60 Commonly Asked Questions about Medicare
60 Commonly Asked Questions about Medicare
This booklet is meant to provide information about
the Medicare
program but is not a legal document. The official
Medicare
program provisions are contained in the relevant
laws,
regulations and rulings.
MEDICARE AND MEDICAID
Q. What is Medicare?
A. Medicare is a Federal health insurance
program established
in 1965 for people aged 65 or older. It now
also covers
people of any age with permanent kidney failure,
and
certain disabled people. It is administered
by the Health
Care Financing Administration (HCFA) of the
U.S.
Department of Health and Human Services.
Local Social
Security Administration offices take applications
for
Medicare and provide information about the
program.
Q. What is the difference between Medicare
and Medicaid?
A. Medicare is a Federal health insurance
program for the
elderly and disabled regardless of income
and assets.
Medicaid, on the other hand, is a medical
assistance
program jointly financed by the State and
Federal
governments for eligible low-income individuals.
Medicaid
covers health care expenses for all recipients
of Aid to
Families with Dependent Children (AFDC),
and most States
also cover the needy elderly, blind, and
disabled who
receive cash assistance under the Supplemental
Security
Income (SSI) program. Coverage also is extended
to certain
infants and low-income pregnant women, and,
at the option
of the State, other low-income individuals
with medical
bills that qualify them as categorically
or medically
needy.
Q. How many people are covered by Medicare?
A. Medicare currently covers approximately
35 million people,
of whom about 3 million are disabled and
some 150,000 are
kidney disease patients.
YOUR MEDICARE COVERAGE
Q. What does Medicare cover?
A. Medicare has two parts: Hospital insurance
(Part A) and
Supplementary Medical insurance (Part B).
Part A helps pay
for inpatient care in a hospital or skilled
nursing
facility, or for care from a home health
agency or
hospice. If you are admitted to a hospital,
Medicare
provides coverage for a semiprivate room,
meals, regular
nursing services, operating and recovery
room costs,
intensive care, drugs, laboratory tests,
X-rays, and all
other medically necessary services and supplies.
Covered
services in a skilled nursing facility include
a
semi-private room, meals, regular nursing
services,
rehabilitation services, drugs, medical supplies,
and
appliances.
Part B helps pay for physician services,
outpatient
hospital care, clinical laboratory tests,
and various
other medical services and supplies, including
durable
medical equipment. Doctors' services are
covered no matter
where you receive them in the U.S. Covered
services
include surgical services, diagnostic tests
and X-rays
that are part of your treatment, medical
supplies
furnished in a doctor's office, and drugs
which cannot be
self-administered and are part of your treatment.
Medicare pays only for care that it determines
is
medically necessary.
WHAT MEDICARE DOESN'T COVER
Q. Are there services Medicare does not cover?
A. While Medicare helps pay a large portion
of your medical
expenses, there are various health care services
and
products for which Medicare will not pay.
These generally
include custodial care; eyeglasses, hearing
aids, and
examinations to prescribe or fit them; a
telephone, TV, or
radio in your hospital room; and most outpatient
prescription drugs and patent medicines.
Medicare also
does not pay for cosmetic surgery, most immunizations,
dental care, routine foot care, and routine
physical
checkups. Although some personal care services
(for
example: bathing assistance, eating assistance,
etc.) can
be covered along with skilled care, they
are never covered
alone except under the hospice benefit.
PAYING FOR MEDICARE
Q. How is Medicare financed?
A. Medicare Hospital Insurance (Part A) is
financed mainly
from a portion of the Social Security payroll
tax (the
HCA) deduction. The Medicare pan of the payroll
tax is
1.45 percent from the employee and 1.45 percent
from the
employer on wages up to $125,000 in 1991.
Medicare Medical
Insurance (Part B), which is optional, is
financed by the
monthly premiums paid by enrollees and from
Federal
general revenues. The monthly premium in
1991 is $29.90.
The premium pays about 25 percent of the
cost of the Part
B program and general tax revenues pay about
75 percent.
WHO'S ELIGIBLE?
