The Medicare Handbook


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The Medicare Handbook

 

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 enrolment 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
Enrolment in Medicare
Your Medicare Card
Assistance for Low-Income Beneficiaries
Intermediaries and Carriers
Peer Review Organisations
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 Enrol in Coordinated Care Plans?
Joining a Coordinated Care Plan
Ending Enrolment 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 Enrolment 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 Organisations (PROs)
Appealing Decisions of Intermediaries on Part A Claims
Appealing Decisions Made by Carriers on Part B Claims
Appealing Decisions Made by Health Maintenance
Organisations (HMOs)
For More Information

Appendices

Charts: Medicare Covered Services
Medicare Carriers
Medicare Peer Review Organisations (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 enrol 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 enrol 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.)

Enrolment 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 enrolment period, to avoid late enrolment penalties under
Medicare Part B (unless you qualify for a special enrolment period as
described on page 33). Your initial enrolment 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 enrolment period, there will be a delay in starting your Part B
coverage. Your coverage will be delayed from one to three months after
enrolment.

If you do not enrol for Medicare Part B at any time during your initial
enrolment period, you will not have another chance to enrol until the next
general enrolment period. A general enrolment period is held each year from
January 1 through March 31 and if you enrol 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 enrolment (unless you qualify for a special enrolment
period as described on page 33).

The enrolment period requirements and penalties for late enrolment
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 Medicare 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 organisations
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 Organisations

Peer Review Organisations (PROs) are groups of practising 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 non coverage 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 centres; and certain health maintenance
organisations.

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 enrol in a
Medicare-approved hospice or health maintenance organisation, 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) hot line at 1-800-638-6833. There is no charge to you
when you call this number. The hot line 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 organisations (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 Enrol in Coordinated Care Plans?

Most Medicare beneficiaries are eligible to enrol in HMOs. HMOs cannot
screen applicants to decide if they are healthy, or delay coverage for
pre-existing conditions. The only enrolment 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 enrolment 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 enrol 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
authorised 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 Enrolment in a Coordinated Care Plan

To end your enrolment 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 Organisation (PRO). PROs are groups of
practising 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 enrolment, 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 Standardised 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 standardised
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 standardised 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 standardised plan.

Open Enrolment Period for Medigap Policies

An open enrolment 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 enrol in Part B--whether by automatic notification or
through an initial, special or general enrolment 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 enrolment ends.

NOTE: Even when you buy your Medigap policy in this open enrolment
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 ageing. Some of these offices may have free
counselling 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 pre existing 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 re instituted 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 enrolment 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 authorises 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 hospitalised 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 non covered
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
Utilisation 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 Utilisation Review Committee of the hospital, a Peer Review
Organisation 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 non
replacement fees charged for the first three pints of whole blood or units of
packed red cells per calendar year. (The non replacement fee is the amount
that some hospitals and skilled nursing facilities charge for blood that is
not replaced.)

You are responsible for the non replacement fees for the first three
pints or units of blood furnished by a hospital or skilled nursing facility.
If you are charged non replacement 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 organisation 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 non covered 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
specialises 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 specialises 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 organisation 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 counselling.

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 short term 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 speech language pathology.

* Home health aide and homemaker services.

* Medical social services.

* Medical supplies and appliances.

* Short-term inpatient care, including respite care.

* Counselling.

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 non replacement fees charged for the first three pints
or units of blood and blood components you use each year. (The non
replacement 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.

* Immunisations (except pneumococcal pneumonia vaccinations or
immunisations 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 hospitalised 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 authorised 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 anaesthetist.

* 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 hospitalisation 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 self administered.

* 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.

* Immunisations (except pneumococcal pneumonia and hepatitis B
vaccinations, or immunisations 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 centre 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 centre for certain approved surgical
procedures. However, by law Medicare can only pay centres that have an
agreement with Medicare to participate in the Medicare program. If you do not
know whether an ambulatory surgical centre participates in Medicare, ask
someone in the centre'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
centre, 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 non covered services.

Also, you can receive services directly from an independently practising,
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 practising speech pathologists.)
But, the maximum amount Medicare pays for each of these services provided by
an independently practising 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 Medicare participating comprehensive outpatient
rehabilitation facility (CORF). Covered services include physicians'
services; physical, speech, occupational and respiratory therapies;
counselling; 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 Hospitalisation for Mental Health Treatment

Partial hospitalisation (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 centres. 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 centres are located in both rural and urban
areas and any Medicare beneficiary may seek services at them. As part of the
"federally qualified health centre 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 centre benefit, Medicare helps pay for certain preventive
health services. The centre can tell you what services are part of the
federally qualified health centre benefit.

You do not have to pay the Medicare Part B annual deductible for
services provided under the federally qualified health centre 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 centre may waive all or part of the 20 percent
Part B coinsurance which is applicable for centre services.)

Federally qualified health centres often provide services in addition
to those offered under the Medicare federally qualified health centre
benefit. Examples of these services are X-rays and equipment like crutches
and canes. As long as the centre 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 orthopaedic 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.

Haemophilia Clotting Factors

Medicare Part B helps pay for blood clotting factors and items related
to their administration for haemophilia 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 anaemia 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 care
givers.

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 non physician practitioners. These professionals
furnish services in various settings, for example, hospitals, comprehensive
outpatient rehabilitation facilities, community mental health centres, 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 hospitalisation 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 hospitalisation 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 agrees to "take assignment."

The assignment method can save you money. The doctor or supplier sends
the claim to Medicare. Medicare pays your doctor or supplier 80 percent of
the Medicare approved amount, after subtracting any part of the $100 annual
deductible you have not met. The doctor or supplier can charge you only for
the part of the $100 annual deductible you have not met and for the
coinsurance, which is the remaining 20 percent of the approved amount. Of
course, your doctor or supplier also can charge you for services that
Medicare does not cover.

Doctors and certain other practitioners and suppliers must take
assignment on all claims for services furnished to Medicare beneficiaries who
are eligible for medical assistance through their state Medicaid program,
including Qualified Medicare Beneficiaries. (See 'Assistance for Low-Income
Beneficiaries,' page 2.)

Participating Doctors and Suppliers

Doctors and suppliers may sign agreements to become Medicare
participating. Medicare-participating doctors and suppliers have agreed in
advance to accept assignment on all Medicare claims. Doctors and suppliers
are given the opportunity to sign participation agreements each year.
Medicare-participating doctors and suppliers can display emblems or
certificates that show they accept assignment on all Medicare claims.

The names and addresses of Medicare-participating doctors 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 (see pages 39 to 44); or you can call your
carrier and ask for names of some participating doctors and suppliers in your
area. Also, this directory is available for you to use in Social Security
offices, state and area offices of the Administration on Ageing, and in most
hospitals.

When Your Doctor Does Not Accept Assignment

If your doctor or supplier does not accept assignment, you must pay the
doctor or supplier directly. You are usually responsible for the part of your
bill that is more than the Medicare-approved amount since your doctor or
supplier did not agree to accept the Medicare approved amount as payment in
full. In this case, Medicare pays you 80 percent of the approved amount,
after subtracting any part of the $100 annual deductible you have not met.

Even though a doctor does not accept assignment, for most covered
services, there are limits on the amount that he or she can actually charge
you. In 1993, the most the doctor can charge you is 115 percent of what
Medicare approves (see "Medicare Approved Amounts," page 29.)
Doctors who charge more than these limits may be fined.

If you think you have been charged more than the limiting charge, ask
the doctor for a reduction in the charge. If you have already paid more than
the charge limit, ask for a refund. If you cannot get a reduction or refund,
you can call your Medicare carrier and ask for assistance.

