermediary will refund
the amount
you overpaid.
Major outpatient hospital services covered
by Part B:
* Services in an emergency room or outpatient
clinic,
including same-day surgery
* Laboratory tests billed by the hospital.
* Mental health care in a partial hospitalization
psychiatric program, if a physician certifies
that
inpatient treatment would be required without
it.
* X-rays and other radiology services billed
by the
hospital.
* Medical supplies such as splints and casts.
* Drugs and biologicals that cannot be selfadministered.
* Blood transfusions furnished to you as
an outpatient.
Some outpatient hospital services not covered
by Part B:
* Routine physical examinations and tests
directly related
to such examinations (except some Pap smears
and
mammograms, see page 25).
* Eye or ear examinations to prescribe or
fit eyeglasses or
hearing aids.
* Immunizations (except pneumococcal pneumonia
and hepatitis
B vaccinations, or immunizations required
because of an
injury or immediate risk of infection).
* Most routine foot care.
Other Services and Supplies Covered by Medicare
Ambulatory Surgical Services
An ambulatory surgical center is a facility
that provides
surgical services that do not require a hospital
stay. Medicare
Part B will pay for the use of an ambulatory surgical
center
for certain approved surgical procedures. However,
by law
Medicare can only pay centers that have an agreement
with
Medicare to participate in the Medicare program.
If you do not
know whether an ambulatory surgical center participates
in
Medicare, ask someone in the center's business
office. If that
person does not know, contact Social Security
and ask them to
check with the Health Care Financing Administration.
In addition to helping pay for the use
of the ambulatory
surgical center, Medicare also helps pay for physician
and
anesthesia services that are provided in connection
with the
procedure.
Home Health Services
If you have both Medicare Part A and Part
B, your Part A
pays for home health services. But Part B will
pay for home
health services if you do not have Part A. Medicare
home health
services are described on page 18.
Outpatient Physical and Occupational Therapy
and Speech
Pathology Services
Medicare Part B helps pay for medically
necessary
outpatient physical and occupational therapy or
speech
pathology services, if all the following three
conditions are
met:
1) Your doctor prescribes the service.
2) Your doctor or therapist sets up the plan
of treatment.
3) Your doctor periodically reviews that
plan.
You can receive physical therapy, occupational
therapy or
speech pathology services as an outpatient of
a participating
hospital or skilled nursing facility, or from
a participating
home health agency, rehabilitation agency, or
public health
agency. The provider of services may charge you
only for any
part of the $100 annual deductible you have not
met, 20
percent of the remaining approved amount, and
any noncovered
services.
Also, you can receive services directly
from an
independently practicing, Medicare-approved physical
or
occupational therapist in his or her office or
in your home if
such treatment is prescribed by a doctor. (Medicare
does not
pay for services provided by independently practicing
speech
pathologists.) But, the maximum amount Medicare
pays for each
of these services provided by an independently
practicing
physical or occupational therapist in 1993 is
$600 a year.
(This is 80 percent of the maximum approved amount
of up to
$750.) The Medicare payment would be less than
$600 if charges
for these services are used to meet part or all
of your $100
annual deductible.
Comprehensive Outpatient Rehabilitation Facility
Services
Under certain circumstances, Medicare
helps pay for
outpatient services you receive from a Medicareparticipating
comprehensive outpatient rehabilitation facility
(CORF).
Covered services include physicians' services;
physical,
speech, occupational and respiratory therapies;
counseling; and
other related services. You must be referred by
a physician who
certifies that you need skilled rehabilitation
services. For
most CORF services, you are responsible only for
the annual
deductible and 20 percent of the Medicare approved-charges.
Medicare helps pay for mental health treatment
in a CORF; the
Medicare payment limit for mental health treatment
in a CORF is
discussed on page 27.
Partial Hospitalization for Mental Health Treatment
Partial hospitalization (sometimes called
day treatment)
is a program of outpatient mental health care.
Under certain
conditions, Medicare Part B helps pay for these
programs when
provided by hospital outpatient departments or
by community
mental health centers. If you are considering
mental health
treatment, check with the program you have chosen
to see if it
meets the conditions for Medicare payment.
Rural Health Clinic Services
Medicare Part B helps pay for services
of physicians,
nurse practitioners, physician assistants, nurse
midwives,
visiting nurses (under certain conditions), clinical
psychologists, and clinical social workers furnished
by a rural
health clinic. You are responsible only for the
annual Medicare
Part B deductible plus 20 percent of the Medicare-approved
charge for the clinic.
Federally Qualified Health Center Services
Federally qualified health centers are
located in both
rural and urban areas and any Medicare beneficiary
may seek
services at them. As part of the "federally
qualified health
center benefit," Medicare Part B helps pay
for services of
physicians, nurse practitioners, physician assistants,
nurse
midwives, visiting nurses (under certain conditions),
clinical
psychologists, and clinical social workers. Also,
as part of
the federally qualified health center benefit,
Medicare helps
pay for certain preventive health services. The
center can tell
you what services are part of the federally qualified
health
center benefit.
You do not have to pay the Medicare Part
B annual
deductible for services provided under the federally
qualified
health center benefit. You are responsible for
20 percent of
the Medicare-approved charge for the clinic. (There
are some
cases, under Public Health Service guidelines,
when the
federally qualified health center may waive all
or part of the
20 percent Part B coinsurance which is applicable
for center
services.)
Federally qualified health centers often
provide services
in addition to those offered under the Medicare
federally
qualified health center benefit. Examples of these
services are
X-rays and equipment like crutches and canes.
As long as the
center meets Medicare requirements to provide
these services,
Medicare Part B can help pay for them. You are
responsible for
any unmet part of the annual Medicare Part B deductible
plus 20
percent of the Medicare-approved charge for the
service.
Laboratory Services
All laboratories must be certified under
the Clinical
Laboratory Improvement Amendments to perform laboratory
testing. Medicare Part B pays the full approved
fee for covered
clinical diagnostic tests provided by certified
laboratories
that are participating in Medicare. The laboratory
can be
independent, part of a hospital outpatient department
or in a
doctor's office. The laboratory must accept assignment
for the
tests. (See page 28 for an explanation of assignment.)
It may
not bill you for the tests.*
* In the state of Maryland only, you may
be charged 20
percent coinsurance for hospital outpatient
tests.
Some laboratories are approved only for
certain kinds of
tests. Your doctor can usually tell you which
laboratories are
approved and whether the tests he or she is ordering
from an
approved laboratory are covered by Medicare. If
your doctor can
not tell you, call your Part B carrier. (Carriers
are listed on
pages 39 to 44.)
Portable Diagnostic X-ray Services
Medicare Part B helps pay for portable
diagnostic X-ray
services you receive in your home or other locations
if they
are ordered by a doctor and if they are provided
by a
Medicare-approved supplier. You can ask your Part
B carrier
whether the supplier is Medicare-approved. (Carriers
are listed
on pages 39 to 44.)
Other Diagnostic Tests
Medicare Part B also helps pay for other
diagnostic tests,
including X-rays, that your doctor orders to evaluate
your
medical problems.
Pap Smear Screening
Medicare Part B helps pay once every three
years for Pap
smears to screen for cervical cancer. Medicare
helps pay more
frequently for certain women at high risk.
Medicare also pays for diagnostic Pap
smears as needed
when symptoms are present.
Breast-Cancer Screening (Mammography)
Medicare Part B helps pay for X-ray screenings
for the
detection of breast cancer, if they are provided
by a
Medicare-approved supplier. Women 65 or older
can use the
benefit every other year. Some younger women covered
by
Medicare can use the screening benefit more frequently.
Your
Medicare carrier can tell you how often Medicare
will pay for a
screening mammogram for you. Medicare also pays
for diagnostic
mammograms as needed when symptoms are present.
For accurate up-to-date information on
cancer prevention,
detection, diagnosis, and treatment for patients,
their
families, and the general public, call the Cancer
Information
Service at 1-800-4-CANCER.
Radiation Therapy
Medicare Part B helps pay for outpatient
radiation therapy
given under the supervision of your doctor.
Kidney Dialysis and Transplants
Medicare Part B helps pay for kidney dialysis
and
transplants. For detailed information on this
coverage, you can
get a copy of Medicare Coverage of Kidney Dialysis
and Kidney
Transplant Services from the Consumer Information
Center (see
inside back cover).
Heart and Liver Transplants
Under certain limited conditions, Medicare
Part B helps
pay for heart and liver transplants in a Medicare-approved
facility. If you are considering a heart or liver
transplant,
you and your physician can find out about Medicare
coverage by
contacting your Medicare carrier. If you belong
to an HMO, the
HMO will give you the information you need about
Medicare
coverage.
Ambulance Transportation
Medicare Part B helps pay for medically
necessary
ambulance transportation, including air ambulance,
but only if:
* The ambulance, equipment and personnel
meet Medicare
requirements.
* Transportation in any other vehicle could
endanger your
health.
