Medicare

Medicare

Q & A

60 COMMONLY ASKED QUESTIONS ABOUT MEDICARE

This booklet is meant to provide information about the Medicare

program but is not a legal document. The official Medicare

program provisions are contained in the relevant laws,

regulations and rulings.

MEDICARE AND MEDICAID

Q. What is Medicare?

A. Medicare is a Federal health insurance program established

in 1965 for people aged 65 or older. It now also covers

people of any age with permanent kidney failure, and

certain disabled people. It is administered by the Health

Care Financing Administration (HCFA) of the U.S.

Department of Health and Human Services. Local Social

Security Administration offices take applications for

Medicare and provide information about the program.

Q. What is the difference between Medicare and Medicaid?

A. Medicare is a Federal health insurance program for the

elderly and disabled regardless of income and assets.

Medicaid, on the other hand, is a medical assistance

program jointly financed by the State and Federal

governments for eligible low-income individuals. Medicaid

covers health care expenses for all recipients of Aid to

Families with Dependent Children (AFDC), and most States

also cover the needy elderly, blind, and disabled who

receive cash assistance under the Supplemental Security

Income (SSI) program. Coverage also is extended to certain

infants and low-income pregnant women, and, at the option

of the State, other low-income individuals with medical

bills that qualify them as categorically or medically

needy.

Q. How many people are covered by Medicare?

A. Medicare currently covers approximately 35 million people,

of whom about 3 million are disabled and some 150,000 are

kidney disease patients.

YOUR MEDICARE COVERAGE

Q. What does Medicare cover?

A. Medicare has two parts: Hospital insurance (Part A) and

Supplementary Medical insurance (Part B). Part A helps pay

for inpatient care in a hospital or skilled nursing

facility, or for care from a home health agency or

hospice. If you are admitted to a hospital, Medicare

provides coverage for a semiprivate room, meals, regular

nursing services, operating and recovery room costs,

intensive care, drugs, laboratory tests, X-rays, and all

other medically necessary services and supplies. Covered

services in a skilled nursing facility include a

semi-private room, meals, regular nursing services,

rehabilitation services, drugs, medical supplies, and

appliances.

Part B helps pay for physician services, outpatient

hospital care, clinical laboratory tests, and various

other medical services and supplies, including durable

medical equipment. Doctors' services are covered no matter

where you receive them in the U.S. Covered services

include surgical services, diagnostic tests and X-rays

that are part of your treatment, medical supplies

furnished in a doctor's office, and drugs which cannot be

self-administered and are part of your treatment.

Medicare pays only for care that it determines is

medically necessary.

WHAT MEDICARE DOESN'T COVER

Q. Are there services Medicare does not cover?

A. While Medicare helps pay a large portion of your medical

expenses, there are various health care services and

products for which Medicare will not pay. These generally

include custodial care; eyeglasses, hearing aids, and

examinations to prescribe or fit them; a telephone, TV, or

radio in your hospital room; and most outpatient

prescription drugs and patent medicines. Medicare also

does not pay for cosmetic surgery, most immunizations,

dental care, routine foot care, and routine physical

checkups. Although some personal care services (for

example: bathing assistance, eating assistance, etc.) can

be covered along with skilled care, they are never covered

alone except under the hospice benefit.

PAYING FOR MEDICARE

Q. How is Medicare financed?

A. Medicare Hospital Insurance (Part A) is financed mainly

from a portion of the Social Security payroll tax (the

HCA) deduction. The Medicare pan of the payroll tax is

1.45 percent from the employee and 1.45 percent from the

employer on wages up to $125,000 in 1991. Medicare Medical

Insurance (Part B), which is optional, is financed by the

monthly premiums paid by enrollees and from Federal

general revenues. The monthly premium in 1991 is $29.90.

The premium pays about 25 percent of the cost of the Part

B program and general tax revenues pay about 75 percent.

WHO'S ELIGIBLE?

Q. Who is eligible for Medicare?

A. Generally, people age 65 and over can get Part A benefits

if they can establish their eligibility for monthly Social

Security or Railroad Retirement benefits on their own or

their spouse's work record. In addition, certain

government employees whose work has been covered for

Medicare purposes, and their spouses, can also have Part

A.

