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

enrollment period.

* New Benefits

Recently added Medicare Part B benefits for cancer

screening--mammograms and Pap smears--are described on page 25.

* Who Pays First?

Medicare is not always the insurer that pays first

on claims. For example, some people are employed, or their

spouse is employed, and the employer health insurance pays

first. For more about who pays first, see pages 10 and 11.

* Where to Call or Write

Look on the inside front cover to find where to call or

write to ask questions about Medicare.

This handbook is meant to explain the Medicare program,

but is not a legal document. The official Medicare program

provisions are contained in the relevant laws, regulations and

Rulings.

Save this handbook for reference. It is revised each year

and is available from Social Security, but you will not

automatically get a handbook in the mail unless there are major

changes in the Medicare program.

Contents

What is Medicare?

The Two Parts of Medicare

Who Can Get Medicare Hospital Insurance

Who Can Get Medicare Medical Insurance (Part B)?

Buying Medicare Part A and Part B

Enrollment in Medicare

Your Medicare Card

Assistance for Low-Income Beneficiaries

Intermediaries and Carriers

Peer Review Organizations

Your Right to Decide About Your Medical Care

Fraud and Abuse

Your Rights Under the Privacy Act

Medicare Coordinated Care Plans

What Are Coordinated Care Plans

Who Can Enroll in Coordinated Care Plans?

Joining a Coordinated Care Plan

Ending Enrollment in a Coordinated Care Plan

If You Have Problems

Medicare and Other Insurance

Buying Health Insurance to Supplement Medicare

When Other Insurance Pays Before Medicare

What Medicare Does Not Pay For

Custodial Care

Care Not Reasonable and Necessary Under Medicare Program

Standards

Services Medicare Does Not Pay For

Limitation of Liability

Medicare Hospital Insurance (Part A)

What Medicare Part A Includes

How Medicare Pays for Part A Services

When You Are a Hospital Inpatient

Skilled Nursing Facility Care

Home Health Care

Hospice Care

Medicare Medical Insurance (Part B)

What Medicare Part B Includes

Deductible and Coinsurance Amounts Under Part B

Doctors' Services Covered by Medicare Part B

Second Opinion Before Surgery

Services of Special Practitioners

Outpatient Hospital Services

Other Services and Supplies Covered by Medicare

Drugs and Biologicals

Medicare Payments for Outpatient Treatment of Mental

Illness

Medicare Medical Insurance (Part B) Payments

The Assignment Payment Method

Participating Doctors and Suppliers

When Your Doctor Does Not Accept Assignment

Participating Providers

Medicare Approved Amounts

Submitting Part B Claims

Getting the Part of Medicare You Do Not Have

Getting Medicare Medical Insurance (Part B)

Getting Medicare Hospital Insurance (Part A)

Special Enrollment Period

Events That Can Change Your Medicare Protection

When Protection Ends for People 65 and Older

When Protection Ends for the Disabled

When Protection Ends for Those With Permanent Kidney

Failure

How to Appeal Medicare Decisions

Appealing Decisions Made by Providers of Part A Services

Appealing Decisions Made by Peer Review Organizations

(PROs)

Appealing Decisions of Intermediaries on Part A Claims

Appealing Decisions Made by Carriers on Part B Claims

Appealing Decisions Made by Health Maintenance

Organizations (HMOs)

For More Information

Appendices

Charts: Medicare Covered Services

Medicare Carriers

Medicare Peer Review Organizations (PROs)

Index

What is Medicare?

The Medicare program is a federal health insurance program

for people 65 or older and certain disabled people. It is run

by the Health Care Financing Administration of the U.S.

Department of Health and Human Services. Social Security

Administration offices across the country take applications for

Medicare and provide general information about the program.

The Two Parts of Medicare

There are two parts to the Medicare program. Hospital

Insurance (Part A) helps pay for inpatient hospital care,

inpatient care in a skilled nursing facility, home health care

and hospice care. Medical Insurance (Part B) helps pay for

doctors' services, outpatient hospital services, durable

medical equipment, and a number of other medical services and

supplies that are not covered by the Hospital Insurance part of

Medicare. Throughout this handbook, Medicare Hospital Insurance

is called Part A and Medicare Medical Insurance is called

Part B.

Part A has deductibles and coinsurance, but most people do

not have to pay premiums for Part A (see page 33). Part B has

premiums, deductibles, and coinsurance amounts that you must

pay yourself or through coverage by another insurance plan.

Premium, deductible and coinsurance amounts are set each year

based on formulas established by law. New payment amounts begin

each January 1. When amounts increase, you will be notified.

For 1993 deductible, premium and coinsurance amounts, see the

charts on pages 37 and 38.

Who Can Get Medicare Hospital Insurance (Part A)?

Generally, people age 65 and older can get premium-free

Medicare Part A benefits, based on their own or their spouses'

employment. (Premium-free means there are no premium payments.

Most people do not pay premiums for Medicare Part A.) You can

get premium-free Medicare Part A if you are 65 or older and any

of these three statements is true:

* You receive benefits under the Social Security or Railroad

Retirement system.

* You could receive benefits under Social Security or the

Railroad Retirement system but have not filed for them.

* You or your spouse had Medicare-covered government

employment.

If you are under 65, you can get premium-free Medicare Part

A benefits if you have been a disabled beneficiary under Social

Security or the Railroad Retirement Board for more than 24

months.

Certain government employees and certain members of their

families can also get Medicare when they are disabled for more

than 29 months. They should apply at the Social Security

Administration office as soon as they become disabled.

Or, you may be able to get premium-free Medicare Part A

benefits if you receive continuing dialysis for permanent

kidney failure or if you have had a kidney transplant. (People

who can get Medicare because of kidney disease may get a copy

of Medicare Coverage of Kidney Dialysis and Kidney Transplant

Services from the Consumer Information Center. See inside back

cover for how to order.)

Check with Social Security to see if you have worked long

enough under Social Security, Railroad Retirement, as a

government employee, or a combination of these systems to be

able to get Medicare Part A benefits. Generally, if either you

or your spouse worked for 10 years, you will be able to get

premium-free Medicare Part A benefits.

Who Can Get Medicare Medical Insurance (Part B)?

Any person who can get premium-free Medicare Part A

benefits based on work as described above can enroll for Part

B, pay the monthly Part B premiums (in 1993, $36.60 for most

beneficiaries), and get Part B benefits. In addition, most

United States residents age 65 or over can enroll in Part B.

Buying Medicare Part A and Part B

If you or your spouse do not have enough work credits to

be able to get Medicare Part A benefits and you are 65 or over,

you may be able to buy Medicare Parts A and B--or just Medicare

Part B--by paying monthly premiums. Also, you may be able to buy

Medicare Parts A and B if you are disabled and lost your

premium-free

Part A solely because you are working. (See page 34 for

more information.)

Enrollment in Medicare

If you are already getting Social Security or Railroad

Retirement benefit payments when you turn 65, you will

automatically get a Medicare card in the mail. The card will

show that you can get both Medicare Hospital Insurance (Part A)

and Medical Insurance (Part B) benefits. If you do not want

Part B, follow the instructions that come with the card.

The above process also applies when you have been a

disability beneficiary under Social Security or Railroad

Retirement for 24 months. A Medicare card will come in the

mail.

Some people do not automatically get a Medicare card. They

must file an application to get Medicare benefits. If you have

not applied for Social Security or Railroad Retirement

benefits, or if government employment is involved, or if you

have kidney disease, you must file an application for Medicare.

Check with Social Security if you are able to get Medicare

under the Social Security system or based on Medicare-covered

government employment; check with the Railroad Retirement

office if you are able to get Medicare under the Railroad

Retirement system.

If you must file an application for Medicare, you should

apply during your initial enrollment period, to avoid late

enrollment penalties under Medicare Part B (unless you qualify

for a special enrollment period as described on page 33). Your

initial enrollment period is a seven-month period that starts

three months before the month you first meet the requirements

for Medicare. If you do not sign up for Medicare during the

first three months of your initial enrollment period, there

will be a delay in starting your Part B coverage. Your coverage

will be delayed from one to three months after enrollment.