Q. Who is eligible for Medicare?
A. Generally, people age 65 and over can
get Part A benefits
if they can establish their eligibility for
monthly Social
Security or Railroad Retirement benefits
on their own or
their spouse's work record. In addition,
certain
government employees whose work has been
covered for
Medicare purposes, and their spouses, can
also have Part
A.
In rare cases, involving those who became
age 65 in 1974
or earlier, Part A may be available if these
people meet
certain United States residence and citizenship
or legal
alien requirements.
Part A is also available to most individuals
with
end-stage renal disease, and to those who
have been
entitled to Social Security disability benefits
or
Railroad Retirement disability benefits
for more than 24
months, and to certain disabled government
employees whose
work has been covered for Medicare purposes.
Any person who is eligible for Part A
is also eligible to
enroll in Part B. Enrollees in Part B must
pay a monthly
premium of $29.90 in 1991.
MEDICARE ENROLLMENT
Q. How do I sign up for Medicare?
A. 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 usually show that you are entitled to
both Part A and
Part B, and the beginning dates of your entitlement
to
each. If you do not want Part B, you can
refuse it by
following the instructions that come with
the card. If you
are not receiving such payments, you may
have to apply for
Medicare coverage. Check with Social Security
to see 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 do
so during your initial seven-month enrollment
period that
starts three months before the month you
first meet the
requirements for Medicare.
GETTING MORE INFORMATION
Q. Whom do I call to get more information
about Medicare?
A. If you want to know how and when to sign
up for Medicare,
or how to change an address or replace a
lost Medicare
card, contact any Social Security office.
ENROLLING LATE FOR PART B
Q. When I enrolled in Medicare Part A, I
did not sign up for
Part B. Is that coverage still available
to me on the same
terms?
A. You may still enroll in Part B during
the annual general
enrollment period from January 1 to March
31, and your
coverage will begin on July 1. However, your
monthly
premium may be higher than it would have
been had you
enrolled in Part B when you enrolled in Part
A. In most
cases, if you defer your enrollment in Part
B, you must
pay a monthly premium surcharge. The surcharge
is 10
percent for each 12-month period in which
you could have
been enrolled but were not.
You may not have to pay the surcharge
if you are covered
by an employer health plan. Delayed enrollment
without
penalty is generally available if you have
been covered by
an employer health plan based on your or
your spouse's
current employment since you were first able
to get
Medicare. In that case, you can enroll in
Part B during a
special 7-month enrollment period. The period
begins with
the month the employer group health plan
coverage ends, or
with the month the employment on which it
is based ends,
whichever is earlier. In the case of certain
disability
beneficiaries, the special period begins
when Medicare
replaces the employer group health plan as
the primary
payer of the beneficiary's covered medical
services.
DO YOU HAVE BOTH PART A & B COVERAGE?
Q. How do I know whether I'm covered by one
or both parts of
Medicare?
A. Your Medicare card shows the coverage
you have [Hospital
Insurance (Part A), Medical Insurance (Part
B), or both]
and the date your protection started.
Q. What does the letter mean that appears
after my health
insurance claim number on my Medicare card?
A. It is a code used by Social Security to
indicate the type
of benefits you are receiving. There may
also be another
number after the letter. Your full claim
number must
always be included on all Medicare claims
and
correspondence.
BUYING MEDICARE
Q. If I am not entitled to Medicare based
on employment, can
I buy the coverage?
A. Individuals age 65 or over who are United
States residents
and either United States citizens, or aliens
who have been
lawfully admitted for permanent residence
and have resided
in the United States for at least five years
at the time
of filing, can purchase both Part A and Part
B, or just
Part B. The monthly premiums in 1991 are
$177 for Part A
and $29.90 for Part B.
GETTING MEDICARE-COVERED CARE
Q. Are there different health care systems
Medicare
beneficiaries can use to get their Medicare
benefits?
A. Yes. You can receive services covered
by Medicare either
through the traditional fee-for-service (pay-as-you-go)
delivery system or through coordinated care
plans, such as
health maintenance organizations (HMOs) and
competitive
medical plans (CMPs), which have contracts
with Medicare.
Whether you choose fee-for-service or
coordinated care,
you get all of Medicare's hospital and medical
benefits.
