INCLUDING INFORMATION FOR BENEFICIARIES ON:
* MEDICARE BENEFITS
* PARTICIPATING PHYSICIANS AND SUPPLIERS
* HEALTH INSURANCE TO SUPPLEMENT MEDICARE
* LIMITS TO MEDICARE COVERAGE
ABOUT THIS HANDBOOK
Medicare pays for many of your health care expenses, but
it does not cover all of them. It is important for you to know
what Medicare does and does not pay for. This Handbook will
help you understand how the Medicare program works and what
your benefits are. You can use the alphabetical index at the
back of the book to find information on specific subjects. This
Handbook is also available in Spanish. (See inside back cover
for how to order.)
Don't Miss
* The Assignment Method of Payment
Many doctors and suppliers have agreed to be part of
Medicare's participating physician and supplier program. They
accept assignment on all Medicare claims. If you get your
medical services from one of these participating doctors or
suppliers, you can often save money. See page 28 for more
information about the assignment method of payment, and what
you can do to find a participating doctor or supplier.
* Your Appeal Rights
Pages 35 and 36 explain how to appeal when Medicare does
not pay your Part A or Part B claims.
* If You Need Financial Assistance to Pay for Health Care
Sometimes you can get help paying for Medicare. Look on
pages 2 and 3 for more information.
* New primary and preventive services
Medicare now has a Federally Qualified Health Center
benefit. Look on page 24.
* New Information About Insurance to Supplement Medicare
Some people want to have insurance to pay medical bills
Medicare doesn't cover. See pages 8 and 9 to find out about
Medicare supplement "Medigap" insurance, including a new open
enrollment period.
* New Benefits
Recently added Medicare Part B benefits for cancer
screening--mammograms and Pap smears--are described on page 25.
* Who Pays First?
Medicare is not always the insurer that pays first
on claims. For example, some people are employed, or their
spouse is employed, and the employer health insurance pays
first. For more about who pays first, see pages 10 and 11.
* Where to Call or Write
Look on the inside front cover to find where to call or
write to ask questions about Medicare.
This handbook is meant to explain the Medicare program,
but is not a legal document. The official Medicare program
provisions are contained in the relevant laws, regulations and
Rulings.
Save this handbook for reference. It is revised each year
and is available from Social Security, but you will not
automatically get a handbook in the mail unless there are major
changes in the Medicare program.
Contents
What is Medicare?
The Two Parts of Medicare
Who Can Get Medicare Hospital Insurance
Who Can Get Medicare Medical Insurance (Part B)?
Buying Medicare Part A and Part B
Enrollment in Medicare
Your Medicare Card
Assistance for Low-Income Beneficiaries
Intermediaries and Carriers
Peer Review Organizations
Your Right to Decide About Your Medical Care
Fraud and Abuse
Your Rights Under the Privacy Act
Medicare Coordinated Care Plans
What Are Coordinated Care Plans
Who Can Enroll in Coordinated Care Plans?
Joining a Coordinated Care Plan
Ending Enrollment in a Coordinated Care Plan
If You Have Problems
Medicare and Other Insurance
Buying Health Insurance to Supplement Medicare
When Other Insurance Pays Before Medicare
What Medicare Does Not Pay For
Custodial Care
Care Not Reasonable and Necessary Under Medicare Program
Standards
Services Medicare Does Not Pay For
Limitation of Liability
Medicare Hospital Insurance (Part A)
What Medicare Part A Includes
How Medicare Pays for Part A Services
When You Are a Hospital Inpatient
Skilled Nursing Facility Care
Home Health Care
Hospice Care
Medicare Medical Insurance (Part B)
What Medicare Part B Includes
Deductible and Coinsurance Amounts Under Part B
Doctors' Services Covered by Medicare Part B
Second Opinion Before Surgery
Services of Special Practitioners
Outpatient Hospital Services
Other Services and Supplies Covered by Medicare
Drugs and Biologicals
Medicare Payments for Outpatient Treatment of Mental
Illness
Medicare Medical Insurance (Part B) Payments
The Assignment Payment Method
Participating Doctors and Suppliers
When Your Doctor Does Not Accept Assignment
Participating Providers
Medicare Approved Amounts
Submitting Part B Claims
Getting the Part of Medicare You Do Not Have
Getting Medicare Medical Insurance (Part B)
Getting Medicare Hospital Insurance (Part A)
Special Enrollment Period
Events That Can Change Your Medicare Protection
When Protection Ends for People 65 and Older
When Protection Ends for the Disabled
When Protection Ends for Those With Permanent Kidney
Failure
How to Appeal Medicare Decisions
Appealing Decisions Made by Providers of Part A Services
Appealing Decisions Made by Peer Review Organizations
(PROs)
Appealing Decisions of Intermediaries on Part A Claims
Appealing Decisions Made by Carriers on Part B Claims
Appealing Decisions Made by Health Maintenance
Organizations (HMOs)
For More Information
Appendices
Charts: Medicare Covered Services
Medicare Carriers
Medicare Peer Review Organizations (PROs)
Index
What is Medicare?
The Medicare program is a federal health insurance program
for people 65 or older and certain disabled people. It is run
by the Health Care Financing Administration of the U.S.
Department of Health and Human Services. Social Security
Administration offices across the country take applications for
Medicare and provide general information about the program.
The Two Parts of Medicare
There are two parts to the Medicare program. Hospital
Insurance (Part A) helps pay for inpatient hospital care,
inpatient care in a skilled nursing facility, home health care
and hospice care. Medical Insurance (Part B) helps pay for
doctors' services, outpatient hospital services, durable
medical equipment, and a number of other medical services and
supplies that are not covered by the Hospital Insurance part of
Medicare. Throughout this handbook, Medicare Hospital Insurance
is called Part A and Medicare Medical Insurance is called
Part B.
Part A has deductibles and coinsurance, but most people do
not have to pay premiums for Part A (see page 33). Part B has
premiums, deductibles, and coinsurance amounts that you must
pay yourself or through coverage by another insurance plan.
Premium, deductible and coinsurance amounts are set each year
based on formulas established by law. New payment amounts begin
each January 1. When amounts increase, you will be notified.
For 1993 deductible, premium and coinsurance amounts, see the
charts on pages 37 and 38.
Who Can Get Medicare Hospital Insurance (Part A)?
Generally, people age 65 and older can get premium-free
Medicare Part A benefits, based on their own or their spouses'
employment. (Premium-free means there are no premium payments.
Most people do not pay premiums for Medicare Part A.) You can
get premium-free Medicare Part A if you are 65 or older and any
of these three statements is true:
* You receive benefits under the Social Security or Railroad
Retirement system.
* You could receive benefits under Social Security or the
Railroad Retirement system but have not filed for them.
* You or your spouse had Medicare-covered government
employment.
If you are under 65, you can get premium-free Medicare Part
A benefits if you have been a disabled beneficiary under Social
Security or the Railroad Retirement Board for more than 24
months.
Certain government employees and certain members of their
families can also get Medicare when they are disabled for more
than 29 months. They should apply at the Social Security
Administration office as soon as they become disabled.
Or, you may be able to get premium-free Medicare Part A
benefits if you receive continuing dialysis for permanent
kidney failure or if you have had a kidney transplant. (People
who can get Medicare because of kidney disease may get a copy
of Medicare Coverage of Kidney Dialysis and Kidney Transplant
Services from the Consumer Information Center. See inside back
cover for how to order.)
Check with Social Security to see if you have worked long
enough under Social Security, Railroad Retirement, as a
government employee, or a combination of these systems to be
able to get Medicare Part A benefits. Generally, if either you
or your spouse worked for 10 years, you will be able to get
premium-free Medicare Part A benefits.
Who Can Get Medicare Medical Insurance (Part B)?
Any person who can get premium-free Medicare Part A
benefits based on work as described above can enroll for Part
B, pay the monthly Part B premiums (in 1993, $36.60 for most
beneficiaries), and get Part B benefits. In addition, most
United States residents age 65 or over can enroll in Part B.
Buying Medicare Part A and Part B
If you or your spouse do not have enough work credits to
be able to get Medicare Part A benefits and you are 65 or over,
you may be able to buy Medicare Parts A and B--or just Medicare
Part B--by paying monthly premiums. Also, you may be able to buy
Medicare Parts A and B if you are disabled and lost your
premium-free
Part A solely because you are working. (See page 34 for
more information.)
Enrollment in Medicare
If you are already getting Social Security or Railroad
Retirement benefit payments when you turn 65, you will
automatically get a Medicare card in the mail. The card will
show that you can get both Medicare Hospital Insurance (Part A)
and Medical Insurance (Part B) benefits. If you do not want
Part B, follow the instructions that come with the card.
The above process also applies when you have been a
disability beneficiary under Social Security or Railroad
Retirement for 24 months. A Medicare card will come in the
mail.
Some people do not automatically get a Medicare card. They
must file an application to get Medicare benefits. If you have
not applied for Social Security or Railroad Retirement
benefits, or if government employment is involved, or if you
have kidney disease, you must file an application for Medicare.
Check with Social Security if you are able to get Medicare
under the Social Security system or based on Medicare-covered
government employment; check with the Railroad Retirement
office if you are able to get Medicare under the Railroad
Retirement system.
If you must file an application for Medicare, you should
apply during your initial enrollment period, to avoid late
enrollment penalties under Medicare Part B (unless you qualify
for a special enrollment period as described on page 33). Your
initial enrollment period is a seven-month period that starts
three months before the month you first meet the requirements
for Medicare. If you do not sign up for Medicare during the
first three months of your initial enrollment period, there
will be a delay in starting your Part B coverage. Your coverage
will be delayed from one to three months after enrollment.
If you do not enroll for Medicare Part B at any time
during your initial enrollment period, you will not have
another chance to enroll until the next general enrollment
period. A general enrollment period is held each year from
January 1 through March 31 and if you enroll during this period
you will not be able to get Medicare until July of that year.
You may also be charged a premium penalty for late enrollment
(unless you qualify for a special enrollment period as
described on page 33).
The enrollment period requirements and penalties for late
enrollment described above for Part B also apply to people who
buy Part A. (See page 33 for more information about buying
Medicare Part A.)
Your Medicare Card
The Medicare card shows the Medicare coverage you
have--Hospital Insurance (Part A), Medical Insurance (Part B),
or both--and the date your protection started. If you do not
have both parts of Medicare, see page 33 for information on how
you can get the part you don't have.
Your Medicare card also shows your health insurance claim
number. Sometimes this claim number is referred to as your
Medicare number. The claim number usually has nine digits and
one or two letters. There may also be another number after the
letter. Your full claim number must always be included on all
Medicare claims and correspondence. When a husband and wife
both have Medicare, each receives a separate card and claim
number. Each spouse must use the exact name and claim number
shown on his or her card.