If you do not enroll for Medicare Part B at any time

during your initial enrollment period, you will not have

another chance to enroll until the next general enrollment

period. A general enrollment period is held each year from

January 1 through March 31 and if you enroll during this period

you will not be able to get Medicare until July of that year.

You may also be charged a premium penalty for late enrollment

(unless you qualify for a special enrollment period as

described on page 33).

The enrollment period requirements and penalties for late

enrollment described above for Part B also apply to people who

buy Part A. (See page 33 for more information about buying

Medicare Part A.)

Your Medicare Card

The Medicare card shows the Medicare coverage you

have--Hospital Insurance (Part A), Medical Insurance (Part B),

or both--and the date your protection started. If you do not

have both parts of Medicare, see page 33 for information on how

you can get the part you don't have.

Your Medicare card also shows your health insurance claim

number. Sometimes this claim number is referred to as your

Medicare number. The claim number usually has nine digits and

one or two letters. There may also be another number after the

letter. Your full claim number must always be included on all

Medicare claims and correspondence. When a husband and wife

both have Medicare, each receives a separate card and claim

number. Each spouse must use the exact name and claim number

shown on his or her card.

It is important that you remember to:

* Use your Medicare card only after the effective date shown

on it.

* Keep your card handy. And be sure to carry your card with

you whenever you are away from home.

* Always show your Medicare card when you receive services

that Medicare helps pay for.

* Always write your complete health insurance claim number

(including any letters) on all checks for Medicare

premium payments or any correspondence about Medicare.

Also, you should have your Medicare card available when

you make a telephone inquiry.

* Immediately ask Social Security to get you a new card if

you lose yours.

* Never let anyone else use your Medicare card.

Assistance for Low-Income Beneficiaries

Federal law requires that state Medicaid programs pay

Medicare costs for certain elderly and disabled people with low

incomes and very limited resources, described below. The

following is a general description only; rules may vary from

state to state.

Qualified Medicare Beneficiaries (QMB)

In general, you must meet these requirements:

* You must be entitled to Medic are Hospital Insurance (Part

A).

* Your annual income for 1992 must be at or below $7,050 for

one person and $9,430 for a family of two (amounts are

somewhat higher in Alaska and Hawaii).* Amounts for 1993

will be slightly higher than those for 1992.

* You cannot have resources such as bank accounts or stocks

and bonds worth more than $4,000 for an individual or

$6,000 for a couple. Your personal home, automobile,

burial plot, furniture, jewelry, or life insurance are not

counted, unless those items are of extraordinary value.

If you qualify as a QMB, your Medicare premiums,

deductibles and coinsurance will be covered.

* This amount is based on a percentage of the national

poverty guidelines plus an income disregard of $240.

Specified Low-income Medicare Beneficiaries (SLMB)

Beginning January 1, 1993, there is a new program for

certain low-income Medicare beneficiaries whose income is above

the level to qualify as a QMB, but whose income is below 110

percent of the national poverty guidelines. If you qualify as a

SLMB, Medicaid will pay your Medicare Part B premium only

($36.60 per month in 1993).

Where to Apply

If you think you may qualify for any of these benefits,

you should file an application at the state or local welfare,

social service or public health agency that serves people on

Medicaid. All of these agencies are state--not

federal--agencies.

If you need the telephone number for Medicaid, call

1-800-638-6833. Give the operator the name of your state and

explain that you want the Medicaid telephone number so you can

get information about these benefits.

Intermediaries and Carriers

The federal government contracts with private insurance

organizations called intermediaries and carriers to process

claims and make Medicare payments. Intermediaries handle

inpatient and outpatient claims submitted on your behalf by

hospitals, skilled nursing facilities, home health agencies,

hospices and certain other providers of services.

You will not usually need to get in touch with

intermediaries because Medicare pays most hospitals, skilled

nursing facilities, home health agencies, hospices and other

providers of services directly. But, if you have a question

about your Part A bill, ask someone who works at the facility

for help. If you cannot get an answer there, ask someone in the

billing office at the facility to help you get in touch with

the Medicare intermediary.

Carriers handle claims for services by doctors and

suppliers covered under Medicare's Part B program. If you have

questions about Medicare Part B claims, contact your Medicare

carrier. The addresses and phone numbers of carriers are on

pages 39 to 44.

If you want someone to contact Medicare for you, see "Your

Rights Under the Privacy Act," (page 5) for more information.

Peer Review Organizations

Peer Review Organizations (PROs) are groups of practicing

doctors and other health care professionals who are paid by the

federal government to review the care given to Medicare

patients. Each state has a PRO that decides, for Medicare

payment purposes, whether care is reasonable, necessary, and

provided in the most appropriate setting. PROs also decide

whether care meets the standards of quality generally accepted

by the medical profession. PROs have the authority to deny

payments if care is not medically necessary or not delivered in

the most appropriate setting.

PROs investigate individual patient complaints about the

quality of care and respond to:

* Requests for review of notices of noncoverage issued by

hospitals to beneficiaries; and

* Requests for reconsideration of PRO decisions by

beneficiaries, physicians, and hospitals.

The PRO will tell you in writing if the service you

got was not covered by Medicare. See page 12 for a discussion

of what is not covered by Medicare.

If you are admitted to a Medicare participating hospital,

you will receive An Important Message From Medicare which

explains your rights as a hospital patient and provides the

name, address and phone number of the PRO for your state. If

you are not given a copy of the message, be sure to ask for

one.

If you feel that you are improperly refused admission to a

hospital or that you are forced to leave the hospital too soon,

ask for a written explanation of the decision. Such a written

notice must fully explain how you can appeal the decision and

it must give you the name, address and phone number of the PRO

where your appeal or request for review can be submitted. (See

page 35 for further discussion of your appeal fights under

Medicare.)

Beneficiary Complaints

PROs are responsible for reviewing beneficiary complaints

about the quality of care provided by inpatient hospitals,

hospital outpatient departments and hospital emergency rooms;

skilled nursing facilities; home health agencies; ambulatory

surgical centers; and certain health maintenance organizations.

If you believe that you have received poor quality care

from one of these facilities, you may complain to the PRO. The

PRO will investigate written complaints from beneficiaries, or

their representatives, about the quality of Medicare services

received.

Your complaint must be in writing. If you wish, the PRO

will help you put your complaint in writing by taking the

information from you over the telephone and writing the

complaint. If someone other than the PRO makes a complaint for

you or on your behalf, you must give written permission for

that person to represent you in the complaint.

Medicare PROs for each state are listed on pages 45 to

49.

Your Right to Decide About Your Medical Care

Under a new Medicare law, when you are admitted to a

Medicare hospital or skilled nursing facility, get Medicare

home health care, or enroll in a Medicare-approved hospice or

health maintenance organization, you must be given written

information about your rights to make decisions about your

medical care.

Generally, you will be told about your fight to accept or

refuse medical or surgical treatment. You will also be told

about your fight to make--if you choose--an "advance

directive." An advance directive contains written instructions

about your choices for health care or naming someone to make

those choices for you. The instructions are to be used if you

are too sick or otherwise unable to talk. (The paper giving

your health care choices may be called a "living will" or "a

durable power of attorney for health care.")

You do not have to have an advance directive. But, if you

have one you can say "yes" in advance to treatment you want if

you get too sick to talk to your health care provider. You can

also say "no" in advance to treatment you don't want.

Laws governing advance directives vary from state to

state. Your treatment choices will depend on what is legal in

your state. You can ask health care professionals in your state

about the state's rules for living wills or durable powers of

attorney. You can also contact your local state's attorney's

office for this information.

Fraud and Abuse

Suspected Fraud Should be Reported

If you have reason to believe that a doctor, hospital, or

other provider of health care services is performing

unnecessary or inappropriate services, or is billing Medicare

for services you did not receive, you should immediately report

to the Medicare carrier or intermediary that handles your

claims (see page 3).

The routine waiver of deductibles and coinsurance by

doctors or suppliers of durable medical equipment is unlawful.

Coinsurance and deductible payments may be waived only after

careful consideration of a particular patient's financial

hardship. Therefore, if a doctor or supplier offers to waive

coinsurance or deductible payments, without having considered

your individual circumstances or when you have not asked to

have the payments waived, you should immediately report the.

offer to the Medicare carrier or intermediary.

