Your Medicare handbook

64 Pages·1995·5 MB·English

by  United States. Health Care Financing Administration

SOCIALSECURITYACT
NAMEOFBENEFICIARY
JOHN DOE
D.
MEDICARECLAIMNUMBER SEX
123-45-6789A MALE
ISENTITLEDTO EFFECTIVEDATE
HOSPITAL INSURANCE (PARTA) 1/1/95
MEDICAL INSURANCE (PART B)
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Health Care Financing Administration
PUBS S»VIC*o
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412 ART A HOSPITAL INSURANCE
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Y68 ART B MEDICAL INSURANCE
1995
HealthCareFinancingAdministration
DepartmentofHealthandHumanServices
For almost 30 years, Medicare has assisted As Administrator of the Health Care
people age 65 and older and certain disabled Financing Administration (HCFA), I'd
Americans in meeting the costs of health care. like to welcome you to the Medicare
Medicare is an important resource that will help program. HCFA is the Federal agency that
you pay for the services of the most advanced administers Medicare, our Nation's health
medical system in the world. insurance program for olderAmericans,
the disabled, and persons with permanent
All of us in the Federal Government who work
kidney failure.
for you, from President Clinton and Vice
President Gore to the thousands of women and In 1995, HCFA expects to serve over 37
men who make up the Department of Health and million Americans across the country who
Human Services are dedicated to serving you. are covered by Medicare. Over the years,
And we are committed to continually improving the Medicare program has changed to
the ways we deliver service. meet your needs. This booklet will help
For example. Medicare now pays for certain you understand what is covered by
Medicare and what is not. It will also help
preventive services such as flu shots,
you understand your rights and
mammography screening, and Pap smear
responsibilities as a Medicare beneficiary.
screening. The program offers you the
opportunity to choose how and where to receive We want Medicare to be easy for you to
—
your benefits through the traditional "fee for use. We also hope that you will be
service" environment or enrollment in a actively involved in decisions about your
managed care plan. There are also options health care. It's our aim to provide you
available for buying insurance benefits that with information that will help you do so.
supplement Medicare's coverage, known as
At HCFA, it's ourjob to assure that your
"Medigap" policies. And, beneficiaries with low
Medicare coverage provides you with
incomes can be helped with premium,
access to quality, affordable health care.
deductible, and copayment expenses.
After all, HCFA and Medicare were
If you are new to the Medicare program, I created to serve beneficiaries.
welcome you. I hope you will find this booklet Beneficiaries are our top priority.
to be a helpful explanation of your Medicare
benefits.
Bruce C. Vladeck
Donna E. Shalala Administrator, Health Care
Secretary ofHealth and Human Services FinancingAdministration
^—
YOU HAVE
IF
Comments
• • •
Your opinion of this publication (and all of our publications) is very important to us. If after
using this or any of our other publications, you would like to share your thoughts with us, please
write to us at the address below. We are particularly interested in whether you found Your
Medicare Handbook complete, readable, well arranged and useful. Your comments will be
carefully considered as we prepare next year's revisions.
M
^\X3 Please send your comments to:
1^5" HCFA Office of Beneficiary Services
Room 604 EHR _!
c 3
6325 Security Blvd.
Baltimore, MD 21207
YOU HAVE
IF
Questions ???
—
This Handbook outlines your benefits what Medicare covers and what it does not.
The Handbook also tells you about your options and rights under Medicare. You can use the
alphabetical index at the back of the book to find information on specific subjects.
This Handbook is also available for people with special needs: in Spanish (see inside back cover
for how to order); on audiotape for the visually impaired; and on TTY for the hearing and speech
impaired (call 1-800-820-1202 for more information).
Call your Medicare Carrier Call Social Security
(See pages 42 to 47 for addresses and tele- (1-800-772-1213) about Medicare entitlement;
phone numbers) about Medicare claims, pay- how or when to enroll; or getting a new Medi-
ments and appeals. Carriers can supply new care card. Social Security can also supply a
Handbooks. new Handbook.
This handbookexplains the Medicareprogram, butis nota legal document. The official
Medicareprogram provisions are containedin the relevantlaws, regulations andRulings.