In rare cases, involving those who became age 65 in 1974

or earlier, Part A may be available if these people meet

certain United States residence and citizenship or legal

alien requirements.

Part A is also available to most individuals with

end-stage renal disease, and to those who have been

entitled to Social Security disability benefits or

Railroad Retirement disability benefits for more than 24

months, and to certain disabled government employees whose

work has been covered for Medicare purposes.

Any person who is eligible for Part A is also eligible to

enroll in Part B. Enrollees in Part B must pay a monthly

premium of $29.90 in 1991.

MEDICARE ENROLLMENT

Q. How do I sign up for Medicare?

A. If you are already getting Social Security or Railroad

Retirement benefit payments when you turn 65, you will

automatically get a Medicare card in the mail. The card

will usually show that you are entitled to both Part A and

Part B, and the beginning dates of your entitlement to

each. If you do not want Part B, you can refuse it by

following the instructions that come with the card. If you

are not receiving such payments, you may have to apply for

Medicare coverage. Check with Social Security to see if

you are able to get Medicare under the Social Security

system or based on Medicare-covered government employment;

check with the Railroad Retirement office if you are able

to get Medicare under the Railroad Retirement system. If

you must file an application for Medicare, you should do

so during your initial seven-month enrollment period that

starts three months before the month you first meet the

requirements for Medicare.

GETTING MORE INFORMATION

Q. Whom do I call to get more information about Medicare?

A. If you want to know how and when to sign up for Medicare,

or how to change an address or replace a lost Medicare

card, contact any Social Security office.

ENROLLING LATE FOR PART B

Q. When I enrolled in Medicare Part A, I did not sign up for

Part B. Is that coverage still available to me on the same

terms?

A. You may still enroll in Part B during the annual general

enrollment period from January 1 to March 31, and your

coverage will begin on July 1. However, your monthly

premium may be higher than it would have been had you

enrolled in Part B when you enrolled in Part A. In most

cases, if you defer your enrollment in Part B, you must

pay a monthly premium surcharge. The surcharge is 10

percent for each 12-month period in which you could have

been enrolled but were not.

You may not have to pay the surcharge if you are covered

by an employer health plan. Delayed enrollment without

penalty is generally available if you have been covered by

an employer health plan based on your or your spouse's

current employment since you were first able to get

Medicare. In that case, you can enroll in Part B during a

special 7-month enrollment period. The period begins with

the month the employer group health plan coverage ends, or

with the month the employment on which it is based ends,

whichever is earlier. In the case of certain disability

beneficiaries, the special period begins when Medicare

replaces the employer group health plan as the primary

payer of the beneficiary's covered medical services.

DO YOU HAVE BOTH PART A & B COVERAGE?

Q. How do I know whether I'm covered by one or both parts of

Medicare?

A. Your Medicare card shows the coverage you have [Hospital

Insurance (Part A), Medical Insurance (Part B), or both]

and the date your protection started.

Q. What does the letter mean that appears after my health

insurance claim number on my Medicare card?

A. It is a code used by Social Security to indicate the type

of benefits you are receiving. There may also be another

number after the letter. Your full claim number must

always be included on all Medicare claims and

correspondence.

BUYING MEDICARE

Q. If I am not entitled to Medicare based on employment, can

I buy the coverage?

A. Individuals age 65 or over who are United States residents

and either United States citizens, or aliens who have been

lawfully admitted for permanent residence and have resided

in the United States for at least five years at the time

of filing, can purchase both Part A and Part B, or just

Part B. The monthly premiums in 1991 are $177 for Part A

and $29.90 for Part B.

GETTING MEDICARE-COVERED CARE

Q. Are there different health care systems Medicare

beneficiaries can use to get their Medicare benefits?

A. Yes. You can receive services covered by Medicare either

through the traditional fee-for-service (pay-as-you-go)

delivery system or through coordinated care plans, such as

health maintenance organizations (HMOs) and competitive

medical plans (CMPs), which have contracts with Medicare.