Report to the Medicare Carrier or Intermediary First

Call the carrier or intermediary first when you suspect

fraud. Medicare carriers and intermediaries routinely look into

cases of possible fraud and will appreciate your alerting them

to your case. The carrier or intermediary will need to know the

exact nature of the wrongdoing you suspect, the date it

occurred, and the name and address of the party involved. Have

this information ready when you call. (The telephone number of

the Medicare intermediary or carrier is listed on the notice

explaining Medicare's decision on your Medicare claim. Medicare

carriers are also listed on pages 39 to 44.)

Calling For Further Help

If the Medicare carrier or intermediary does not respond

to your report of Medicare fraud or abuse, you may call the

Health Care Financing Administration (HCFA) hotline at

1-800-638-6833. There is no charge to you when you call this

number. The hotline operator will refer you to the appropriate

staff person at a HCFA regional office.

Be prepared to tell the HCFA regional office staff person:

* The exact nature of the wrongdoing you suspect, the date

it occurred, and the name and address of the party

involved.

* The name and location of the Medicare intermediary or

carrier you reported it to, and when you reported it.

* The name of any intermediary or carrier employee to whom

you spoke and what advice that person gave you.

Your Rights Under the Privacy Act

Under the Privacy Act all federal agencies must safeguard

information they collect about the people they serve.

When the Health Care Financing Administration (the agency

that administers the Medicare program) asks you to fill out

forms giving information about yourself to Medicare, we must:

* Explain why we are collecting the information.

* Tell you whom we plan to give it to.

* Tell you whether you must, by law, give us the

information.

When you give Medicare information, the Privacy Act allows

you to:

* Review your records for accuracy.

* Make corrections, if you believe there are errors.

* Know exactly what we will do with your records.

The Privacy Act also allows the government to verify the

information you give us, using computer matches with other

federal or state governments. If we do computer matches, we

must tell you that they take place and give you a chance to

protest our findings.

We include information about matches on all the forms you

fill out. We also put a notice in the Federal Register, which

is published by the federal government to notify the public of

official actions. Copies are available at many libraries. (A

computer-data match using Medicare, Internal Revenue Service

and Social Security information is discussed on page 11.)

Medicare Carriers and Intermediaries must follow Privacy

Act rules: These Medicare contractors may not discuss personal

information about you with your family members or others who

write or telephone on your behalf unless you give the

contractors written permission.

What Are Coordinated Care Plans?

More and more Medicare beneficiaries are joining

coordinated care plans. These coordinated care plans are

prepaid, managed care plans, most of which are health

maintenance organizations (HMOs) or competitive medical plans

(CMPs). Both HMOs and CMPs contract with Medicare and follow

the same contracting rules. In this handbook, HMOs will be used

to illustrate the benefits for both.

Many beneficiaries find that coordinated care plans are a

good way to get more health care for their dollar. HMOs provide

or arrange for all Medicare covered services, and generally

charge you fixed monthly premiums and only small co-payments.

This means that if you join a coordinated care plan and get all

of your services through the HMO, your out-of-pocket costs are

usually more predictable. Also, depending on your health needs,

those costs may be less than you would pay if you had to pay

the regular Medicare deductible and coinsurance amounts.

Coordinated care plans may also offer benefits not

covered by Medicare for little or no additional cost. Benefits

may include preventive care, dental care, heating aids and

eyeglasses.

Who Can Enroll in Coordinated Care Plans?

Most Medicare beneficiaries are eligible to enroll in

HMOs. HMOs cannot screen applicants to decide if they are

healthy, or delay coverage for pre-existing conditions. The

only enrollment criteria for Medicare HMOs are:

* You must be enrolled in Medicare Part B and continue to

pay the Part B premiums (you do not need to be able to get

Part A).

* You must live in the plan's service area.

* You cannot be receiving care in a Medicare-certified

hospice.

* You cannot have permanent kidney failure.

If you develop permanent kidney failure after joining a

coordinated care plan, the plan will provide, pay for, or

arrange for your care. If you choose to receive hospice care

after joining a coordinated care plan, the plan must inform you

about hospice services available in your area. Staff at the

coordinated care plan will explain how the hospice choice

affects your plan membership.

Joining a Coordinated Care Plan

To join a coordinated care plan, contact plans in your

area that have a contract with Medicare. All HMOs with Medicare

contracts have an advertised open enrollment period at least

once a year. Once you join, you may stay with the plan as long

as it continues to contract with Medicare. And you may return

to regular Medicare at any time.You can find out if there are

HMOs in your area that contract with Medicare by calling the

Health Care Financing Administration (HCFA) regional office

nearest you. Medicare Coordinated Care contact numbers are

listed in the box on page 7.

If you enroll in a coordinated care plan you will usually

be required to get all care from the plan. In most cases, if

you get services that are not authorized by the HMO (unless

they are emergency services or services you urgently need when

you are out of the plan's service area) neither the plan nor

Medicare will pay for the services.

When you join an HMO, be sure to read your membership

materials carefully to learn your fights and coverage.

Ending Enrollment in a Coordinated Care Plan

To end your enrollment in a coordinated care plan, send a

signed request to your plan or to your local Social Security or

Railroad Retirement Board office. You return to regular

Medicare the first day of the month following the month your

request is received by one of these offices. (If you leave a

coordinated care plan to return to regular Medicare and buy a

Medigap policy, you may have to wait for up to 6 months for the

new Medigap policy to cover any pre-existing condition.)

If You Have Problems

If you belong to a Medicare HMO and you are unhappy with

the quality of care, you can:

* Follow your HMO's grievance procedure, or

* Complain to your Peer Review Organization (PRO). PROs are

groups of practicing doctors and other health care

professionals under contract to Medicare to review the

care provided to Medicare patients (seepage 3).

If you have reason to believe that your Medicare HMO did

not give you necessary care, inappropriately ended your

enrollment, charged you an excessive premium, or falsified or

misrepresented information, you can:

* Write to the Office of Prepaid Health Care Operations and

Oversight, Room 4406 Cohen Building, 330 Independence

Ave., SW, Washington, DC 20201.

* Describe your problem. The Office will see that your case

is reviewed.

If you believe that your HMO has made an incorrect

decision on coverage of benefits or payment of a claim, you can

appeal--your appeal fights are similar to those provided under

traditional Medicare. (See page 36 for more information about

appeals.)

NOTE: A new Medicare supplement (Medigap) option is now

available in some states. It is a kind of coordinated care plan

called Medicare SELECT (see page 8 for more information).

If you need more information about Medicare and

coordinated care plans, you can get a copy of Medicare and

Coordinated Care Plans from the Consumer Information Center

(see inside back cover).

Regional Office Coordinated Care Contacts

Health Care Financing Administration staff at the offices

listed below can tell you if there are HMOs in your area that

contract with Medicare.

Boston: (Connecticut, Maine, Massachusetts, New Hampshire,

Rhode Island and Vermont) Beneficiary Services Branch

(617) 565-1232

New York: (New Jersey, New York, Puerto Rico and the Virgin

Islands) Carrier Operations Branch

(212) 264-8522

Philadelphia: (Delaware, District of Columbia,

Maryland, Pennsylvania, Virginia and West Virginia)

Beneficiary Services Branch

(215) 596-1332

Atlanta: (Alabama, North and South Carolina,

Florida, Georgia, Kentucky, Mississippi, and

Tennessee)

Beneficiary Services and HMO Branch

(404) 331-2549

Chicago: (Illinois, Indiana, Michigan, Minnesota, Ohio and

Wisconsin)

Beneficiary Services and HMO Branch

(312) 353-7180

Dallas: (Arkansas, Louisiana, New Mexico,

Oklahoma and Texas)

Beneficiary Services Branch

(214) 767-6401

Kansas City: (Iowa, Kansas, Missouri and

Nebraska)

Program Services Branch

(816) 426-2866

Denver: (Colorado, Montana, North and South

Dakota, Utah and Wyoming)

Beneficiary Services Branch

(303) 844-4024 ext 238

San Francisco: (American Samoa, Arizona,

California, Guam, Hawaii and Nevada)

Beneficiary Services Branch

(415) 744-3617

Seattle: (Alaska, Idaho, Oregon and

Washington)

Beneficiary Services Branch

(206) 553-0800

Medicare and Other Insurance

Buying Health Insurance to Supplement Medicare

Medicare provides basic protection against the cost of

health care, but it will not pay all of your medical expenses,

nor most long-term care expenses. For this reason, many private

insurance companies sell supplement (Medigap) insurance as well

as separate long-term care insurance. The federal government

does not sell or service such insurance.