The care provided by both systems is comparable.
The
differences in the two systems include how
the benefits
are delivered, how and when payment is made
and how much
you might have to pay out of your pocket.
Most of the
information in this booklet pertains to fee-for-service
health care. For more information about coordinated
care
plans, request a copy of the leaflet titled
Medicare and
Coordinated Care Plans from any Social Security
office.
FEE-FOR-SERVICE
Q. How does the fee-for-service system work?
A. Under the fee-for-service health care
system you have
freedom of choice. You can choose any licensed
physician
and use the services of any hospital, health
care
provider, or facility approved by Medicare
that agrees to
accept you as a patient. Generally a fee
is paid each time
a service is used. Medicare, within certain
limits, pays a
large portion of the hospital, physician,
and other health
care expenses.
HMOs AND CMPs
Q. How do coordinated care plans work?
A. In a coordinated care plan (HMO or CMP)
a network of
health care providers (doctors, hospitals,
skilled nursing
facilities, etc.) generally offers comprehensive,
coordinated medical services to plan members
on a prepaid
basis. Except in an emergency, services usually
must be
obtained from the health care professionals
and facilities
that are part of the plan. Care may be provided
at a
central facility or in the private practice
offices of the
doctors and other professionals affiliated
with the plan.
ENROLLING IN AN HMO
Q. Can I enroll in a HMO?
A. Yes. You may enroll in any HMO or CMP
that has a contract
with Medicare. The only requirements are
that you live in
the plan's service area and be enrolled in
Medicare Part
B. Medicare makes a monthly payment to the
plan to provide
you with Medicare-covered services. Some
plans provide
additional services, and most charge enrollees
a monthly
premium and nominal copayments when a service
is used.
Contact plans in your area for enrollment
and coverage
information.
DISENROLLING FROM AN HMO
Q. If I enroll in a coordinated care plan,
can I later return
to fee-for-service Medicare coverage?
A. Yes. You may disenroll from a coordinated
care plan at any
time. Your coverage under fee-for-service
Medicare will
begin the first day of the following month.
You may also
change from one plan to another simply by
enrolling in the
second plan.
CHARGES YOU PAY
Q. Do Medicare beneficiaries have to pay
any charges out of
their own pockets when they use covered services?
A. Yes. Both Part A and Part B have deductible
and
coinsurance amounts for which you are liable.
You also
must pay all permissible charges in excess
of Medicare's
approved amounts for Part B services, and
charges for
services not covered by Medicare. These charges
do not
apply to you if you are enrolled in a coordinated
care
plan. Instead, you generally must pay a monthly
premium to
the plan and nominal copayments when a service
is used.
HELP FOR LOW-INCOME BENEFICIARIES
Q. Is assistance available to help low-income
Medicare
beneficiaries pay Medicare's premiums, deductibles
and
coinsurance amounts?
A. Yes. If your annual income is below the
national poverty
level and you do not have access to many
financial
resources, you may qualify for government
assistance under
the State Medicaid program in paying Medicare
monthly
premiums and at least some of the deductibles
and
coinsurance amounts. The national poverty
income levels
for 1991 are $6,620 for one person and $8,880
for a family
of two. If you think you may qualify, you
should contact
your State or local welfare, social service
or public
health agency.
PART B DEDUCTIBLE AND COINSURANCE AMOUNTS
Q. How much are the Part B deductible and
coinsurance
amounts?
A. The Medicare Part B deductible in 1991
is $100 per year.
This means that you are responsible for the
first $100 of
approved expenses for physician and other
medical services
and supplies. The deductible is paid when
you are first
charged for covered services. After the deductible
has
been met, then Medicare starts paying. Medicare
generally
pays 80 percent of all other approved charges
for covered
services for the rest of the year. You are
responsible for
the other 20 percent. If the physician or
supplier does
not accept assignment of the Medicare claim
(that is,
accept Medicare's approved amount as payment
in full), you
are responsible for all permissible charges
in excess of
the approved amount. You also generally are
liable for
charges for services not covered by Medicare.
Them is no
deductible or coinsurance for home health
services.
PART A DEDUCTIBLE AND COINSURANCE AMOUNTS
Q. How much are the Part A deductible and
coinsurance
amounts?
