Medicare Questions & Answers


Welcome! You Are Here arrow3 Articles/How To/Medicare Questions & Answers.


Medicare Questions & Answers

 

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 immunisations, 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
enrolees 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 enrol in Part
B. Enrolees in Part B must pay a monthly premium of $29.90 in 1991.

MEDICARE ENROLMENT

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
enrolment 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 enrol in Part B during the annual general enrolment
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 enrolment 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 enrolment 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 enrol in Part B during a special 7-month enrolment 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 organisations (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 enrol in a HMO?

A. Yes. You may enrol 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 enrolees a monthly premium and nominal
copayments when a service is used. Contact plans in your area for enrolment
and coverage information.

DISENROLLING FROM AN HMO

Q. If I enrol 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 hospitalised 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 hospitalised 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 organisations
under contract to the Federal government. The organisations 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 organisations 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 non participating physicians. In 1992
the limiting charge for all services covered by Medicare will be 120 percent
of the fee schedule amount for non participating 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 Ageing, 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 enrol in a hospice
program.

PROs

Q. What are PROs?

A. Utilisation and Quality Control Peer Review Organisations (PROs) are
physician-sponsored organisations 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 STANDARDISED IN 1992

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

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 labour
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 authorised 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 ageing,
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 Centre, 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
Centre.



----------- END -----------

You are heresignpostArticles/How To/Medicare Questions & Answers

arrow_upTop of Page

dog2