Shopping for Medigap Insurance

If you are thinking about buying a new private insurance

policy or replacing an old policy to supplement your Medicare

protection or cover long-term care costs, you should shop

carefully. You can get a booklet, Guide to Health Insurance for

People with Medicare, to help you make Medicare supplement

decisions. (See box below for more information about the

guide.)

New Standardized Medigap Policies

Most states have adopted regulations limiting the sale of

Medigap insurance to no more than 10 standard policies. One of

the 10 is a basic policy offering a "core package" of benefits.

These standardized plans are identified by the letters A

through J. Plan A is the core package. The other nine plans

each have a different combination of benefits, but they all

include the core package. The basic policy, offering the core

package of benefits, is available in all states.

To find out what standardized policies are available in

your state, check with your state insurance department. The

telephone number of your state insurance department is probably

listed under "state agencies" in your telephone book. If not,

you can get a copy of the Guide to Health Insurance for People

with Medicare (see box below).

In most cases, if you already have a Medigap policy, you

may keep it but there are a few states where you must convert

your policy to one of the standard plans. In all cases, if you

buy a new policy, you will be required to choose a standardized

plan.

Open Enrollment Period for Medigap Policies

An open enrollment period for selecting Medigap policies

guarantees that for six months immediately following the

effective date of Medicare Part B coverage, people age 65 or

older cannot be denied Medigap insurance or charged higher

premiums because of health problems.

No matter how you enroll in Part B--whether by automatic

notification or through an initial, special or general

enrollment period--you are covered by the new guarantees if

both of the following are true:

* You are 65 or older and are enrolled in Medicare based on

age rather than disability.

* The date you get by adding six months to the effective

date for your Part B coverage (printed on your Medicare

card) is in the future. The date you get tells you when

your Medigap open enrollment ends.

NOTE: Even when you buy your Medigap policy in this open

enrollment period, the policy may still exclude coverage for

"pre-existing conditions" during the first six months the

policy is in effect. Pre-existing conditions are conditions

that were either diagnosed or treated during the six-month

period before the Medigap policy became effective.

Medicare SELECT

A new kind of Medigap insurance-available through 1994-has

been introduced in 15 states. It is called Medicare SELECT. The

difference between Medicare SELECT and regular Medigap

insurance is that a Medicare SELECT policy may (except in

emergencies) limit Medigap benefits to items and services

provided by certain selected health care professionals or may

pay only partial benefits when you get health care from other

health care professionals.

You can order a free copy of the Guide to health Insurance

for People With Medicare from the Consumer Information Center.

There is ordering information on the inside back cover of this

book. The guide:

* Explains how supplemental insurance works.

* Tells how to shop for Medigap insurance.

* Gives information on the new standard plans.

* Gives information on Medicare SELECT.

* Lists names, addresses and telephone numbers of state

insurance departments and state agencies on aging. Some of

these offices may have free counseling services available.

Insurers, including some HMOs, offer Medicare SELECT in

the same way standard Medigap insurance is offered. The

policies are required to meet certain federal standards and are

regulated by the states in which they are approved. The

premiums charged for Medicare SELECT policies are expected to

be lower than premiums for comparable Medigap policies that do

not have this selected-provider feature.

Medicare SELECT policies are permitted to be offered in

Alabama, Arizona, California, Florida, Illinois, Indiana,

Kentucky, Massachusetts, Minnesota, Missouri, North Dakota,

Ohio, Texas, Washington and Wisconsin. If you live in one of

these states, you can ask your state insurance department about

the Medicare SELECT policies that have been approved for sale

in the state.

Employment-related Retiree Coverage Instead of Medigap

Some retired people can get health coverage through their

former employer or union. This health coverage may supplement

Medicare but it is not Medigap insurance and does not have to

meet federal and state Medigap requirements. (See below for

rules about selling Medigap Insurance.)

Retiree coverage is usually provided free or at a greatly

reduced price and may be a good bargain. But the benefits may

not be adequate to serve as your supplement to Medicare. Does

your retiree plan have an "escape clause," so that benefits

might be changed? On the other hand, does your retiree plan

protect you from the preexisting condition restriction that

might be applied during the first six months under a Medigap

policy? Check carefully before you decide whether to stay with

your retiree coverage or buy a Medigap policy.

Medicaid Recipients

Low-income people who are eligible for Medicaid usually do

not need additional insurance. Medicaid pays for certain health

care benefits beyond those covered by Medicare, such as

long-term nursing home care. If you have Medigap insurance

purchased on or after November 5, 1991, and you become eligible

for Medicaid, you can ask that the Medigap benefits and

premiums be suspended for up to two years while you are covered

Medicaid. If you become ineligible for Medicaid benefits during

the two years, your Medigap policy is automatically

reinstituted if you give proper notice and begin paying

premiums again.

Coordinated Care Plans Instead of Medigap

Coordinated care plans that contract with Medicare are not

Medigap plans, but they can be an alternative to standard

Medigap insurance. (See page 6 for more information about

coordinated care plans.)

There are Rules for Selling Medigap Insurance

Both state and federal laws govern sales of Medigap

insurance. Companies or agents selling Medigap insurance must

avoid certain illegal practices. Federal criminal and civil

penalties (fines) may be imposed against any insurance company

or agent that knowingly:

* Sells you a health insurance policy that duplicates your

Medicare or Medicaid coverage, or any private health

insurance coverage you may have.

* Tells you that they are employees or agents of the

Medicare program or of any government agency.

* Makes a false statement that a policy meets legal

standards for certification when it does not.

* Sells you a Medigap policy that is not one of the 10

approved standard policies (after the new standards have

been put in place in your state).

* Denies you your Medigap open enrollment period by

refusing to issue you a policy, placing conditions on the

policy, or discriminating in the price of a policy because

of your health status, claims experience, receipt of

health care, or your medical condition.

* Uses the U.S. mail in a state for advertising or

delivering health insurance policies to supplement

Medicare if the policies have not been approved for sale

in that state.

If You Suspect Illegal Sales Practices

If you suspect that you have been the victim of illegal

sales practices, you should report these practices to your

state insurance department. States are responsible for the

regulation of insurance policies issued within their

boundaries. Because federal laws also govern Medigap sales

practices, you should also report the practices to the

appropriate federal officials.

Your state insurance department may be listed in your

telephone book. If not, you can get a copy of the booklet,

Guide to Health Insurance for People with Medicare (see box on

page 8).

To talk to federal officials about the suspected illegal

sales practices, you may call this number: 1-800-638-6833.

When Other Insurance Pays Before Medicare

If any of the following insurance situations applies to

you, please notify your doctor, hospital, and all other

providers of services. For more information about any of these

insurance situations, ask Social Security for a copy of

Medicare and Other Health Benefits. The publication is also

available free from the Consumer Information Center (see inside

back cover).

When You or Your Spouse Continue To Work

Medicare has special rules that apply to beneficiaries who

have employer group health plan coverage through their current

employment or the current employment of a spouse.

Group health plans of employers with 20 or more employees

are primary payers and Medicare is secondary payer for workers

age 65 or older, and workers' spouses age 65 or older. Group

health plans must offer these people the same health insurance

benefits under the same conditions offered to younger workers

and spouses. You and your spouse have the option to reject the

plan offered by the employer. If you reject the employer's

health plan, Medicare will remain the primary health insurance

payer. In that case, the employer's plan is not permitted to

offer you coverage that supplements Medicare covered services.

If your employer plan denies you coverage, offers you different

coverage, or pays benefits that are secondary to Medicare,

notify the carrier that handles your Medicare claims.

If You Are Disabled and Under Age 65

Medicare is the secondary payer for certain disabled

people who have premium-free Medicare Part A and are covered

under their employer's health plan or the employer health plan

of an employed family member. This secondary payer provision

applies to group health plans of employers that employ 100 or

more people. The secondary payer provision also applies to

group health plans of employers with fewer than 100 employees

if their employers are part of a multi-employer plan in which

at least one employer has 100 or more employees.