Under these conditions, Medicare helps
pay for ambulance
transportation but only to a hospital or skilled
nursing
facility, or from a hospital or skilled nursing
facility to
your home. Medicare does not pay for ambulance
use from your
home to a doctor's office or to a dialysis facility
that is not
in or next to a hospital.
Medicare usually helps pay only if the
ambulance
transportation is in your local area. But, if
there are no
local facilities equipped to provide the care
you need,
Medicare helps pay for necessary ambulance transportation
to
the closest facility outside your local area that
can provide
the necessary care. If there is a local facility
equipped to
provide the care you need but you choose to go
to another
institution that is farther away, Medicare payment
is based on
the charge for transportation to the closest facility
that can
provide the necessary care.
Durable Medical Equipment
Medicare Part B helps pay for durable
medical equipment
such as oxygen equipment, wheelchairs, and other
medically
necessary equipment that your doctor prescribes
for use in your
home. (A hospital or facility that mainly provides
skilled
nursing or rehabilitation services cannot be considered
your
home.)
To be considered durable medical equipment,
the equipment
must be able to be used over again by other patients,
must
primarily serve a medical purpose, must not be
useful to people
who are not sick or injured, and must be appropriate
for use in
your home. Not all types of equipment that you
might find
useful can meet all four of these requirements.
Only your own doctor should prescribe
medical equipment
for you. An equipment supplier should not take
any of the
following actions:
* Contact you first, either by phone or
by mail, and offer
to get your doctor or Medicare to approve
an item. (It is
all fight for the supplier to contact you
in response to
calls from your doctor or other health care
workers.)
* Say he or she works for, or represents,
Medicare.
* Deliver equipment to your home that neither
you nor your
doctor ordered.
* Send you used items, while billing Medicare
for new ones.
Some of these actions may be against the
law. If you
believe a supplier has taken any of these actions,
you should
alert Medicare. First, ask your doctor whether
he or she
ordered the item. If your doctor did not order
the item, you
should file a complaint with your Medicare carrier.
You can
file a complaint by phone, in person or in writing.
Your
carrier will investigate.
It is also illegal for a supplier to offer
you items at no
cost to you or offer to pay the Medicare coinsurance
on items.
If a supplier makes one of these offers, file
a complaint with
your Medicare carrier as described above.
NOTE: The durable medical equipment supplier
must have
your doctor's prescription before delivering any
of the
following items: seat lift chairs, power-operated
vehicles,
equipment for care of pressure sores, or transcutaneous
electrical nerve stimulators. In the case of seat
lift chairs,
Medicare covers only the lift mechanism, not the
chair itself.
Medicare pays for different kinds of durable
medical
equipment in different ways; some equipment must
be rented,
other equipment must be purchased, and for some
equipment you
may choose rental or purchase. Your Medicare carrier
will be
able to provide more specific guidance on which
method will be
used for a particular item. (Carriers are listed
on pages 39 to
44.)
Prosthetic Devices
Medicare Part B helps pay for prosthetic
devices needed to
replace an internal body organ. These include
Medicare-approved
corrective lenses needed after a cataract operation,
ostomy
bags and certain related supplies, and breast
prostheses
(including a surgical brassiere) after a mastectomy.
Medicare
also helps pay for artificial limbs and eyes,
and for arm, leg,
back, and neck braces. Medicare does not pay for
orthopedic
shoes unless they are an integral part of leg
braces and the
cost is included in the charge for the braces.
Medicare does
not pay for dental plates or other dental devices.
Medical Supplies
Medicare Part B helps pay for surgical
dressings, splints,
and casts ordered by a doctor in connection with
your medical
treatment. This does not include adhesive tape,
antiseptics, or
other common first-aid supplies.
Drugs and Biologicals
Pneumococcal Pneumonia Vaccine
Medicare Part B pays the full approved
charges for
pneumococcal pneumonia vaccine and its administration.
Neither
the $100 annual deductible nor the 20 percent
coinsurance
applies to this service.
Hepatitis B Vaccine
Medicare Part B helps pay for hepatitis
B vaccine
administered to beneficiaries considered to be
at high or
intermediate risk of contracting the disease.
Hemophilia Clotting Factors
Medicare Part B helps pay for blood clotting
factors and
items related to their administration for hemophilia
patients
who are able to use them to control bleeding without
medical or
other supervision. The amount of clotting factors
necessary to
have on hand for a specific period is determined
for each
patient individually.
Blood
Medicare Part B helps pay for blood and
blood components
you receive as a hospital outpatient or as part
of other
services. (See page 21 for an explanation of the
blood
deductible.)
Antigens
Under certain circumstances, Medicare
Part B helps pay for
antigens prepared for you by your doctor. You
can check with
your Medicare carrier to see if Medicare will
pay for your
antigens. (Carriers are listed on pages 39 to
44.)
Immunosuppressive Drugs
Immunosuppressive drugs are often given
to prevent
rejection of transplanted organs. Medicare Part
B helps pay for
drugs used in immunosuppressive therapy for one
year beginning
with the date of discharge from the inpatient
hospital stay
during which a Medicare-covered organ transplant
was performed.
Epoetin Alfa
Medicare Part B may help pay for the drug
Epoetin alfa
when used to treat Medicare beneficiaries with
anemia related
to chronic kidney failure, or related to use of
AZT in
HIV-positive beneficiaries or for other uses that
a Medicare
carrier finds medically appropriate. (The kidney
failure
patients are not required to be on dialysis.)
The Epoetin alfa
must be administered incident to the services
of a doctor in
the office or in a hospital outpatient department.
Part B also
helps pay for Epoetin alpha that is self-administered
by home
dialysis patients or administered by their caregivers.
Medicare Payments for Outpatient Treatment
of Mental Illness
Medicare helps pay for outpatient mental
health services
you receive from professionals such as physicians,
clinical
psychologists, clinical social workers and other
nonphysician
practitioners. These professionals furnish services
in various
settings, for example, hospitals, comprehensive
outpatient
rehabilitation facilities, community mental health
centers, and
skilled nursing facilities.
When furnished on an outpatient basis,
mental health
treatment services are subject to a payment limitation
that is
called the "outpatient mental health limitation."
In effect,
once the annual deductible is met, Medicare Part
B pays only 50
percent (not 80 percent) of the approved amount
for these
services. On assigned claims, beneficiaries are
responsible for
paying the remaining 50 percent. For unassigned
claims,
beneficiaries may have to pay more. (See page
28 for
information about assignment.)
Partial hospitalization services (except
those furnished
by a physician) for treatment of mental illness
are not subject
to this payment limitation. Also, brief office
visits for the
sole purpose of monitoring or changing drug prescriptions
used
in the treatment of mental illness are not subject
to this
payment limitation. (See page 24 for more information
about
partial hospitalization services.)
Medicare Medical Insurance (Part B) Payments
The Assignment Payment Method
Under the assignment method, your doctor
or supplier
agrees to accept the amount approved by the Medicare
carrier as
total payment for covered services: the doctor
or supplier
agrees to "take assignment."
The assignment method can save you money.
The doctor or
supplier sends the claim to Medicare. Medicare
pays your doctor
or supplier 80 percent of the Medicareapproved
amount, after
subtracting any part of the $100 annual deductible
you have not
met. The doctor or supplier can charge you only
for the part of
the $100 annual deductible you have not met and
for the
coinsurance, which is the remaining 20 percent
of the approved
amount. Of course, your doctor or supplier also
can charge you
for services that Medicare does not cover.
Doctors and certain other practitioners
and suppliers must
take assignment on all claims for services furnished
to
Medicare beneficiaries who are eligible for medical
assistance
through their state Medicaid program, including
Qualified
Medicare Beneficiaries. (See 'Assistance for Low-Income
Beneficiaries,' page 2.)
Participating Doctors and Suppliers
Doctors and suppliers may sign agreements
to become
Medicare participating. Medicare-participating
doctors and
suppliers have agreed in advance to accept assignment
on all
Medicare claims. Doctors and suppliers are given
the
opportunity to sign participation agreements each
year.
Medicare-participating doctors and suppliers can
display
emblems or certificates that show they accept
assignment on all
Medicare claims.
The names and addresses of Medicare-participating
doctors
and suppliers are listed (by geographic area)
in the
Medicare-Participating Physician/Supplier Directory.
You can
get the directory for your area free of charge
from your
Medicare carrier (see pages 39 to 44); or you
can call your
carrier and ask for names of some participating
doctors and
suppliers in your area. Also, this directory is
available for
you to use in Social Security offices, state and
area offices
of the Administration on Aging, and in most hospitals.
When Your Doctor Does Not Accept Assignment
If your doctor or supplier does not accept
assignment, you
must pay the doctor or supplier directly. You
are usually
responsible for the part of your bill that is
more than the
Medicare-approved amount since your doctor or
supplier did not
agree to accept the Medicareapproved amount as
payment in full.
In this case, Medicare pays you 80 percent of
the approved
amount, after subtracting any part of the $100
annual
deductible you have not met.