It is important that you remember to:
* Use your Medicare card only after the effective date shown
on it.
* Keep your card handy. And be sure to carry your card with
you whenever you are away from home.
* Always show your Medicare card when you receive services
that Medicare helps pay for.
* Always write your complete health insurance claim number
(including any letters) on all checks for Medicare
premium payments or any correspondence about Medicare.
Also, you should have your Medicare card available when
you make a telephone inquiry.
* Immediately ask Social Security to get you a new card if
you lose yours.
* Never let anyone else use your Medicare card.
Assistance for Low-Income Beneficiaries
Federal law requires that state Medicaid programs pay
Medicare costs for certain elderly and disabled people with low
incomes and very limited resources, described below. The
following is a general description only; rules may vary from
state to state.
Qualified Medicare Beneficiaries (QMB)
In general, you must meet these requirements:
* You must be entitled to Medic are Hospital Insurance (Part
A).
* Your annual income for 1992 must be at or below $7,050 for
one person and $9,430 for a family of two (amounts are
somewhat higher in Alaska and Hawaii).* Amounts for 1993
will be slightly higher than those for 1992.
* You cannot have resources such as bank accounts or stocks
and bonds worth more than $4,000 for an individual or
$6,000 for a couple. Your personal home, automobile,
burial plot, furniture, jewelry, or life insurance are not
counted, unless those items are of extraordinary value.
If you qualify as a QMB, your Medicare premiums,
deductibles and coinsurance will be covered.
* This amount is based on a percentage of the national
poverty guidelines plus an income disregard of $240.
Specified Low-income Medicare Beneficiaries (SLMB)
Beginning January 1, 1993, there is a new program for
certain low-income Medicare beneficiaries whose income is above
the level to qualify as a QMB, but whose income is below 110
percent of the national poverty guidelines. If you qualify as a
SLMB, Medicaid will pay your Medicare Part B premium only
($36.60 per month in 1993).
Where to Apply
If you think you may qualify for any of these benefits,
you should file an application at the state or local welfare,
social service or public health agency that serves people on
Medicaid. All of these agencies are state--not
federal--agencies.
If you need the telephone number for Medicaid, call
1-800-638-6833. Give the operator the name of your state and
explain that you want the Medicaid telephone number so you can
get information about these benefits.
Intermediaries and Carriers
The federal government contracts with private insurance
organizations called intermediaries and carriers to process
claims and make Medicare payments. Intermediaries handle
inpatient and outpatient claims submitted on your behalf by
hospitals, skilled nursing facilities, home health agencies,
hospices and certain other providers of services.
You will not usually need to get in touch with
intermediaries because Medicare pays most hospitals, skilled
nursing facilities, home health agencies, hospices and other
providers of services directly. But, if you have a question
about your Part A bill, ask someone who works at the facility
for help. If you cannot get an answer there, ask someone in the
billing office at the facility to help you get in touch with
the Medicare intermediary.
Carriers handle claims for services by doctors and
suppliers covered under Medicare's Part B program. If you have
questions about Medicare Part B claims, contact your Medicare
carrier. The addresses and phone numbers of carriers are on
pages 39 to 44.
If you want someone to contact Medicare for you, see "Your
Rights Under the Privacy Act," (page 5) for more information.
Peer Review Organizations
Peer Review Organizations (PROs) are groups of practicing
doctors and other health care professionals who are paid by the
federal government to review the care given to Medicare
patients. Each state has a PRO that decides, for Medicare
payment purposes, whether care is reasonable, necessary, and
provided in the most appropriate setting. PROs also decide
whether care meets the standards of quality generally accepted
by the medical profession. PROs have the authority to deny
payments if care is not medically necessary or not delivered in
the most appropriate setting.
PROs investigate individual patient complaints about the
quality of care and respond to:
* Requests for review of notices of noncoverage issued by
hospitals to beneficiaries; and
* Requests for reconsideration of PRO decisions by
beneficiaries, physicians, and hospitals.
The PRO will tell you in writing if the service you
got was not covered by Medicare. See page 12 for a discussion
of what is not covered by Medicare.
If you are admitted to a Medicare participating hospital,
you will receive An Important Message From Medicare which
explains your rights as a hospital patient and provides the
name, address and phone number of the PRO for your state. If
you are not given a copy of the message, be sure to ask for
one.
If you feel that you are improperly refused admission to a
hospital or that you are forced to leave the hospital too soon,
ask for a written explanation of the decision. Such a written
notice must fully explain how you can appeal the decision and
it must give you the name, address and phone number of the PRO
where your appeal or request for review can be submitted. (See
page 35 for further discussion of your appeal fights under
Medicare.)
Beneficiary Complaints
PROs are responsible for reviewing beneficiary complaints
about the quality of care provided by inpatient hospitals,
hospital outpatient departments and hospital emergency rooms;
skilled nursing facilities; home health agencies; ambulatory
surgical centers; and certain health maintenance organizations.
If you believe that you have received poor quality care
from one of these facilities, you may complain to the PRO. The
PRO will investigate written complaints from beneficiaries, or
their representatives, about the quality of Medicare services
received.
Your complaint must be in writing. If you wish, the PRO
will help you put your complaint in writing by taking the
information from you over the telephone and writing the
complaint. If someone other than the PRO makes a complaint for
you or on your behalf, you must give written permission for
that person to represent you in the complaint.
Medicare PROs for each state are listed on pages 45 to
49.
Your Right to Decide About Your Medical Care
Under a new Medicare law, when you are admitted to a
Medicare hospital or skilled nursing facility, get Medicare
home health care, or enroll in a Medicare-approved hospice or
health maintenance organization, you must be given written
information about your rights to make decisions about your
medical care.
Generally, you will be told about your fight to accept or
refuse medical or surgical treatment. You will also be told
about your fight to make--if you choose--an "advance
directive." An advance directive contains written instructions
about your choices for health care or naming someone to make
those choices for you. The instructions are to be used if you
are too sick or otherwise unable to talk. (The paper giving
your health care choices may be called a "living will" or "a
durable power of attorney for health care.")
You do not have to have an advance directive. But, if you
have one you can say "yes" in advance to treatment you want if
you get too sick to talk to your health care provider. You can
also say "no" in advance to treatment you don't want.
Laws governing advance directives vary from state to
state. Your treatment choices will depend on what is legal in
your state. You can ask health care professionals in your state
about the state's rules for living wills or durable powers of
attorney. You can also contact your local state's attorney's
office for this information.
Fraud and Abuse
Suspected Fraud Should be Reported
If you have reason to believe that a doctor, hospital, or
other provider of health care services is performing
unnecessary or inappropriate services, or is billing Medicare
for services you did not receive, you should immediately report
to the Medicare carrier or intermediary that handles your
claims (see page 3).
The routine waiver of deductibles and coinsurance by
doctors or suppliers of durable medical equipment is unlawful.
Coinsurance and deductible payments may be waived only after
careful consideration of a particular patient's financial
hardship. Therefore, if a doctor or supplier offers to waive
coinsurance or deductible payments, without having considered
your individual circumstances or when you have not asked to
have the payments waived, you should immediately report the.
offer to the Medicare carrier or intermediary.
Report to the Medicare Carrier or Intermediary First
Call the carrier or intermediary first when you suspect
fraud. Medicare carriers and intermediaries routinely look into
cases of possible fraud and will appreciate your alerting them
to your case. The carrier or intermediary will need to know the
exact nature of the wrongdoing you suspect, the date it
occurred, and the name and address of the party involved. Have
this information ready when you call. (The telephone number of
the Medicare intermediary or carrier is listed on the notice
explaining Medicare's decision on your Medicare claim. Medicare
carriers are also listed on pages 39 to 44.)
Calling For Further Help
If the Medicare carrier or intermediary does not respond
to your report of Medicare fraud or abuse, you may call the
Health Care Financing Administration (HCFA) hotline at
1-800-638-6833. There is no charge to you when you call this
number. The hotline operator will refer you to the appropriate
staff person at a HCFA regional office.
Be prepared to tell the HCFA regional office staff person:
* The exact nature of the wrongdoing you suspect, the date
it occurred, and the name and address of the party
involved.
* The name and location of the Medicare intermediary or
carrier you reported it to, and when you reported it.
* The name of any intermediary or carrier employee to whom
you spoke and what advice that person gave you.
Your Rights Under the Privacy Act
Under the Privacy Act all federal agencies must safeguard
information they collect about the people they serve.
When the Health Care Financing Administration (the agency
that administers the Medicare program) asks you to fill out
forms giving information about yourself to Medicare, we must:
* Explain why we are collecting the information.
* Tell you whom we plan to give it to.
* Tell you whether you must, by law, give us the
information.
When you give Medicare information, the Privacy Act allows
you to:
* Review your records for accuracy.
* Make corrections, if you believe there are errors.
* Know exactly what we will do with your records.
The Privacy Act also allows the government to verify the
information you give us, using computer matches with other
federal or state governments. If we do computer matches, we
must tell you that they take place and give you a chance to
protest our findings.
We include information about matches on all the forms you
fill out. We also put a notice in the Federal Register, which
is published by the federal government to notify the public of
official actions. Copies are available at many libraries. (A
computer-data match using Medicare, Internal Revenue Service
and Social Security information is discussed on page 11.)
Medicare Carriers and Intermediaries must follow Privacy
Act rules: These Medicare contractors may not discuss personal
information about you with your family members or others who
write or telephone on your behalf unless you give the
contractors written permission.
What Are Coordinated Care Plans?
More and more Medicare beneficiaries are joining
coordinated care plans. These coordinated care plans are
prepaid, managed care plans, most of which are health
maintenance organizations (HMOs) or competitive medical plans
(CMPs). Both HMOs and CMPs contract with Medicare and follow
the same contracting rules. In this handbook, HMOs will be used
to illustrate the benefits for both.
Many beneficiaries find that coordinated care plans are a
good way to get more health care for their dollar. HMOs provide
or arrange for all Medicare covered services, and generally
charge you fixed monthly premiums and only small co-payments.
This means that if you join a coordinated care plan and get all
of your services through the HMO, your out-of-pocket costs are
usually more predictable. Also, depending on your health needs,
those costs may be less than you would pay if you had to pay
the regular Medicare deductible and coinsurance amounts.
Coordinated care plans may also offer benefits not
covered by Medicare for little or no additional cost. Benefits
may include preventive care, dental care, heating aids and
eyeglasses.
Who Can Enroll in Coordinated Care Plans?
Most Medicare beneficiaries are eligible to enroll in
HMOs. HMOs cannot screen applicants to decide if they are
healthy, or delay coverage for pre-existing conditions. The
only enrollment criteria for Medicare HMOs are:
* You must be enrolled in Medicare Part B and continue to
pay the Part B premiums (you do not need to be able to get
Part A).