Whether you choose fee-for-service or coordinated care,

you get all of Medicare's hospital and medical benefits.

The care provided by both systems is comparable. The

differences in the two systems include how the benefits

are delivered, how and when payment is made and how much

you might have to pay out of your pocket. Most of the

information in this booklet pertains to fee-for-service

health care. For more information about coordinated care

plans, request a copy of the leaflet titled Medicare and

Coordinated Care Plans from any Social Security office.

FEE-FOR-SERVICE

Q. How does the fee-for-service system work?

A. Under the fee-for-service health care system you have

freedom of choice. You can choose any licensed physician

and use the services of any hospital, health care

provider, or facility approved by Medicare that agrees to

accept you as a patient. Generally a fee is paid each time

a service is used. Medicare, within certain limits, pays a

large portion of the hospital, physician, and other health

care expenses.

HMOs AND CMPs

Q. How do coordinated care plans work?

A. In a coordinated care plan (HMO or CMP) a network of

health care providers (doctors, hospitals, skilled nursing

facilities, etc.) generally offers comprehensive,

coordinated medical services to plan members on a prepaid

basis. Except in an emergency, services usually must be

obtained from the health care professionals and facilities

that are part of the plan. Care may be provided at a

central facility or in the private practice offices of the

doctors and other professionals affiliated with the plan.

ENROLLING IN AN HMO

Q. Can I enroll in a HMO?

A. Yes. You may enroll in any HMO or CMP that has a contract

with Medicare. The only requirements are that you live in

the plan's service area and be enrolled in Medicare Part

B. Medicare makes a monthly payment to the plan to provide

you with Medicare-covered services. Some plans provide

additional services, and most charge enrollees a monthly

premium and nominal copayments when a service is used.

Contact plans in your area for enrollment and coverage information.

DISENROLLING FROM AN HMO

Q. If I enroll in a coordinated care plan, can I later return

to fee-for-service Medicare coverage?

A. Yes. You may disenroll from a coordinated care plan at any

time. Your coverage under fee-for-service Medicare will

begin the first day of the following month. You may also

change from one plan to another simply by enrolling in the second

plan.

CHARGES YOU PAY

Q. Do Medicare beneficiaries have to pay any charges out of

their own pockets when they use covered services?

A. Yes. Both Part A and Part B have deductible and

coinsurance amounts for which you are liable. You also

must pay all permissible charges in excess of Medicare's

approved amounts for Part B services, and charges for

services not covered by Medicare. These charges do not

apply to you if you are enrolled in a coordinated care

plan. Instead, you generally must pay a monthly premium to

the plan and nominal copayments when a service is used.

HELP FOR LOW-INCOME BENEFICIARIES

Q. Is assistance available to help low-income Medicare

beneficiaries pay Medicare's premiums, deductibles and

coinsurance amounts?

A. Yes. If your annual income is below the national poverty

level and you do not have access to many financial

resources, you may qualify for government assistance under

the State Medicaid program in paying Medicare monthly

premiums and at least some of the deductibles and

coinsurance amounts. The national poverty income levels

for 1991 are $6,620 for one person and $8,880 for a family

of two. If you think you may qualify, you should contact

your State or local welfare, social service or public health agency.

PART B DEDUCTIBLE AND COINSURANCE AMOUNTS

Q. How much are the Part B deductible and coinsurance

amounts?

A. The Medicare Part B deductible in 1991 is $100 per year.

This means that you are responsible for the first $100 of

approved expenses for physician and other medical services

and supplies. The deductible is paid when you are first

charged for covered services. After the deductible has

been met, then Medicare starts paying. Medicare generally

pays 80 percent of all other approved charges for covered

services for the rest of the year. You are responsible for

the other 20 percent. If the physician or supplier does

not accept assignment of the Medicare claim (that is,

accept Medicare's approved amount as payment in full), you

are responsible for all permissible charges in excess of

the approved amount. You also generally are liable for

charges for services not covered by Medicare. Them is no

deductible or coinsurance for home health services.