Some states have laws that could further reduce your medical costs. If
you live in one of the states listed below, you can ask the state office
listed here about the laws in your state:

Connecticut:
Connecticut Department of Ageing
CONNMAP
175 Main Street Hartford, CT 06106
1-800-634-8852

Massachusetts:
Executive Office of Elder Affairs
1 Ashburton Place Boston, MA 02108
1-800-882-2003

Pennsylvania:
Department of Ageing
Market Street State Office Bldg.
400 Market Street
Harrisburg, PA 17101

(717) 783-8975

Rhode Island:
Department of Elderly Affairs
160 Pine Street
Providence, RI 02903-3708
1-800-322-2880

Vermont: Department of Ageing and Disabilities
103 South Main Street
Waterbury, VT 05676
1-800-642-5119

New York:
State Office for the Ageing
2 Empire State Plaza
Albany, NY 12223
1-800-342-9871 (toll-free in New York)
(518) 474-5731

Special rule for doctors performing elective surgery: Medicare law
requires doctors who do not take assignment for elective surgery to give you
a written estimate of your costs before the surgery if the total charge for
the surgical procedure is $500 or more. If the doctor did not give you a
written estimate, you are entitled to a refund of any amount you paid him or
her over the Medicare approved amount.

Many doctors and suppliers who do not take assignment on all claims may
take assignment on some or most claims. Ask your doctor or supplier whether
he or she will take assignment on your claims.

Three payment examples for the same service are shown above. Dr. A
participates in the Medicare program and therefore accepts assignment on the
claim. Drs. B and C do not participate and do not accept assignment. In all
three examples, the beneficiary has already met the $100 deductible. Even
though Dr. A's bill is not the lowest, the beneficiary pays the least for Dr.
A's services. Also, even though Drs. B and C charge different amounts, the
beneficiary pays the same amount because of the limiting charge.

Participating Providers

Hospitals, skilled nursing facilities, home health agencies, hospices,
comprehensive outpatient rehabilitation facilities, and providers of
outpatient physical and occupational therapy and speech pathology services
are all participating providers under Medicare Part B. They submit their
claims to Medicare. Medicare subtracts any deductible you have not met and
any coinsurance amount and pays the provider. The provider must accept the
Medicare-approved amount as payment in full for covered services. The
provider bills you only for any deductible and coinsurance amounts you owe.

Medicare Approved Amounts

Medicare Part B payments are based for the most part on Medicare fee
schedule amounts. The fee schedule for physicians and certain suppliers lists
payments for each Part B service and takes into account geographic variation
in the cost of practice. The fee schedule amount is often less than the
actual charges billed by doctors and suppliers. Part B usually pays 80
percent of the fee schedule amount, even if it is less than the actual
charge.

When a Part B claim is submitted, the carrier compares the actual
charge shown on the claim with the fee schedule amount for that service. The
Medicare-approved amount is the lower of the actual charge or the fee
schedule amount.

Submitting Part B Claims

Doctors, Suppliers and Other Providers Must Submit Claims for You

Since September 1, 1990, doctors, suppliers and other providers of Part
B services have in most cases been required to submit Medicare claims for
you, even if they do not take assignment. They must submit the claims within
one year of providing the service to you or may be subject to certain
penalties. (If you have other health insurance that should pay before
Medicare, you can submit your claims yourself. See 'Filing Your Own Claims,'
page 32.)

You should notify your Medicare carrier if your doctor or supplier
refuses to submit a Part B Medicare claim for you if you believe the services
may be covered by Medicare. (Phone numbers and addresses of carriers are
listed on pages 39 to 44.)

How Does the Doctor or Supplier Submit Claims?

Your doctor or supplier must submit a form, called a HCFA-1500,
requesting that Medicare Part B payment be made for your covered services,
whether or not assignment is taken. The doctor or supplier completes the
HCFA-1500 form and shows it to you. You sign the form and then the doctor or
supplier sends it to the proper Medicare carrier.

If your claim is for the rental or purchase of durable medical
equipment, a doctor's prescription, or certificate of medical necessity, must
be included with the claim. The prescription must show the equipment you
need, the medical reason for the need, and an estimate of how long the
equipment will be medically necessary.

If You are Enrolled in a Coordinated Care Plan

If you are enrolled in a coordinated care plan--a prepaid health care
organisation such as an HMO--a claim will seldom need to be submitted on your
behalf. Medicare pays the HMO a set amount and the HMO provides your medical
care. In most cases, you are required to receive all non-emergency care
through your HMO, or through arrangements they make before you receive care.
However, if you get an out-of-plan service, the claim should be submitted
directly to your HMO.

If your doctor or supplier needs an address, consult your HMO
membership handbook, or contact the HMO.

Submitting Claims to the Railroad Retirement System

If you get Medicare under the Railroad Retirement system, the doctor or
supplier must submit your claims to The Travellers Insurance Company office
that serves your region. Regional offices of The Travellers are listed in
Your Medicare Handbook for Railroad Retirement Beneficiaries, which is
available at any Railroad Retirement office.

Explanation of Your Medicare Part B Benefits Notice

After your doctor, provider, or supplier sends in a Part B claim,
Medicare will send you a notice called Explanation of Your Medicare Part B
Benefits to tell you the decision on the claim. An illustration of the notice
is shown on page 31.

The sample notice on page 31 is for services of a doctor and shows what
charges were made and what Medicare approved. It shows what the co-payment is
and what Medicare is paying. If the $100 annual deductible had not been met,
that would also be shown. The notice gives the address and toll-free
telephone number for contacting the carrier. Note that this doctor did not
take assignment, so the limiting charge is shown. Notices for other Part B
services are much like the ones for doctor services.

Please read your notices carefully. If you believe payments were made
for services or supplies you didn't receive, or payments are otherwise questionable,
call or write your carrier.

Filing Your Own Claims

In some cases, you may need to file your own Medicare Part B claim. If
you do, send the claim to the carrier responsible for processing Medicare
claims in your area. No claims should be sent to the Health Care Financing
Administration in Baltimore, Maryland.

To find out whether you need to file your own claim, call or write your
Medicare carrier. (Carrier addresses and phone numbers are listed on pages 39
to 44.)

Time Limits

Under the law, there are time limits for submitting your own Medicare
Part B claims. For Medicare to make payments on your claims, you must send in
your claims within these time limits. You always have at least 15 months to
submit claims. The table below tells you exactly what the time limits are.

Your claim must


For service you get between     be submitted by
Oct 1, 1991 & Sept 30, 1992      Dec 31, 1993
Oct 1, 1992 & Sept 30, 1993      Dec 31, 1994
Oct 1, 1993 & Sept 30, 1994      Dec 31, 1995

Calling Your Medicare Carrier

Many carriers have installed an automated telephone answering system to
help make their response to you faster and more accurate. When you call, if
your carrier has a system of this type, you will be connected to a special
automated voice system. If you have a touch tone telephone, follow the
instructions you receive over the phone to get information about the status
of your claims.

If you need other information or want to talk about a claim, you can
ask the system to connect you with a customer service representative at any
time. If you do not have a touch-tone telephone, stay on the line after you
dial and you will be connected to a customer service representative.

Claims for a Person Who Has Died

When a Medicare beneficiary dies, the way Medicare pays Part B claims
depends on whether the doctor's or supplier's bill has been paid. (Any Part A
payments due to the hospital, skilled nursing facility, home health agency or
hospice will be made directly to the provider of services.)