Other Situations Where Medicare is the Secondary Payer

If you have a work-related illness or injury, services

provided as treatment of that illness or injury should be

covered by workers' compensation or federal black lung

benefits. It is important that your Medicare claim form note

that the treatment is related to a work-related illness or

injury, even if the injury or illness occurred in the past.

Medicare is a secondary payer during a period (generally

18 months) for beneficiaries who have Medicare solely on the

basis of permanent kidney failure, if they have employer group

health plan coverage themselves or through a family member.

Medicare also serves as the secondary payer in cases where

no-fault insurance or liability insurance is available as the

primary payer.

Although Medicare benefits are secondary to benefits paid

by liability insurers, Medicare may make a conditional payment

if it receives a claim for services covered by liability

insurance. In those cases, Medicare may pay the claim; then,

when a liability settlement is reached, Medicare recovers its

conditional payment from the settlement amount.

If You Have or Can Get Both Medicare and Veterans Benefits

If you have or can get both Medicare and veterans

benefits, you may choose to get treatment under either program.

But, Medicare:

* Cannot pay for services you receive from Veterans Affairs

(VA) hospitals or other VA facilities, except for certain

emergency hospital services; and

* Generally cannot pay if the VA pays for VA-authorized

services that you get in a non-VA hospital or from a

non-VA physician.

Since July 1986, the VA has been charging coinsur-

ance payments to some veterans who have non-service connected

conditions for treatment in a VA hospital or medical facility,

or for VA-authorized treatment by nonVA sources. The VA charges

coinsurance payments when the veteran's income exceeds a

particular level. If the VA charges you a coinsurance payment

for VA-authorized care by a non-VA physician or hospital,

Medicare may be able to reimburse you, in whole or in part, for

your VA coinsurance payment obligation. (If you have Medigap

insurance, your Medigap policy may pay the VA coinsurance and

deductible obligations, even if Medicare cannot.)

NOTE: Medicare cannot reimburse you for VA coinsurance

payments for services furnished by VA hospitals and facilities,

unless the services are emergency inpatient or outpatient

hospital services. Then, the Medicare payment is subject to

Medicare deductible and coinsurance amounts.

If you have questions about whether the VA or Medicare

should pay for your doctor or other services covered under

Medicare Part B, contact your Medicare carrier. If you have

questions about whether the VA or Medicare should pay for

hospital or other services covered under Medicare Part A, ask

the provider of services to check with the Medicare

intermediary.

The Data Match

In 1989, Congress passed a; law that will help Medicare

get back an estimated $1 billion in taxpayer money. The law

enables Medicare to get accurate information about

beneficiaries' health insurance.

The law authorizes the Health Care Financing

Administration (the agency that administers the Medicare

program), the Internal Revenue Service, and the Social Security

Administration to share information about whether Medicare

beneficiaries or their spouses are working and whether they

have employment-related health insurance.

The process for sharing information from other agencies is

called the Data Match. The Data Match will help Medicare find

cases where another insurer should have paid first on Medicare

beneficiaries' health care claims. A designated Medicare

contractor will contact employers to confirm health insurance

coverage information. (For information about your fights under

the Data Match, see "Your Rights Under the Privacy Act,"

page 5.)

What Medicare Does Not Pay For

Custodial Care

Medicare does not pay for custodial care when that is the

only kind of care you need. Care is considered custodial when

it is primarily for the purpose of helping you with daily

living or meeting personal needs and could be provided safely

and reasonably by people without professional skills or

training. Much of the care provided in nursing homes to people

with chronic, long-term illnesses or disabilities is considered

custodial care. For example, custodial care includes help in

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

and taking medicine. Even if you are in a participating

hospital or skilled nursing facility, Medicare does not cover

your stay if you need only custodial care.

Care Not Reasonable and Necessary Under Medicare Program

Standards

Medicare does not pay for services that are not reasonable

and necessary for the diagnosis or treatment of an illness or

injury. These services include drugs or devices that have not

been approved by the Food and Drug Administration (FDA);

medical procedures and services performed using drugs or

devices not approved by FDA;* and services, including drugs or

devices, not considered safe and effective because they are

experimental or investigational.

* Some services are not covered by Medicare even when FDA

has approved the drug or device used.

If a doctor admits you to a hospital or skilled nursing

facility when the kind of care you need could be provided

elsewhere (for example, at home or in an outpatient facility),

your stay will not be considered reasonable and necessary, and

Medicare will not pay for your stay. If you stay in a hospital

or skilled nursing facility longer than you need to be there,

Medicare payments will end when inpatient care is no longer

reasonable and necessary.

If a doctor (or other practitioner) comes to treat

you---or you visit him or her for treatment--more often than is

medically necessary, Medicare will not pay for the "extra"

visits. Medicare will not pay for more services than are

reasonable and necessary for your treatment.

Medicare always bases decisions about what is reasonable

and necessary on professional medical advice.

Services Medicare Does Not Pay For

Medicare, by law, cannot pay for certain services. These

include services performed by immediate relatives or members of

your household, and services paid for by another government

program. If you have a question about whether Medicare pays for

a particular service, ask your Medicare carrier. (See pages 39

to 44 for the name and telephone number of your carrier.)

Limitation of Liability

Under Medicare law you will not be held responsible for

payment of the cost of certain health care services for which

you were denied Medicare payment if you did not know or you

could not reasonably be expected to know (for example, you had

not received a written notice) that the services were not

covered by Medicare. This provision is called limitation of

liability and is often referred to as a "waiver of liability."

This protection from financial liability applies only when the

care was denied because it was one of the following: Custodial

care.

Not "reasonable and necessary" under Medicare program

standards for diagnosis or treatment.

* For home health services, the patient was not homebound or

not receiving skilled nursing care on an intermittent

basis.

* The only reason for the denial is that, in error, you were

placed in a skilled nursing facility bed that was not

approved by Medicare.

This limitation of liability provision does not apply to

Medicare Part B services provided by a non-participating

physician or supplier who did not accept assignment of the

claim. However, in certain situations Medicare law will protect

you from paying for services provided by a non-participating

physician on a non-assigned basis that are denied as "not

reasonable and necessary." If your physician knows or should

know that Medicare will not pay for a particular service as

"not reasonable and necessary," he or she must give you written

notice--before performing the service--of the reasons why he

or she believes Medicare will not pay. The physician must get

your written agreement to pay for the services. If you did not

receive this notice, you are not required to pay for the

service. If you did pay, you may be entitled to a refund. (This

written notice is not an official Medicare. determination. If

you disagree with it, you may ask your doctor to submit a claim

for payment to get an official Medicare determination.)

Medicare Hospital Insurance (Part A)

What Medicare Part A Includes

Medicare Part A helps pay for four kinds of medically

necessary care:

1) Inpatient hospital care.

2) Inpatient care in a skilled nursing facility following a

hospital stay.

3) Home health care.

4) Hospice care.

There is a limit on how many days of hospital or skilled

nursing facility care Medicare helps pay for in each benefit

period. But, your Part A protection is renewed every time you

start a new benefit period. (Benefit periods are described

below.)

Skilled nursing facility care is the only type of nursing

home care that Medicare covers. Medicare does not pay for care

that is primarily custodial. (See pages 17 and 20 for more

about custodial care.)

Benefit Periods

A benefit period is a way of measuring your use of

services under Medicare Part A. Your First benefit period

starts the first time you receive inpatient hospital care after

your Hospital Insurance begins. A benefit period ends when you

have been out of a hospital or other facility primarily

providing skilled nursing or rehabilitation services for 60

days in a row (including the day of discharge). If you remain

in a facility (other than a hospital) that primarily provides

skilled nursing or-rehabilitation services, a benefit period

ends when you have not received any skilled care there for 60

days in a row. After one benefit period has ended, another one

will start whenever you again receive inpatient hospital care.

There is no limit to the number of benefit periods you can

have for hospital and skilled nursing facility care. However,

special limited benefit periods apply to hospice care (see page

19).