* You must live in the plan's service area.
* You cannot be receiving care in a Medicare-certified
hospice.
* You cannot have permanent kidney failure.
If you develop permanent kidney failure after joining a
coordinated care plan, the plan will provide, pay for, or
arrange for your care. If you choose to receive hospice care
after joining a coordinated care plan, the plan must inform you
about hospice services available in your area. Staff at the
coordinated care plan will explain how the hospice choice
affects your plan membership.
Joining a Coordinated Care Plan
To join a coordinated care plan, contact plans in your
area that have a contract with Medicare. All HMOs with Medicare
contracts have an advertised open enrollment period at least
once a year. Once you join, you may stay with the plan as long
as it continues to contract with Medicare. And you may return
to regular Medicare at any time.You can find out if there are
HMOs in your area that contract with Medicare by calling the
Health Care Financing Administration (HCFA) regional office
nearest you. Medicare Coordinated Care contact numbers are
listed in the box on page 7.
If you enroll in a coordinated care plan you will usually
be required to get all care from the plan. In most cases, if
you get services that are not authorized by the HMO (unless
they are emergency services or services you urgently need when
you are out of the plan's service area) neither the plan nor
Medicare will pay for the services.
When you join an HMO, be sure to read your membership
materials carefully to learn your fights and coverage.
Ending Enrollment in a Coordinated Care Plan
To end your enrollment in a coordinated care plan, send a
signed request to your plan or to your local Social Security or
Railroad Retirement Board office. You return to regular
Medicare the first day of the month following the month your
request is received by one of these offices. (If you leave a
coordinated care plan to return to regular Medicare and buy a
Medigap policy, you may have to wait for up to 6 months for the
new Medigap policy to cover any pre-existing condition.)
If You Have Problems
If you belong to a Medicare HMO and you are unhappy with
the quality of care, you can:
* Follow your HMO's grievance procedure, or
* Complain to your Peer Review Organization (PRO). PROs are
groups of practicing doctors and other health care
professionals under contract to Medicare to review the
care provided to Medicare patients (seepage 3).
If you have reason to believe that your Medicare HMO did
not give you necessary care, inappropriately ended your
enrollment, charged you an excessive premium, or falsified or
misrepresented information, you can:
* Write to the Office of Prepaid Health Care Operations and
Oversight, Room 4406 Cohen Building, 330 Independence
Ave., SW, Washington, DC 20201.
* Describe your problem. The Office will see that your case
is reviewed.
If you believe that your HMO has made an incorrect
decision on coverage of benefits or payment of a claim, you can
appeal--your appeal fights are similar to those provided under
traditional Medicare. (See page 36 for more information about
appeals.)
NOTE: A new Medicare supplement (Medigap) option is now
available in some states. It is a kind of coordinated care plan
called Medicare SELECT (see page 8 for more information).
If you need more information about Medicare and
coordinated care plans, you can get a copy of Medicare and
Coordinated Care Plans from the Consumer Information Center
(see inside back cover).
Regional Office Coordinated Care Contacts
Health Care Financing Administration staff at the offices
listed below can tell you if there are HMOs in your area that
contract with Medicare.
Boston: (Connecticut, Maine, Massachusetts, New Hampshire,
Rhode Island and Vermont) Beneficiary Services Branch
(617) 565-1232
New York: (New Jersey, New York, Puerto Rico and the Virgin
Islands) Carrier Operations Branch
(212) 264-8522
Philadelphia: (Delaware, District of Columbia,
Maryland, Pennsylvania, Virginia and West Virginia)
Beneficiary Services Branch
(215) 596-1332
Atlanta: (Alabama, North and South Carolina,
Florida, Georgia, Kentucky, Mississippi, and
Tennessee)
Beneficiary Services and HMO Branch
(404) 331-2549
Chicago: (Illinois, Indiana, Michigan, Minnesota, Ohio and
Wisconsin)
Beneficiary Services and HMO Branch
(312) 353-7180
Dallas: (Arkansas, Louisiana, New Mexico,
Oklahoma and Texas)
Beneficiary Services Branch
(214) 767-6401
Kansas City: (Iowa, Kansas, Missouri and
Nebraska)
Program Services Branch
(816) 426-2866
Denver: (Colorado, Montana, North and South
Dakota, Utah and Wyoming)
Beneficiary Services Branch
(303) 844-4024 ext 238
San Francisco: (American Samoa, Arizona,
California, Guam, Hawaii and Nevada)
Beneficiary Services Branch
(415) 744-3617
Seattle: (Alaska, Idaho, Oregon and
Washington)
Beneficiary Services Branch
(206) 553-0800
Medicare and Other Insurance
Buying Health Insurance to Supplement Medicare
Medicare provides basic protection against the cost of
health care, but it will not pay all of your medical expenses,
nor most long-term care expenses. For this reason, many private
insurance companies sell supplement (Medigap) insurance as well
as separate long-term care insurance. The federal government
does not sell or service such insurance.
Shopping for Medigap Insurance
If you are thinking about buying a new private insurance
policy or replacing an old policy to supplement your Medicare
protection or cover long-term care costs, you should shop
carefully. You can get a booklet, Guide to Health Insurance for
People with Medicare, to help you make Medicare supplement
decisions. (See box below for more information about the
guide.)
New Standardized Medigap Policies
Most states have adopted regulations limiting the sale of
Medigap insurance to no more than 10 standard policies. One of
the 10 is a basic policy offering a "core package" of benefits.
These standardized plans are identified by the letters A
through J. Plan A is the core package. The other nine plans
each have a different combination of benefits, but they all
include the core package. The basic policy, offering the core
package of benefits, is available in all states.
To find out what standardized policies are available in
your state, check with your state insurance department. The
telephone number of your state insurance department is probably
listed under "state agencies" in your telephone book. If not,
you can get a copy of the Guide to Health Insurance for People
with Medicare (see box below).
In most cases, if you already have a Medigap policy, you
may keep it but there are a few states where you must convert
your policy to one of the standard plans. In all cases, if you
buy a new policy, you will be required to choose a standardized
plan.
Open Enrollment Period for Medigap Policies
An open enrollment period for selecting Medigap policies
guarantees that for six months immediately following the
effective date of Medicare Part B coverage, people age 65 or
older cannot be denied Medigap insurance or charged higher
premiums because of health problems.
No matter how you enroll in Part B--whether by automatic
notification or through an initial, special or general
enrollment period--you are covered by the new guarantees if
both of the following are true:
* You are 65 or older and are enrolled in Medicare based on
age rather than disability.
* The date you get by adding six months to the effective
date for your Part B coverage (printed on your Medicare
card) is in the future. The date you get tells you when
your Medigap open enrollment ends.
NOTE: Even when you buy your Medigap policy in this open
enrollment period, the policy may still exclude coverage for
"pre-existing conditions" during the first six months the
policy is in effect. Pre-existing conditions are conditions
that were either diagnosed or treated during the six-month
period before the Medigap policy became effective.
Medicare SELECT
A new kind of Medigap insurance-available through 1994-has
been introduced in 15 states. It is called Medicare SELECT. The
difference between Medicare SELECT and regular Medigap
insurance is that a Medicare SELECT policy may (except in
emergencies) limit Medigap benefits to items and services
provided by certain selected health care professionals or may
pay only partial benefits when you get health care from other
health care professionals.
You can order a free copy of the Guide to health Insurance
for People With Medicare from the Consumer Information Center.
There is ordering information on the inside back cover of this
book. The guide:
* Explains how supplemental insurance works.
* Tells how to shop for Medigap insurance.
* Gives information on the new standard plans.
* Gives information on Medicare SELECT.
* Lists names, addresses and telephone numbers of state
insurance departments and state agencies on aging. Some of
these offices may have free counseling services available.
Insurers, including some HMOs, offer Medicare SELECT in
the same way standard Medigap insurance is offered. The
policies are required to meet certain federal standards and are
regulated by the states in which they are approved. The
premiums charged for Medicare SELECT policies are expected to
be lower than premiums for comparable Medigap policies that do
not have this selected-provider feature.
Medicare SELECT policies are permitted to be offered in
Alabama, Arizona, California, Florida, Illinois, Indiana,
Kentucky, Massachusetts, Minnesota, Missouri, North Dakota,
Ohio, Texas, Washington and Wisconsin. If you live in one of
these states, you can ask your state insurance department about
the Medicare SELECT policies that have been approved for sale
in the state.
Employment-related Retiree Coverage Instead of Medigap
Some retired people can get health coverage through their
former employer or union. This health coverage may supplement
Medicare but it is not Medigap insurance and does not have to
meet federal and state Medigap requirements. (See below for
rules about selling Medigap Insurance.)
Retiree coverage is usually provided free or at a greatly
reduced price and may be a good bargain. But the benefits may
not be adequate to serve as your supplement to Medicare. Does
your retiree plan have an "escape clause," so that benefits
might be changed? On the other hand, does your retiree plan
protect you from the preexisting condition restriction that
might be applied during the first six months under a Medigap
policy? Check carefully before you decide whether to stay with
your retiree coverage or buy a Medigap policy.
Medicaid Recipients
Low-income people who are eligible for Medicaid usually do
not need additional insurance. Medicaid pays for certain health
care benefits beyond those covered by Medicare, such as
long-term nursing home care. If you have Medigap insurance
purchased on or after November 5, 1991, and you become eligible
for Medicaid, you can ask that the Medigap benefits and
premiums be suspended for up to two years while you are covered
Medicaid. If you become ineligible for Medicaid benefits during
the two years, your Medigap policy is automatically
reinstituted if you give proper notice and begin paying
premiums again.
Coordinated Care Plans Instead of Medigap
Coordinated care plans that contract with Medicare are not
Medigap plans, but they can be an alternative to standard
Medigap insurance. (See page 6 for more information about
coordinated care plans.)
There are Rules for Selling Medigap Insurance
Both state and federal laws govern sales of Medigap
insurance. Companies or agents selling Medigap insurance must
avoid certain illegal practices. Federal criminal and civil
penalties (fines) may be imposed against any insurance company
or agent that knowingly:
* Sells you a health insurance policy that duplicates your
Medicare or Medicaid coverage, or any private health
insurance coverage you may have.
* Tells you that they are employees or agents of the
Medicare program or of any government agency.
* Makes a false statement that a policy meets legal
standards for certification when it does not.
* Sells you a Medigap policy that is not one of the 10
approved standard policies (after the new standards have
been put in place in your state).
* Denies you your Medigap open enrollment period by
refusing to issue you a policy, placing conditions on the
policy, or discriminating in the price of a policy because
of your health status, claims experience, receipt of
health care, or your medical condition.
* Uses the U.S. mail in a state for advertising or
delivering health insurance policies to supplement
Medicare if the policies have not been approved for sale
in that state.