If the bill was paid by the patient or with funds from the patient's
estate, Medicare's payment will be made either to the estate representative
or to a surviving member of the patient's immediate family. If someone other
than the patient paid the bill, payment may be made to that person.

If the bill has not been paid and the doctor or supplier does not
accept assignment, the Medicare payment can be made to the person who has or
assumes legal obligation to pay the bill for the deceased patient.

Your Medicare carrier can provide additional information about how to
claim a Medicare Part B payment after a patient dies.

Getting the Part of Medicare You Do Not Have

Getting Medicare Medical Insurance (Part B)

If you have Medicare premium-free Hospital Insurance but do not have Medicare
Part B, you can sign up for Part B during a general enrolment period. A
general enrolment period is held January 1 through March 31 each year. Your
protection will begin July 1 of the year you enrol. If you enrol during a
general enrolment period, your monthly premium may be increased by 10 percent
for each 12-month period you could have had Part B but were not enrolled. (If
you are covered under an employer group health plan based on current
employment as described on this page, the premium penalty may be decreased or
waived.)

Getting Medicare Hospital Insurance (Part A)

Some people 65 or older have Medicare Medical Insurance (Part B), but
do not meet the requirements for premium-free Part A. If you are in this
category, you can get Part A by paying a monthly premium. This is called
"premium hospital insurance." The Part A premium is $221 a month
through December 31, 1993. (This amount will change January 1, 1994.)

You can sign up for premium Part A during a general enrolment period:
January 1 through March 31 each year. If you enrol during a general enrolment
period that begins more than one year after you became eligible to buy Part
A, your monthly premium may be 10 percent higher than the basic premium
amount. Your protection will begin July 1 of the year you enrol. (Also see
this page for information on the special enrolment period.)

If you have been covered under an HMO, you can sign up for premium Part
A at any time while you are in the HMO and up to eight months after the HMO
coverage has ended. The premium penalty, if any, may be reduced because of
the coverage under the HMO.

For more information about premium amounts, premium surcharges, and how
to get the part of Medicare you do not have, contact Social Security.

Special Enrolment Period

If you are covered by an employer group health plan based on your own
or your spouse's current employment (not a plan for retired people and their
spouses), you may be able to delay enrolment in Medicare Medical Insurance
(Part B) or premium Hospital Insurance (Part A) without premium penalty and
without waiting for a general enrolment period to enrol. Delayed enrolment
without penalty or wait is usually available if you are covered by an
employer group health plan at the time you are first able to get Medicare.

In general, if you are 65 or over, you may enrol in Medicare Part B
during the seven-month period beginning with the month:

* Your or your spouse's current employment ends, or

* Your coverage under the employer group health plan ends, whichever
comes first.

If you are disabled and covered by an employer group health plan, you
are also given a special enrolment period in certain circumstances. If you
are covered under a group health plan based on current employment status when
you are first able to get Medicare, you may enrol in Medicare Part B during
the seven-month period that begins:

* When the employment status ends,

* When the plan is no longer classifiable as a large group health plan
(one that covers 100 or more employees), or

* When the plan coverage is terminated.

Contact Social Security as soon as employment ends, or the plan
coverage ends or changes, to be sure that you get the information you need
about enrolling in Medicare Part B.

Events That Can Change Your Medicare Protection

When Protection Ends for People 65 and Older

If you have Medicare Hospital Insurance (Part A) based on your spouse's
work record, your protection will end if you and your spouse are divorced
during the first 10 years of your marriage. But if you have Part A based on
your own work record, your protection will continue as long as you live.

Your Medicare Part B protection will stop if your premiums are not paid
or if you voluntarily cancel. If you are thinking about cancelling Part B,
remember that you may not be able to get private insurance that offers the
same protection. If you cancel Part B and then later decide to re-enroll, you
will have to wait for a general enrolment period (January 1 through March 31
of each year). Also, your premium may be higher and your protection will not
begin again until July 1 of the year you re-enroll. (If you are covered under
an employer group health plan based on current employment as described on
page 9, you may be eligible for a special enrolment period and the premium
penalty may be decreased or waived as noted on page 33.)

If you are buying Medicare Part A by paying monthly premiums (see page
33), you will lose it if you cancel your Medicare Part B. People who buy
Medicare Part A must also enrol and pay the premium for Part B. But, you can
cancel Part A and still continue to buy Part B.

If you want more information about cancelling your Medicare protection,
contact Social Security.

When Protection Ends for the Disabled

If you have Medicare because you are disabled, your protection will end
if you recover from your disability before you are 65. If you work but are
still disabled, your premium-free Part A protection will continue for at
least 48 months after you begin working. Your Part B will also continue for
at least 48 months if you continue to pay the monthly premiums.

If you remain disabled longer than 48 months after you return to work
and lose your premium-free Part A (and your Part B) solely because you are
working, you may buy Part A only or both Part A and Part B. (You cannot buy
Part B only.) You can continue to buy Medicare as long as you remain
disabled.

You may enrol during your initial enrolment period which begins with
the month you are notified you are no longer eligible for premium-free Part A
and continues for seven full months after that month. If you do not enrol
during this initial enrolment period, you may enrol in a subsequent general
enrolment period (January through March of each year) or during a special
enrolment period (see page 33).

If you ever want to cancel the Medicare protection for which you pay
premiums, contact Social Security.

When Protection Ends for Those With Permanent Kidney Failure

If you have Medicare because of permanent kidney failure, your
protection will end 12 months after the month maintenance dialysis treatment
stops or 36 months after the month you have a kidney transplant.

Your Medicare Part B protection could stop before that if you fail to
pay the premiums, or if you decide to cancel. Call Social Security if you
ever want to cancel your Part B protection.

If you need more information about Medicare coverage of permanent
kidney failure, you can get a copy of Medicare Coverage of Kidney Dialysis
and Kidney Transplant Services from Social Security or the Consumer
Information Center (see inside back cover).

How to Appeal Medicare Decisions

If you disagree with a decision on the amount Medicare will pay on a
claim or whether services you received are covered by Medicare, you have the
right to appeal the decision. The notice Medicare sends you tells you the
decision made on the claim and exactly what appeal steps you can take.
Appealing decisions by Part A providers, peer review organisations,
intermediaries, carriers and health maintenance organisations are discussed
below.

Appealing Decisions Made by Providers of Part A Services

In many cases the first written notice of non coverage you receive will
come from the provider of the services (for example, a hospital, skilled
nursing facility, home health agency or hospice). This notice of non coverage
from the provider should explain why the provider believes Medicare will not
pay for the services. This notice is not an official Medicare determination,
but you can ask the provider to get an official Medicare determination. If
you ask for an official Medicare determination, the provider must file a
claim on your behalf to Medicare. Then you will receive a Notice of
Utilisation, which is the official Medicare determination. If you still
disagree, you can appeal by following the instructions on the Notice of
Utilisation.

Appealing Decisions Made by Peer Review Organisations (PROs)

When you are admitted to a Medicare-participating hospital, you will be
given a notice called An Important Message From Medicare. The notice contains
a brief description of PROs, and the name, address and phone number of the
PRO in your state. Also, it describes your appeal fights.

PROs make determinations mainly about inpatient hospital care and
ambulatory surgical centre care. The PROs decide whether care provided to
Medicare patients is medically necessary, provided in the most appropriate
setting, and is of good quality. When you disagree with a PRO decision about
your case, you can appeal by requesting a reconsideration. Then, if you
disagree with the PRO's reconsideration decision, and the amount remaining in
question is $200 or more, you can request a hearing by an Administrative Law
Judge. Cases involving $2,000 or more can eventually be appealed to a Federal
Court.