Even though a doctor does not accept assignment,
for most
covered services, there are limits on the amount
that he or she
can actually charge you. In 1993, the most the
doctor can
charge you is 115 percent of what Medicare approves
(see
"Medicare Approved Amounts," page 29.)
Doctors who charge more
than these limits may be fined.
If you think you have been charged more
than the limiting
charge, ask the doctor for a reduction in the
charge. If you
have already paid more than the charge limit,
ask for a refund.
If you cannot get a reduction or refund, you can
call your
Medicare carrier and ask for assistance.
Some states have laws that could further
reduce your
medical costs. If you live in one of the states
listed below,
you can ask the state office listed here about
the laws in your
state:
Connecticut:
Connecticut Department of Aging
CONNMAP
175 Main Street Hartford, CT 06106
1-800-634-8852
Massachusetts:
Executive Office of Elder Affairs
1 Ashburton Place Boston, MA 02108
1-800-882-2003
Pennsylvania:
Department of Aging
Market Street State Office Bldg.
400 Market Street
Harrisburg, PA 17101
(717) 783-8975
Rhode Island:
Department of Elderly Affairs
160 Pine Street
Providence, RI 02903-3708
1-800-322-2880
Vermont: Department of Aging and Disabilities
103 South Main Street
Waterbury, VT 05676
1-800-642-5119
New York:
State Office for the Aging
2 Empire State Plaza
Albany, NY 12223
1-800-342-9871 (toll-free in New York)
(518) 474-5731
Special rule for doctors performing elective
surgery:
Medicare law requires doctors who do not take
assignment for
elective surgery to give you a written estimate
of your costs
before the surgery if the total charge for the
surgical
procedure is $500 or more. If the doctor did not
give you a
written estimate, you are entitled to a refund
of any amount
you paid him or her over the Medicare approved
amount.
Many doctors and suppliers who do not
take assignment on
all claims may take assignment on some or most
claims. Ask your
doctor or supplier whether he or she will take
assignment on
your claims.
Three payment examples for the same service
are shown
above. Dr. A participates in the Medicare program
and therefore
accepts assignment on the claim. Drs. B and C
do not
participate and do not accept assignment. In all
three
examples, the beneficiary has already met the
$100 deductible.
Even though Dr. A's bill is not the lowest, the
beneficiary
pays the least for Dr. A's services. Also, even
though Drs. B
and C charge different amounts, the beneficiary
pays the same
amount because of the limiting charge.
Participating Providers
Hospitals, skilled nursing facilities,
home health
agencies, hospices, comprehensive outpatient rehabilitation
facilities, and providers of outpatient physical
and
occupational therapy and speech pathology services
are all
participating providers under Medicare Part B.
They submit
their claims to Medicare. Medicare subtracts any
deductible you
have not met and any coinsurance amount and pays
the provider.
The provider must accept the Medicare-approved
amount as
payment in full for covered services. The provider
bills you
only for any deductible and coinsurance amounts
you owe.
Medicare Approved Amounts
Medicare Part B payments are based for
the most part on
Medicare fee schedule amounts. The fee schedule
for physicians
and certain suppliers lists payments for each
Part B service
and takes into account geographic variation in
the cost of
practice. The fee schedule amount is often less
than the actual
charges billed by doctors and suppliers. Part
B usually pays 80
percent of the fee schedule amount, even if it
is less than the
actual charge.
When a Part B claim is submitted, the
carrier compares the
actual charge shown on the claim with the fee
schedule amount
for that service. The Medicare-approved amount
is the lower of
the actual charge or the fee schedule amount.
Submitting Part B Claims
Doctors, Suppliers and Other Providers
Must Submit Claims
for You
Since September 1, 1990, doctors, suppliers
and other
providers of Part B services have in most cases
been required
to submit Medicare claims for you, even if they
do not take
assignment. They must submit the claims within
one year of
providing the service to you or may be subject
to certain
penalties. (If you have other health insurance
that should pay
before Medicare, you can submit your claims yourself.
See
'Filing Your Own Claims,' page 32.)
You should notify your Medicare carrier
if your doctor or
supplier refuses to submit a Part B Medicare claim
for you if
you believe the services may be covered by Medicare.
(Phone
numbers and addresses of carriers are listed on
pages 39 to
44.)
How Does the Doctor or Supplier Submit Claims?
Your doctor or supplier must submit a
form, called a
HCFA-1500, requesting that Medicare Part B payment
be made for
your covered services, whether or not assignment
is taken. The
doctor or supplier completes the HCFA-1500 form
and shows it to
you. You sign the form and then the doctor or
supplier sends it
to the proper Medicare carrier.
If your claim is for the rental or purchase
of durable
medical equipment, a doctor's prescription, or
certificate of
medical necessity, must be included with the claim.
The
prescription must show the equipment you need,
the medical
reason for the need, and an estimate of how long
the equipment
will be medically necessary.
If You are Enrolled in a Coordinated Care Plan
If you are enrolled in a coordinated care
plan--a prepaid
health care organization such as an HMO--a claim
will seldom
need to be submitted on your behalf. Medicare
pays the HMO a
set amount and the HMO provides your medical care.
In most
cases, you are required to receive all non-emergency
care
through your HMO, or through arrangements they
make before you
receive care. However, if you get an out-of-plan
service, the
claim should be submitted directly to your HMO.
If your doctor or supplier needs an address,
consult your
HMO membership handbook, or contact the HMO.
Submitting Claims to the Railroad Retirement
System
If you get Medicare under the Railroad
Retirement system,
the doctor or supplier must submit your claims
to The Travelers
Insurance Company office that serves your region.
Regional
offices of The Travelers are listed in Your Medicare
Handbook
for Railroad Retirement Beneficiaries, which is
available at
any Railroad Retirement office.
Explanation of Your Medicare Part B Benefits
Notice
After your doctor, provider, or supplier
sends in a Part B
claim, Medicare will send you a notice called
Explanation of
Your Medicare Part B Benefits to tell you the
decision on the
claim. An illustration of the notice is shown
on page 31.
The sample notice on page 31 is for
services of a doctor
and shows what charges were made and what Medicare
approved. It
shows what the co-payment is and what Medicare
is paying. If
the $100 annual deductible had not been met, that
would also be
shown. The notice gives the address and toll-free
telephone
number for contacting the carrier. Note that this
doctor did
not take assignment, so the limiting charge is
shown. Notices
for other Part B services are much like the ones
for doctor
services.
Please read your notices carefully. If
you believe
payments were made for services or supplies you
didn't receive,
or payments are otherwise questionable, call or
write your
carrier.
Filing Your Own Claims
In some cases, you may need to file your
own Medicare Part
B claim. If you do, send the claim to the carrier
responsible
for processing Medicare claims in your area. No
claims should
be sent to the Health Care Financing Administration
in
Baltimore, Maryland.
To find out whether you need to file your
own claim, call
or write your Medicare carrier. (Carrier addresses
and phone
numbers are listed on pages 39 to 44.)
Time Limits
Under the law, there are time limits for
submitting your
own Medicare Part B claims. For Medicare to make
payments on
your claims, you must send in your claims within
these time
limits. You always have at least 15 months to
submit claims.
The table below tells you exactly what the time
limits are.
Your
claim must
For service you get between be submitted
by
Oct 1, 1991 & Sept 30, 1992
Dec 31, 1993
Oct 1, 1992 & Sept 30, 1993 Dec
31, 1994
Oct 1, 1993 & Sept 30, 1994 Dec
31, 1995
Calling Your Medicare Carrier
Many carriers have installed an automated
telephone
answering system to help make their response to
you faster and
more accurate. When you call, if your carrier
has a system of
this type, you will be connected to a special
automated voice
system. If you have a touchtone telephone, follow
the
instructions you receive over the phone to get
information
about the status of your claims.
If you need other information or want
to talk about a
claim, you can ask the system to connect you with
a customer
service representative at any time. If you do
not have a
touch-tone telephone, stay on the line after you
dial and you
will be connected to a customer service representative.
Claims for a Person Who Has Died
When a Medicare beneficiary dies, the
way Medicare pays
Part B claims depends on whether the doctor's
or supplier's
bill has been paid. (Any Part A payments due to
the hospital,
skilled nursing facility, home health agency or
hospice will be
made directly to the provider of services.)
If the bill was paid by the patient or
with funds from the
patient's estate, Medicare's payment will be made
either to the
estate representative or to a surviving member
of the patient's
immediate family. If someone other than the patient
paid the
bill, payment may be made to that person.
If the bill has not been paid and the
doctor or supplier
does not accept assignment, the Medicare payment
can be made to
the person who has or assumes legal obligation
to pay the bill
for the deceased patient.
Your Medicare carrier can provide additional
information
about how to claim a Medicare Part B payment after
a patient
dies.
Getting the Part of Medicare You Do Not Have
Getting Medicare Medical Insurance (Part B)
If you have Medicare premium-free Hospital
Insurance but
do not have Medicare Part B, you can sign up for
Part B during
a general enrollment period. A general enrollment
period is
held January 1 through March 31 each year. Your
protection will
begin July 1 of the year you enroll. If you enroll
during a
general enrollment period, your monthly premium
may be
increased by 10 percent for each 12-month period
you could have
had Part B but were not enrolled. (If you are
covered under an
employer group health plan based on current employment
as
described on this page, the premium penalty may
be decreased or
waived.)