&
Health Insurance Information Counseling
Every state, plus Puerto Rico, the Virgin Islands, and the District of Columbia, has a health insur-
ance counseling program that can give you free information and assistance on Medicare, Medicaid,
Medigap, long term care and other health insurance benefits. You can call your state counseling
office and ask for printed information, help with choosing health insurance coverage, or even help
understanding your bills, insurance claims and explanation forms. Phone numbers are listed below
(the 800 numbers work only within the state). If you have trouble reaching your counseling office,
call the Medicare hotline at 1-800-638-6833.
State Counseling Offices
Alabama 1-800-243-5463
Alaska 1-800-478-6065
Arizona 1-800-432-4040
Arkansas 1-800-852-5494
California 1-800-927-4357
Colorado [phone], ext 356
Connecticut 1-800-443-9946
Delaware 1-800-336-9500
District ofColumbia [phone]
Florida [phone]
Georgia 1-800-669-8387
Hawaii [phone]
Idaho 1-800-247-4422
Ilbnois 1-800-548-9034
Indiana 1-800-452-4800
Iowa [phone]
Kansas 1-800-432-3535
Kentucky 1-800-372-2973
Louisiana 1-800-259-5301
Maine 1-800-750-5353
Maryland 1-800-243-3425
Massachusetts 1-800-882-2003
Michigan [phone]
ii
State Counseling Offices (cont'd)
Minnesota 1-800-882-6262
Mississippi 1-800-948-3090
Missouri 1-800-390-3330
Montana 1-800-332-2272
Nebraska [phone]
Nevada 1-800-307-4444
New Hampshire [phone]
New Jersey 1-800-792-8820
New Mexico 1-800-432-2080
New York 1-800-333-4114
North Carolina 1-800-443-9354
North Dakota 1-800-247-0560
Ohio 1-800-686-1578
Oklahoma [phone]
Oregon 1-800-722-4134
Pennsylvania [phone]
Puerto Rico [phone]
Rhode Island 1-800-322-2880
South Carolina 1-800-868-9095
South Dakota [phone]
Tennessee 1-800-525-2816
Texas 1-800-252-3439
Utah [phone]
Vermont 1-800-642-5119
Virginia 1-800-552-3402
Virgin Islands [phone]
Washington 1-800-397-4422
West Virginia [phone]
Wisconsin 1-800-242-1060
Wyoming 1-800-438-5768
iii
Contents
What Medicare?
is
Medicare Hospital Insurance (Part A) 4
Medicare Medical Insurance (Part B) 14
Medicare Medical Insurance (Part B) Payments 21
What Medicare Does Not Pay For 26
Medicare Managed Care Plans 28
Medicare and Other Insurance 30
How
to Appeal Medicare Decisions 35
Getting the Part of Medicare You Do Not Have 38
Events That Can End Your Medicare Protection 39
Other Things You Should Know About Medicare 40
Medicare Carriers 42
Medicare Peer Review Organizations (PROs) 48
Index 53
Save this Handbook for reference. It is revised each year and is available from Social Security or
your Medicare Carrier, but you will not automatically get a Handbook in the mail unless there are
major changes in the Medicare program.
IV
What Medicare?
is
A
Medicare is a federal health insurance program for Part if you are 65 or older and any of these three
people65orolderandcertaindisabledpeople. Itisrunby statements is true:
the Health Care Financing Administration of the U.S. • You receive benefits under the Social Security or
Department of Health and Human Services. Social Railroad Retirement system.
Security Administration offices across the country take • YoucouldreceivebenefitsunderSocialSecurityor
applications for Medicare and provide general informa- the Railroad Retirement system but have not filed
tion about the program. for them.
• You or your spouse had Medicare-covered
The Two Parts of Medicare government employment.
Hospital Insurance (Part A) If you are under 65, you can get premium-free
Medicare Part A benefits if you have been a disabled
Hospitalandskillednursingfacility, beneficiary under Social Security or the Railroad
home health andhospice care. Retirement Board for more than 24 months.