If you belong to a Medicare health maintenance organisation (HMO), the
HMO will usually make decisions about the medical necessity, the
appropriateness of setting and the quality of your care. In most cases, you
do not have the fight to appeal to the PRO, but you always have the fight to
register complaints about the quality of your hospital care to the PRO. (See
page 36 for more information about appeal fights for members of HMOs.)

NOTE: In the case of elective (non-emergency) surgery, either the
hospital or the PRO may be involved in pre-admission decisions. If the
hospital believes that your proposed stay will not be covered by Medicare, it
may recommend, without consulting the PRO, that you not be admitted to the
hospital. If this is the case, the hospital must give you its decision in
writing. If you or your doctor disagree with the hospital's decision, you
should make a request to the PRO for immediate review. If you want an
immediate review, you must make your request, by telephone or in writing,
within three calendar days after receipt of the notice.

Appealing Decisions of Intermediaries on Part A Claims

Appeals of decisions on most other services covered under Medicare Part
A (skilled nursing facility care, home health care, hospice services, and a
few inpatient hospital matters not handled by PROs) are handled by Medicare
intermediaries. If you disagree with the intermediary's initial decision, you
have 60 days from the date you receive the initial decision to request a
reconsideration. The request can be submitted directly to the intermediary or
through Social Security. If you disagree with the intermediary's
reconsideration decision and the amount remaining in question is $100 or
more, you have 60 days from the date you receive the reconsideration decision
to request a hearing by an Administrative Law Judge. Cases involving $1,000
or more can eventually be appealed to a Federal Court.

Appealing Decisions Made by Carriers on Part B Claims

If you disagree with Medicare's decision on a Part B claim, you have
the right to appeal that decision. You have six months from the date of the
decision to ask the carrier to review it. Then, if you disagree with the
carrier's written explanation of its review decision and the amount remaining
in question is $100 or more, you have six months from the date of the review
decision to request a heating before a carrier hearing officer. You may
combine claims that have been reviewed or reopened so long as all claims combined
are at the proper level of appeal and the appeal for each claim combined is
filed on time.

If you disagree with the carrier hearing officer's decision and the
amount remaining in question is $500 or more, you have 60 days from the date
you receive the decision to request a hearing before an Administrative Law
Judge. You may combine claims that have had a carrier hearing officer's
decision so long as the appeal for each claim combined is filed within 60
days of the date you received the carrier hearing decision for that claim.
Cases involving $1,000 or more can eventually be appealed to a Federal Court.

Appealing Decisions Made by Health Maintenance Organisations (HMOs)

If you have Medicare coverage through an HMO, decisions about coverage
and payment for services will usually be made by your HMO. When your HMO
makes a decision to deny payment for Medicare-covered services or refuses to
provide Medicare-covered supplies you request, you will be given a Notice of
Initial Determination. Along with the notice, your HMO is required to provide
a full, written explanation of your appeal fights.

If you believe that the decision your HM0 made was not correct, you
have the fight to ask for a reconsideration. You must file your request for
reconsideration within 60 days after you receive the Notice of Initial
Determination. Your request must be in writing. You may mail it or deliver it
personally to your HMO or to a Social Security office. (or the Railroad
Retirement Board if you get Medicare through Railroad Retirement).

Your HMO is responsible for reconsidering its initial determination to
deny payment or services. If your HMO does not role fully in your favour, the
HMO must send your reconsideration request to the Health Care Financing
Administration (HCFA) for a review and determination.

If you disagree with HCFA's decision, and the amount in question is
$100 or more, you have 60 days from receipt of HCFA's decision to request a
heating before an Administrative Law Judge. Cases involving $1,000 or more
can eventually be appealed to a Federal Court.

For More Information

If you need more information about your fight to appeal and how to
request it, call Social Security, or the Medicare intermediary or carrier in
your state. (The number of the Medicare intermediary or carrier is listed on
the notice explaining Medicare's decision on the claim. Medicare carriers are
also listed on pages 39 to 44.) If you need more information about your fight
to appeal a Peer Review Organisation (PRO) decision, you can call the PRO in
your state. (PROs are listed on pages 45 to 49).

MEDICARE CARRIERS

Carriers can answer questions about Medical Insurance (Part B)

Note:

-- The toll-free or 800 numbers listed below, in many cases, can be
used only in the states where the carriers are located. Also listed are the
local Commercial numbers for the carriers. Out-of-state callers may use the
commercial numbers.

-- These carrier toll-free numbers are for beneficiaries to use and
should not be used by doctors and suppliers.

-- Many carriers have installed an automated telephone answering
system. If you have a touch-tone telephone, you can follow the system
instructions to find out about your latest claims and get other information.
If you do not have a touch tone telephone, stay on the line and someone will
help you.

ALABAMA
Medicare/Blue Cross-Blue Shield of Alabama
P.O. Box 83140
Birmingham, Alabama 35282
1-800-292-8855
205-988-2244

ALASKA
Medicare/Aetna Life Insurance Company
200 S.W. Market St.,
P.O. Box 1998
Portland, Oregon 97207-1998
1-800-452-0125 (toll-free: Alaska to customer service in Oregon)
503-222-6831 (customer service site in Oregon)

ARIZONA
Medicare/Aetna Life Insurance Company
P.O. Box 37200
Phoenix, Arizona 85069
1-800-352-0411
602-861-1968

ARKANSAS
Medicare/Arkansas Blue Cross and Blue Shield
P.O. Box 1418
Little Rock, Arkansas 72203-1418
1-800-482-5525
501-378-2320

CALIFORNIA
Counties of: Los Angeles, Orange, San Diego, Ventura, Imperial, San Luis
Obispo, Santa Barbara
Medicare/Transamerica Occidental Life Insurance Co.
Box 30540
Los Angeles, California 90030-0540
1-800-675-2266
213-748-2311

Rest of state:
Medicare Claims Dept.
Blue Shield of California
Chico, California 95976
(In area codes 209, 408, 415, 707, 916)
1-800-952-8627
916-743-1583

(In the following area codes--other than Los Angeles, Orange, San
Diego, Ventura, Imperial, San Luis Obispo, and Santa Barbara counties -- 213,
619, 714, 805, 818)
1-800-848-7713
714-796-9393

COLORADO
Medicare/Blue Cross and Blue Shield of Colorado
Coordination of Benefits:
P.O. Box 173550
Denver, Colorado 80217
Correspondence/Appeals:
P.O. Box 173500
Denver, Colorado 80217
(Metro Denver) 303-83 1-2661
(In Colorado, outside of metro area) 1-800-332-6681

CONNECTICUT
Medicare/The Travellers Companies
538 Preston Avenue
P.O. Box 9000
Meriden, Connecticut 06454-9000
1-800-982-6819
(In Hartford) 203-728-6783
(In the Meriden area) 203-237-8592

DELAWARE
Medicare/Pennsylvania Blue Shield
P.O. Box 890200
Camp Hill, Pennsylvania 17089-0200
1-800-851-3535

DISTRICT OF COLUMBIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124

FLORIDA
Medicare/Blue Cross and Blue Shield of Florida, Inc.
P.O. Box 2360
Jacksonville, Florida 32231

For fast service on simple inquiries including requests for copies of
Explanation of Your Medicare Part B Benefits notices, requests for MEDPAR
directories, brief claims inquiries (status or verification of receipt), and
address changes:
1-800-666-7586
904-355-8899