A. The Part A deductible is $628 per benefit
period in 1991.
This means that if you are admitted to the
hospital, you
are responsible for the first $628 of Medicare-covered
expenses. After that, Medicare pays all covered
expenses
for the first 60 days. For the next 30 days,
Medicare pays
all covered expenses except for a coinsurance
amount of
$157 per day in 1991. You are responsible
for the $157 per
day. Whenever more than 90 days of inpatient
hospital care
are needed in a benefit period, you can use
your lifetime
reserve days to pay for covered services.
Every person
enrolled in Part A has a lifetime reserve
of 60 days for
inpatient hospital care. Once used, these
days are not
renewed. When a reserve day is used, Medicare
pays for all
covered services except for a coinsurance
amount of $314 a
day in 1991. You are responsible for the
$314 a day.
Because the Part A deductible applies to
each benefit
period, you could have to pay more than one
deductible in
a year if you were hospitalized more than
once.
SKILLED NURSING FACILITY CARE
Q. What if I require care in a skilled nursing
facility after
leaving the hospital?
A. If, after being in a hospital for at least
three days, you
receive covered care in a skilled nursing
facility that
has been approved to participate in the Medicare
program,
Part A will help cover services for up to
100 days per
benefit period. Medicare pays all covered
expenses for the
first 20 days and all but $78.50 per day
in 1991 for the
next 80 days. You are responsible for the
$78.50 per day.
BENEFIT PERIOD
Q. What is a benefit period?
A. A benefit period is a way of measuring
your use of
Medicare Part A services. A benefit period,
which applies
to hospital and skilled nursing facility
care, begins the
day you are hospitalized and ends after you
have been out
of the hospital or skilled nursing facility
for 60 days in
a row. It also ends if you remain in a skilled
nursing
facility but do not receive any skilled care
there for 60
days in a row. There is no limit to the number
of benefit
periods you can have.
PROCESSING MEDICARE CLAIMS
Q. Who processes Medicare claims and payments?
A. Medicare claims and payments are handled
by insurance
organizations under contract to the Federal
government.
The organizations handling claims from hospitals,
skilled
nursing facilities, home health agencies,
and hospices are
called "intermediaries." You almost
never have to get
involved in the Part A claims process. The
insurance
organizations that handle Medicare's Part
B claims are
called "carriers." The names and
addresses of the carriers
and areas they serve are listed in the back
of The
Medicare Handbook, available from any Social
Security
Administration office.
MEDICARE APPROVED AMOUNT
Q. How does Medicare determine its approved
amounts for
physician services?
A. Medicare's approved amount, which is also
referred to as
the reasonable or allowable charge, is determined
in the
following manner for most Part B claims:
When a doctor submits a claim, the Medicare
carrier
compares the amount submitted with the doctor's
usual
charge for the service and with the amounts
other
physicians in the community usually charge
for the same
service. The lowest of the three becomes
the approved
amount. After you have met the Part B annual
deductible
($100 in 1991), Medicare generally pays 80
percent of the
approved amount and you are liable for the
other 20
percent. A NEW SYSTEM FOR DETERMINING THE
AMOUNT
PHYSICIANS WILL BE PAID FOR PROVIDING SERVICES
COVERED BY
MEDICARE WILL BE INTRODUCED IN 1992.
ACCEPTING MEDICARE ASSIGNMENT
Q. What does it mean when a physician accepts
assignment?
A. Physicians and suppliers who accept assignment
of Medicare
claims agree to not charge you more than
the Medicare
approved amount for services and supplies
covered by Part
B. They are paid directly by Medicare, except
for the
deductible and coinsurance amounts for which
you are
responsible. Some physicians and suppliers
have signed
agreements to participate in Medicare. In
doing so, they
have agreed to accept assignment of Medicare
claims all of
the time. Other physicians and suppliers
will accept
assignment on a case-by-case basis or not
at all.
PHYSICIANS WHO DON'T ACCEPT ASSIGNMENT
Q. What if a physician does not accept assignment
of a
Medicare claim?