Certaingovernmentemployeesandcertainmembers
Medical Insurance (Part B) of their families can also get Medicare when they are
disabled formore than 29 months. They should apply at
Doctors'services, outpatienthospitalservices, the Social Security Administration officeas soon as they
durable medicalequipment, anda numberof become disabled.
othermedicalservices andsupplies thatare Or, you may be able to getpremium-free Medicare
notcoveredby PartA. Part A benefits if you receive continuing dialysis for
permanent kidney failure or if you have had a kidney
Throughout this handbook, Medicare Hospital In- transplant. (People who can get Medicare because of
suranceiscalledPartAandMedicareMedicalInsurance kidney disease may get a copy of Medicare Coverage
is called Part B. of Kidney Dialysis and Kidney Transplant Services
A
Part has deductibles and coinsurance, but most fromthe ConsumerInformation Center. Seeinsideback
peopledonothavetopaypremiumsforPartA. PartBhas cover for how to order.)
premiums, deductibles, and coinsurance amounts that Check with Social Security to see if you have
you must pay yourself or through coverage by another worked long enough under Social Security, Railroad
insurance plan. Premium, deductible and coinsurance Retirement, as a government employee, or a combina-
amounts are seteach yearbased onformulas established tion of these systems to be able to get Medicare Part A
by law. New payment amounts begin each January 1. benefits. Generally, ifeitheryou oryourspouse worked
When amounts increase, you will be notified. For 1995 for 10 years, you will be able to get premium-free
deductible, premium and coinsurance amounts, see the Medicare Part A benefits.
charts on pages 3 and 13.
Who Can Get Medicare Medical
Who Can Get Medicare Hospital
Insurance (Part B)?
Insurance (Part A)?
Any person who can get premium-free Medicare
Generally people age 65andoldercangetpremium-
freeMedicareP,artAbenefits,basedontheirownortheir Part A benefits based on work as described above can
spouses' employment. (Premium-free means there are enroll for Part B, pay the monthly Part B premiums (in
nopremiumpayments.Mostpeopledonotpaypremiums 1995, $46.10 for most beneficiaries), and get Part B
forMedicarePartA Youcangetpremium-freeMedicare benefits. Inaddition,mostUnitedStatesresidentsage65
.)
or overcan enroll in Part B.
Buying Medicare Part A and Part B anotherchancetoenrolluntilthenextgeneralenrollment
A
If you or your spouse do not have enough work period. general enrollment period is held each year
creditstobeabletogetMedicarePartAbenefits andyou fromJanuary 1 throughMarch31andifyouenrollduring
are 65 orover, you may be able tobuy Medicare Parts A thisperiodyouwill notbe abletogetMedicareuntilJuly
and B—or just Medicare Part B—by paying monthly ofthatyear.Youmayalsobechargedapremiumsurcharge
premiums. Also, you maybe able tobuy Medicare Parts forlateenrollment(unlessyou arecoveredunderagroup
A and B ifyou are disabled and lost your premium-free healthplanbasedoncurrentemploymentasdescribedon
A page 38).
Part solely because you are working. (See page 39 for
Theenrollmentperiodrequirementsandsurcharges
more information.)
forlateenrollmentdescribedabove forPart B alsoapply
Enrollment in Medicare to people who buy Part A. (See page 38 for more
information about buying Medicare Part A.)
Automatic Enrollment
If you are already getting Social Security or Rail- Your Medicare Card
roadRetirementbenefitpaymentswhenyouturn65,you The Medicare card shows the Medicare coverage
—
willautomaticallyget aMedicarecardinthemail. Ifyou you have Hospital Insurance (Part A), Medical
—
are disabled, you will automatically get a Medicare card Insurance (PartB),orboth andthedateyourprotection
in the mail when you have been a disability beneficiary started. If you do not have both parts of Medicare, see
under Social Security or Railroad Retirement for 24 page 40 for information on how you can get the partyou
months. don't have.
The Medicare card will show that you can get both Your Medicare card also shows your health insur-
MedicareHospital Insurance (Part A)andMedical Insur- ance claim number. Sometimes this claim number is
ance (Part B) benefits. Ifyou do not want Part B, follow referredtoasyourMedicare number. Theclaimnumber
the instructions that come with the card. usually has nine digits and oneortwo letters.There may
Some People Have to Apply also be another number after the letter. Your full claim
You may not automatically get a Medicare card in number must always be included on all Medicare claims
and correspondence. When a husband and wife both
the mail. You will have to apply for Medicare benefits if : have Medicare, each receives a separate card and claim
• You have not applied for Social Security or Railroad
number. Each spouse must usetheexact nameandclaim
Retirement benefits
number shown on his or her card.