If You Suspect Illegal Sales Practices
If you suspect that you have been the victim of illegal
sales practices, you should report these practices to your
state insurance department. States are responsible for the
regulation of insurance policies issued within their
boundaries. Because federal laws also govern Medigap sales
practices, you should also report the practices to the
appropriate federal officials.
Your state insurance department may be listed in your
telephone book. If not, you can get a copy of the booklet,
Guide to Health Insurance for People with Medicare (see box on
page 8).
To talk to federal officials about the suspected illegal
sales practices, you may call this number: 1-800-638-6833.
When Other Insurance Pays Before Medicare
If any of the following insurance situations applies to
you, please notify your doctor, hospital, and all other
providers of services. For more information about any of these
insurance situations, ask Social Security for a copy of
Medicare and Other Health Benefits. The publication is also
available free from the Consumer Information Center (see inside
back cover).
When You or Your Spouse Continue To Work
Medicare has special rules that apply to beneficiaries who
have employer group health plan coverage through their current
employment or the current employment of a spouse.
Group health plans of employers with 20 or more employees
are primary payers and Medicare is secondary payer for workers
age 65 or older, and workers' spouses age 65 or older. Group
health plans must offer these people the same health insurance
benefits under the same conditions offered to younger workers
and spouses. You and your spouse have the option to reject the
plan offered by the employer. If you reject the employer's
health plan, Medicare will remain the primary health insurance
payer. In that case, the employer's plan is not permitted to
offer you coverage that supplements Medicare covered services.
If your employer plan denies you coverage, offers you different
coverage, or pays benefits that are secondary to Medicare,
notify the carrier that handles your Medicare claims.
If You Are Disabled and Under Age 65
Medicare is the secondary payer for certain disabled
people who have premium-free Medicare Part A and are covered
under their employer's health plan or the employer health plan
of an employed family member. This secondary payer provision
applies to group health plans of employers that employ 100 or
more people. The secondary payer provision also applies to
group health plans of employers with fewer than 100 employees
if their employers are part of a multi-employer plan in which
at least one employer has 100 or more employees.
Other Situations Where Medicare is the Secondary Payer
If you have a work-related illness or injury, services
provided as treatment of that illness or injury should be
covered by workers' compensation or federal black lung
benefits. It is important that your Medicare claim form note
that the treatment is related to a work-related illness or
injury, even if the injury or illness occurred in the past.
Medicare is a secondary payer during a period (generally
18 months) for beneficiaries who have Medicare solely on the
basis of permanent kidney failure, if they have employer group
health plan coverage themselves or through a family member.
Medicare also serves as the secondary payer in cases where
no-fault insurance or liability insurance is available as the
primary payer.
Although Medicare benefits are secondary to benefits paid
by liability insurers, Medicare may make a conditional payment
if it receives a claim for services covered by liability
insurance. In those cases, Medicare may pay the claim; then,
when a liability settlement is reached, Medicare recovers its
conditional payment from the settlement amount.
If You Have or Can Get Both Medicare and Veterans Benefits
If you have or can get both Medicare and veterans
benefits, you may choose to get treatment under either program.
But, Medicare:
* Cannot pay for services you receive from Veterans Affairs
(VA) hospitals or other VA facilities, except for certain
emergency hospital services; and
* Generally cannot pay if the VA pays for VA-authorized
services that you get in a non-VA hospital or from a
non-VA physician.
Since July 1986, the VA has been charging coinsurance payments to some veterans who have non-service connected conditions for treatment in a VA hospital or medical facility, or for VA-authorized treatment by nonVA sources. The VA charges
coinsurance payments when the veteran's income exceeds a particular level. If the VA charges you a coinsurance payment for VA-authorized care by a non-VA physician or hospital, Medicare may be able to reimburse you, in whole or in part, for
your VA coinsurance payment obligation. (If you have Medigap
insurance, your Medigap policy may pay the VA coinsurance and
deductible obligations, even if Medicare cannot.)
NOTE: Medicare cannot reimburse you for VA coinsurance
payments for services furnished by VA hospitals and facilities,
unless the services are emergency inpatient or outpatient
hospital services. Then, the Medicare payment is subject to
Medicare deductible and coinsurance amounts.
If you have questions about whether the VA or Medicare
should pay for your doctor or other services covered under
Medicare Part B, contact your Medicare carrier. If you have
questions about whether the VA or Medicare should pay for
hospital or other services covered under Medicare Part A, ask
the provider of services to check with the Medicare
intermediary.
The Data Match
In 1989, Congress passed a; law that will help Medicare
get back an estimated $1 billion in taxpayer money. The law
enables Medicare to get accurate information about
beneficiaries' health insurance.
The law authorizes the Health Care Financing
Administration (the agency that administers the Medicare
program), the Internal Revenue Service, and the Social Security
Administration to share information about whether Medicare
beneficiaries or their spouses are working and whether they
have employment-related health insurance.
The process for sharing information from other agencies is
called the Data Match. The Data Match will help Medicare find
cases where another insurer should have paid first on Medicare
beneficiaries' health care claims. A designated Medicare
contractor will contact employers to confirm health insurance
coverage information. (For information about your fights under
the Data Match, see "Your Rights Under the Privacy Act,"
page 5.)
What Medicare Does Not Pay For
Custodial Care
Medicare does not pay for custodial care when that is the
only kind of care you need. Care is considered custodial when
it is primarily for the purpose of helping you with daily
living or meeting personal needs and could be provided safely
and reasonably by people without professional skills or
training. Much of the care provided in nursing homes to people
with chronic, long-term illnesses or disabilities is considered
custodial care. For example, custodial care includes help in
walking, getting in and out of bed, bathing, dressing, eating,
and taking medicine. Even if you are in a participating
hospital or skilled nursing facility, Medicare does not cover
your stay if you need only custodial care.
Care Not Reasonable and Necessary Under Medicare Program
Standards
Medicare does not pay for services that are not reasonable
and necessary for the diagnosis or treatment of an illness or
injury. These services include drugs or devices that have not
been approved by the Food and Drug Administration (FDA);
medical procedures and services performed using drugs or
devices not approved by FDA;* and services, including drugs or
devices, not considered safe and effective because they are
experimental or investigational.
* Some services are not covered by Medicare even when FDA
has approved the drug or device used.
If a doctor admits you to a hospital or skilled nursing
facility when the kind of care you need could be provided
elsewhere (for example, at home or in an outpatient facility),
your stay will not be considered reasonable and necessary, and
Medicare will not pay for your stay. If you stay in a hospital
or skilled nursing facility longer than you need to be there,
Medicare payments will end when inpatient care is no longer
reasonable and necessary.
If a doctor (or other practitioner) comes to treat
you---or you visit him or her for treatment--more often than is
medically necessary, Medicare will not pay for the "extra"
visits. Medicare will not pay for more services than are
reasonable and necessary for your treatment.
Medicare always bases decisions about what is reasonable
and necessary on professional medical advice.
Services Medicare Does Not Pay For
Medicare, by law, cannot pay for certain services. These
include services performed by immediate relatives or members of
your household, and services paid for by another government
program. If you have a question about whether Medicare pays for
a particular service, ask your Medicare carrier. (See pages 39
to 44 for the name and telephone number of your carrier.)
Limitation of Liability
Under Medicare law you will not be held responsible for
payment of the cost of certain health care services for which
you were denied Medicare payment if you did not know or you
could not reasonably be expected to know (for example, you had
not received a written notice) that the services were not
covered by Medicare. This provision is called limitation of
liability and is often referred to as a "waiver of liability."
This protection from financial liability applies only when the
care was denied because it was one of the following: Custodial
care.
Not "reasonable and necessary" under Medicare program
standards for diagnosis or treatment.
* For home health services, the patient was not homebound or
not receiving skilled nursing care on an intermittent
basis.
* The only reason for the denial is that, in error, you were
placed in a skilled nursing facility bed that was not
approved by Medicare.
This limitation of liability provision does not apply to
Medicare Part B services provided by a non-participating
physician or supplier who did not accept assignment of the
claim. However, in certain situations Medicare law will protect
you from paying for services provided by a non-participating
physician on a non-assigned basis that are denied as "not
reasonable and necessary." If your physician knows or should
know that Medicare will not pay for a particular service as
"not reasonable and necessary," he or she must give you written
notice--before performing the service--of the reasons why he
or she believes Medicare will not pay. The physician must get
your written agreement to pay for the services. If you did not
receive this notice, you are not required to pay for the
service. If you did pay, you may be entitled to a refund. (This
written notice is not an official Medicare. determination. If
you disagree with it, you may ask your doctor to submit a claim
for payment to get an official Medicare determination.)
Medicare Hospital Insurance (Part A)
What Medicare Part A Includes
Medicare Part A helps pay for four kinds of medically
necessary care:
1) Inpatient hospital care.
2) Inpatient care in a skilled nursing facility following a
hospital stay.
3) Home health care.
4) Hospice care.
There is a limit on how many days of hospital or skilled
nursing facility care Medicare helps pay for in each benefit
period. But, your Part A protection is renewed every time you
start a new benefit period. (Benefit periods are described
below.)
Skilled nursing facility care is the only type of nursing
home care that Medicare covers. Medicare does not pay for care
that is primarily custodial. (See pages 17 and 20 for more
about custodial care.)
Benefit Periods
A benefit period is a way of measuring your use of
services under Medicare Part A. Your First benefit period
starts the first time you receive inpatient hospital care after
your Hospital Insurance begins. A benefit period ends when you
have been out of a hospital or other facility primarily
providing skilled nursing or rehabilitation services for 60
days in a row (including the day of discharge). If you remain
in a facility (other than a hospital) that primarily provides
skilled nursing or-rehabilitation services, a benefit period
ends when you have not received any skilled care there for 60
days in a row. After one benefit period has ended, another one
will start whenever you again receive inpatient hospital care.
There is no limit to the number of benefit periods you can
have for hospital and skilled nursing facility care. However,
special limited benefit periods apply to hospice care (see page
19).
Here are two examples of how the benefit period works:
Example 1: Ms. Jones enters the hospital on January 5. She
is discharged on January 15. She has used 10 days of her first
benefit period. Ms. Jones is not hospitalized again until July
20. Since more than 60 days elapsed between her hospital stays,
she begins a new benefit period, her Part A coverage is
completely renewed, and she will again pay the hospital
deductible. (The hospital deductible is explained on page 15.)
Example 2: Ms. Smith enters the hospital on August 14. She
is discharged on August 24. She also has used 10 days of her
first benefit period. However, she is then readmitted to the
hospital on September 20. Since fewer than 60 days elapsed
between hospital stays, Ms. Smith is still in her first benefit
period and will not be required to pay another hospital
deductible. This means that the first day of her second
admission is counted as the eleventh day of hospital care in
that benefit period. Ms. Smith will not begin a new benefit
period until she has been out of the hospital (and has not
received any skilled care in a skilled nursing facility) for 60
consecutive days.