For all your other Medicare needs:
1-800-333-7586
904-355-3680

MEDICARE CARRIERS

Carriers can answer questions about Medical Insurance (Part B)

GEORGIA
Medicare/Aetna Life Insurance Company
P.O. Box 3018
Savannah, Georgia 31402-3018
1-800-727-0827
912-920-2412

HAWAII
Medicare/Aetna Life Insurance Company
P.O. Box 3947
Honolulu, Hawaii 96812
1-800-272-5242
808-524-1240

IDAHO
Connecticut General Life Insurance Company
3150 N. Lakeharbor Lane, Suite 254
P.O. Box 8048
Boise, Idaho 83707-6219
1-800-627-2782
208-342-7763

ILLINOIS
Medicare Claims/Health Care Service Corporation
P.O. Box 4422
Marion, Illinois 62959
1-800-642-6930
312-938-8000

INDIANA
Medicare Part B/AdminaStar Federal
P.O. Box 7073
Indianapolis, Indiana 46207
1-800-622-4792
317-842-4151

IOWA
Medicare/IASD Health Services Corporation
(d/b/a Blue Cross & Blue Shield of Iowa)
636 Grand
Des Moines, Iowa 50309
1-800-532-1285
515-245-4785

KANSAS
The counties of Johnson and Wyandotte:
Medicare/Blue Cross and Blue Shield of Kansas, Inc.
P.O. Box 419840
Kansas City, Missouri 64141-6840
1-800-892-5900
816-561-0900

Rest of state:
Medicare/Blue Cross and Blue Shield of Kansas, Inc.
1133 S.W. Topeka Boulevard
Topeka, Kansas 66629-0001
1-800-432-3531
913-232-3773

KENTUCKY
Medicare-Part B/Blue Cross & Blue Shield of Kentucky, Inc.
100 East Vine St.
Lexington, Kentucky 40507
1-800-999-7608
606-233-1441

LOUISIANA
Arkansas Blue Cross & Blue Shield, Inc. Medicare Administration
P.O. Box 83830
Baton Rouge, Louisiana 70884-3830
1-800-462-9666
(In New Orleans) 504-529-1494
(In Baton Rouge) 504-927-3490

MAINE
Medicare/C and S Administrative Services
P.O. Box 9790
Portland, Maine 04104-5090
1-800-492-0919
207-828-4300

MARYLAND
Counties of: Montgomery, Prince Georges
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124

Rest of state:
Blue Cross and Blue Shield of Maryland, Inc.
1946 Greenspring Drive
Timonium, Maryland 21093
1-800-492-4795
410-561-4160

MASSACHUSETTS
For Non-assigned Claims:
Medicare/C and S Administrative Services
P.O. Box 2222
Hingham, Massachusetts 02044
1-800-882-1228
617-741-3300

For Assigned Claims:
Medicare/C and S Administrative Services
P.O. Box 1111
Hingham, Massachusetts 02044
1-800-882-1228
617-741-3300

MICHIGAN
Medicare Part B
Blue Cross & Blue Shield of Michigan
P.O. Box 2201
Detroit, Michigan 48231-2201
313-225-8200
1-800-482-4045

MINNESOTA
Counties of: Anoka, Dakota, Fillmore, Goodhue, Hennepin, Houston, Olmstead,
Ramsey, Wabasha, Washington, Winona
Medicare/The Travellers Ins. Co.
8120 Penn Avenue South
Bloomington, Minnesota 55431
1-800-352-2762
612-884-7171

Rest of state:
Medicare/Blue Cross and Blue Shield of Minnesota
P.O. Box 64357
St. Paul, Minnesota 55164
1-800-392-0343
612-456-5070

MISSISSIPPI
Medicare/The Travellers Ins. Co.
P.O. Box 22545
Jackson, Mississippi 39225-2545
1-800-682-5417
601-956-0372

MISSOURI
Counties of: Andrew, Atchison, Bates, Benton, Buchanan, Caldwell, Carroll,
Cass, Clay, Clinton, Daviess, DeKalb, Gentry, Grundy, Harrison, Henry, Holt,
Jackson, Johnson, Lafayette, Livingston, Mercer, Nodaway, Pettis, Plane, Ray,
St. Clair, Saline, Vernon, Worth

Medicare/Blue Cross and Blue Shield of Kansas, Inc.
P.O. Box 419840
Kansas City, Missouri 64141-6840
1-800-892-5900
816-561-0900

Rest of state:
Medicare
General American Life Insurance Co.
P.O. Box 505
St. Louis, Missouri 63166
1-800-392-3070
314-843-8880

MONTANA
Medicare/Blue Cross and Blue Shield of Montana, Inc.
2501 Beltview
P.O. Box 4310
Helena, Montana 59604
1-800-332-6146
406-444-8350

NEBRASKA
The carrier for Nebraska is Blue Cross and Blue Shield of Kansas, Inc.
Claims, however, should be sent to:

Medicare Part B
Blue Cross/Blue Shield of Nebraska
P.O. Box 3106
Omaha, Nebraska 68103-0106
1-800-633-1113
913-232-3773 (customer service site in Kansas)

NEVADA
Medicare/Aetna Life Insurance Company
P.O. Box 37230
Phoenix, Arizona 85069
1-800-528-0311
602-861-1968

NEW HAMPSHIRE
Medicare/C and S Administrative Services
P.O. Box 9790
Portland, Maine 04104-5090
1-800-447-1142
207-828-4300

NEW JERSEY
Medicare/Pennsylvania Blue Shield
P.O. Box 400010
Harrisburg, Pennsylvania 17140-0010
1-800-462-9306
717-975-7333

NEW MEXICO
Medicare/Aetna Life Insurance Company,
P.O. Box 25500
Oklahoma City, Oklahoma 73125-0500
1-800-423-2925
(In Albuquerque) 505-821-3350

NEW YORK
Counties of: Nassau, Suffolk
Medicare B/Empire Blue Cross and Blue Shield
P.O. Box 2280
Peekskill, New York 10566
516-244-5100

Counties of: Bronx, Columbia, Delaware, Dutchess, Greene, Kings, New
York, Orange, Putnam, Richmond, Rockland, Suffolk, Sullivan, Ulster,
Westchester
Medicare B/Empire Blue Cross and Blue Shield
P.O. Box 2280
Peekskill, New York 10566
1-800-442-8430
516-244-5100

County of: Queens
Medicare/Group Health, Inc.
P.O. Box 1608, Ansonia Station
New York, New York 10023
212-721-1770

Rest of state:
Blue Shield of Western New York
Upstate Medicare Division-Part B
7-9 Court Street
Binghamton, New York 13901-3197
607-772-6906
1-800-252-6550

NORTH CAROLINA
Connecticut General Life Insurance Company
P.O. Box 671
Nashville, Tennessee 37202
1-800-672-3071
919-665-0348

NORTH DAKOTA
Medicare/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-247-2267
701-282-0691

OHIO
Medicare/Nationwide Mutual Ins. Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-282-0530
614-249-7157

OKLAHOMA
Medicare/Aetna Life Insurance Company
701 N.W. 63rd St.
Oklahoma City, Oklahoma 73116-7693
1-800-522-9079
405-848-7711

OREGON
Medicare/Aetna Life Insurance Company
200 S.W. Market St.
P.O. Box 1997
Portland, Oregon 97207-1997
1-800-452-0125
503-222-6831

PENNSYLVANIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890065
Camp Hill, Pennsylvania 17089-0065
1-800-382-1274
717-763-3601