Getting Medicare Hospital Insurance (Part A)
Some people 65 or older have Medicare
Medical Insurance
(Part B), but do not meet the requirements for
premium-free
Part A. If you are in this category, you can get
Part A by
paying a monthly premium. This is called "premium
hospital
insurance." The Part A premium is $221 a
month through December
31, 1993. (This amount will change January 1,
1994.)
You can sign up for premium Part A during
a general
enrollment period: January 1 through March 31
each year. If you
enroll during a general enrollment period that
begins more than
one year after you became eligible to buy Part
A, your monthly
premium may be 10 percent higher than the basic
premium amount.
Your protection will begin July 1 of the year
you enroll. (Also
see this page for information on the special enrollment
period.)
If you have been covered under an HMO,
you can sign up for
premium Part A at any time while you are in the
HMO and up to
eight months after the HMO coverage has ended.
The premium
penalty, if any, may be reduced because of the
coverage under
the HMO.
For more information about premium amounts,
premium
surcharges, and how to get the part of Medicare
you do not
have, contact Social Security.
Special Enrollment Period
If you are covered by an employer group
health plan based
on your own or your spouse's current employment
(not a plan
for retired people and their spouses), you may
be able to delay
enrollment in Medicare Medical Insurance (Part
B) or premium
Hospital Insurance (Part A) without premium penalty
and without
waiting for a general enrollment period to enroll.
Delayed
enrollment without penalty or wait is usually
available if you
are covered by an employer group health plan at
the time you
are first able to get Medicare.
In general, if you are 65 or over, you
may enroll in
Medicare Part B during the seven-month period
beginning with
the month:
* Your or your spouse's current employment
ends, or
* Your coverage under the employer group
health plan ends,
whichever comes first.
If you are disabled and covered by an
employer group
health plan, you are also given a special enrollment
period in
certain circumstances. If you are covered under
a group health
plan based on current employment status when you
are first able
to get Medicare, you may enroll in Medicare Part
B during the
seven-month period that begins:
* When the employment status ends,
* When the plan is no longer classifiable
as a large group
health plan (one that covers 100 or more
employees), or
* When the plan coverage is terminated.
Contact Social Security as soon as employment
ends, or the
plan coverage ends or changes, to be sure that
you get the
information you need about enrolling in Medicare
Part B.
Events That Can Change Your Medicare Protection
When Protection Ends for People 65 and Older
If you have Medicare Hospital Insurance
(Part A) based on
your spouse's work record, your protection will
end if you and
your spouse are divorced during the first 10 years
of your
marriage. But if you have Part A based on your
own work record,
your protection will continue as long as you live.
Your Medicare Part B protection will stop
if your premiums
are not paid or if you voluntarily cancel. If
you are thinking
about cancelling Part B, remember that you may
not be able to
get private insurance that offers the same protection.
If you
cancel Part B and then later decide to re-enroll,
you will have
to wait for a general enrollment period (January
1 through
March 31 of each year). Also, your premium may
be higher and
your protection will not begin again until July
1 of the year
you re-enroll. (If you are covered under an employer
group
health plan based on current employment as described
on page 9,
you may be eligible for a special enrollment period
and the
premium penalty may be decreased or waived as
noted on page
33.)
If you are buying Medicare Part A by paying
monthly
premiums (see page 33), you will lose it if you
cancel your
Medicare Part B. People who buy Medicare Part
A must also
enroll and pay the premium for Part B. But, you
can cancel Part
A and still continue to buy Part B.
If you want more information about cancelling
your
Medicare protection, contact Social Security.
When Protection Ends for the Disabled
If you have Medicare because you are disabled,
your
protection will end if you recover from your disability
before
you are 65. If you work but are still disabled,
your
premium-free Part A protection will continue for
at least 48
months after you begin working. Your Part B will
also continue
for at least 48 months if you continue to pay
the monthly
premiums.
If you remain disabled longer than 48
months after you
return to work and lose your premium-free Part
A (and your Part
B) solely because you are working, you may buy
Part A only or
both Part A and Part B. (You cannot buy Part B
only.) You can
continue to buy Medicare as long as you remain
disabled.
You may enroll during your initial enrollment
period which
begins with the month you are notified you are
no longer
eligible for premium-free Part A and continues
for seven full
months after that month. If you do not enroll
during this
initial enrollment period, you may enroll in a
subsequent
general enrollment period (January through March
of each year)
or during a special enrollment period (see page
33).
If you ever want to cancel the Medicare
protection for
which you pay premiums, contact Social Security.
When Protection Ends for Those With Permanent
Kidney Failure
If you have Medicare because of permanent
kidney failure,
your protection will end 12 months after the month
maintenance
dialysis treatment stops or 36 months after the
month you have
a kidney transplant.
Your Medicare Part B protection could
stop before that if
you fail to pay the premiums, or if you decide
to cancel. Call
Social Security if you ever want to cancel your
Part B
protection.
If you need more information about Medicare
coverage of
permanent kidney failure, you can get a copy of
Medicare
Coverage of Kidney Dialysis and Kidney Transplant
Services from
Social Security or the Consumer Information Center
(see inside
back cover).
How to Appeal Medicare Decisions
If you disagree with a decision on the
amount Medicare
will pay on a claim or whether services you received
are
covered by Medicare, you have the right to appeal
the decision.
The notice Medicare sends you tells you the decision
made on
the claim and exactly what appeal steps you can
take. Appealing
decisions by Part A providers, peer review organizations,
intermediaries, carriers and health maintenance
organizations
are discussed below.
Appealing Decisions Made by Providers of Part
A Services
In many cases the first written notice
of noncoverage you
receive will come from the provider of the services
(for
example, a hospital, skilled nursing facility,
home health
agency or hospice). This notice of noncoverage
from the
provider should explain why the provider believes
Medicare will
not pay for the services. This notice is not an
official
Medicare determination, but you can ask the provider
to get an
official Medicare determination. If you ask for
an official
Medicare determination, the provider must file
a claim on your
behalf to Medicare. Then you will receive a Notice
of
Utilization, which is the official Medicare determination.
If
you still disagree, you can appeal by following
the
instructions on the Notice of Utilization.
Appealing Decisions Made by Peer Review Organizations
(PROs)
When you are admitted to a Medicare-participating
hospital, you will be given a notice called An
Important
Message From Medicare. The notice contains a brief
description
of PROs, and the name, address and phone number
of the PRO in
your state. Also, it describes your appeal fights.
PROs make determinations mainly about
inpatient hospital
care and ambulatory surgical center care. The
PROs decide
whether care provided to Medicare patients is
medically
necessary, provided in the most appropriate setting,
and is of
good quality. When you disagree with a PRO decision
about your
case, you can appeal by requesting a reconsideration.
Then, if
you disagree with the PRO's reconsideration decision,
and the
amount remaining in question is $200 or more,
you can request a
hearing by an Administrative Law Judge. Cases
involving $2,000
or more can eventually be appealed to a Federal
Court.
If you belong to a Medicare health maintenance
organization (HMO), the HMO will usually make
decisions about
the medical necessity, the appropriateness of
setting and the
quality of your care. In most cases, you do not
have the fight
to appeal to the PRO, but you always have the
fight to register
complaints about the quality of your hospital
care to the PRO.
(See page 36 for more information about appeal
fights for
members of HMOs.)
NOTE: In the case of elective (non-emergency)
surgery,
either the hospital or the PRO may be involved
in pre-admission
decisions. If the hospital believes that your
proposed stay
will not be covered by Medicare, it may recommend,
without
consulting the PRO, that you not be admitted to
the hospital.
If this is the case, the hospital must give you
its decision in
writing. If you or your doctor disagree with the
hospital's
decision, you should make a request to the PRO
for immediate
review. If you want an immediate review, you must
make your
request, by telephone or in writing, within three
calendar days
after receipt of the notice.
Appealing Decisions of Intermediaries on Part
A Claims
Appeals of decisions on most other services
covered under
Medicare Part A (skilled nursing facility care,
home health
care, hospice services, and a few inpatient hospital
matters
not handled by PROs) are handled by Medicare intermediaries.
If
you disagree with the intermediary's initial decision,
you have
60 days from the date you receive the initial
decision to
request a reconsideration. The request can be
submitted
directly to the intermediary or through Social
Security. If you
disagree with the intermediary's reconsideration
decision and
the amount remaining in question is $100 or more,
you have 60
days from the date you receive the reconsideration
decision to
request a hearing by an Administrative Law Judge.
Cases
involving $1,000 or more can eventually be appealed
to a
Federal Court.
Appealing Decisions Made by Carriers on Part
B Claims
If you disagree with Medicare's decision
on a Part B
claim, you have the right to appeal that decision.
