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
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
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
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.
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
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
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.
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
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
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
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.
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
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
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
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
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
PART B DEDUCTIBLE AND COINSURANCE AMOUNTS
Q. How much are the Part B deductible and coinsurance
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
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.
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
MEDICARE APPROVED AMOUNT
Q. How does Medicare determine its approved amounts for
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
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
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.
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
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.
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.
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
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.
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.
Q. How much does Medicare pay toward the cost of home health
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
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.
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
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
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
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
Q. What is the difference between Medicare SELECT and other
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
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.
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.
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
Q. What free publications are available that explain
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.