PART A DEDUCTIBLE AND COINSURANCE AMOUNTS

Q. How much are the Part A deductible and coinsurance amounts?

A. The Part A deductible is $628 per benefit period in 1991.

This means that if you are admitted to the hospital, you

are responsible for the first $628 of Medicare-covered

expenses. After that, Medicare pays all covered expenses

for the first 60 days. For the next 30 days, Medicare pays

all covered expenses except for a coinsurance amount of

$157 per day in 1991. You are responsible for the $157 per

day. Whenever more than 90 days of inpatient hospital care

are needed in a benefit period, you can use your lifetime

reserve days to pay for covered services. Every person

enrolled in Part A has a lifetime reserve of 60 days for

inpatient hospital care. Once used, these days are not

renewed. When a reserve day is used, Medicare pays for all

covered services except for a coinsurance amount of $314 a

day in 1991. You are responsible for the $314 a day.

Because the Part A deductible applies to each benefit

period, you could have to pay more than one deductible in

a year if you were hospitalized more than once.

SKILLED NURSING FACILITY CARE

Q. What if I require care in a skilled nursing facility after

leaving the hospital?

A. If, after being in a hospital for at least three days, you

receive covered care in a skilled nursing facility that

has been approved to participate in the Medicare program,

Part A will help cover services for up to 100 days per

benefit period. Medicare pays all covered expenses for the

first 20 days and all but $78.50 per day in 1991 for the

next 80 days. You are responsible for the $78.50 per day.

BENEFIT PERIOD

Q. What is a benefit period?

A. A benefit period is a way of measuring your use of

Medicare Part A services. A benefit period, which applies

to hospital and skilled nursing facility care, begins the

day you are hospitalized and ends after you have been out

of the hospital or skilled nursing facility for 60 days in

a row. It also ends if you remain in a skilled nursing

facility but do not receive any skilled care there for 60

days in a row. There is no limit to the number of benefit

periods you can have.

PROCESSING MEDICARE CLAIMS

Q. Who processes Medicare claims and payments?

A. Medicare claims and payments are handled by insurance

organizations under contract to the Federal government.

The organizations handling claims from hospitals, skilled

nursing facilities, home health agencies, and hospices are

called "intermediaries." You almost never have to get

involved in the Part A claims process. The insurance

organizations that handle Medicare's Part B claims are

called "carriers." The names and addresses of the carriers

and areas they serve are listed in the back of The

Medicare Handbook, available from any Social Security

Administration office.

MEDICARE APPROVED AMOUNT

Q. How does Medicare determine its approved amounts for

physician services?

A. Medicare's approved amount, which is also referred to as

the reasonable or allowable charge, is determined in the

following manner for most Part B claims:

When a doctor submits a claim, the Medicare carrier

compares the amount submitted with the doctor's usual

charge for the service and with the amounts other

physicians in the community usually charge for the same

service. The lowest of the three becomes the approved

amount. After you have met the Part B annual deductible

($100 in 1991), Medicare generally pays 80 percent of the

approved amount and you are liable for the other 20

percent. A NEW SYSTEM FOR DETERMINING THE AMOUNT

PHYSICIANS WILL BE PAID FOR PROVIDING SERVICES

COVERED BY MEDICARE WILL BE INTRODUCED IN 1992.

ACCEPTING MEDICARE ASSIGNMENT

Q. What does it mean when a physician accepts assignment?

A. Physicians and suppliers who accept assignment of Medicare

claims agree to not charge you more than the Medicare

approved amount for services and supplies covered by Part

B. They are paid directly by Medicare, except for the

deductible and coinsurance amounts for which you are

responsible. Some physicians and suppliers have signed

agreements to participate in Medicare. In doing so, they

have agreed to accept assignment of Medicare claims all of

the time. Other physicians and suppliers will accept

assignment on a case-by-case basis or not at all.

PHYSICIANS WHO DON'T ACCEPT ASSIGNMENT

Q. What if a physician does not accept assignment of a

Medicare claim?

A. Physicians and suppliers who do not accept assignment of

Medicare claims may charge more than the Medicare approved

amount and collect full payment directly from you.