How Medicare Pays for Part A Services
Medicare Part A helps pay for most but not all of the
services you receive in a hospital or skilled nursing facility
or from a home health agency or hospice program. There are
covered services and noncovered services under each kind of
care. Covered services are services and supplies that Part A
pays for.
Hospitals, skilled nursing facilities, home health
agencies and hospices are called "providers" under the Medicare
Part A program. Providers submit their claims directly to
Medicare--you cannot submit claims for their services. The
provider will charge you for any part of the Part A deductible
you have not met and any coinsurance payment you owe. Providers
cannot require you to make a deposit before being admitted for
inpatient care that is or may be covered under Part A of
Medicare.
When a hospital, skilled nursing facility, home health
agency, or hospice sends Medicare a Part A claim for payment,
you get a Notice of Utilization that explains the decision
Medicare made on the claim. This notice is not a bill. If you
have any questions about the notice, get in touch with the
people who sent you the notice.
When You Are a Hospital Inpatient
Medicare Part A helps pay for inpatient hospital care if
all of the following four conditions are met:
1) A doctor prescribes inpatient hospital care for treatment
of your illness or injury.
2) You require the kind of care that can be provided only in
a hospital.
3) The hospital is participating in Medicare.*
4) The Utilization Review Committee of the hospital, a Peer
Review Organization or an intermediary does not disapprove
your stay.
* Under certain conditions, Medicare helps pay for
emergency inpatient care you receive in a
non-participating hospital.
If you meet these four conditions, Medicare will help pay
for up to 90 days of medically necessary inpatient hospital
care in each benefit period.**
** Medicare pays for only limited inpatient care in a
psychiatric hospital (see page 16). The hospital can tell
you about these limits.
During 1993, from the first day through the 60th day in a
hospital during each benefit period, Part A pays for all
covered services except the first $676. This is called the
inpatient hospital deductible. (A deductible is an amount you
owe before Medicare begins paying for services and supplies
covered by the program.) The hospital may charge you the
deductible only for your first admission in each benefit
period. If you are discharged and then readmitted before the
benefit period ends, you do not have to pay the deductible
again.
From the 61st through the 90th day in a hospital during
each benefit period, Part A pays for all covered services
except for $169 a day. This daily amount is called coinsurance.
The hospital charges you the $169.
Hospital reserve days (explained below) can help with your
expenses if you need more than 90 days of inpatient hospital
care in a benefit period.
Medicare Part A does not pay for the services of doctors
and certain other practitioners, even though you receive these
services in a hospital. Instead, those services are covered
under Medicare Part B. (A description of Medicare Part B begins
on page 21.)
Major services covered under Part A when you are a
hospital inpatient:
* A semiprivate room (two to four beds in a room).
* All your meals, including special diets.
* Regular nursing services.
* Costs of special care units, such as intensive care or
coronary care units.
* Drugs furnished by the hospital during your stay.
* Blood transfusions furnished by the hospital during your
stay. (See page 16 for information about coverage of
blood.)
* Lab tests included in your hospital bill.
* X-rays and other radiology services, including radiation
therapy, billed by the hospital.
* Medical supplies such as casts, surgical dressings, and
splints.
* Use of appliances, such as a wheelchair.
* Operating and recovery room costs.
* Rehabilitation services, such as physical therapy,
occupational therapy, and speech pathology services.
Some services not covered under Part A when you are a
hospital inpatient:
* Personal convenience items that you request such as a
telephone or television in your room.
* Private duty nurses.
* Any extra charges for a private room unless it is
determined to be medically necessary.
NOTE: If you disagree with a decision on the amount
Medicare will pay on a claim or whether services you receive
are covered by Medicare, you always have the fight to appeal
the decision (see page 35).
Hospital Inpatient Reserve Days
Medicare helps pay for your care in a hospital for up to
90 days in each benefit period. Medicare Part A also includes
an extra 60 hospital days you can use if you have a long
illness and have to stay in the hospital for more than 90 days.
These extra days are called reserve days.
You have only 60 reserve days in your lifetime. For
example, if you use 8 reserve days in your first hospital stay
this year, the next time you visit a hospital you will have
only 52 reserve days left to use, whether or not you have a new
benefit period.
You can decide when you want to use your reserve days.
After you have been in the hospital 90 days, you can use all or
some of your 60 reserve days if you wish.
If you do not want to use your reserve days, you must tell
the hospital in writing, either when you are admitted to the
hospital, or at any time afterwards up to 90 days after you are
discharged. If you use reserve days and then decide that you
did not want to use them, you must request approval from the
hospital to get them restored.
During 1993, Medicare Part A pays for all covered services
except $338 a day for each reserve day you use. You are
responsible for paying this $338.
All Medigap plans pay some part of hospital bills after
you have used all your reserve days. (See page 8 for more
information about Medigap insurance.)
Coverage of Blood Under Part A
Part A helps pay for blood (whole blood or units of packed
red blood cells), blood components, and the cost of blood
processing and administration. If you receive blood as an
inpatient of a hospital or skilled nursing facility, Part A
will pay for these blood costs, except for any nonreplacement
fees charged for the first three pints of whole blood or units
of packed red cells per calendar year. (The nonreplacement fee
is the amount that some hospitals and skilled nursing
facilities charge for blood that is not replaced.)
You are responsible for the nonreplacement fees for the
first three pints or units of blood furnished by a hospital or
skilled nursing facility. If you are charged nonreplacement
fees, you have the option of either paying the fees or having
the blood replaced. If you choose to have the blood replaced,
you can either replace the blood personally or arrange to have
another person or an organization replace it for you. A
hospital or skilled nursing facility cannot charge you for any
of the first three pints of blood you replace or arrange to
replace. (If you have already paid for or replaced blood under
Medicare Part B during the calendar year, you do not have to
meet those costs again under Medicare Part A. See page 21 for
an explanation of coverage of blood under Medicare Part B.)
Care in a Psychiatric Hospital
Part A helps pay for no more than 190 days of inpatient
care in a participating psychiatric hospital in your lifetime.
Once you have used these 190 days, Part A does not pay for any
more inpatient care in a psychiatric hospital.
Also, a special role applies if you are in a participating
psychiatric hospital at the time your Part A starts. Social
Security can give you more information.
Care Outside the United States
Medicare generally does not pay for hospital or medical
services outside the United States. (Puerto Rico, the U.S.
Virgin Islands, Guam, American Samoa, and the Northern Mariana
Islands are considered part of the United States.)
If you are planning to travel outside the United States,
you may want to buy special short-term health insurance for
foreign travel. If you have other health insurance in addition
to Medicare, check to see if health care in a foreign country
is covered under your policy.
There are rare emergency cases where Medicare can pay for
care in Canada or Mexico. Also, Medicare can sometimes pay if a
Mexican or Canadian hospital is closer to your home than the
nearest U.S. hospital that can provide the care you need. If
you get emergency treatment in a Canadian or Mexican hospital
or if you live near a Canadian or Mexican hospital, ask someone
who works at the hospital about Medicare coverage, or have the
hospital help you contact the Medicare intermediary.
Care in a Christian Science Sanatorium
Medicare Part A helps pay for inpatient hospital and
skilled nursing facility services you receive in a
participating Christian Science sanatorium if it is operated or
listed and certified by the First Church of Christ, Scientist,
in Boston. (However, Medicare Part B will not pay for the
practitioner.)
The Prospective Payment System
Medicare pays for most inpatient hospital care under the
Prospective Payment System (PPS). Under PPS, hospitals are paid
a predetermined rate per discharge for inpatient services
furnished to Medicare beneficiaries. The predetermined rates
are based on payment categories called Diagnosis Related
Groups, or DRGs. In some cases, the Medicare payment will be
more than the hospital's costs; in other cases, the payment
will be less than the hospital's costs. In special cases,
where costs for necessary care are unusually high or the length
of stay is unusually long, the hospital receives additional
payment. But even if Medicare pays the hospital less than the
cost of your care, you do not have to make up the difference.
It is important to remember that the PPS system does not
change your Medicare Part A protection as described in this
handbook. PPS does not determine the length of your stay in the
hospital or the extent of care you receive. The law requires
participating hospitals to accept Medicare payments as payment
in full, and those hospitals are prohibited from billing the
Medicare patient for anything other than the applicable
deductible and coinsurance amounts, plus any amounts due for
noncovered items or services such as television, telephone or
private duty nurses.
Skilled Nursing Facility Care
Medicare Part A can help pay for certain inpatient care in
a Medicare-participating skilled nursing facility following a
hospital stay. Your condition must require daily skilled
nursing or skilled rehabilitation services which, as a
practical matter, can only be provided in a skilled nursing
facility, and the skilled care you receive must be based on a
doctor's orders.
What is a Skilled Nursing Facility?
A skilled nursing facility is a specially qualified
facility that specializes in skilled care. It has the staff and
equipment to provide skilled nursing care or skilled
rehabilitation services and other related health services.
Skilled nursing care means care that can only be performed by,
or under the supervision of, licensed nursing personnel.
Skilled rehabilitation services may include such services as
physical therapy performed by, or under the supervision of, a
professional therapist.
Most nursing homes in the United States are not skilled
nursing facilities that participate in Medicare. In some
facilities, only certain portions participate in Medicare. If
you are not sure whether a facility participates in Medicare as
a skilled nursing facility, ask someone in the facility's
business office. If staff at the facility cannot tell you, ask
Social Security to check with the Health Care Financing
Administration.
When Can Medicare Pay?
Medicare Part A can help pay for your care in a
Medicare-participating skilled nursing facility if you meet all
of these five conditions:
1) Your condition requires daily skilled nursing or skilled
rehabilitation services which, as a practical matter, can
only be provided in a skilled nursing facility.
2) You have been in a hospital at least three days in a row
(not counting the day of discharge) before you are admitted
to a participating skilled nursing facility.
3) You are admitted to the facility within a short time
(generally within 30 days) after you leave the hospital.
4) Your care in the skilled nursing facility is for a
condition that was treated in the hospital, or for a
condition that arose while you were receiving care in the
skilled nursing facility for a condition which was treated
in the hospital.
5) A medical professional certifies that you need, and you
receive, skilled nursing or skilled rehabilitation services
on a daily basis.
All five conditions must be met. Remember, you must need
skilled nursing care or skilled rehabilitation services on a
daily basis. Part A will not pay for your stay if you need
skilled nursing or rehabilitation services only occasionally,
such as once or twice a week, or if you do not need to be in a
skilled nursing facility to get skilled services. Also,
Medicare will not pay for your stay if you are in a skilled
nursing facility mainly because you need custodial care.
Skilled Care or Custodial Care?