A. Physicians and suppliers who do not accept
assignment of
Medicare claims may charge more than the
Medicare approved
amount and collect full payment directly
from you.
Medicare then pays you 80 percent of the
approved amount
for the covered service, less any unmet portion
of the
$100 Part B deductible. You are liable for
all permissible
charges in excess of Medicare's approved
amount.
LIMITING A PHYSICIAN'S CHARGES
Q. Is there a limit to the amount a physician
can charge a
Medicare beneficiary for a covered service?
A. Yes. Physicians who do not accept assignment
of a Medicare
claim are limited as to the amount they can
charge
Medicare beneficiaries for covered services.
In 1991,
charges for visits and consultations cannot
be more than
140% of the Medicare prevailing charge for
physicians who
do not participate in Medicare. For most
other services
(surgery, for example) the limit is 125 percent
of the
prevailing charge for nonparticipating physicians.
In 1992
the limiting charge for all services covered
by Medicare
will be 120 percent of the fee schedule amount
for
nonparticipating physicians and in 1993 it
will be 115
percent of the fee schedule amount.
FINDING PARTICIPATING PHYSICIAN
Q. How can I find a Medicare-participating
physician or
supplier?
A. The names and addresses of Medicare-participating
physicians 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 (listed in the
back of The
Medicare Handbook) or you can call your carrier
and ask
for names of some participating physicians
and suppliers
in your area. This directory is also available
for review
in Social Security offices, State and area
offices of the
Administration on Aging, and in most hospitals.
Physicians
and suppliers are given the opportunity each
year to sign
Medicare participation agreements.
FILING A PART B CLAIM
Q. When a physician provides Medicare-covered
services to a
Medicare beneficiary, does the physician
or beneficiary
file the claim with the Medicare carrier
for payment?
A. For Medicare-covered services and supplies
received on or
after September 1, 1990, the physician or
supplier is
required to submit the claim for the beneficiary.
For
services and supplies provided prior to that
date, the
physician or supplier was not required to
submit the claim
unless the physician or supplier participated
in Medicare
or had agreed to accept assignment of the
claim.
WHAT TO DO WHEN YOU HAVE A PROBLEM WITH A CLAIM
Q. Whom do I call if I have a question about
a Medicare claim
for a doctor's services?
A. Call the Medicare carrier for your area.
The carrier's
name and toll-free telephone number are listed
in the back
of The Medicare Handbook and appear on all
Explanation of
Medicare Benefit (EOMB) forms.
Q. How long should I wait before contacting
the Medicare
carrier to check on the status of a claim?
A. Allow 30 to 45 days for the claim to be
paid. If you have
not received a check or an Explanation of
Medicare Benefit
(EOMB) payment statement after 45 days, call
the Medicare
carrier for your area.
APPEALING A CLAIMS PAYMENT DECISION
Q. What recourse do I have if Medicare denies
payment for a
claim or pays less than I think it should?
A. You have a fight to appeal Medicare's
coverage and payment
determinations for both the hospital (Part
A) and medical
(Part B) segments of Medicare. The appeals
processes are
explained in The Medicare Handbook.
AMBULANCE SERVICES
Q. Does Medicare cover ambulance services?
A. Medicare Part B can help pay for certain
medically
necessary ambulance services when: (1) the
ambulance,
equipment, and personnel meet Medicare requirements;
and
(2) transportation by any other means would
endanger your
health. This includes transportation from
a hospital to a
skilled nursing facility, or from a hospital
or skilled
nursing facility to your home. Medicare will
also cover a
round trip from a hospital or a participating
skilled
nursing facility to an outside supplier to
obtain
medically necessary diagnostic or therapeutic
services not
available at the hospital or skilled nursing
facility
where you are an inpatient.
MEDICARE COVERAGE FOR WHEELCHAIRS, PACEMAKERS,
AND ARTIFICIAL
LIMBS
Q. Does Medicare cover prostheses and medical
devices?