Medicare then pays you 80 percent of the approved amount

for the covered service, less any unmet portion of the

$100 Part B deductible. You are liable for all permissible

charges in excess of Medicare's approved amount.

LIMITING A PHYSICIAN'S CHARGES

Q. Is there a limit to the amount a physician can charge a

Medicare beneficiary for a covered service?

A. Yes. Physicians who do not accept assignment of a Medicare

claim are limited as to the amount they can charge

Medicare beneficiaries for covered services. In 1991,

charges for visits and consultations cannot be more than

140% of the Medicare prevailing charge for physicians who

do not participate in Medicare. For most other services

(surgery, for example) the limit is 125 percent of the

prevailing charge for nonparticipating physicians. In 1992

the limiting charge for all services covered by Medicare

will be 120 percent of the fee schedule amount for

nonparticipating physicians and in 1993 it will be 115

percent of the fee schedule amount.

FINDING PARTICIPATING PHYSICIAN

Q. How can I find a Medicare-participating physician or

supplier?

A. The names and addresses of Medicare-participating

physicians and suppliers are listed by geographic area in

the Medicare-Participating Physician/Supplier Directory.

You can get the directory for your area free of charge

from your Medicare carrier (listed in the back of The

Medicare Handbook) or you can call your carrier and ask

for names of some participating physicians and suppliers

in your area. This directory is also available for review

in Social Security offices, State and area offices of the

Administration on Aging, and in most hospitals. Physicians

and suppliers are given the opportunity each year to sign

Medicare participation agreements.

FILING A PART B CLAIM

Q. When a physician provides Medicare-covered services to a

Medicare beneficiary, does the physician or beneficiary

file the claim with the Medicare carrier for payment?

A. For Medicare-covered services and supplies received on or

after September 1, 1990, the physician or supplier is

required to submit the claim for the beneficiary. For

services and supplies provided prior to that date, the

physician or supplier was not required to submit the claim

unless the physician or supplier participated in Medicare

or had agreed to accept assignment of the claim.

WHAT TO DO WHEN YOU HAVE A PROBLEM WITH A CLAIM

Q. Whom do I call if I have a question about a Medicare claim

for a doctor's services?

A. Call the Medicare carrier for your area. The carrier's

name and toll-free telephone number are listed in the back

of The Medicare Handbook and appear on all Explanation of

Medicare Benefit (EOMB) forms.

Q. How long should I wait before contacting the Medicare

carrier to check on the status of a claim?

A. Allow 30 to 45 days for the claim to be paid. If you have

not received a check or an Explanation of Medicare Benefit

(EOMB) payment statement after 45 days, call the Medicare

carrier for your area.

APPEALING A CLAIMS PAYMENT DECISION

Q. What recourse do I have if Medicare denies payment for a

claim or pays less than I think it should?

A. You have a fight to appeal Medicare's coverage and payment

determinations for both the hospital (Part A) and medical

(Part B) segments of Medicare. The appeals processes are

explained in The Medicare Handbook.

AMBULANCE SERVICES

Q. Does Medicare cover ambulance services?

A. Medicare Part B can help pay for certain medically

necessary ambulance services when: (1) the ambulance,

equipment, and personnel meet Medicare requirements; and

(2) transportation by any other means would endanger your

health. This includes transportation from a hospital to a

skilled nursing facility, or from a hospital or skilled

nursing facility to your home. Medicare will also cover a

round trip from a hospital or a participating skilled

nursing facility to an outside supplier to obtain

medically necessary diagnostic or therapeutic services not

available at the hospital or skilled nursing facility

where you are an inpatient.

MEDICARE COVERAGE FOR WHEELCHAIRS,

PACEMAKERS, AND ARTIFICIAL LIMBS

Q. Does Medicare cover prostheses and medical devices?

A. Yes. Medicare covers these items when provided by a

hospital, skilled nursing facility, home health agency,

hospice, comprehensive outpatient rehabilitation facility

(CORP), or a rural health clinic. Medicare also covers

cardiac pacemakers, corrective lenses needed after

cataract surgery, colostomy or ileostomy supplies, breast

prostheses following a mastectomy, and artificial limbs

and eyes. Coverage also is provided for durable medical

equipment, such as wheelchairs, hospital beds, walkers,

and other equipment prescribed by a doctor for home use.