RHODE ISLAND
Medicare/Blue Cross and Blue Shield of Rhode Island
Inquiry Department
444 Westminster Street
Providence, Rhode Island 02903-3279
1-800-662-5170
401-861-2273

SOUTH CAROLINA
Medicare Part B
Blue Cross and Blue Shield of South Carolina
P.O. Box 100190
Columbia, South Carolina 29202
1-800-868-2522
803-788-3882

SOUTH DAKOTA
Medicare Part B/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-437-4762
701-282-0691

TENNESSEE
Connecticut General Life Insurance Company
P.O. Box 1465
Nashville, Tennessee 37202
1-800-342-8900
615-244-5650

TEXAS
Medicare/Blue Cross & Blue Shield of Texas, Inc.
P.O. Box 660031
Dallas, Texas 75266-0031
1-800-442-2620
214-235-3433

UTAH
Medicare/Blue Shield of Utah
P.O. Box 30269
Salt Lake City, Utah 84130-0269
1-800-426-3477
801-481-6196

VERMONT
Medicare/C and S Administrative Services
P.O. Box 9790
Portland, Maine 04104-5090
1-800-447-1142
207-828-4300

VIRGINIA
Counties of: Arlington, Fairfax; Citys of: Alexandria, Falls Church, Fairfax
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
717-763-3601

Rest of state:
Medicare/The Travellers Ins. Co.
P.O. Box 26463
Richmond, Virginia 23261
1-800-552-3423
804-330-4786

WASHINGTON
Medicare
King County Medical Blue Shield
P.O. Box 91070

Seattle, Washington 98111-9170
(In Seattle)
1-800-422-4087
206-464-3711
(In Spokane)
1-800-572-5256
509-536-4550
(In Tacoma)
206-597-6530

WEST VIRGINIA
Medicare/Nationwide Mutual Insurance Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-848-0106
614-249-7157

WISCONSIN
Medicare/WPS
Box 1787
Madison, Wisconsin 53701
1-800-944-0051
(In Madison) 608-221-3330

WYOMING
Blue Cross and Blue Shield of North Dakota
P.O. Box 628
Cheyenne, Wyoming 82003
1-800-442-2371
307-632-9381

AMERICAN SAMOA
Medicare/Aetna Life Insurance Company
P.O. Box 860
Honolulu, Hawaii 96808
808-944-2247

GUAM
Medicare/Aetna Life Insurance Company
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240

NORTHERN MARIANA ISLANDS
Medicare/Aetna Life Insurance Company
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240

PUERTO RICO
Medicare/Seguros De Servicio De Salud De Puerto Rico
Call Box 71391
San Juan, Puerto Rico 00936
(In Puerto Rico) 800-462-7015
(In U.S. Virgin Islands) 800-474-7448
(In Puerto Rico metro area) 809-749-4900

VIRGIN ISLANDS
Medicare/Seguros De Servicio De
Salud De Puerto Rico
Call Box 71391
San Juan, Puerto Rico 00936
(In U.S. Virgin Islands) 800-474-7448

MEDICARE PEER REVIEW ORGANIZATIONS (PROs)

PROs can answer questions about hospital stays and other Hospital
Insurance (Part A) services. Do not call the PRO with questions about
Medicare Medical Insurance (Part B).

ALABAMA
Alabama Quality Assurance Foundation, Inc.
Suite 600
600 Beacon Parkway West
Birmingham, AL 35209-3154
1-800-288-4992

ALASKA Professional Review Organisation for Washington
(PRO for Alaska)
Suite 100
10700 Meridian Avenue,
North Seattle, WA 98133-9008
1-800-445-6941
(in Anchorage dial 562-2252)

AMERICAN SAMOA and GUAM (see Hawaii)

ARIZONA
Health Services Advisory Group, Inc.
P.O. Box 16731
Phoenix, AZ 85011-6731
1-800-626-1577
(in Arizona dial 1-800-359-9909 or 1-800-223-6693)

ARKANSAS
Arkansas Foundation for Medical Care, Inc.
P.O. Box 2424
809 Garrison Avenue
Fort Smith, AR 72902
1-800-824-7586
(in Arkansas dial 1-800-272-5528)

CALIFORNIA
California Medical Review, Inc. Suite 500
60 Spear Street
San Francisco, CA 94105
1-800-84 1-1602 (in-state only)
1-415-882-5800*

COLORADO
Colorado Foundation for Medical Care
1260 South Parker Road
P.O. Box 17300
Denver, CO 80217-0300
1-800-727-7086 (in-state only)
1-303-695-3333*

CONNECTICUT
Connecticut Peer Review Organisation, Inc.
100 Roscommon Drive, Suite 200
Middletown, CT 06457
1-800-553-7590 (in-state only)
1-203-632-2008*

DELAWARE
West Virginia Medical Institute, Inc.
(PRO for Delaware)
3001 Chesterfield Place
Charleston, WV 25304
1-800-642-8686 ext. 266
(in Wilmington dial 655-3077)

DISTRICT OF COLUMBIA
Delmarva Foundation for Medical Care, Inc.
(PRO for D.C.)
9240 Centreville Road
Easton, MD 21601
1-800-645-0011
(in Maryland dial 1-800-492-5811)

FLORIDA
Blue Cross and Blue Shield of Florida, Inc.
PRO Review
P.O. Box 45267
Jacksonville, FL 32232-5267
1-800-964-5785 (in-state only)
904-791-8262

GEORGIA
Georgia Medical Care Foundation Suite 200
57 Executive Park South
Atlanta, GA 30329
1-800-282-2614 (in-state only)
404-982-0411

HAWAII
Hawaii Medical Service Association
(PRO for American Samoa/Guam and Hawaii)
818 Keeaumoku Street
P.O. Box 860
Honolulu, HI 96808-0860
1-808-944-3586*

IDAHO
Professional Review Organisation for Washington
(PRO for Idaho)
Suite 100
10700 Meridian Avenue,
North Seattle, WA 98133-9008
1-800-445-6941
1-208-343-4617 (local Boise and collect)

ILLINOIS
Crescent Counties Foundation for Medical Care
280 Shuman Boulevard, Suite 240
Naperville, IL 60563
1-800-647-8089

INDIANA
Indiana Medical Review Organisation
2901 Ohio Boulevard
P.O. Box 3713
Terre Haute, IN 47803
1-800-288-1499

IOWA
Iowa Foundation for Medical Care Suite 350E
6000 Westown Parkway
West Des Moines, IA 50266-7771
1-800-752-7014 (in-state only)
515-223-2900

KANSAS
The Kansas Foundation for Medical Care, Inc.
2947 S.W. Wanamaker Drive
Topeka, KS 66614
1-800-432-0407 (in-state only)
913-273-2552

KENTUCKY
Kentucky Medical Review Organisation
10503 Timberwood Circle, Suite 200
P.O. Box 23540
Louisville, KY 40223
1-800-288-1499

LOUISIANA
Louisiana Health Care Review, Inc.
8591 United Plaza Blvd., Suite 270
Baton Rouge, LA 70809
1-800-433-4958 (in-state only)
504-926-6353

MAINE
Health Care Review, Inc.
(PRO for Maine)
Henry C. Hall Building
345 Blackstone Blvd.
Providence, RI 02906
1-800-541-9888 or 1-800-528-0700 (both numbers in Maine only)
1-207-945-0244*

MARYLAND
Delmarva Foundation for Medical Care, Inc.
(PRO for Maryland)
9240 Centreville Road
Easton, MD 21601
1-800-645-0011
(in Maryland dial 1-800-492-5811)