A. Yes. Medicare covers these items when
provided by a
hospital, skilled nursing facility, home
health agency,
hospice, comprehensive outpatient rehabilitation
facility
(CORP), or a rural health clinic. Medicare
also covers
cardiac pacemakers, corrective lenses needed
after
cataract surgery, colostomy or ileostomy
supplies, breast
prostheses following a mastectomy, and artificial
limbs
and eyes. Coverage also is provided for durable
medical
equipment, such as wheelchairs, hospital
beds, walkers,
and other equipment prescribed by a doctor
for home use.
NURSING HOME CARE
Q. Does Medicare pay for long-term care in
a nursing home?
A. No. Medicare only helps pay for post-hospital
extended
care in a skilled nursing facility (SNF).
A SNF is a
specially qualified facility with the staff
and equipment
to provide skilled nursing care, a full range
of
rehabilitation therapies, and related health
services.
Medicare only pays when a skilled level of
care is
required as a continuation of a hospital
stay and the care
is provided in a SNF that participates in
Medicare. Even
if you are in a SNF that participates in
Medicare,
Medicare will not pay if the services you
receive are
mainly personal care or custodial services,
such as help
in walking, getting in and out of bed, eating,
dressing,
and bathing. A SNF that participates in Medicare
will
inform you at the time of admission about
potential
Medicare payment and your rights to seek
payment.
CHIROPRACTIC SERVICES
Q. Will Medicare pay for a chiropractor's
services?
A. Medicare helps pay for only one kind of
treatment
furnished by a licensed chiropractor: manual
manipulation
of the spine to correct a subluxation that
can be
demonstrated by X-ray.
PSYCHIATRIC COVERAGE
Q. Does Medicare pay for care in a psychiatric
hospital?
A. Yes. Medicare Part A helps pay for up
to 190 days of
inpatient care in a participating psychiatric
hospital
during a beneficiary's lifetime.
CHECKING FOR CANCER
Q. Does Medicare pay for cervical- and breast-cancer
screenings?
A. Yes. Medicare Part B helps pay for Pap
smears to screen
for the detection of cervical cancer and
for X-ray
screenings for the detection of breast cancer.
HOME HEALTH CARE
Q. Does Medicare cover home health care?
A. Yes. 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. To qualify, you must
be homebound,
need part-time or intermittent skilled nursing
care,
physical therapy, or speech therapy. You
also must be
under the care of a physician who determines
you need home
health care and sets up a home health care
plan for you.
COVERAGE LIMITS
Q. How long can home health care last?
A. Home health care can continue for as long
as you are under
a physician's plan of care and the services
you require
are the type of services Medicare covers,
such as skilled
nursing, physical therapy, and speech therapy.
Home health
aide services are also available if you are
eligible.
Daily skilled care is available on a limited
basis to
those beneficiaries who qualify.
WHO PAYS?
Q. How much does Medicare pay toward the
cost of home health
care?
A. Medicare pays the full approved cost of
all covered home
health visits. There is no coinsurance on
home health
care. 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.
MEDICARE AND HOSPICE CARE
Q. What is hospice care?
A. Hospice is a special way of caring for
a patient whose
disease cannot be cured and whose medical
life expectancy
is six months or less. Patients receive a
full scope of
palliative medical and support services for
their terminal
illnesses.
Q. Is hospice care available to Medicare
beneficiaries?
A. Yes. Medicare beneficiaries certified
by a physician to be
terminally ill may elect to receive hospice
care from a
Medicare-approved hospice program. Under
Medicare, hospice
is primarily a comprehensive home care program
that
provides medical and support services for
the management
of a terminal illness. Beneficiaries who
elect hospice
care are not permitted to use standard Medicare
to cover
services for the treatment of conditions
related to the
terminal illness. Standard Medicare benefits
are provided,
however, for the treatment of conditions
unrelated to the
terminal illness. Medicare has special benefit
periods for
beneficiaries who enroll in a hospice program.
PROs
Q. What are PROs?
A. Utilization and Quality Control Peer Review
Organizations
(PROs) are physician-sponsored organizations
in each State
that the Health Care Financing Administration
(HCFA)
contracts with to ensure that Medicare beneficiaries
receive care which is medically necessary,
reasonable,
provided in the appropriate setting, and
which meets
professionally accepted standards of quality.