The only type of "nursing home" care Medicare helps pay
for is skilled nursing facility care. Medicare does not pay for
custodial care when that is the only kind of care you need.
Care is considered custodial when it is primarily for the
purpose of helping the patient with daily living or meeting
personal needs, and could be provided safely and reasonably by
people Without professional skills or training. For example,
custodial care includes help in walking, getting in and out of
bed, bathing, dressing, eating and taking medicine.
When your stay in a skilled nursing facility is covered by
Medicare, Part A helps pay for a maximum of 100 days in each
benefit period, but only if you need daily skilled nursing care
or rehabilitation services for that long.
If you leave a skilled nursing facility and are readmitted
within 30 days, you do not have to have a new three day stay in
the hospital for your care to be covered. If you have some of
your 100 days left and you need skilled nursing or
rehabilitation services on a daily basis for further treatment
of a condition treated during your previous stay in the
facility, Medicare will help pay.
In each benefit period, Part A pays for all covered
services for the first 20 days you are in a skilled nursing
facility. During 1993, for days 21 through 100, Part A pays for
all covered services except for $84.50 a day. You may be
charged up to this daily coinsurance amount by the skilled
nursing facility.
Medicare Part A does not cover your doctor's services while
you are in a skilled nursing facility. Medicare Part B covers
doctors' services. (A description of Medicare Part B begins on
page 21.)
Major services covered under Part A when you are in a skilled
nursing facility:
* A semiprivate room (two to four beds in a room).
* All your meals, including special diets furnished by the
facility.
* Regular nursing services.
* Physical, occupational, and speech therapy.
* Drugs furnished by the facility during your stay.
* Blood transfusions furnished during your stay. (See page
16 for information about coverage of blood.)
* Medical supplies such as splints and casts furnished by
the facility.
* Use of appliances such as a wheelchair furnished by the
facility.
Some services not covered under Part A when you are in a
skilled nursing facility:
* Personal convenience items that you request such as a
television in your room.
* Private duty nurses.
* Any extra charges for a private room, unless it is
determined to be medically necessary.
Rules That Protect You
Skilled nursing facilities cannot require you to pay a
deposit or other payment as a condition of admission to the
facility unless it is clear that services are not covered by
Medicare.
If you are already an inpatient in a skilled nursing
facility and the staff at the facility decides you no longer
need the level of skilled care covered by Medicare, they must
notify you immediately. If you disagree with this decision, the
facility must submit your claim at your request to Medicare for
an official Medicare decision on coverage. The facility may not
require you to pay a deposit until Medicare issues its
decision. You must pay for any coinsurance while your claim is
being processed, and for any services which are never covered
by Medicare.
Complaints and Appeals
If you want to complain about a skilled nursing facility's
treatment of patients or other conditions that concern you, you
can contact the state survey agency. Each skilled nursing
facility can give you the telephone number and address of the
state survey agency if you ask for it. You can also look at a
copy of the skilled nursing facility's latest certification
survey report. The survey report will tell you the results of
the state survey agency's review of how well the agency thinks
the facility followed the rules about patient's rights, safety
and quality of care.
Also, if you disagree with a decision on the amount
Medicare will pay on a claim or whether services you receive
are covered by Medicare, you always have the fight to appeal
the decision (see page 35).
Home Health Care
If you need skilled health care in your home for the
treatment of an illness or injury, Medicare pays for covered
home health services furnished by a participating home health
agency. A home health agency is a public or private agency that
specializes in giving skilled nursing services and other
therapeutic services, such as physical therapy, in your home.
(A hospital or other facility that mainly provides skilled
nursing or rehabilitation services cannot be considered your
home.)
Medicare pays for home health visits only if all four of
the following conditions are met:
1) The care you need includes intermittent skilled nursing
care, physical therapy, or speech therapy.
2) You are confined to your home (homebound).
3) You are under the care of a physician who determines
you need home health care and sets up a home health
plan for you.
4) The home health agency providing services participates
in Medicare.
Once all four of these conditions are met, either Medicare
Part A or Medicare Part B will pay for all medically necessary
home health services. When you no longer need intermittent
skilled nursing care, physical therapy, or speech therapy,
Medicare will pay for home health services if you continue to
need occupational therapy.
Medicare home health services do not include coverage for
general household services such as laundry, meal preparation,
shopping, or other home care services furnished mainly to
assist people in meeting personal, family, or domestic needs.
To determine whether you can get services under the
Medicare home health benefit, ask your physician to refer you
to a Medicare participating home health agency. The home health
agency will evaluate your case and tell you whether you meet
the requirements for Medicare coverage. Home health agencies
should not charge for this evaluation.
Home health services covered by Medicare:
* Part-time or intermittent skilled nursing care. (This can
include eight hours of reasonable and necessary care per
day for up to 21 consecutive days--or longer in certain
circumstances.)
* Physical therapy.
* Speech therapy.
If you need intermittent skilled nursing care, or
physical or speech therapy, Medicare also pays for:
* Occupational therapy.
* Part-time or intermittent services of home health aides.
* Medical social services.
* Medical supplies.
* Durable medical equipment (80 percent of approved amount).
Home health services not covered by Medicare.
* 24-hour-a-day nursing care at home.
* Drugs and biologicals.
* Meals delivered to your home.
* Homemaker services.
* Blood transfusions.
Medicare pays the full approved cost of all covered home
health visits. You may be charged only for any services or
costs that Medicare does not cover. However, if you need
durable medical equipment, you are responsible for a 20 percent
coinsurance payment for the equipment. (See page 26 for more
information about durable medical equipment.)
The home health agency will submit the claim for payment.
You do not have to send in any bills yourself.
NOTE: If you disagree with a decision on the amount
Medicare will pay on a claim or whether services you receive
are covered by Medicare, you always have the fight to appeal
the decision (see page 35).
Hospice Care
A hospice is a public agency or private organization that
is primarily engaged in providing pain relief, symptom
management and supportive services to terminally ill people.
Hospice care is a special type of care for people who are
terminally ill. It includes both home care and inpatient care,
when needed, and a variety of services not otherwise covered
under Medicare. Under the Medicare hospice benefit, Medicare
pays for services every day and also permits a hospice to
provide appropriate custodial care, including homemaker
services and counseling.
Medicare Part A helps pay for hospice care if all three of
these conditions are met:
1) A doctor certifies that the patient is terminally ill.
2) The patient chooses to receive care from a hospice
instead of standard Medicare benefits for the terminal
illness.
3) Care is provided by a Medicare-participating hospice
program.
Special benefit periods apply to hospice care. Part A pays
for two 90-day periods, followed by a 30-day period, and--when
necessary--an extension period of indefinite duration. If a
beneficiary cancels hospice care during one of the first three
benefit periods, any days left in that period are lost, but the
remaining benefit period(s) are still available, And, a
beneficiary may disenroll from the hospice during any benefit
period, return to regular Medicare coverage, then later
re-elect the hospice benefit if another benefit period is
available.
Two Benefit Period Examples:
* Mr. Jones cancelled his hospice care at the end of 59 days
during his first 90-day benefit period. He lost the 31
remaining days of the first 90-day period. But if he wants
to, he can choose hospice care again. He still has a
90-day period, a 30-day period, and the indefinite
extension period.
* Ms. Smith cancelled hospice care during her final
extension period. She cannot use the Medicare hospice
benefit again.
There are no deductibles under the hospice benefit. The
beneficiary does not pay for Medicare-covered services for the
terminal illness, except for small coinsurance amounts for
outpatient drugs and inpatient respite care.
The patient is responsible for five percent of the cost of
outpatient drugs or $5 toward each prescription, whichever is
less. For inpatient respite care, the patient pays five percent
of the Medicare-allowed rate (approximately $4.48 per day in
1993). The rate varies slightly depending on the area of the
country.
Respite care under the hospice program is a shortterm
inpatient stay in a facility. The Medicare beneficiary's
inpatient stay gives temporary relief--a respite--to the person
who regularly assists with home care. Each inpatient respite
care stay is limited to no more than five days in a row.
While receiving hospice care, if a patient requires
treatment for a condition not related to the terminal illness,
Medicare continues to help pay for all necessary covered
services under the standard Medicare benefit program.
Services covered by Part A when provided by a hospice:
* Nursing services.
* Doctors' services.
* Drugs, including outpatient drugs for pain relief and
symptom management.
* Physical therapy, occupational therapy and speechlanguage
pathology.
* Home health aide and homemaker services.
* Medical social services.
* Medical supplies and appliances.
* Short-term inpatient care, including respite care.
* Counseling.
The Medicare Part A hospice benefit does not pay for
treatments other than for pain relief and symptom management of
a terminal illness. Regular Medicare can usually help pay for
treatments not related to the terminal illness.
NOTE: If you disagree with a decision on the amount
Medicare will pay on a claim or whether services you receive
are covered by Medicare, you always have the right to appeal
the decision (see page 35).
Medicare Medical Insurance (Part B)
What Medicare Part B Includes
Medicare Part B helps pay for:
* Doctors' services.
* Outpatient hospital care.
* Diagnostic tests.
* Durable medical equipment.
* Ambulance services.
* Many other health services and supplies that are not
covered by Medicare Part A.
The following sections tell you more about these different
kinds of care, the services that are and are not covered by
Medicare Part B, and what part of your medical expenses
Medicare will pay.
Deductible and Coinsurance Amounts Under Part B
The Annual Deductible
You must pay the first $100 in approved charges for
covered medical expenses in 1993. This is called the Medicare
Part B annual deductible. You need to meet this $100 deductible
only once during the year, and the deductible can be met by any
combination of covered expenses. You do not have to meet a
separate deductible for each different kind of covered service
you receive.
The Blood Deductible
You must pay any nonreplacement fees charged for the first
three pints or units of blood and blood components you use each
year. (The nonreplacement fee is the amount that some
practitioners and facilities charge for blood that is not
replaced.) This is called the Medicare Part B blood deductible.
After you have replaced or paid for the first three pints of
blood and you have met the $100 annual deductible, Medicare
will pay 80 percent of the approved amount for blood, starting
with the fourth pint. (If you have already paid for or replaced
some units of blood under Medicare Part A during the calendar
year, you do not have to pay for or replace that number of
units again under Medicare Part B.)
Coinsurance
After you pay the annual deductible, you will owe a share
of the Medicare-approved amount for most services and supplies.
This share is called coinsurance. Usually, your coinsurance
share is 20 percent of the Medicare-approved amount.
Medicare determines the approved amount for each service
you receive. If your services were provided "on assignment,"
you pay only the coinsurance (see page 28 for an explanation of
assignment).
If your services were not provided "on assignment," and
the charges for your services were more than the
Medicare-approved amount, you usually owe the Medicare
coinsurance plus certain charges above the Medicare-approved
amount. (See "Medicare Approved Amounts" on page 29.) There are
limits on the amount your doctor can charge you.