MASSACHUSETTS
Massachusetts Peer Review Organisation, Inc.
300 Bearhill Road
Waltham, MA 02154
1-800-252-5533 (in-state only)
1-617-890-0011*

MICHIGAN
Michigan Peer Review Organisation
40600 Ann Arbor Road, Suite 200
Plymouth, MI 48170
1-800-365-5899

MINNESOTA
Foundation for Health Care Evaluation
Suite 400
2901 Metro Drive
Bloomington, MN 55425
1-800444-3423

MISSISSIPPI
Mississippi Foundation for Medical Care, Inc.
P.O. Box 4665
735 Riverside Drive
Jackson, MS 39296-4665
1-800-844-0600 (in-state only)
601-948-8894

MISSOURI
Missouri Patient Care Review Foundation
505 Hobbs Road, Suite. 100
Jefferson City, MO 65109
1-800-347-1016

MONTANA
Montana-Wyoming Foundation for Medical Care
400 North Park, 2nd Floor
Helena, MT 59601
1-800-332-3411 (in-state only)
1-406-443-4020*

NEBRASKA
The Sunderbruch Corporation-NE
1221 "N" Street, Suite 800
Lincoln, NE 69508
1-800-752-0548

NEVADA
Nevada Peer Review
675 East 2100 South, Suite 270
Salt Lake City, UT 84106-1864
1-800-558-0829 (in Nevada only)
(in Reno dial 1-702-826-1996)
1-702-385-9933*

NEW HAMPSHIRE
New Hampshire Foundation for Medical Care
15 Old Rollinsford Road, Suite 302
Dover, NH 03820
1-800-582-7174 (in-state only)
1-603-749-1641*

NEW JERSEY
The Peer Review Organisation of New Jersey, Inc.
Central Division
Brier Hill Court, Building J
East Brunswick, NJ 08816
1-800-624-4557 (in-state only)
1-201-238-5570

NEW MEXICO
New Mexico Medical Review Association
707 Broadway N.E., Suite 200
P.O. Box 27449
Albuquerque, NM 87125-7449
1-800-432-6824 (in-state only)
505-842-6236
(In Albuquerque dial 842-6236)

NEW YORK
Island Peer Review Organisation, Inc.
1979 Marcus Avenue, First floor
Lake Success, NY 11042
1-800-331-7767
1-516-326-7767*

NORTH CAROLINA
Medical Review of North Carolina
Suite 200
P.O. Box 37309
1011 Schaub Drive
Raleigh, NC 27627
1-800-682-2650 (in-state only)
919-851-2955

NORTH DAKOTA
North Dakota Health Care Review, Inc.
Suite 301
900 North Broadway
Minot, ND 58701
1-800-472-2902 (in-state only)
1-701-852-4231*

OHIO
Peer Review Systems, Inc.
Suite 250
3700 Corporate Drive
Columbus, OH 43231-7990
1-800-233-7337

OKLAHOMA
Oklahoma Foundation for Peer Review, Inc.
Suite 400 The Paragon Building
5801 Broadway Extension
Oklahoma City, OK 73118-7489
1-800-522-3414 (in-state only)
405-840-2891

OREGON
Oregon Medical Professional Review Organisation
Suite 200
1220 Southwest Morrison
Portland, OR 97205
1-800-344-4354 (in-state only)
503-279-0100*

PENNSYLVANIA
Keystone Peer Review Organisation, Inc.
777 East Park Drive
P.O. Box 8310
Harrisburg, PA 17105-8310
1-800-322-1914 (in-state only)
717-564-8288

PUERTO RICO
Puerto Rico Foundation for Medical Care
Suite 605 Mercantile Plaza
Hato Rey, PR 00918
1-809-753-6705* or 1-809-753-6708*

RHODE ISLAND
Health Care Review, Inc.
Henry C. Hall Building
345 Blackstone Boulevard
Providence, RI 02906
1-800-221-1691 (New England-wide)
(in Rhode Island dial 1-800-662-5028)
1-401-331-6661*

SOUTH CAROLINA
Carolina Medical Review
101 Executive Center Drive
Suite 123
Columbia, SC 29210
1-800-922-3089 (in-state only)
803-731-8225

SOUTH DAKOTA
South Dakota Foundation for Medical Care
1323 South Minnesota Avenue
Sioux Falls, SD 57105
1-800-658-2285

TENNESSEE
Mid-South Foundation for Medical Care
Suite 400
6401 Poplar Avenue
Memphis, TN 38119
1-800-873-2273

TEXAS
Texas Medical Foundation
Barton Oaks Plaza Two, Suite 200
901 Mopac Expressway South
Austin, TX 78746
1-800-777-8315 (in-state only)
512-329-6610

UTAH
Utah Peer Review Organisation
675 East 2100 South
Suite 270
Salt Lake City, UT 84106-1864
1-800-274-2290

VERMONT
New Hampshire Foundation for Medical Care
(PRO for Vermont)
15 Rollinsford Road, Suite 302
Dover, NH 03820
1-800-639-8427 (in Vermont only)
1-802-655-6302*

VIRGIN ISLANDS
Virgin Islands Medical Institute, Inc.
IAD Estate Diamond Ruby
P.O. Box 1566
Christiansted
St. Croix, U.S., VI 00821-1566
1-809-778-6470*

VIRGINIA
Medical Society of Virginia Review Organisation
1606 Santa Rosa Road, Suite 235
P.O. Box K 70
Richmond, VA 23288
1-800-545-3814 (DC, MD and VA)
804-289-5320
(in Richmond, dial 289-5397)

WASHINGTON
Professional Review Organisation for Washington
Suite 100
10700 Meridian Avenue, North
Seattle, WA 98133-9008
1-800-445-6941
(in Seattle, dial 368-8272)

WEST VIRGINIA
West Virginia Medical Institute, Inc.
3001 Chesterfield Place
Charleston, WV 25304
1-800-642-8686, ext. 266
(in Charlestown, dial 346-9864)

WISCONSIN
Wisconsin Peer Review Organisation
2909 Landmark Place
Madison, WI 53713
1-800-362-2320 (in-state only)
608-274-1940

WYOMING
Montana-Wyoming Foundation for Medical Care
400 North Park, 2nd Floor
Helena, MT 59601
1-800-826-8978 (in Wyoming only)
1-406-443-4020*

* PRO will accept collect calls from out of state on this number.

INDEX

Address lists

Medicare carriers,
Peer Review Organisations,
Advance directives,
Ambulance services,
Ambulatory surgical services,
Annual Part B deductible,
Antigens,
Appeal fights,
Appealing claims decisions
by carriers,
by health maintenance organisations,
by intermediaries,
by Peer Review Organisations,
by providers of Part A services,
Appliances. See Medical appliances.
Application process,
Approved charges,
Assignment payment method,
Assistance for low-income beneficiaries,

Benefit periods
hospice care,
hospital and skilled nursing facility,
Black lung benefits,
Blood
deductible amount,
haemophilia clotting factors,
home health care, transfusions,
hospital inpatient, transfusions,
hospital outpatient, transfusions,
skilled nursing facility, transfusions,
Breast cancer screening,
Buying Medicare,