Among other
things, PROs are responsible for intervening
when quality
problems are identified and for making every
attempt to
resolve them. They ensure that beneficiaries
are advised
of their appeal rights and review all written
complaints
from beneficiaries or their representatives
concerning the
quality of care rendered. If you are admitted
to a
hospital, you will receive a notice explaining
your rights
under Medicare and how to contact the PRO
if the need
arises.
MEDICARE AND FOREIGN TRAVEL
Q. If I require medical services outside
the United States
and its territories, will Medicare pay the
bills?
A. No. But there are three exceptions. Medicare
will help pay
for care in qualified Canadian or Mexican
hospitals if:
(1) You are in the United States when an emergency
occurs, and
a Canadian or Mexican hospital is closer
to, or
substantially more accessible from, the site
of the
emergency than the nearest U.S. hospital
that can provide
the emergency services you need.
(2) You live in the United States and a Canadian
or Mexican
hospital is closer to, or substantially more
accessible
from, your home than the nearest U.S. hospital
that can
provide the care you need, regardless of
whether an
emergency exists, and without regard to where
the illness
or injury occurs.
(3) You are in Canada travelling by the most
direct route
between Alaska and another State when an
emergency occurs,
and a Canadian hospital is closer to, or
substantially
more accessible from, the site of the emergency
than the
nearest U.S. hospital that can provide the
emergency
services you need.
WHO PAYS FIRST?
Q. Is Medicare always the primary payer of
a beneficiary's
medical bills or are there situations when
another insurer
must pay first?
A. There are a number of situations in which
another insurer
is the primary payer of your health care
costs and
Medicare is the secondary payer. For example,
Medicare may
be the secondary payer if you are covered
by an employer
group health insurance plan, are entitled
to veterans
benefits, workers' compensation, or black
lung benefits.
Medicare also can be the secondary payer
if no-fault
insurance or liability insurance (such as
automobile
insurance) is available as the primary payer.
In cases
where Medicare is the secondary payer, Medicare
may pay
some or all of the charges not paid by the
primary payer
for services and supplies covered by Medicare.
This issue
is discussed in more detail in the publication
titled
Medicare Secondary Payer, available from
any Social
Security office.
MEDIGAP INSURANCE
Q. What is "Medigap" insurance?
A. Medigap insurance is private health insurance
designed
specifically to supplement Medicare's benefits
by filling
in some of Medicare's coverage. A Medigap
policy generally
pays for Medicare approved charges not paid
by Medicare
because of deductibles or coinsurance amounts
that you are
liable for. There are Federal minimum standards
for such
policies which most States include as pan
of their
programs to regulate Medigap policies. Because
Medigap
policies can have different combinations
of benefits and
the policies may vary from one insurance
company to
another, you should compare policies before
buying.
Compare the benefits and the premiums. Some
policies may
offer better benefits than others at a lower
premium.
MEDIGAP TO BE STANDARDIZED IN 1992
Q. Is it true that Medigap policies are to
be standardized?
A. Yes. During 1992 most States are expected
to adopt
regulations limiting the Medigap insurance
market to no
more than 10 standard policies. One of the
10 will be a
basic policy offering a "core package"
of benefits. The
other nine will each have a different combination
of
benefits, but they all must include the core
package.
Insurers will not be permitted to change
the combination
of benefits in any of the 10 standard policies.
Individual
States will be allowed to limit the number
of the
different standard policies sold in the State
to fewer
than 10 if they wish to do so, but must ensure
that
insurers offer the basic policy. For more
information on
this subject, contact your State insurance
department.
GAPS IN YOUR MEDICARE COVERAGE
Q. What are the "gaps" in Medicare
coverage?
A. In general, they are charges for which
you are
responsible. They include Medicare's deductibles
and
coinsurance amounts, permissible charges
in excess of
Medicare's approved amounts, additional days
of care in a
hospital or skilled nursing facility, and
the charges for
the various health care services and supplies
that
Medicare does not cover. Medigap insurance
can cover some
or all of these charges, depending on the
policy.