NOTE: This explanation of your deductible and coinsurance
amounts describes Medicare's payment system for most services
covered by Medicare Part B. In cases where payment for services
is handled in a different way, you will be given an explanation
along with the description of services covered. (You will find
more information about how Medicare pays Part B claims in the
section beginning on page 28.)
Doctors' Services Covered By Medicare Part B
Medicare Part B helps pay for covered services you receive
from your doctor in his or her office, in a hospital, in a
skilled nursing facility, in your home, or any other location.
Major doctors' services covered by Medicare Part B:
* Medical and surgical services, including anesthesia.
* Diagnostic tests and procedures that are part of your
treatment.
* Radiology and pathology services by doctors while you are
a hospital inpatient or outpatient.
* Treatment of mental illness. (Medicare payments for
treatment are limited; see page 27)
* Other services such as:
-- X-rays.
-- Services of your doctor's office nurse.
-- Drugs and biologicals that cannot be
self-administered.
-- Transfusions of blood and blood components,
-- Medical supplies.
-- Physical/occupational therapy and speech pathology
services.
Some doctors' services not covered by Medicare Part B:
* Routine physical examinations, and tests directly related
to such examinations (except some Pap smears and
mammograms, see page 25).
* Most routine foot care and dental care.
* Examinations for prescribing or fitting eyeglasses or
hearing aids.
* Immunizations (except pneumococcal pneumonia vaccinations
or immunizations required because of an injury or
immediate risk of infection, and hepatitis B for certain
persons at risk).
* Cosmetic surgery, unless it is needed because of
accidental injury or to improve the function of a
malformed part of the body.
Types of Doctors
Most doctors' services are furnished by a doctor of
medicine or a doctor of osteopathy. Other "physicians" that can
furnish some covered services include chiropractors, doctors of
podiatric medicine (podiatrists), doctors of dental surgery or
of dental medicine (dentists), and doctors of optometry
(optometrists).
Chiropractors' Services
Medicare helps pay for only one kind of treatment
furnished by a licensed chiropractor: manual manipulation of
the spine to correct a subluxation that is demonstrated by
X-ray. Medicare Part B does not pay for any other diagnostic or
therapeutic services, including Xrays, furnished by a
chiropractor.
Podiatrists' Services
Medicare Part B helps pay for any covered services of a
licensed podiatrist to treat injuries and diseases of the foot.
Examples of common problems include ingrown toenails, hammer
toe deformities, bunion deformities and heel spurs.
Medicare generally does not pay for routine foot care such
as cutting or removal of corns and calluses, trimming of nails,
and other hygienic care. But, Medicare does help pay for some
routine foot care if you are being treated by a medical doctor
for a medical condition affecting your legs or feet (such as
diabetes or peripheral vascular disease) which requires that
the routine care be performed by a podiatrist or by a doctor of
medicine or osteopathy.
Dentists' Services
Medicare Part B generally does not pay for care in
connection with the treatment, filling, removal, or replacement
of teeth; root canal therapy; surgery for impacted teeth; or
other surgical procedures involving the teeth or structures
directly supporting the teeth. However, Medicare does help pay
for services of a dentist in certain cases when the medical
problem is more extensive than the teeth or structures directly
supporting them. (If you need to be hospitalized because of the
severity of a dental procedure, Medicare Part A may pay for
your inpatient hospital stay even if the dental care itself is
not covered by Medicare.)
Optometrists' Services
Medicare helps pay for Medicare-covered vision care,
including the services of an optometrist if the optometrist is
legally authorized to perform those services by the state in
which he or she performs them. However, Medicare will not pay
for routine eye exams and usually will not pay for eyeglasses.
(Medicare will pay for cataract spectacles, cataract contact
lenses, or intraocular lenses that replace the natural lens of
the eye after cataract surgery. Medicare will also pay for one
pair of conventional eyeglasses or conventional contact lenses
if necessary after cataract surgery with insertion of an
intraocular lens.)
Second Opinion Before Surgery
Sometimes your doctor may recommend surgery for the
treatment of a medical problem. In some cases, surgery is
unavoidable. But there is increasing evidence that many
conditions can be treated equally well without surgery. Because
even minor surgery involves some risk, we recommend that you
get an opinion from a second doctor to help you decide about
surgery. Medicare will help pay for a second opinion. Medicare
will also help pay for a third opinion if the first and second
opinions contradict each other.
Your own doctor is the best source for referral to another
doctor. But, if you wish, you can call your Medicare Part B
carrier for the names and phone numbers of doctors in your area
who provide second opinions. (Medicare carriers are listed on
pages 39 to 44.)
Services of Special Practitioners
Medicare Part B helps pay for covered services you receive
from certain specially qualified practitioners who are not
physicians. The practitioners must be approved by Medicare.
Medicare-approved practitioners are listed below:
* Certified registered nurse anesthetist.
* Certified nurse midwife.
* Clinical psychologist.
* Clinical social worker (other than in a hospital).
* Physician assistant. (A physician assistant can furnish
certain services in a hospital or certain other
facilities, can serve as an assistant-at-surgery, and can
furnish services in any location that is designated as a
rural health professional shortage area.)
* Nurse practitioner and clinical nurse specialist in
collaboration with a physician. (A nurse practitioner can
furnish services in a skilled nursing facility or a
Medicaid nursing facility in any area. In addition, a
nurse practitioner or clinical nurse specialist can
furnish services in a rural area.)
Outpatient Hospital Services
Medicare Part B helps pay for covered services you receive
as an outpatient from a participating hospital for diagnosis or
treatment of an illness or injury. Under certain conditions,
Medicare helps pay for emergency outpatient care you receive
from a non-participating hospital.
When you get outpatient hospital services, you are
responsible for the annual Medicare Part B deductible. In
addition to the deductible, you are responsible for a
coinsurance of 20 percent of the hospital's charge above the
deductible.
When you go to a hospital for outpatient services, you are
sometimes asked how much of your Part B deductible you have
met. One easy way to answer that question is to show your most
recent Explanation of Your Medicare Part B Benefits notice.
From this form, hospital staff can usually tell how much of the
$100 annual deductible you have met.
If the hospital cannot tell how much of the $100
deductible you have met and the charge for the services you
received is less than $100, the hospital may ask you
to pay the entire bill. The amount you pay the hospital can be
credited toward any part of the deductible you have not met. If
you pay the hospital for deductible amounts you do not owe, the
hospital or the Medicare intermediary will refund the amount
you overpaid.
Major outpatient hospital services covered by Part B:
* Services in an emergency room or outpatient clinic,
including same-day surgery
* Laboratory tests billed by the hospital.
* Mental health care in a partial hospitalization
psychiatric program, if a physician certifies that
inpatient treatment would be required without it.
* X-rays and other radiology services billed by the
hospital.
* Medical supplies such as splints and casts.
* Drugs and biologicals that cannot be selfadministered.
* Blood transfusions furnished to you as an outpatient.
Some outpatient hospital services not covered by Part B:
* Routine physical examinations and tests directly related
to such examinations (except some Pap smears and
mammograms, see page 25).
* Eye or ear examinations to prescribe or fit eyeglasses or
hearing aids.
* Immunizations (except pneumococcal pneumonia and hepatitis
B vaccinations, or immunizations required because of an
injury or immediate risk of infection).
* Most routine foot care.
Other Services and Supplies Covered by Medicare
Ambulatory Surgical Services
An ambulatory surgical center is a facility that provides
surgical services that do not require a hospital stay. Medicare
Part B will pay for the use of an ambulatory surgical center
for certain approved surgical procedures. However, by law
Medicare can only pay centers that have an agreement with
Medicare to participate in the Medicare program. If you do not
know whether an ambulatory surgical center participates in
Medicare, ask someone in the center's business office. If that
person does not know, contact Social Security and ask them to
check with the Health Care Financing Administration.
In addition to helping pay for the use of the ambulatory
surgical center, Medicare also helps pay for physician and
anesthesia services that are provided in connection with the
procedure.
Home Health Services
If you have both Medicare Part A and Part B, your Part A
pays for home health services. But Part B will pay for home
health services if you do not have Part A. Medicare home health
services are described on page 18.
Outpatient Physical and Occupational Therapy and Speech
Pathology Services
Medicare Part B helps pay for medically necessary
outpatient physical and occupational therapy or speech
pathology services, if all the following three conditions are
met:
1) Your doctor prescribes the service.
2) Your doctor or therapist sets up the plan of treatment.
3) Your doctor periodically reviews that plan.
You can receive physical therapy, occupational therapy or
speech pathology services as an outpatient of a participating
hospital or skilled nursing facility, or from a participating
home health agency, rehabilitation agency, or public health
agency. The provider of services may charge you only for any
part of the $100 annual deductible you have not met, 20
percent of the remaining approved amount, and any noncovered
services.
Also, you can receive services directly from an
independently practicing, Medicare-approved physical or
occupational therapist in his or her office or in your home if
such treatment is prescribed by a doctor. (Medicare does not
pay for services provided by independently practicing speech
pathologists.) But, the maximum amount Medicare pays for each
of these services provided by an independently practicing
physical or occupational therapist in 1993 is $600 a year.
(This is 80 percent of the maximum approved amount of up to
$750.) The Medicare payment would be less than $600 if charges
for these services are used to meet part or all of your $100
annual deductible.
Comprehensive Outpatient Rehabilitation Facility Services
Under certain circumstances, Medicare helps pay for
outpatient services you receive from a Medicareparticipating
comprehensive outpatient rehabilitation facility (CORF).
Covered services include physicians' services; physical,
speech, occupational and respiratory therapies; counseling; and
other related services. You must be referred by a physician who
certifies that you need skilled rehabilitation services. For
most CORF services, you are responsible only for the annual
deductible and 20 percent of the Medicare approved-charges.
Medicare helps pay for mental health treatment in a CORF; the
Medicare payment limit for mental health treatment in a CORF is
discussed on page 27.
Partial Hospitalization for Mental Health Treatment
Partial hospitalization (sometimes called day treatment)
is a program of outpatient mental health care. Under certain
conditions, Medicare Part B helps pay for these programs when
provided by hospital outpatient departments or by community
mental health centers. If you are considering mental health
treatment, check with the program you have chosen to see if it
meets the conditions for Medicare payment.
Rural Health Clinic Services
Medicare Part B helps pay for services of physicians,
nurse practitioners, physician assistants, nurse midwives,
visiting nurses (under certain conditions), clinical
psychologists, and clinical social workers furnished by a rural
health clinic. You are responsible only for the annual Medicare
Part B deductible plus 20 percent of the Medicare-approved
charge for the clinic.