Cancelling Part B,
Care not covered,
Certified registered nurse anaesthetist,
Certified nurse midwife,
Charge limits,
Chiropractors, services covered,
Christian Science sanatorium,
Claim number,
Claims
benefits explanation notice,
claim number,
deceased beneficiary,
insurance other than Medicare,
intermediaries' and carriers' role,
Railroad Retirement system,
submission, for home health care,
submission process,
time limit,
Clinical nurse specialists, psychologists, social workers,
CMPs. See Coordinated health care organisations.
Coinsurance, Competitive medical plans (CMPs).
See Coordinated health care organisations.
Complaints
fraud and abuse hot line,
Medigap fraud,
review process,
skilled nursing facility,
Comprehensive Outpatient Rehabilitation
Facility (CORF),
Coordinated Health Care Organisations (HMOs, CMPs)
appealing decisions,
enrolment and coverage,
fraud,
quality of care,
Cosmetic surgery,
Counselling,
Custodial care,

Data matching,
Deductibles
annual, Part B,
blood,
hospital insurance (Part A),
medical insurance (Part B),
Dentists, services covered,
Diagnosis Related Groups (DRGs),
Diagnostic tests,
Dialysis. See Kidney disease.
Disabled people
cancelling or losing Medicare protection,
eligibility for coverage,
employer health plans,
enrolment process,
Doctors
participating,
services covered,
Doctors of osteopathy,
DRGs. See Diagnosis Related Groups.
Drugs and biologicals
coverage under Part A,
coverage under Part B,
haemophilia clotting factors,
hepatitis B vaccine,
immunosuppressive drugs,
pneumococcal pneumonia vaccine,
Durable medical equipment
coinsurance for,
description,
oxygen,
Durable power of attorney for health care,

Elective surgery, written estimate of costs,
Emergency room services,
Enrolment, Medicare cards,
Enrolment process
hospital insurance (Part A),
medical insurance (Part B),
Epoetin alfa,
Equipment. See Durable medical equipment;
Medical appliances.
Explanation of Your Medicare Part B Benefits,
notice,
Eye examinations,

Fee schedule,
Federally qualified health centre,
Financial assistance for
low-income beneficiaries,
Foot care,
Foreign hospital care,
Fraud and abuse,

HCFA 1500, form,
Health maintenance organisations (HMOs).
See Coordinated health care organisations.
Heart transplants,
Haemophilia clotting factors,
Hepatitis B vaccine,
HMOs. See Coordinated health care organisations.
Home health agencies,
Home health aides,
Home health care
Part A coverage,
Part B coverage,
Homemaker services,
Hospice care
and coordinated health care organisations,
description,
services covered,
Hospital inpatient care
blood, payment for,
Christian Science sanatorium,
conditions for payment,
deductible and coinsurance, foreign hospitals,
psychiatric,
reserve days,
services covered/not covered,
Hospital insurance (Part A)
appealing decisions,
benefit periods,
buying,
cancelling or losing protection,
coinsurance,
coverage,
deductible,
eligibility,
enrolment process,
non coverage, notice of,
patient fights,
premiums, premium-free,
prospective payment system,
Hospital outpatient care,
Hot line, fraud and abuse,
Medigap fraud,

Immunisations,
Immunosuppressive drags,
An Important Message From Medicare,
Inpatient care, hospital. See Hospital inpatient care.
Insurance. Also see Hospital insurance (Part A);
Medical insurance (Part B).
illegal sales practices, penalties and fines,
other than Medicare, claims submission,
supplemental,
Intermediaries and carriers
appealing decisions by,
description,

Kidney disease
cancelling or losing Medicare protection,
and coordinated health care organisations,
coverage booklet,
dialysis and transplants,
Medicare as secondary payer,

Laboratory services
doctor's office, independent, hospital outpatient,
hospital inpatient,
Limitation of liability,
Limits to physician charges,
Liver transplants,
Living wills,
Low-income assistance,

Mammography screening,
Managed care. See Coordinated health care organisations.
Medical appliances
hospice care,
inpatient care,
skilled nursing facility,
Medical insurance (Part B)
appealing decisions,
approved charges,
assignment payment method,
benefits explanation notice,
buying,
cancelling or losing protection,
claims,
coverage,
deductible and coinsurance amounts,
doctors and suppliers, participating,
eligibility, enrolment process,
premium amount,
providers, participating,
Medical supplies,
description,
Medicare, Part A. See Hospital insurance (Part A).
Medicare, Part B. See Medical insurance (Part B).
Medicare cards,
Medicare Participating Physician/Supplier
Directory,
Medicare secondary payer,
Medicare SELECT,
Medigap insurance
buying,
fraud, hot line,
Mental illness, outpatient treatment,

Non coverage
notice of,
what Medicare does not cover,
Notice of Utilisation,
Nurse anesthetists, midwives, practitioners, and specialists,
clinical,
Nursing home. See Skilled nursing facility.

Occupational therapy. See Therapy.
Open enrolment period, Medigap,
Optometrists, services covered,
Osteopathy, doctors of,
Outpatient hospital, services covered/not covered,
Oxygen equipment. See Durable medical equipment.

Pap smears,
Part A. See Hospital insurance (Part A).
Part B. See Medical insurance (Part B).
Partial hospitalisation for mental health treatment,
Participating doctors and suppliers,
Participating providers,
Payments. Also see Deductibles.
assignment payment method,
for blood. See Blood.
limitation of liability,
overpayments,
Part A,
prospective payment system,
Peer Review Organisations (PROs)
address and telephone number list,
appealing decisions,
complaints review process,
description,
Physical examinations, routine,
Physical therapy. See Therapy.
Physician assistants,
Physicians
participating,
services covered,
Pneumococcal pneumonia vaccine,
Podiatrists, services .covered,
PPS. See Prospective payment system.
Premium-free eligibility,
Premium, Part A,
Premium, Part B,
Prepaid health care organisations.
See Coordinated health care organisations.
Prescription drugs. See Drugs and biologicals.
Privacy Act,
Private duty nurses,
Private insurance organisations,
Also see Intermediaries and carriers.
PROs. See Peer Review Organisations.
Prospective payment system (PPS),
Prosthetic devices,
Providers, payment of,
Psychiatric care. Also see Mental illness.
psychiatric hospital care,
Psychologists, clinical,

Qualified Medicare Beneficiary,
Quality of care. Also see Peer Review Organisations.
complaints,
fraud and abuse hot line number,

Radiation therapy,
Reasonable and necessary care,
Rehabilitative services. See Therapy.
Relatives, services by,
Reserve days,
Respiratory therapy. See Therapy.
Respite care, hospice,
Routine physical examinations,
Rural health clinic services,

Seat lift chairs. See Durable medical equipment.
Second opinion before surgery,
Secondary payer,
Services not covered,
Skilled nursing facility
inpatient care,
services covered/not covered,
Social Security Administration
disability eligibility,
enrolment, cards, premium amounts, questions,
Social worker, clinical,
Special enrolment period,
Special practitioners,
Speech pathology,
Speech therapy. See Therapy.
State survey agency,
Supplemental insurance. See Medigap insurance.
Supplies. See Medical supplies.
Surgery
ambulatory,
cosmetic,
elective,
second opinion,

Telephone numbers, toll-free
Cancer information,
hot line, fraud and abuse,
Medicare carriers,
Medigap, fraud,
Peer Review Organisations,
second opinion, referral,
Terminal illness. See Hospice care.
Tests, diagnostic,
Therapy
Comprehensive Outpatient Rehabilitation
Facility services,
doctors' services, coverage,
home health care, coverage,
hospice care, coverage,
inpatient, coverage,
occupational,
outpatient, coverage,
physical,
radiation, coverage,
respiratory,
skilled nursing facility, coverage,
speech,
Time limit for claims submission,
Toll-free telephone numbers.
See Telephone numbers.

Vaccines,
Veterans benefits,

Waiver of liability,
Wheelchairs. See Durable medical equipment.
Workers' compensation benefits,

X-ray services,





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