ONE MEDIGAP POLICY IS ENOUGH
Q. Do I need more than one Medigap policy?
A. No. One good policy tailored to your needs
at a price you
can afford is sufficient. Beginning in 1992
most States
are expected to make it unlawful for an insurance
company
or agent to sell a second or replacement
Medigap policy to
an individual unless the purchaser states
in writing that
the first policy is to be cancelled. Medicare
beneficiaries enrolled in coordinated care
plans (HMOs and
CMPs) or who are eligible for Medicaid usually
do not need
Medigap insurance. If you have insurance
from an employer
or labor association, you may also not need
Medigap
insurance.
MEDICARE SELECT
Q. What is Medicare SELECT insurance?
A. Medicare SELECT is the name for a new
Medigap health
insurance product that is expected to be
introduced in
1992 in 15 States to be designated in 1991
by the
Secretary of the U.S. Department of Health
and Human
Services. During the three-year period currently
authorized under Federal law, Medicare SELECT
will be
evaluated to determine how it should eventually
be made
available throughout the Nation. Medicare
SELECT is
private insurance, it is not issued by the
government and
it is not part of Medicare. It is designed
to supplement
Medicare coverage.
Q. What is the difference between Medicare
SELECT and other
Medigap insurance?
A. The principal difference is that Medicare
beneficiaries
who buy a Medicare SELECT policy are expected
to be
charged a lower premium for that policy in
return for
agreeing to use the services of a network
of designated
physicians and other health care professionals.
These
health care professionals, called "preferred
providers,"
will be selected by the insurers. Each insurance
company
that offers a Medicare SELECT policy will
have its own
network of preferred providers. Policyholders
usually will
be required to use a preferred provider if
the insurance
company is to pay full benefits. Medicare
will continue to
pay its portion of covered benefits regardless
of whether
a preferred provider was used or not. Beneficiaries
who
buy other Medigap insurance policies are
not required to
use doctors and other providers designated
by the
insurance company.
GETTING MORE INFORMATION ABOUT SUPPLEMENTAL
INSURANCE
Q. Where can I get information about insurance
to supplement
my Medicare benefits?
A. Contact your local Social Security office,
State office on
aging, or your State insurance department
and ask for a
copy of the Guide to Health Insurance for
People with
Medicare. It describes Medicare's benefits
and the types
of private insurance available to supplement
Medicare. If
you need help in selecting supplemental insurance,
check
with your State insurance department. Some
departments
offer counselling services.
MEDIGAP COMPLAINTS
Q. Whom should I contact if I have a complaint
about the
agent who sold me a Medigap policy?
A. Suspected violations of the laws governing
the sales and
marketing of Medigap policies should be reported
to your
State insurance department or Federal authorities.
The
Federal toll-free telephone number for registering
such
complaints is 1-800-638-6833.
SECOND SURGICAL OPINIONS
Q. Whom do I call if I want a second surgical
opinion?
A. If your physician has recommended surgery
for a
non-emergency condition covered by Medicare
and you want
the names of doctors in your area who provide
second
opinions for elective surgery, call your
Medicare carrier.
Many conditions that do not require immediate
attention
can be treated equally well without surgery.
REPORTING FRAUD
Q. Where do I report suspected cases of Medicare
fraud?
A. If you have evidence of or suspect fraud
or abuse of the
Medicare or Medicaid programs, call your
Medicare carrier.
CHANGING YOUR ADDRESS
Q. I moved. How do I get my address changed?
A. You should call your local Social Security
office and ask
that your Medicare file be changed to reflect
your new
address.
FREE PUBLICATIONS
Q. What free publications are available that
explain
Medicare?
A. The following publications may be obtained
from any Social
Security office or by writing to: Medicare
Publications,
Health Care Financing Administration, 6325
Security
Boulevard, Baltimore, Md. 21207, or Consumer
Information
Center, Department 59, Pueblo, CO 81009.
* The Medicare Handbook
Guide to Health Insurance for People with
Medicare (507-X)
Medicare and Coordinated Care Plans (509-X)
Medicare
Hospice Benefits (508-X)
Medicare and Employer Health Plans (586-X)
Getting A
Second Opinion (536-X)
Medicare Coverage of Kidney Dialysis and
Kidney
Transplant Services (587-X)
* Medicare Secondary Payer
* Not available from Consumer Information
Center.
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