Here are two examples of how the benefit period works:

Example 1: Ms. Jones enters the hospital on January 5. She

is discharged on January 15. She has used 10 days of her first

benefit period. Ms. Jones is not hospitalized again until July

20. Since more than 60 days elapsed between her hospital stays,

she begins a new benefit period, her Part A coverage is

completely renewed, and she will again pay the hospital

deductible. (The hospital deductible is explained on page 15.)

Example 2: Ms. Smith enters the hospital on August 14. She

is discharged on August 24. She also has used 10 days of her

first benefit period. However, she is then readmitted to the

hospital on September 20. Since fewer than 60 days elapsed

between hospital stays, Ms. Smith is still in her first benefit

period and will not be required to pay another hospital

deductible. This means that the first day of her second

admission is counted as the eleventh day of hospital care in

that benefit period. Ms. Smith will not begin a new benefit

period until she has been out of the hospital (and has not

received any skilled care in a skilled nursing facility) for 60

consecutive days.

How Medicare Pays for Part A Services

Medicare Part A helps pay for most but not all of the

services you receive in a hospital or skilled nursing facility

or from a home health agency or hospice program. There are

covered services and noncovered services under each kind of

care. Covered services are services and supplies that Part A

pays for.

Hospitals, skilled nursing facilities, home health

agencies and hospices are called "providers" under the Medicare

Part A program. Providers submit their claims directly to

Medicare--you cannot submit claims for their services. The

provider will charge you for any part of the Part A deductible

you have not met and any coinsurance payment you owe. Providers

cannot require you to make a deposit before being admitted for

inpatient care that is or may be covered under Part A of

Medicare.

When a hospital, skilled nursing facility, home health

agency, or hospice sends Medicare a Part A claim for payment,

you get a Notice of Utilization that explains the decision

Medicare made on the claim. This notice is not a bill. If you

have any questions about the notice, get in touch with the

people who sent you the notice.

When You Are a Hospital Inpatient

Medicare Part A helps pay for inpatient hospital care if

all of the following four conditions are met:

1) A doctor prescribes inpatient hospital care for treatment

of your illness or injury.

2) You require the kind of care that can be provided only in

a hospital.

3) The hospital is participating in Medicare.*

4) The Utilization Review Committee of the hospital, a Peer

Review Organization or an intermediary does not disapprove

your stay.

* Under certain conditions, Medicare helps pay for

emergency inpatient care you receive in a

non-participating hospital.

If you meet these four conditions, Medicare will help pay

for up to 90 days of medically necessary inpatient hospital

care in each benefit period.**

** Medicare pays for only limited inpatient care in a

psychiatric hospital (see page 16). The hospital can tell

you about these limits.

During 1993, from the first day through the 60th day in a

hospital during each benefit period, Part A pays for all

covered services except the first $676. This is called the

inpatient hospital deductible. (A deductible is an amount you

owe before Medicare begins paying for services and supplies

covered by the program.) The hospital may charge you the

deductible only for your first admission in each benefit

period. If you are discharged and then readmitted before the

benefit period ends, you do not have to pay the deductible

again.

From the 61st through the 90th day in a hospital during

each benefit period, Part A pays for all covered services

except for $169 a day. This daily amount is called coinsurance.

The hospital charges you the $169.

Hospital reserve days (explained below) can help with your

expenses if you need more than 90 days of inpatient hospital

care in a benefit period.

Medicare Part A does not pay for the services of doctors

and certain other practitioners, even though you receive these

services in a hospital. Instead, those services are covered

under Medicare Part B. (A description of Medicare Part B begins

on page 21.)

Major services covered under Part A when you are a

hospital inpatient:

* A semiprivate room (two to four beds in a room).

* All your meals, including special diets.

* Regular nursing services.

* Costs of special care units, such as intensive care or

coronary care units.

* Drugs furnished by the hospital during your stay.

* Blood transfusions furnished by the hospital during your

stay. (See page 16 for information about coverage of

blood.)

* Lab tests included in your hospital bill.

* X-rays and other radiology services, including radiation

therapy, billed by the hospital.

* Medical supplies such as casts, surgical dressings, and

splints.

* Use of appliances, such as a wheelchair.

* Operating and recovery room costs.

* Rehabilitation services, such as physical therapy,

occupational therapy, and speech pathology services.

Some services not covered under Part A when you are a

hospital inpatient:

* Personal convenience items that you request such as a

telephone or television in your room.

* Private duty nurses.

* Any extra charges for a private room unless it is

determined to be medically necessary.

NOTE: If you disagree with a decision on the amount

Medicare will pay on a claim or whether services you receive

are covered by Medicare, you always have the fight to appeal

the decision (see page 35).

Hospital Inpatient Reserve Days

Medicare helps pay for your care in a hospital for up to

90 days in each benefit period. Medicare Part A also includes

an extra 60 hospital days you can use if you have a long

illness and have to stay in the hospital for more than 90 days.

These extra days are called reserve days.

You have only 60 reserve days in your lifetime. For

example, if you use 8 reserve days in your first hospital stay

this year, the next time you visit a hospital you will have

only 52 reserve days left to use, whether or not you have a new

benefit period.

You can decide when you want to use your reserve days.

After you have been in the hospital 90 days, you can use all or

some of your 60 reserve days if you wish.

If you do not want to use your reserve days, you must tell

the hospital in writing, either when you are admitted to the

hospital, or at any time afterwards up to 90 days after you are

discharged. If you use reserve days and then decide that you

did not want to use them, you must request approval from the

hospital to get them restored.

During 1993, Medicare Part A pays for all covered services

except $338 a day for each reserve day you use. You are

responsible for paying this $338.

All Medigap plans pay some part of hospital bills after

you have used all your reserve days. (See page 8 for more

information about Medigap insurance.)

Coverage of Blood Under Part A

Part A helps pay for blood (whole blood or units of packed

red blood cells), blood components, and the cost of blood

processing and administration. If you receive blood as an

inpatient of a hospital or skilled nursing facility, Part A

will pay for these blood costs, except for any nonreplacement

fees charged for the first three pints of whole blood or units

of packed red cells per calendar year. (The nonreplacement fee

is the amount that some hospitals and skilled nursing

facilities charge for blood that is not replaced.)

You are responsible for the nonreplacement fees for the

first three pints or units of blood furnished by a hospital or

skilled nursing facility. If you are charged nonreplacement

fees, you have the option of either paying the fees or having

the blood replaced. If you choose to have the blood replaced,

you can either replace the blood personally or arrange to have

another person or an organization replace it for you. A

hospital or skilled nursing facility cannot charge you for any

of the first three pints of blood you replace or arrange to

replace. (If you have already paid for or replaced blood under

Medicare Part B during the calendar year, you do not have to

meet those costs again under Medicare Part A. See page 21 for

an explanation of coverage of blood under Medicare Part B.)

Care in a Psychiatric Hospital

Part A helps pay for no more than 190 days of inpatient

care in a participating psychiatric hospital in your lifetime.

Once you have used these 190 days, Part A does not pay for any

more inpatient care in a psychiatric hospital.

Also, a special role applies if you are in a participating

psychiatric hospital at the time your Part A starts. Social

Security can give you more information.

Care Outside the United States

Medicare generally does not pay for hospital or medical

services outside the United States. (Puerto Rico, the U.S.

Virgin Islands, Guam, American Samoa, and the Northern Mariana

Islands are considered part of the United States.)

If you are planning to travel outside the United States,

you may want to buy special short-term health insurance for

foreign travel. If you have other health insurance in addition

to Medicare, check to see if health care in a foreign country

is covered under your policy.

There are rare emergency cases where Medicare can pay for

care in Canada or Mexico. Also, Medicare can sometimes pay if a

Mexican or Canadian hospital is closer to your home than the

nearest U.S. hospital that can provide the care you need. If

you get emergency treatment in a Canadian or Mexican hospital

or if you live near a Canadian or Mexican hospital, ask someone

who works at the hospital about Medicare coverage, or have the

hospital help you contact the Medicare intermediary.

Care in a Christian Science Sanatorium

Medicare Part A helps pay for inpatient hospital and

skilled nursing facility services you receive in a

participating Christian Science sanatorium if it is operated or

listed and certified by the First Church of Christ, Scientist,

in Boston. (However, Medicare Part B will not pay for the

practitioner.)