NURSING HOME CARE

Q. Does Medicare pay for long-term care in a nursing home?

A. No. Medicare only helps pay for post-hospital extended

care in a skilled nursing facility (SNF). A SNF is a

specially qualified facility with the staff and equipment

to provide skilled nursing care, a full range of

rehabilitation therapies, and related health services.

Medicare only pays when a skilled level of care is

required as a continuation of a hospital stay and the care

is provided in a SNF that participates in Medicare. Even

if you are in a SNF that participates in Medicare,

Medicare will not pay if the services you receive are

mainly personal care or custodial services, such as help

in walking, getting in and out of bed, eating, dressing,

and bathing. A SNF that participates in Medicare will

inform you at the time of admission about potential

Medicare payment and your rights to seek payment.

CHIROPRACTIC SERVICES

Q. Will Medicare pay for a chiropractor's services?

A. Medicare helps pay for only one kind of treatment

furnished by a licensed chiropractor: manual manipulation

of the spine to correct a subluxation that can be

demonstrated by X-ray.

PSYCHIATRIC COVERAGE

Q. Does Medicare pay for care in a psychiatric hospital?

A. Yes. Medicare Part A helps pay for up to 190 days of

inpatient care in a participating psychiatric hospital

during a beneficiary's lifetime.

CHECKING FOR CANCER

Q. Does Medicare pay for cervical- and breast-cancer

screenings?

A. Yes. Medicare Part B helps pay for Pap smears to screen

for the detection of cervical cancer and for X-ray

screenings for the detection of breast cancer.

HOME HEALTH CARE

Q. Does Medicare cover home health care?

A. Yes. If you need skilled health care in your home for the

treatment of an illness or injury, Medicare pays for

covered home health services furnished by a participating

home health agency. To qualify, you must be homebound,

need part-time or intermittent skilled nursing care,

physical therapy, or speech therapy. You also must be

under the care of a physician who determines you need home

health care and sets up a home health care plan for you.

COVERAGE LIMITS

Q. How long can home health care last?

A. Home health care can continue for as long as you are under

a physician's plan of care and the services you require

are the type of services Medicare covers, such as skilled

nursing, physical therapy, and speech therapy. Home health

aide services are also available if you are eligible.

Daily skilled care is available on a limited basis to

those beneficiaries who qualify.

WHO PAYS?

Q. How much does Medicare pay toward the cost of home health

care?

A. Medicare pays the full approved cost of all covered home

health visits. There is no coinsurance on home health

care. You may be charged only for any services or costs

that Medicare does not cover. However, if you need durable

medical equipment, you are responsible for a 20 percent

coinsurance payment for the equipment.

MEDICARE AND HOSPICE CARE

Q. What is hospice care?

A. Hospice is a special way of caring for a patient whose

disease cannot be cured and whose medical life expectancy

is six months or less. Patients receive a full scope of

palliative medical and support services for their terminal

illnesses.

Q. Is hospice care available to Medicare beneficiaries?

A. Yes. Medicare beneficiaries certified by a physician to be

terminally ill may elect to receive hospice care from a

Medicare-approved hospice program. Under Medicare, hospice

is primarily a comprehensive home care program that

provides medical and support services for the management

of a terminal illness. Beneficiaries who elect hospice

care are not permitted to use standard Medicare to cover

services for the treatment of conditions related to the

terminal illness. Standard Medicare benefits are provided,

however, for the treatment of conditions unrelated to the

terminal illness. Medicare has special benefit periods for

beneficiaries who enroll in a hospice program.