Federally Qualified Health Center Services
Federally qualified health centers are located in both
rural and urban areas and any Medicare beneficiary may seek
services at them. As part of the "federally qualified health
center benefit," Medicare Part B helps pay for services of
physicians, nurse practitioners, physician assistants, nurse
midwives, visiting nurses (under certain conditions), clinical
psychologists, and clinical social workers. Also, as part of
the federally qualified health center benefit, Medicare helps
pay for certain preventive health services. The center can tell
you what services are part of the federally qualified health
center benefit.
You do not have to pay the Medicare Part B annual
deductible for services provided under the federally qualified
health center benefit. You are responsible for 20 percent of
the Medicare-approved charge for the clinic. (There are some
cases, under Public Health Service guidelines, when the
federally qualified health center may waive all or part of the
20 percent Part B coinsurance which is applicable for center
services.)
Federally qualified health centers often provide services
in addition to those offered under the Medicare federally
qualified health center benefit. Examples of these services are
X-rays and equipment like crutches and canes. As long as the
center meets Medicare requirements to provide these services,
Medicare Part B can help pay for them. You are responsible for
any unmet part of the annual Medicare Part B deductible plus 20
percent of the Medicare-approved charge for the service.
Laboratory Services
All laboratories must be certified under the Clinical
Laboratory Improvement Amendments to perform laboratory
testing. Medicare Part B pays the full approved fee for covered
clinical diagnostic tests provided by certified laboratories
that are participating in Medicare. The laboratory can be
independent, part of a hospital outpatient department or in a
doctor's office. The laboratory must accept assignment for the
tests. (See page 28 for an explanation of assignment.) It may
not bill you for the tests.*
* In the state of Maryland only, you may be charged 20
percent coinsurance for hospital outpatient tests.
Some laboratories are approved only for certain kinds of
tests. Your doctor can usually tell you which laboratories are
approved and whether the tests he or she is ordering from an
approved laboratory are covered by Medicare. If your doctor can
not tell you, call your Part B carrier. (Carriers are listed on
pages 39 to 44.)
Portable Diagnostic X-ray Services
Medicare Part B helps pay for portable diagnostic X-ray
services you receive in your home or other locations if they
are ordered by a doctor and if they are provided by a
Medicare-approved supplier. You can ask your Part B carrier
whether the supplier is Medicare-approved. (Carriers are listed
on pages 39 to 44.)
Other Diagnostic Tests
Medicare Part B also helps pay for other diagnostic tests,
including X-rays, that your doctor orders to evaluate your
medical problems.
Pap Smear Screening
Medicare Part B helps pay once every three years for Pap
smears to screen for cervical cancer. Medicare helps pay more
frequently for certain women at high risk.
Medicare also pays for diagnostic Pap smears as needed
when symptoms are present.
Breast-Cancer Screening (Mammography)
Medicare Part B helps pay for X-ray screenings for the
detection of breast cancer, if they are provided by a
Medicare-approved supplier. Women 65 or older can use the
benefit every other year. Some younger women covered by
Medicare can use the screening benefit more frequently. Your
Medicare carrier can tell you how often Medicare will pay for a
screening mammogram for you. Medicare also pays for diagnostic
mammograms as needed when symptoms are present.
For accurate up-to-date information on cancer prevention,
detection, diagnosis, and treatment for patients, their
families, and the general public, call the Cancer Information
Service at 1-800-4-CANCER.
Radiation Therapy
Medicare Part B helps pay for outpatient radiation therapy
given under the supervision of your doctor.
Kidney Dialysis and Transplants
Medicare Part B helps pay for kidney dialysis and
transplants. For detailed information on this coverage, you can
get a copy of Medicare Coverage of Kidney Dialysis and Kidney
Transplant Services from the Consumer Information Center (see
inside back cover).
Heart and Liver Transplants
Under certain limited conditions, Medicare Part B helps
pay for heart and liver transplants in a Medicare-approved
facility. If you are considering a heart or liver transplant,
you and your physician can find out about Medicare coverage by
contacting your Medicare carrier. If you belong to an HMO, the
HMO will give you the information you need about Medicare
coverage.
Ambulance Transportation
Medicare Part B helps pay for medically necessary
ambulance transportation, including air ambulance, but only if:
* The ambulance, equipment and personnel meet Medicare
requirements.
* Transportation in any other vehicle could endanger your
health.
Under these conditions, Medicare helps pay for ambulance
transportation but only to a hospital or skilled nursing
facility, or from a hospital or skilled nursing facility to
your home. Medicare does not pay for ambulance use from your
home to a doctor's office or to a dialysis facility that is not
in or next to a hospital.
Medicare usually helps pay only if the ambulance
transportation is in your local area. But, if there are no
local facilities equipped to provide the care you need,
Medicare helps pay for necessary ambulance transportation to
the closest facility outside your local area that can provide
the necessary care. If there is a local facility equipped to
provide the care you need but you choose to go to another
institution that is farther away, Medicare payment is based on
the charge for transportation to the closest facility that can
provide the necessary care.
Durable Medical Equipment
Medicare Part B helps pay for durable medical equipment
such as oxygen equipment, wheelchairs, and other medically
necessary equipment that your doctor prescribes for use in your
home. (A hospital or facility that mainly provides skilled
nursing or rehabilitation services cannot be considered your
home.)
To be considered durable medical equipment, the equipment
must be able to be used over again by other patients, must
primarily serve a medical purpose, must not be useful to people
who are not sick or injured, and must be appropriate for use in
your home. Not all types of equipment that you might find
useful can meet all four of these requirements.
Only your own doctor should prescribe medical equipment
for you. An equipment supplier should not take any of the
following actions:
* Contact you first, either by phone or by mail, and offer
to get your doctor or Medicare to approve an item. (It is
all fight for the supplier to contact you in response to
calls from your doctor or other health care workers.)
* Say he or she works for, or represents, Medicare.
* Deliver equipment to your home that neither you nor your
doctor ordered.
* Send you used items, while billing Medicare for new ones.
Some of these actions may be against the law. If you
believe a supplier has taken any of these actions, you should
alert Medicare. First, ask your doctor whether he or she
ordered the item. If your doctor did not order the item, you
should file a complaint with your Medicare carrier. You can
file a complaint by phone, in person or in writing. Your
carrier will investigate.
It is also illegal for a supplier to offer you items at no
cost to you or offer to pay the Medicare coinsurance on items.
If a supplier makes one of these offers, file a complaint with
your Medicare carrier as described above.
NOTE: The durable medical equipment supplier must have
your doctor's prescription before delivering any of the
following items: seat lift chairs, power-operated vehicles,
equipment for care of pressure sores, or transcutaneous
electrical nerve stimulators. In the case of seat lift chairs,
Medicare covers only the lift mechanism, not the chair itself.
Medicare pays for different kinds of durable medical
equipment in different ways; some equipment must be rented,
other equipment must be purchased, and for some equipment you
may choose rental or purchase. Your Medicare carrier will be
able to provide more specific guidance on which method will be
used for a particular item. (Carriers are listed on pages 39 to
44.)
Prosthetic Devices
Medicare Part B helps pay for prosthetic devices needed to
replace an internal body organ. These include Medicare-approved
corrective lenses needed after a cataract operation, ostomy
bags and certain related supplies, and breast prostheses
(including a surgical brassiere) after a mastectomy. Medicare
also helps pay for artificial limbs and eyes, and for arm, leg,
back, and neck braces. Medicare does not pay for orthopedic
shoes unless they are an integral part of leg braces and the
cost is included in the charge for the braces. Medicare does
not pay for dental plates or other dental devices.
Medical Supplies
Medicare Part B helps pay for surgical dressings, splints,
and casts ordered by a doctor in connection with your medical
treatment. This does not include adhesive tape, antiseptics, or
other common first-aid supplies.
Drugs and Biologicals
Pneumococcal Pneumonia Vaccine
Medicare Part B pays the full approved charges for
pneumococcal pneumonia vaccine and its administration. Neither
the $100 annual deductible nor the 20 percent coinsurance
applies to this service.
Hepatitis B Vaccine
Medicare Part B helps pay for hepatitis B vaccine
administered to beneficiaries considered to be at high or
intermediate risk of contracting the disease.
Hemophilia Clotting Factors
Medicare Part B helps pay for blood clotting factors and
items related to their administration for hemophilia patients
who are able to use them to control bleeding without medical or
other supervision. The amount of clotting factors necessary to
have on hand for a specific period is determined for each
patient individually.
Blood
Medicare Part B helps pay for blood and blood components
you receive as a hospital outpatient or as part of other
services. (See page 21 for an explanation of the blood
deductible.)
Antigens
Under certain circumstances, Medicare Part B helps pay for
antigens prepared for you by your doctor. You can check with
your Medicare carrier to see if Medicare will pay for your
antigens. (Carriers are listed on pages 39 to 44.)
Immunosuppressive Drugs
Immunosuppressive drugs are often given to prevent
rejection of transplanted organs. Medicare Part B helps pay for
drugs used in immunosuppressive therapy for one year beginning
with the date of discharge from the inpatient hospital stay
during which a Medicare-covered organ transplant was performed.
Epoetin Alfa
Medicare Part B may help pay for the drug Epoetin alfa
when used to treat Medicare beneficiaries with anemia related
to chronic kidney failure, or related to use of AZT in
HIV-positive beneficiaries or for other uses that a Medicare
carrier finds medically appropriate. (The kidney failure
patients are not required to be on dialysis.) The Epoetin alfa
must be administered incident to the services of a doctor in
the office or in a hospital outpatient department. Part B also
helps pay for Epoetin alpha that is self-administered by home
dialysis patients or administered by their caregivers.
Medicare Payments for Outpatient Treatment of Mental Illness
Medicare helps pay for outpatient mental health services
you receive from professionals such as physicians, clinical
psychologists, clinical social workers and other nonphysician
practitioners. These professionals furnish services in various
settings, for example, hospitals, comprehensive outpatient
rehabilitation facilities, community mental health centers, and
skilled nursing facilities.
When furnished on an outpatient basis, mental health
treatment services are subject to a payment limitation that is
called the "outpatient mental health limitation." In effect,
once the annual deductible is met, Medicare Part B pays only 50
percent (not 80 percent) of the approved amount for these
services. On assigned claims, beneficiaries are responsible for
paying the remaining 50 percent. For unassigned claims,
beneficiaries may have to pay more. (See page 28 for
information about assignment.)
Partial hospitalization services (except those furnished
by a physician) for treatment of mental illness are not subject
to this payment limitation. Also, brief office visits for the
sole purpose of monitoring or changing drug prescriptions used
in the treatment of mental illness are not subject to this
payment limitation. (See page 24 for more information about
partial hospitalization services.)
Medicare Medical Insurance (Part B) Payments
The Assignment Payment Method
Under the assignment method, your doctor or supplier
agrees to accept the amount approved by the Medicare carrier as
total payment for covered services: the doctor or supplier