The Prospective Payment System

Medicare pays for most inpatient hospital care under the

Prospective Payment System (PPS). Under PPS, hospitals are paid

a predetermined rate per discharge for inpatient services

furnished to Medicare beneficiaries. The predetermined rates

are based on payment categories called Diagnosis Related

Groups, or DRGs. In some cases, the Medicare payment will be

more than the hospital's costs; in other cases, the payment

will be less than the hospital's costs. In special cases,

where costs for necessary care are unusually high or the length

of stay is unusually long, the hospital receives additional

payment. But even if Medicare pays the hospital less than the

cost of your care, you do not have to make up the difference.

It is important to remember that the PPS system does not

change your Medicare Part A protection as described in this

handbook. PPS does not determine the length of your stay in the

hospital or the extent of care you receive. The law requires

participating hospitals to accept Medicare payments as payment

in full, and those hospitals are prohibited from billing the

Medicare patient for anything other than the applicable

deductible and coinsurance amounts, plus any amounts due for

noncovered items or services such as television, telephone or

private duty nurses.

Skilled Nursing Facility Care

Medicare Part A can help pay for certain inpatient care in

a Medicare-participating skilled nursing facility following a

hospital stay. Your condition must require daily skilled

nursing or skilled rehabilitation services which, as a

practical matter, can only be provided in a skilled nursing

facility, and the skilled care you receive must be based on a

doctor's orders.

What is a Skilled Nursing Facility?

A skilled nursing facility is a specially qualified

facility that specializes in skilled care. It has the staff and

equipment to provide skilled nursing care or skilled

rehabilitation services and other related health services.

Skilled nursing care means care that can only be performed by,

or under the supervision of, licensed nursing personnel.

Skilled rehabilitation services may include such services as

physical therapy performed by, or under the supervision of, a

professional therapist.

Most nursing homes in the United States are not skilled

nursing facilities that participate in Medicare. In some

facilities, only certain portions participate in Medicare. If

you are not sure whether a facility participates in Medicare as

a skilled nursing facility, ask someone in the facility's

business office. If staff at the facility cannot tell you, ask

Social Security to check with the Health Care Financing

Administration.

When Can Medicare Pay?

Medicare Part A can help pay for your care in a

Medicare-participating skilled nursing facility if you meet all

of these five conditions:

1) Your condition requires daily skilled nursing or skilled

rehabilitation services which, as a practical matter, can

only be provided in a skilled nursing facility.

2) You have been in a hospital at least three days in a row

(not counting the day of discharge) before you are admitted

to a participating skilled nursing facility.

3) You are admitted to the facility within a short time

(generally within 30 days) after you leave the hospital.

4) Your care in the skilled nursing facility is for a

condition that was treated in the hospital, or for a

condition that arose while you were receiving care in the

skilled nursing facility for a condition which was treated

in the hospital.

5) A medical professional certifies that you need, and you

receive, skilled nursing or skilled rehabilitation services

on a daily basis.

All five conditions must be met. Remember, you must need

skilled nursing care or skilled rehabilitation services on a

daily basis. Part A will not pay for your stay if you need

skilled nursing or rehabilitation services only occasionally,

such as once or twice a week, or if you do not need to be in a

skilled nursing facility to get skilled services. Also,

Medicare will not pay for your stay if you are in a skilled

nursing facility mainly because you need custodial care.

Skilled Care or Custodial Care?

The only type of "nursing home" care Medicare helps pay

for is skilled nursing facility care. Medicare does not pay for

custodial care when that is the only kind of care you need.

Care is considered custodial when it is primarily for the

purpose of helping the patient with daily living or meeting

personal needs, and could be provided safely and reasonably by

people Without professional skills or training. For example,

custodial care includes help in walking, getting in and out of

bed, bathing, dressing, eating and taking medicine.

When your stay in a skilled nursing facility is covered by

Medicare, Part A helps pay for a maximum of 100 days in each

benefit period, but only if you need daily skilled nursing care

or rehabilitation services for that long.

If you leave a skilled nursing facility and are readmitted

within 30 days, you do not have to have a new three day stay in

the hospital for your care to be covered. If you have some of

your 100 days left and you need skilled nursing or

rehabilitation services on a daily basis for further treatment

of a condition treated during your previous stay in the

facility, Medicare will help pay.

In each benefit period, Part A pays for all covered

services for the first 20 days you are in a skilled nursing

facility. During 1993, for days 21 through 100, Part A pays for

all covered services except for $84.50 a day. You may be

charged up to this daily coinsurance amount by the skilled

nursing facility.

Medicare Part A does not cover your doctor's services while

you are in a skilled nursing facility. Medicare Part B covers

doctors' services. (A description of Medicare Part B begins on

page 21.)

Major services covered under Part A when you are in a skilled

nursing facility:

* A semiprivate room (two to four beds in a room).

* All your meals, including special diets furnished by the

facility.

* Regular nursing services.

* Physical, occupational, and speech therapy.

* Drugs furnished by the facility during your stay.

* Blood transfusions furnished during your stay. (See page

16 for information about coverage of blood.)

* Medical supplies such as splints and casts furnished by

the facility.

* Use of appliances such as a wheelchair furnished by the

facility.

Some services not covered under Part A when you are in a

skilled nursing facility:

* Personal convenience items that you request such as a

television in your room.

* Private duty nurses.

* Any extra charges for a private room, unless it is

determined to be medically necessary.

Rules That Protect You

Skilled nursing facilities cannot require you to pay a

deposit or other payment as a condition of admission to the

facility unless it is clear that services are not covered by

Medicare.

If you are already an inpatient in a skilled nursing

facility and the staff at the facility decides you no longer

need the level of skilled care covered by Medicare, they must

notify you immediately. If you disagree with this decision, the

facility must submit your claim at your request to Medicare for

an official Medicare decision on coverage. The facility may not

require you to pay a deposit until Medicare issues its

decision. You must pay for any coinsurance while your claim is

being processed, and for any services which are never covered

by Medicare.

Complaints and Appeals

If you want to complain about a skilled nursing facility's

treatment of patients or other conditions that concern you, you

can contact the state survey agency. Each skilled nursing

facility can give you the telephone number and address of the

state survey agency if you ask for it. You can also look at a

copy of the skilled nursing facility's latest certification

survey report. The survey report will tell you the results of

the state survey agency's review of how well the agency thinks

the facility followed the rules about patient's rights, safety

and quality of care.

Also, if you disagree with a decision on the amount

Medicare will pay on a claim or whether services you receive

are covered by Medicare, you always have the fight to appeal

the decision (see page 35).

Home Health Care

If you need skilled health care in your home for the

treatment of an illness or injury, Medicare pays for covered

home health services furnished by a participating home health

agency. A home health agency is a public or private agency that

specializes in giving skilled nursing services and other

therapeutic services, such as physical therapy, in your home.

(A hospital or other facility that mainly provides skilled

nursing or rehabilitation services cannot be considered your

home.)

Medicare pays for home health visits only if all four of

the following conditions are met:

1) The care you need includes intermittent skilled nursing

care, physical therapy, or speech therapy.

2) You are confined to your home (homebound).

3) You are under the care of a physician who determines

you need home health care and sets up a home health

plan for you.

4) The home health agency providing services participates

in Medicare.

Once all four of these conditions are met, either Medicare

Part A or Medicare Part B will pay for all medically necessary

home health services. When you no longer need intermittent

skilled nursing care, physical therapy, or speech therapy,

Medicare will pay for home health services if you continue to

need occupational therapy.

Medicare home health services do not include coverage for

general household services such as laundry, meal preparation,

shopping, or other home care services furnished mainly to

assist people in meeting personal, family, or domestic needs.

To determine whether you can get services under the

Medicare home health benefit, ask your physician to refer you

to a Medicare participating home health agency. The home health

agency will evaluate your case and tell you whether you meet

the requirements for Medicare coverage. Home health agencies

should not charge for this evaluation.

Home health services covered by Medicare:

* Part-time or intermittent skilled nursing care. (This can

include eight hours of reasonable and necessary care per

day for up to 21 consecutive days--or longer in certain

circumstances.)

* Physical therapy.

* Speech therapy.

If you need intermittent skilled nursing care, or

physical or speech therapy, Medicare also pays for:

* Occupational therapy.

