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 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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