You have six
months from the date of the decision to ask the
carrier to
review it. Then, if you disagree with the carrier's
written
explanation of its review decision and the amount
remaining in
question is $100 or more, you have six months
from the date of
the review decision to request a heating before
a carrier
hearing officer. You may combine claims that have
been reviewed
or reopened so long as all claims combined are
at the proper
level of appeal and the appeal for each claim
combined is filed
on time.
If you disagree with the carrier hearing
officer's
decision and the amount remaining in question
is $500 or more,
you have 60 days from the date you receive the
decision to
request a hearing before an Administrative Law
Judge. You may
combine claims that have had a carrier hearing
officer's
decision so long as the appeal for each claim
combined is filed
within 60 days of the date you received the carrier
hearing
decision for that claim. Cases involving $1,000
or more can
eventually be appealed to a Federal Court.
Appealing Decisions Made by Health Maintenance
Organizations
(HMOs)
If you have Medicare coverage through
an HMO, decisions
about coverage and payment for services will usually
be made by
your HMO. When your HMO makes a decision to deny
payment for
Medicare-covered services or refuses to provide
Medicare-covered supplies you request, you will
be given a
Notice of Initial Determination. Along with the
notice, your
HMO is required to provide a full, written explanation
of your
appeal fights.
If you believe that the decision your
HM0 made was not
correct, you have the fight to ask for a reconsideration.
You
must file your request for reconsideration within
60 days after
you receive the Notice of Initial Determination.
Your request
must be in writing. You may mail it or deliver
it personally to
your HMO or to a Social Security office. (or the
Railroad
Retirement Board if you get Medicare through Railroad
Retirement).
Your HMO is responsible for reconsidering
its initial
determination to deny payment or services. If
your HMO does not
role fully in your favor, the HMO must send your
reconsideration request to the Health Care Financing
Administration (HCFA) for a review and determination.
If you disagree with HCFA's decision,
and the amount in
question is $100 or more, you have 60 days from
receipt of
HCFA's decision to request a heating before an
Administrative
Law Judge. Cases involving $1,000 or more can
eventually be
appealed to a Federal Court.
For More Information
If you need more information about your
fight to appeal
and how to request it, call Social Security, or
the Medicare
intermediary or carrier in your state. (The number
of the
Medicare intermediary or carrier is listed on
the notice
explaining Medicare's decision on the claim. Medicare
carriers
are also listed on pages 39 to 44.) If you need
more
information about your fight to appeal a Peer
Review
Organization (PRO) decision, you can call the
PRO in your
state. (PROs are listed on pages 45 to 49).
MEDICARE CARRIERS
Carriers can answer questions about Medical
Insurance
(Part B)
Note:
-- The toll-free or 800 numbers listed below,
in many cases,
can be used only in the states where the
carriers are
located. Also listed are the local Commercial
numbers for
the carriers. Out-of-state callers may use
the commercial
numbers.
-- These carrier toll-free numbers are for
beneficiaries to
use and should not be used by doctors and
suppliers.
-- Many carriers have installed an automated
telephone
answering system. If you have a touch-tone
telephone, you
can follow the system instructions to find
out about your
latest claims and get other information.
If you do not
have a touchtone telephone, stay on the line
and someone
will help you.
ALABAMA
Medicare/Blue Cross-Blue Shield of Alabama
P.O. Box 83140
Birmingham, Alabama 35282
1-800-292-8855
205-988-2244
ALASKA
Medicare/Aetna Life Insurance Company
200 S.W. Market St.,
P.O. Box 1998
Portland, Oregon 97207-1998
1-800-452-0125 (toll-free: Alaska to customer
service in Oregon)
503-222-6831 (customer service site in Oregon)
ARIZONA
Medicare/Aetna Life Insurance Company
P.O. Box 37200
Phoenix, Arizona 85069
1-800-352-0411
602-861-1968
ARKANSAS
Medicare/Arkansas Blue Cross and Blue Shield
P.O. Box 1418
Little Rock, Arkansas 72203-1418
1-800-482-5525
501-378-2320
CALIFORNIA
Counties of: Los Angeles, Orange, San Diego, Ventura,
Imperial,
San Luis Obispo, Santa Barbara
Medicare/Transamerica Occidental Life Insurance
Co.
Box 30540
Los Angeles, California 90030-0540
1-800-675-2266
213-748-2311
Rest of state: Medicare Claims Dept.
Blue Shield of California
Chico, California 95976
(In area codes 209, 408, 415, 707, 916)
1-800-952-8627
916-743-1583
(In the following area codes--other than Los Angeles,
Orange,
San Diego, Ventura, Imperial, San Luis Obispo,
and Santa
Barbara counties -- 213, 619, 714, 805, 818)
1-800-848-7713
714-796-9393
COLORADO
Medicare/Blue Cross and Blue Shield of Colorado
Coordination of Benefits:
P.O. Box 173550
Denver, Colorado 80217
Correspondence/Appeals:
P.O. Box 173500
Denver, Colorado 80217
(Metro Denver) 303-83 1-2661
(In Colorado, outside of metro area) 1-800-332-6681
CONNECTICUT
Medicare/The Travelers Companies
538 Preston Avenue
P.O. Box 9000
Meriden, Connecticut 06454-9000
1-800-982-6819
(In Hartford) 203-728-6783
(In the Meriden area) 203-237-8592
DELAWARE
Medicare/Pennsylvania Blue Shield
P.O. Box 890200
Camp Hill, Pennsylvania 17089-0200
1-800-851-3535
DISTRICT OF COLUMBIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
FLORIDA
Medicare/Blue Cross and Blue Shield of Florida,
Inc.
P.O. Box 2360
Jacksonville, Florida 32231
For fast service on simple inquiries including
requests for
copies of Explanation of Your Medicare Part B
Benefits notices,
requests for MEDPAR directories, brief claims
inquiries (status
or verification of receipt), and address changes:
1-800-666-7586
904-355-8899
For all your other Medicare needs:
1-800-333-7586
904-355-3680
MEDICARE CARRIERS
Carriers can answer questions about Medical
Insurance
(Part B)
GEORGIA
Medicare/Aetna Life Insurance Company
P.O. Box 3018
Savannah, Georgia 31402-3018
1-800-727-0827
912-920-2412
HAWAII
Medicare/Aetna Life Insurance Company
P.O. Box 3947
Honolulu, Hawaii 96812
1-800-272-5242
808-524-1240
IDAHO
Connecticut General Life Insurance Company
3150 N. Lakeharbor Lane, Suite 254
P.O. Box 8048
Boise, Idaho 83707-6219
1-800-627-2782
208-342-7763
ILLINOIS
Medicare Claims/Health Care Service Corporation
P.O. Box 4422
Marion, Illinois 62959
1-800-642-6930
312-938-8000
INDIANA
Medicare Part B/AdminaStar Federal
P.O. Box 7073
Indianapolis, Indiana 46207
1-800-622-4792
317-842-4151
IOWA
Medicare/IASD Health Services Corporation
(d/b/a Blue Cross & Blue Shield of Iowa)
636 Grand
Des Moines, Iowa 50309
1-800-532-1285
515-245-4785
KANSAS
The counties of Johnson and Wyandotte:
Medicare/Blue Cross and Blue Shield of Kansas,
Inc.
P.O. Box 419840
Kansas City, Missouri 64141-6840
1-800-892-5900
816-561-0900
Rest of state: Medicare/Blue Cross and Blue Shield
of
Kansas, Inc.
1133 S.W. Topeka Boulevard
Topeka, Kansas 66629-0001
1-800-432-3531
913-232-3773
KENTUCKY
Medicare-Part B/Blue Cross & Blue Shield of
Kentucky, Inc.
100 East Vine St.
Lexington, Kentucky 40507
1-800-999-7608
606-233-1441
LOUISIANA
Arkansas Blue Cross & Blue Shield, Inc. Medicare
Administration
P.O. Box 83830
Baton Rouge, Louisiana 70884-3830
1-800-462-9666
(In New Orleans) 504-529-1494
(In Baton Rouge) 504-927-3490
MAINE
Medicare/C and S Administrative Services
P.O. Box 9790
Portland, Maine 04104-5090
1-800-492-0919
207-828-4300
MARYLAND
Counties of: Montgomery, Prince Georges
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
Rest of state: Blue Cross and Blue Shield of Maryland,
Inc.
1946 Greenspring Drive
Timonium, Maryland 21093
1-800-492-4795
410-561-4160
MASSACHUSETTS
For Non-assigned Claims:
Medicare/C and S Administrative Services
P.O. Box 2222
Hingham, Massachusetts 02044
1-800-882-1228
617-741-3300
For Assigned Claims:
Medicare/C and S Administrative Services
P.O. Box 1111
Hingham, Massachusetts 02044
1-800-882-1228
617-741-3300
MICHIGAN
Medicare Part B
Blue Cross & Blue Shield of Michigan
P.O. Box 2201
Detroit, Michigan 48231-2201
313-225-8200
1-800-482-4045
MINNESOTA
Counties of: Anoka, Dakota, Fillmore, Goodhue,
Hennepin,
Houston, Olmstead, Ramsey, Wabasha, Washington,
Winona
Medicare/The Travelers Ins. Co.