PROs

Q. What are PROs?

A. Utilization and Quality Control Peer Review Organizations

(PROs) are physician-sponsored organizations in each State

that the Health Care Financing Administration (HCFA)

contracts with to ensure that Medicare beneficiaries

receive care which is medically necessary, reasonable,

provided in the appropriate setting, and which meets

professionally accepted standards of quality. Among other

things, PROs are responsible for intervening when quality

problems are identified and for making every attempt to

resolve them. They ensure that beneficiaries are advised

of their appeal rights and review all written complaints

from beneficiaries or their representatives concerning the

quality of care rendered. If you are admitted to a

hospital, you will receive a notice explaining your rights

under Medicare and how to contact the PRO if the need

arises.

MEDICARE AND FOREIGN TRAVEL

Q. If I require medical services outside the United States

and its territories, will Medicare pay the bills?

A. No. But there are three exceptions. Medicare will help pay

for care in qualified Canadian or Mexican hospitals if:

(1) You are in the United States when an emergency occurs, and

a Canadian or Mexican hospital is closer to, or

substantially more accessible from, the site of the

emergency than the nearest U.S. hospital that can provide

the emergency services you need.

(2) You live in the United States and a Canadian or Mexican

hospital is closer to, or substantially more accessible

from, your home than the nearest U.S. hospital that can

provide the care you need, regardless of whether an

emergency exists, and without regard to where the illness

or injury occurs.

(3) You are in Canada travelling by the most direct route

between Alaska and another State when an emergency occurs,

and a Canadian hospital is closer to, or substantially

more accessible from, the site of the emergency than the

nearest U.S. hospital that can provide the emergency services you

need.

WHO PAYS FIRST?

Q. Is Medicare always the primary payer of a beneficiary's

medical bills or are there situations when another insurer

must pay first?

A. There are a number of situations in which another insurer

is the primary payer of your health care costs and

Medicare is the secondary payer. For example, Medicare may

be the secondary payer if you are covered by an employer

group health insurance plan, are entitled to veterans

benefits, workers' compensation, or black lung benefits.

Medicare also can be the secondary payer if no-fault

insurance or liability insurance (such as automobile

insurance) is available as the primary payer. In cases

where Medicare is the secondary payer, Medicare may pay

some or all of the charges not paid by the primary payer

for services and supplies covered by Medicare. This issue

is discussed in more detail in the publication titled

Medicare Secondary Payer, available from any Social Security office.

MEDIGAP INSURANCE

Q. What is "Medigap" insurance?

A. Medigap insurance is private health insurance designed

specifically to supplement Medicare's benefits by filling

in some of Medicare's coverage. A Medigap policy generally

pays for Medicare approved charges not paid by Medicare

because of deductibles or coinsurance amounts that you are

liable for. There are Federal minimum standards for such

policies which most States include as pan of their

programs to regulate Medigap policies. Because Medigap

policies can have different combinations of benefits and

the policies may vary from one insurance company to

another, you should compare policies before buying.

Compare the benefits and the premiums. Some policies may

offer better benefits than others at a lower premium.

MEDIGAP TO BE STANDARDIZED IN 1992

Q. Is it true that Medigap policies are to be standardized?

A. Yes. During 1992 most States are expected to adopt

regulations limiting the Medigap insurance market to no

more than 10 standard policies. One of the 10 will be a

basic policy offering a "core package" of benefits. The

other nine will each have a different combination of

benefits, but they all must include the core package.

Insurers will not be permitted to change the combination

of benefits in any of the 10 standard policies. Individual

States will be allowed to limit the number of the

different standard policies sold in the State to fewer

than 10 if they wish to do so, but must ensure that

insurers offer the basic policy. For more information on

this subject, contact your State insurance department.

GAPS IN YOUR MEDICARE COVERAGE

Q. What are the "gaps" in Medicare coverage?

A. In general, they are charges for which you are

responsible. They include Medicare's deductibles and

coinsurance amounts, permissible charges in excess of

Medicare's approved amounts, additional days of care in a

hospital or skilled nursing facility, and the charges for

the various health care services and supplies that

Medicare does not cover. Medigap insurance can cover some

or all of these charges, depending on the policy.