• Government employment is involved, or
• You have kidney disease. It is important that you remember to:
• UseyourMedicarecardonly aftertheeffectivedate
You should file your application during your initial shown on
it.
enrollment period, to avoid late enrollment surcharges • Keep your card handy. And be sure to carry your
under Medicare Part B (unless you qualify for a special card with you when you are away from home.
enrollment period as described on page 38). Your initial • Always show your Medicare card when you get
enrollment period is a seven-month period that starts care.
three months before the month you first meet the • Always write yourcompletehealth insuranceclaim
requirements for Medicare. If you t\o not sign up for number (including any letters) on all checks for
Medicare during the first three months of your initial Medicarepremiumpaymentsoranycorrespondence
enrollment period, there will be a delay in starting your about Medicare. Also, have your Medicare card
PartBcoverage. Yourcoverage willbedelayed fromone available when you make a telephone inquiry.
to three months after enrollment. • Immediately ask Social Security to get you a new
Ifyou do notenroll for Medicare Part B at any time card ifyou lose yours.
during your initial enrollment period, you will not have • Never let anyone else use your Medicare card.
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Medicare Hospital Insurance (Part A)
What Part A Includes Example2: Ms.SmithentersthehospitalonAugust
Medicare Part A helps pay for four kinds ofmedi- 14. SheisdischargedonAugust24. Shealsohasused 10
cally necessary care: days of her first benefit period. However, she is then
>- readmittedtothe hospital on September20. Sincefewer
Inpatient hospital care.
>- Inpatient care in a skilled nursing than60dayselapsedbetweenhospitalstays,Ms. Smithis
still in herfirst benefit period and will not berequired to
facility following a hospital stay.
payanotherhospitaldeductible. Thismeansthatthefirst
>* Home
health care.
day ofher second admission is counted as the eleventh
>" Hospice care. dayofhospitalcareinthatbenefitperiod. Ms. Smithwill
There is a limit on how many days of hospital or not begin a new benefit period until she has been out of
skilled nursing facility care Medicare helps pay for in the hospital (and has not received any skilled care in a
each benefit period. But, your Part A protection is skilled nursing facility) for 60 consecutive days.
renewed every time you start a new benefit period. How Medicare Pays for Part A Services
(Benefit periods are described below.) A
Medicare Part helpspayforcoveredservices you
Skilled nursing facility care is the only type of receive in a hospital or skilled nursing facility or from a
nursinghomecarethatMedicarecovers. Medicaredoes home health agency or hospice program.
notpayforcarethatisprimarilycustodial. (Seepages Hospitals, skilled nursing facilities, home health
7 and 26 for more about custodial care.) agencies and hospices are called "providers" under the
Benefit Periods Medicare Part A program. Providers submit theirclaims
—
A benefit period is a way ofmeasuring your use of directlytoMedicare youcannotsubmitclaimsfortheir
servicesunderMedicarePartA. Yourfirstbenefitperiod services. The providerwill charge you foranypartofthe
starts the first time you receive inpatient hospital care Part A deductible you have not met and any coinsurance
after your Hospital Insurance begins. A benefit period paymentyouowe. Providerscannotrequireyoutomake
ends when you have been out of a hospital or other a deposit before being admitted for inpatient care that is
facility primarilyproviding skilled nursingorrehabilita- or may be covered under Part A ofMedicare.
tion services for 60 days in a row (including the day of Intermediaries
discharge). Afterone benefit period has ended, another Intermediaries process claims submitted on your
one will start whenever you again receive inpatient behalfbyhospitals,skillednursingfacilities,homehealth
hospital care. agencies,hospicesandcertainotherprovidersofservices.
There is no limit to the number of benefit periods When the Medicare intermediary pays aclaim, you geta
you can have for hospital and skilled nursing facility Notice ofMedicare Benefit. This notice is not a bill. If
care. you have any questions about the notice, contact the
Here are two examples of how the benefit period
intermediary.
works:
Example I: Ms.JonesentersthehospitalonJanuary Coverage ofBlood Under Part A
5. She is discharged on January 15. She has used 10 days Part A helps pay for blood (whole blood or units of
ofher first benefit period. Ms. Jones is not hospitalized packed red blood cells), blood components, and the cost
again until July 20. Since more than 60 days elapsed of blood processing and administration. If you receive
between her hospital stays, she begins a new benefit blood as an inpatient of a hospital or skilled nursing
period, her Part A coverage is completely renewed, and facility, Part A will pay for these blood costs, except for
she will again pay the hospital deductible.
^