8120 Penn Avenue South
Bloomington, Minnesota 55431
1-800-352-2762
612-884-7171
Rest of state: Medicare/Blue Cross and Blue Shield
of Minnesota
P.O. Box 64357
St. Paul, Minnesota 55164
1-800-392-0343
612-456-5070
MISSISSIPPI
Medicare/The Travelers Ins. Co.
P.O. Box 22545
Jackson, Mississippi 39225-2545
1-800-682-5417
601-956-0372
MISSOURI
Counties of: Andrew, Atchison, Bates, Benton,
Buchanan,
Caldwell, Carroll, Cass, Clay, Clinton, Daviess,
DeKalb,
Gentry, Grundy, Harrison, Henry, Holt, Jackson,
Johnson,
Lafayette, Livingston, Mercer, Nodaway, Pettis,
Plane, Ray, St.
Clair, Saline, Vernon, Worth
Medicare/Blue Cross and Blue Shield of Kansas,
Inc.
P.O. Box 419840
Kansas City, Missouri 64141-6840
1-800-892-5900
816-561-0900
Rest of state: Medicare
General American Life Insurance Co.
P.O. Box 505
St. Louis, Missouri 63166
1-800-392-3070
314-843-8880
MONTANA
Medicare/Blue Cross and Blue Shield of Montana,
Inc.
2501 Beltview
P.O. Box 4310
Helena, Montana 59604
1-800-332-6146
406-444-8350
NEBRASKA
The carrier for Nebraska is Blue Cross and Blue
Shield of
Kansas, Inc. Claims, however, should be sent to:
Medicare Part B
Blue Cross/Blue Shield of Nebraska
P.O. Box 3106
Omaha, Nebraska 68103-0106
1-800-633-1113
913-232-3773 (customer service site in Kansas)
NEVADA
Medicare/Aetna Life Insurance Company
P.O. Box 37230
Phoenix, Arizona 85069
1-800-528-0311
602-861-1968
NEW HAMPSHIRE
Medicare/C and S Administrative Services
P.O. Box 9790
Portland, Maine 04104-5090
1-800-447-1142
207-828-4300
NEW JERSEY
Medicare/Pennsylvania Blue Shield
P.O. Box 400010
Harrisburg, Pennsylvania 17140-0010
1-800-462-9306
717-975-7333
NEW MEXICO
Medicare/Aetna Life Insurance Company,
P.O. Box 25500
Oklahoma City, Oklahoma 73125-0500
1-800-423-2925
(In Albuquerque) 505-821-3350
NEW YORK
Counties of: Nassau, Suffolk
Medicare B/Empire Blue Cross and Blue Shield
P.O. Box 2280
Peekskill, New York 10566
516-244-5100
Counties of: Bronx, Columbia, Delaware, Dutchess,
Greene,
Kings, New York, Orange, Putnam, Richmond, Rockland,
Suffolk,
Sullivan, Ulster, Westchester
Medicare B/Empire Blue Cross and Blue Shield
P.O. Box 2280
Peekskill, New York 10566
1-800-442-8430
516-244-5100
County of: Queens
Medicare/Group Health, Inc.
P.O. Box 1608, Ansonia Station
New York, New York 10023
212-721-1770
Rest of state:
Blue Shield of Western New York
Upstate Medicare Division-Part B
7-9 Court Street
Binghamton, New York 13901-3197
607-772-6906
1-800-252-6550
NORTH CAROLINA
Connecticut General Life Insurance Company
P.O. Box 671
Nashville, Tennessee 37202
1-800-672-3071
919-665-0348
NORTH DAKOTA
Medicare/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-247-2267
701-282-0691
OHIO
Medicare/Nationwide Mutual Ins. Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-282-0530
614-249-7157
OKLAHOMA
Medicare/Aetna Life Insurance Company
701 N.W. 63rd St.
Oklahoma City, Oklahoma 73116-7693
1-800-522-9079
405-848-7711
OREGON
Medicare/Aetna Life Insurance Company
200 S.W. Market St.
P.O. Box 1997
Portland, Oregon 97207-1997
1-800-452-0125
503-222-6831
PENNSYLVANIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890065
Camp Hill, Pennsylvania 17089-0065
1-800-382-1274
717-763-3601
RHODE ISLAND
Medicare/Blue Cross and Blue Shield of Rhode Island
Inquiry Department
444 Westminster Street
Providence, Rhode Island 02903-3279
1-800-662-5170
401-861-2273
SOUTH CAROLINA
Medicare Part B
Blue Cross and Blue Shield of South Carolina
P.O. Box 100190
Columbia, South Carolina 29202
1-800-868-2522
803-788-3882
SOUTH DAKOTA
Medicare Part B/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-437-4762
701-282-0691
TENNESSEE
Connecticut General Life Insurance Company
P.O. Box 1465
Nashville, Tennessee 37202
1-800-342-8900
615-244-5650
TEXAS
Medicare/Blue Cross & Blue Shield of Texas,
Inc.
P.O. Box 660031
Dallas, Texas 75266-0031
1-800-442-2620
214-235-3433
UTAH
Medicare/Blue Shield of Utah
P.O. Box 30269
Salt Lake City, Utah 84130-0269
1-800-426-3477
801-481-6196
VERMONT
Medicare/C and S Administrative Services
P.O. Box 9790
Portland, Maine 04104-5090
1-800-447-1142
207-828-4300
VIRGINIA
Counties of: Arlington, Fairfax;
Citys of: Alexandria, Falls Church, Fairfax
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
717-763-3601
Rest of state: Medicare/The Travelers Ins. Co.
P.O. Box 26463
Richmond, Virginia 23261
1-800-552-3423
804-330-4786
WASHINGTON
Medicare
King County Medical Blue Shield
P.O. Box 91070
Seattle, Washington 98111-9170
(In Seattle)
1-800-422-4087
206-464-3711
(In Spokane)
1-800-572-5256
509-536-4550
(In Tacoma)
206-597-6530
WEST VIRGINIA
Medicare/Nationwide Mutual Insurance Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-848-0106
614-249-7157
WISCONSIN
Medicare/WPS
Box 1787
Madison, Wisconsin 53701
1-800-944-0051
(In Madison) 608-221-3330
WYOMING
Blue Cross and Blue Shield of North Dakota
P.O. Box 628
Cheyenne, Wyoming 82003
1-800-442-2371
307-632-9381
AMERICAN SAMOA
Medicare/Aetna Life Insurance Company
P.O. Box 860
Honolulu, Hawaii 96808
808-944-2247
GUAM
Medicare/Aetna Life Insurance Company
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240
NORTHERN MARIANA ISLANDS
Medicare/Aetna Life Insurance Company
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240
PUERTO RICO Medicare/Seguros De Servicio De
Salud De Puerto Rico
Call Box 71391
San Juan, Puerto Rico 00936
(In Puerto Rico) 800-462-7015
(In U.S. Virgin Islands) 800-474-7448
(In Puerto Rico metro area) 809-749-4900
VIRGIN ISLANDS
Medicare/Seguros De Servicio De
Salud De Puerto Rico
Call Box 71391
San Juan, Puerto Rico 00936
(In U.S. Virgin Islands) 800-474-7448
MEDICARE PEER REVIEW ORGANIZATIONS (PROs)
PROs can answer questions about hospital
stays and other
Hospital Insurance (Part A) services. Do not call
the PRO with
questions about Medicare Medical Insurance (Part
B).
ALABAMA
Alabama Quality Assurance Foundation, Inc.
Suite 600
600 Beacon Parkway West
Birmingham, AL 35209-3154
1-800-288-4992
ALASKA
Professional Review Organization for Washington
(PRO for Alaska)
Suite 100
10700 Meridian Avenue, North
Seattle, WA 98133-9008
1-800-445-6941
(in Anchorage dial 562-2252)
AMERICAN SAMOA and GUAM (see Hawaii)
ARIZONA
Health Services Advisory Group, Inc.
P.O. Box 16731
Phoenix, AZ 85011-6731
1-800-626-1577
(in Arizona dial 1-800-359-9909 or 1-800-223-6693)
ARKANSAS
Arkansas Foundation for Medical Care, Inc.
P.O. Box 2424
809 Garrison Avenue
Fort Smith, AR 72902
1-800-824-7586
(in Arkansas dial 1-800-272-5528)
CALIFORNIA
California Medical Review, Inc. Suite 500
60 Spear Sweet
San Francisco, CA 94105
1-800-84 1-1602 (in-state only)
1-415-882-5800*
COLORADO
Colorado Foundation for Medical Care
1260 South Parker Road
P.O. Box 17300
Denver, CO 80217-0300
1-800-727-7086 (in-state only)
1-303-695-3333*
CONNECTICUT
Connecticut Peer Review Organization, Inc.