ONE MEDIGAP POLICY IS ENOUGH

Q. Do I need more than one Medigap policy?

A. No. One good policy tailored to your needs at a price you

can afford is sufficient. Beginning in 1992 most States

are expected to make it unlawful for an insurance company

or agent to sell a second or replacement Medigap policy to

an individual unless the purchaser states in writing that

the first policy is to be cancelled. Medicare

beneficiaries enrolled in coordinated care plans (HMOs and

CMPs) or who are eligible for Medicaid usually do not need

Medigap insurance. If you have insurance from an employer

or labor association, you may also not need Medigap insurance.

MEDICARE SELECT

Q. What is Medicare SELECT insurance?

A. Medicare SELECT is the name for a new Medigap health

insurance product that is expected to be introduced in

1992 in 15 States to be designated in 1991 by the

Secretary of the U.S. Department of Health and Human

Services. During the three-year period currently

authorized under Federal law, Medicare SELECT will be

evaluated to determine how it should eventually be made

available throughout the Nation. Medicare SELECT is

private insurance, it is not issued by the government and

it is not part of Medicare. It is designed to supplement

Medicare coverage.

Q. What is the difference between Medicare SELECT and other

Medigap insurance?

A. The principal difference is that Medicare beneficiaries

who buy a Medicare SELECT policy are expected to be

charged a lower premium for that policy in return for

agreeing to use the services of a network of designated

physicians and other health care professionals. These

health care professionals, called "preferred providers,"

will be selected by the insurers. Each insurance company

that offers a Medicare SELECT policy will have its own

network of preferred providers. Policyholders usually will

be required to use a preferred provider if the insurance

company is to pay full benefits. Medicare will continue to

pay its portion of covered benefits regardless of whether

a preferred provider was used or not. Beneficiaries who

buy other Medigap insurance policies are not required to

use doctors and other providers designated by the

insurance company.

GETTING MORE INFORMATION ABOUT SUPPLEMENTAL INSURANCE

Q. Where can I get information about insurance to supplement

my Medicare benefits?

A. Contact your local Social Security office, State office on

aging, or your State insurance department and ask for a

copy of the Guide to Health Insurance for People with

Medicare. It describes Medicare's benefits and the types

of private insurance available to supplement Medicare. If

you need help in selecting supplemental insurance, check

with your State insurance department. Some departments

offer counselling services.

MEDIGAP COMPLAINTS

Q. Whom should I contact if I have a complaint about the

agent who sold me a Medigap policy?

A. Suspected violations of the laws governing the sales and

marketing of Medigap policies should be reported to your

State insurance department or Federal authorities. The

Federal toll-free telephone number for registering such

complaints is 1-800-638-6833.

SECOND SURGICAL OPINIONS

Q. Whom do I call if I want a second surgical opinion?

A. If your physician has recommended surgery for a

non-emergency condition covered by Medicare and you want

the names of doctors in your area who provide second

opinions for elective surgery, call your Medicare carrier.

Many conditions that do not require immediate attention

can be treated equally well without surgery.

REPORTING FRAUD

Q. Where do I report suspected cases of Medicare fraud?

A. If you have evidence of or suspect fraud or abuse of the

Medicare or Medicaid programs, call your Medicare carrier.

CHANGING YOUR ADDRESS

Q. I moved. How do I get my address changed?

A. You should call your local Social Security office and ask

that your Medicare file be changed to reflect your new address.

FREE PUBLICATIONS

Q. What free publications are available that explain

Medicare?

A. The following publications may be obtained from any Social

Security office or by writing to: Medicare Publications,

Health Care Financing Administration, 6325 Security

Boulevard, Baltimore, Md. 21207, or Consumer Information

Center, Department 59, Pueblo, CO 81009.

* The Medicare Handbook

Guide to Health Insurance for People with Medicare (507-X)

Medicare and Coordinated Care Plans (509-X) Medicare

Hospice Benefits (508-X)

Medicare and Employer Health Plans (586-X) Getting A

Second Opinion (536-X)

Medicare Coverage of Kidney Dialysis and Kidney

Transplant Services (587-X)

* Medicare Secondary Payer

* Not available from Consumer Information Center.