100 Roscommon Drive, Suite 200
Middletown, CT 06457
1-800-553-7590 (in-state only)
1-203-632-2008*
DELAWARE
West Virginia Medical Institute, Inc.
(PRO for Delaware)
3001 Chesterfield Place
Charleston, WV 25304
1-800-642-8686 ext. 266
(in Wilmington dial 655-3077)
DISTRICT OF COLUMBIA
Delmarva Foundation for Medical Care, Inc.
(PRO for D.C.)
9240 Centreville Road
Easton, MD 21601
1-800-645-0011
(in Maryland dial 1-800-492-5811)
FLORIDA
Blue Cross and Blue Shield of Florida, Inc.
PRO Review
P.O. Box 45267
Jacksonville, FL 32232-5267
1-800-964-5785 (in-state only)
904-791-8262
GEORGIA
Georgia Medical Care Foundation Suite 200
57 Executive Park South
Atlanta, GA 30329
1-800-282-2614 (in-state only)
404-982-0411
HAWAII
Hawaii Medical Service Association
(PRO for American Samoa/Guam and Hawaii)
818 Keeaumoku Street
P.O. Box 860
Honolulu, HI 96808-0860
1-808-944-3586*
IDAHO
Professional Review Organization for Washington
(PRO for Idaho)
Suite 100
10700 Meridian Avenue, North
Seattle, WA 98133-9008
1-800-445-6941
1-208-343-4617 (local Boise and collect)
ILLINOIS
Crescent Counties Foundation for Medical Care
280 Shuman Boulevard, Suite 240
Naperville, IL 60563
1-800-647-8089
INDIANA
Indiana Medical Review Organization
2901 Ohio Boulevard
P.O. Box 3713
Terre Haute, IN 47803
1-800-288-1499
IOWA
Iowa Foundation for Medical Care Suite 350E
6000 Westown Parkway
West Des Moines, IA 50266-7771
1-800-752-7014 (in-state only)
515-223-2900
KANSAS
The Kansas Foundation for Medical Care, Inc.
2947 S.W. Wanamaker Drive
Topeka, KS 66614
1-800-432-0407 (in-state only)
913-273-2552
KENTUCKY
Kentucky Medical Review Organization
10503 Timberwood Circle, Suite 200
P.O. Box 23540
Louisville, KY 40223
1-800-288-1499
LOUISIANA
Louisiana Health Care Review, Inc.
8591 United Plaza Blvd., Suite 270
Baton Rouge, LA 70809
1-800-433-4958 (in-state only)
504-926-6353
MAINE
Health Care Review, Inc.
(PRO for Maine)
Henry C. Hall Building
345 Blackstone Blvd.
Providence, RI 02906
1-800-541-9888 or 1-800-528-0700 (both numbers
in Maine only)
1-207-945-0244*
MARYLAND
Delmarva Foundation for Medical Care, Inc.
(PRO for Maryland)
9240 Centreville Road
Easton, MD 21601
1-800-645-0011
(in Maryland dial 1-800-492-5811)
MASSACHUSETTS
Massachusetts Peer Review Organization, Inc.
300 Bearhill Road
Waltham, MA 02154
1-800-252-5533 (in-state only)
1-617-890-0011*
MICHIGAN
Michigan Peer Review Organization
40600 Ann Arbor Road, Suite 200
Plymouth, MI 48170
1-800-365-5899
MINNESOTA
Foundation for Health Care Evaluation
Suite 400
2901 Metro Drive
Bloomington, MN 55425
1-800444-3423
MISSISSIPPI
Mississippi Foundation for Medical Care, Inc.
P.O. Box 4665
735 Riverside Drive
Jackson, MS 39296-4665
1-800-844-0600 (in-state only)
601-948-8894
MISSOURI
Missouri Patient Care Review Foundation
505 Hobbs Road, Suite. 100
Jefferson City, MO 65109
1-800-347-1016
MONTANA
Montana-Wyoming Foundation for Medical Care
400 North Park, 2nd Floor
Helena, MT 59601
1-800-332-3411 (in-state only)
1-406-443-4020*
NEBRASKA
The Sunderbruch Corporation-NE
1221 "N" Street, Suite 800
Lincoln, NE 69508
1-800-752-0548
NEVADA
Nevada Peer Review
675 East 2100 South, Suite 270
Salt Lake City, UT 84106-1864
1-800-558-0829 (in Nevada only)
(in Reno dial 1-702-826-1996)
1-702-385-9933*
NEW HAMPSHIRE
New Hampshire Foundation for Medical Care
15 Old Rollinsford Road, Suite 302
Dover, NH 03820
1-800-582-7174 (in-state only)
1-603-749-1641*
NEW JERSEY
The Peer Review Organization of New Jersey, Inc.
Central Division
Brier Hill Court, Building J
East Brunswick, NJ 08816
1-800-624-4557 (in-state only)
1-201-238-5570
NEW MEXICO
New Mexico Medical Review Association
707 Broadway N.E., Suite 200
P.O. Box 27449
Albuquerque, NM 87125-7449
1-800-432-6824 (in-state only)
505-842-6236
(In Albuquerque dial 842-6236)
NEW YORK
Island Peer Review Organization, Inc.
1979 Marcus Avenue, First floor
Lake Success, NY 11042
1-800-331-7767
1-516-326-7767*
NORTH CAROLINA
Medical Review of North Carolina
Suite 200
P.O. Box 37309
1011 Schaub Drive
Raleigh, NC 27627
1-800-682-2650 (in-state only)
919-851-2955
NORTH DAKOTA
North Dakota Health Care Review, Inc.
Suite 301
900 North Broadway
Minot, ND 58701
1-800-472-2902 (in-state only)
1-701-852-4231*
OHIO
Peer Review Systems, Inc.
Suite 250
3700 Corporate Drive
Columbus, OH 43231-7990
1-800-233-7337
OKLAHOMA
Oklahoma Foundation for Peer Review, Inc.
Suite 400 The Paragon Building
5801 Broadway Extension
Oklahoma City, OK 73118-7489
1-800-522-3414 (in-state only)
405-840-2891
OREGON
Oregon Medical Professional Review Organization
Suite 200
1220 Southwest Morrison
Portland, OR 97205
1-800-344-4354 (in-state only)
503-279-0100*
PENNSYLVANIA
Keystone Peer Review Organization, Inc.
777 East Park Drive
P.O. Box 8310
Harrisburg, PA 17105-8310
1-800-322-1914 (in-state only)
717-564-8288
PUERTO RICO
Puerto Rico Foundation for Medical Care
Suite 605 Mercantile Plaza
Hato Rey, PR 00918
1-809-753-6705* or 1-809-753-6708*
RHODE ISLAND
Health Care Review, Inc.
Henry C. Hall Building
345 Blackstone Boulevard
Providence, RI 02906
1-800-221-1691 (New England-wide)
(in Rhode Island dial 1-800-662-5028)
1-401-331-6661*
SOUTH CAROLINA
Carolina Medical Review
101 Executive Center Drive
Suite 123
Columbia, SC 29210
1-800-922-3089 (in-state only)
803-731-8225
SOUTH DAKOTA
South Dakota Foundation for Medical Care
1323 South Minnesota Avenue
Sioux Falls, SD 57105
1-800-658-2285
TENNESSEE
Mid-South Foundation for Medical Care
Suite 400
6401 Poplar Avenue
Memphis, TN 38119
1-800-873-2273
TEXAS
Texas Medical Foundation
Barton Oaks Plaza Two, Suite 200
901 Mopac Expressway South
Austin, TX 78746
1-800-777-8315 (in-state only)
512-329-6610
UTAH
Utah Peer Review Organization
675 East 2100 South
Suite 270
Salt Lake City, UT 84106-1864
1-800-274-2290
VERMONT
New Hampshire Foundation for Medical Care
(PRO for Vermont)
15 Rollinsford Road, Suite 302
Dover, NH 03820
1-800-639-8427 (in Vermont only)
1-802-655-6302*
VIRGIN ISLANDS
Virgin Islands Medical Institute, Inc.
IAD Estate Diamond Ruby
P.O. Box 1566
Christiansted
St. Croix, U.S., VI 00821-1566
1-809-778-6470*
VIRGINIA
Medical Society of Virginia Review Organization
1606 Santa Rosa Road, Suite 235
P.O. Box K 70
Richmond, VA 23288
1-800-545-3814 (DC, MD and VA)
804-289-5320
(in Richmond, dial 289-5397)
WASHINGTON
Professional Review Organization for Washington
Suite 100
10700 Meridian Avenue, North
Seattle, WA 98133-9008
1-800-445-6941
(in Seattle, dial 368-8272)
WEST VIRGINIA
West Virginia Medical Institute, Inc.
3001 Chesterfield Place
Charleston, WV 25304
1-800-642-8686, ext. 266
(in Charlestown, dial 346-9864)
WISCONSIN
Wisconsin Peer Review Organization
2909 Landmark Place
Madison, WI 53713
1-800-362-2320 (in-state only)
608-274-1940
WYOMING
Montana-Wyoming Foundation for Medical Care
400 North Park, 2nd Floor
Helena, MT 59601
1-800-826-8978 (in Wyoming only)
1-406-443-4020*
* PRO will accept collect calls from out
of state on this
number.
INDEX
Address lists
Medicare carriers,
Peer Review Organizations,
Advance directives,
Ambulance services,
Ambulatory surgical services,
Annual Part B deductible,
Antigens,
Appeal fights,
Appealing claims decisions
by carriers,
by health maintenance organizations,
by intermediaries,
by Peer Review Organizations,
by providers of Part A services,
Appliances. See Medical appliances.
Application process,
Approved charges,
Assignment payment method,
Assistance for low-income beneficiaries,
Benefit periods
hospice care,
hospital and skilled nursing facility,
Black lung benefits,
Blood
deductible amount,
hemophilia clotting factors,
home health care, transfusions,
hospital inpatient, transfusions,
hospital outpatient, transfusions,
skilled nursing facility, transfusions,
Breast cancer screening,
Buying Medicare,
Cancelling Part B,
Care not covered,
Certified registered nurse anesthetist,
Certified nurse midwife,
Charge limits,
Chiropractors, services covered,
Christian Science sanatorium,
Claim number,
Claims
benefits explanation notice,
claim number,
deceased beneficiary,
insurance other than Medicare,
intermediaries' and carriers' role,
Railroad Retirement system,
submission, for home health care,
submission process,
time limit,
Clinical nurse specialists, psychologists, social
workers,
CMPs. See Coordinated health care organizations.
Coinsurance, Competitive medical plans (CMPs).
See Coordinated health care organizations.
Complaints
fraud and abuse hot line,
Medigap fraud,
review process,
skilled nursing facility,
Comprehensive Outpatient Rehabilitation
Facility (CORF),
Coordinated Health Care Organizations (HMOs, CMPs)
appealing decisions,
enrollment and coverage,
fraud,
quality of care,
Cosmetic surgery,
Counseling,
Custodial care,
Data matching,
Deductibles
annual, Part B,
blood,
hospital insurance (Part A),
medical insurance (Part B),
Dentists, services covered,
Diagnosis Related Groups (DRGs),
Diagnostic tests,
Dialysis. See Kidney disease.
Disabled people
cancelling or losing Medicare protection,
eligibility for coverage,
employer health plans,
enrollment process,
Doctors
participating,
services covered,
Doctors of osteopathy,
DRGs. See Diagnosis Related Groups.
Drugs and biologicals
coverage under Part A,
coverage under Part B,
hemophilia clotting factors,
hepatitis B vaccine,
immunosuppressive drugs,
pneumococcal pneumonia vaccine,
Durable medical equipment
coinsurance for,
description,
oxygen,
Durable power of attorney for health care,
Elective surgery, written estimate of costs,
Emergency room services,
Enrollment, Medicare cards,
Enrollment process
hospital insurance (Part A),
medical insurance (Part B),
Epoetin alfa,
Equipment. See Durable medical equipment;
Medical appliances.
Explanation of Your Medicare Part B Benefits,
notice,
Eye examinations,
Fee schedule,
Federally qualified health center,
Financial assistance for
low-income beneficiaries,
Foot care,
Foreign hospital care,
Fraud and abuse,
HCFA 1500, form,
Health maintenance organizations (HMOs).
See Coordinated health care organizations.
Heart transplants,
Hemophilia clotting factors,
Hepatitis B vaccine,
HMOs. See Coordinated health care organizations.
Home health agencies,
Home health aides,
Home health care
Part A coverage,
Part B coverage,
Homemaker services,
Hospice care
and coordinated health care organizations,
description,
services covered,
Hospital inpatient care
blood, payment for,
Christian Science sanatorium,
conditions for payment,
deductible and coinsurance, foreign hospitals,
psychiatric,
reserve days,
services covered/not covered,
Hospital insurance (Part A)
appealing decisions,
benefit periods,
buying,
cancelling or losing protection,
coinsurance,
coverage,
deductible,
eligibility,
enrollment process,
noncoverage, notice of,
patient fights,
premiums, premium-free,
prospective payment system,
Hospital outpatient care,
Hot line, fraud and abuse,
Medigap fraud,
Immunizations,
Immunosuppressive drags,
An Important Message From Medicare,
Inpatient care, hospital. See Hospital inpatient
care.
Insurance. Also see Hospital insurance (Part A);
Medical insurance (Part B).
illegal sales practices, penalties and fines,
other than Medicare, claims submission,
supplemental,
Intermediaries and carriers
appealing decisions by,
description,
Kidney disease
cancelling or losing Medicare protection,
and coordinated health care organizations,
coverage booklet,
dialysis and transplants,
Medicare as secondary payer,
Laboratory services
doctor's office, independent, hospital outpatient,
hospital inpatient,
Limitation of liability,
Limits to physician charges,
Liver transplants,
Living wills,
Low-income assistance,
Mammography screening,
Managed care. See Coordinated health care organizations.
Medical appliances
hospice care,
inpatient care,
skilled nursing facility,
Medical insurance (Part B)
appealing decisions,
approved charges,
assignment payment method,
benefits explanation notice,
buying,
cancelling or losing protection,
claims,
coverage,
deductible and coinsurance amounts,
doctors and suppliers, participating,
eligibility, enrollment process,
premium amount,
providers, participating,
Medical supplies,
description,
Medicare, Part A. See Hospital insurance (Part
A).
Medicare, Part B. See Medical insurance (Part
B).
Medicare cards,
Medicare Participating Physician/Supplier
Directory,
Medicare secondary payer,
Medicare SELECT,
Medigap insurance
buying,
fraud, hotline,
Mental illness, outpatient treatment,
Noncoverage
notice of,
what Medicare does not cover,
Notice of Utilization,
Nurse anesthetists, midwives, practitioners, and
specialists,
clinical,
Nursing home. See Skilled nursing facility.
Occupational therapy. See Therapy.
Open enrollment period, Medigap,
Optometrists, services covered,
Osteopathy, doctors of,
Outpatient hospital, services covered/not covered,
Oxygen equipment. See Durable medical equipment.
Pap smears,
Part A. See Hospital insurance (Part A).
Part B. See Medical insurance (Part B).
Partial hospitalization for mental health treatment,
Participating doctors and suppliers,
Participating providers,
Payments. Also see Deductibles.
assignment payment method,
for blood. See Blood.
limitation of liability,
overpayments,
Part A,
prospective payment system,
Peer Review Organizations (PROs)
address and telephone number list,
appealing decisions,
complaints review process,
description,
Physical examinations, routine,
Physical therapy. See Therapy.
Physician assistants,
Physicians
participating,
services covered,
Pneumococcal pneumonia vaccine,
Podiatrists, services .covered,
PPS. See Prospective payment system.
Premium-free eligibility,
Premium, Part A,
Premium, Part B,
Prepaid health care organizations.
See Coordinated health care organizations.
Prescription drugs. See Drugs and biologicals.
Privacy Act,
Private duty nurses,
Private insurance organizations,
Also see Intermediaries and carriers.
PROs. See Peer Review Organizations.
Prospective payment system (PPS),
Prosthetic devices,
Providers, payment of,
Psychiatric care. Also see Mental illness.
psychiatric hospital care,
Psychologists, clinical,
Qualified Medicare Beneficiary,
Quality of care. Also see Peer Review Organizations.
complaints,
fraud and abuse hot line number,
Radiation therapy,
Reasonable and necessary care,
Rehabilitative services. See Therapy.
Relatives, services by,
Reserve days,
Respiratory therapy. See Therapy.
Respite care, hospice,
Routine physical examinations,
Rural health clinic services,
Seat lift chairs. See Durable medical equipment.
Second opinion before surgery,
Secondary payer,
Services not covered,
Skilled nursing facility
inpatient care,
services covered/not covered,
Social Security Administration
disability eligibility,
enrollment, cards, premium amounts, questions,
Social worker, clinical,
Special enrollment period,
Special practitioners,
Speech pathology,
Speech therapy. See Therapy.
State survey agency,
Supplemental insurance. See Medigap insurance.
Supplies. See Medical supplies.
Surgery
ambulatory,
cosmetic,
elective,
second opinion,
Telephone numbers, toll-free
Cancer information,
hot line, fraud and abuse,
Medicare carriers,
Medigap, fraud,
Peer Review Organizations,
second opinion, referral,
Terminal illness. See Hospice care.
Tests, diagnostic,
Therapy
Comprehensive Outpatient Rehabilitation
Facility services,
doctors' services, coverage,
home health care, coverage,
hospice care, coverage,
inpatient, coverage,
occupational,
outpatient, coverage,
physical,
radiation, coverage,
respiratory,
skilled nursing facility, coverage,
speech,
Time limit for claims submission,
Toll-free telephone numbers.
See Telephone numbers.
Vaccines,
Veterans benefits,
Waiver of liability,
Wheelchairs. See Durable medical equipment.
Workers' compensation benefits,
X-ray services,
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