* Part-time or intermittent services of home health aides.

* Medical social services.

* Medical supplies.

* Durable medical equipment (80 percent of approved amount).

Home health services not covered by Medicare.

* 24-hour-a-day nursing care at home.

* Drugs and biologicals.

* Meals delivered to your home.

* Homemaker services.

* Blood transfusions.

Medicare pays the full approved cost of all covered home

health visits. You may be charged only for any services or

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

durable medical equipment, you are responsible for a 20 percent

coinsurance payment for the equipment. (See page 26 for more

information about durable medical equipment.)

The home health agency will submit the claim for payment.

You do not have to send in any bills yourself.

NOTE: If you disagree with a decision on the amount

Medicare will pay on a claim or whether services you receive

are covered by Medicare, you always have the fight to appeal

the decision (see page 35).

Hospice Care

A hospice is a public agency or private organization that

is primarily engaged in providing pain relief, symptom

management and supportive services to terminally ill people.

Hospice care is a special type of care for people who are

terminally ill. It includes both home care and inpatient care,

when needed, and a variety of services not otherwise covered

under Medicare. Under the Medicare hospice benefit, Medicare

pays for services every day and also permits a hospice to

provide appropriate custodial care, including homemaker

services and counseling.

Medicare Part A helps pay for hospice care if all three of

these conditions are met:

1) A doctor certifies that the patient is terminally ill.

2) The patient chooses to receive care from a hospice

instead of standard Medicare benefits for the terminal

illness.

3) Care is provided by a Medicare-participating hospice

program.

Special benefit periods apply to hospice care. Part A pays

for two 90-day periods, followed by a 30-day period, and--when

necessary--an extension period of indefinite duration. If a

beneficiary cancels hospice care during one of the first three

benefit periods, any days left in that period are lost, but the

remaining benefit period(s) are still available, And, a

beneficiary may disenroll from the hospice during any benefit

period, return to regular Medicare coverage, then later

re-elect the hospice benefit if another benefit period is

available.

Two Benefit Period Examples:

* Mr. Jones cancelled his hospice care at the end of 59 days

during his first 90-day benefit period. He lost the 31

remaining days of the first 90-day period. But if he wants

to, he can choose hospice care again. He still has a

90-day period, a 30-day period, and the indefinite

extension period.

* Ms. Smith cancelled hospice care during her final

extension period. She cannot use the Medicare hospice

benefit again.

There are no deductibles under the hospice benefit. The

beneficiary does not pay for Medicare-covered services for the

terminal illness, except for small coinsurance amounts for

outpatient drugs and inpatient respite care.

The patient is responsible for five percent of the cost of

outpatient drugs or $5 toward each prescription, whichever is

less. For inpatient respite care, the patient pays five percent

of the Medicare-allowed rate (approximately $4.48 per day in

1993). The rate varies slightly depending on the area of the

country.

Respite care under the hospice program is a shortterm

inpatient stay in a facility. The Medicare beneficiary's

inpatient stay gives temporary relief--a respite--to the person

who regularly assists with home care. Each inpatient respite

care stay is limited to no more than five days in a row.

While receiving hospice care, if a patient requires

treatment for a condition not related to the terminal illness,

Medicare continues to help pay for all necessary covered

services under the standard Medicare benefit program.

Services covered by Part A when provided by a hospice:

* Nursing services.

* Doctors' services.

* Drugs, including outpatient drugs for pain relief and

symptom management.

* Physical therapy, occupational therapy and speechlanguage

pathology.

* Home health aide and homemaker services.

* Medical social services.

* Medical supplies and appliances.

* Short-term inpatient care, including respite care.

* Counseling.

The Medicare Part A hospice benefit does not pay for

treatments other than for pain relief and symptom management of

a terminal illness. Regular Medicare can usually help pay for

treatments not related to the terminal illness.

NOTE: If you disagree with a decision on the amount

Medicare will pay on a claim or whether services you receive

are covered by Medicare, you always have the right to appeal

the decision (see page 35).

Medicare Medical Insurance (Part B)

What Medicare Part B Includes

Medicare Part B helps pay for:

* Doctors' services.

* Outpatient hospital care.

* Diagnostic tests.

* Durable medical equipment.

* Ambulance services.

* Many other health services and supplies that are not

covered by Medicare Part A.

The following sections tell you more about these different

kinds of care, the services that are and are not covered by

Medicare Part B, and what part of your medical expenses

Medicare will pay.

Deductible and Coinsurance Amounts Under Part B

The Annual Deductible

You must pay the first $100 in approved charges for

covered medical expenses in 1993. This is called the Medicare

Part B annual deductible. You need to meet this $100 deductible

only once during the year, and the deductible can be met by any

combination of covered expenses. You do not have to meet a

separate deductible for each different kind of covered service

you receive.

The Blood Deductible

You must pay any nonreplacement fees charged for the first

three pints or units of blood and blood components you use each

year. (The nonreplacement fee is the amount that some

practitioners and facilities charge for blood that is not

replaced.) This is called the Medicare Part B blood deductible.

After you have replaced or paid for the first three pints of

blood and you have met the $100 annual deductible, Medicare

will pay 80 percent of the approved amount for blood, starting

with the fourth pint. (If you have already paid for or replaced

some units of blood under Medicare Part A during the calendar

year, you do not have to pay for or replace that number of

units again under Medicare Part B.)

Coinsurance

After you pay the annual deductible, you will owe a share

of the Medicare-approved amount for most services and supplies.

This share is called coinsurance. Usually, your coinsurance

share is 20 percent of the Medicare-approved amount.

Medicare determines the approved amount for each service

you receive. If your services were provided "on assignment,"

you pay only the coinsurance (see page 28 for an explanation of

assignment).

If your services were not provided "on assignment," and

the charges for your services were more than the

Medicare-approved amount, you usually owe the Medicare

coinsurance plus certain charges above the Medicare-approved

amount. (See "Medicare Approved Amounts" on page 29.) There are

limits on the amount your doctor can charge you.

NOTE: This explanation of your deductible and coinsurance

amounts describes Medicare's payment system for most services

covered by Medicare Part B. In cases where payment for services

is handled in a different way, you will be given an explanation

along with the description of services covered. (You will find

more information about how Medicare pays Part B claims in the

section beginning on page 28.)

Doctors' Services Covered By Medicare Part B

Medicare Part B helps pay for covered services you receive

from your doctor in his or her office, in a hospital, in a

skilled nursing facility, in your home, or any other location.

Major doctors' services covered by Medicare Part B:

* Medical and surgical services, including anesthesia.

* Diagnostic tests and procedures that are part of your

treatment.

* Radiology and pathology services by doctors while you are

a hospital inpatient or outpatient.

* Treatment of mental illness. (Medicare payments for

treatment are limited; see page 27)

* Other services such as:

-- X-rays.

-- Services of your doctor's office nurse.

-- Drugs and biologicals that cannot be

self-administered.

-- Transfusions of blood and blood components,

-- Medical supplies.

-- Physical/occupational therapy and speech pathology

services.

Some doctors' services not covered by Medicare Part B:

* Routine physical examinations, and tests directly related

to such examinations (except some Pap smears and

mammograms, see page 25).

* Most routine foot care and dental care.

* Examinations for prescribing or fitting eyeglasses or

hearing aids.

* Immunizations (except pneumococcal pneumonia vaccinations

or immunizations required because of an injury or

immediate risk of infection, and hepatitis B for certain

persons at risk).

* Cosmetic surgery, unless it is needed because of

accidental injury or to improve the function of a

malformed part of the body.

Types of Doctors

Most doctors' services are furnished by a doctor of

medicine or a doctor of osteopathy. Other "physicians" that can

furnish some covered services include chiropractors, doctors of

podiatric medicine (podiatrists), doctors of dental surgery or

of dental medicine (dentists), and doctors of optometry

(optometrists).

Chiropractors' Services

Medicare helps pay for only one kind of treatment

furnished by a licensed chiropractor: manual manipulation of

the spine to correct a subluxation that is demonstrated by

X-ray. Medicare Part B does not pay for any other diagnostic or

therapeutic services, including Xrays, furnished by a

chiropractor.

Podiatrists' Services

Medicare Part B helps pay for any covered services of a

licensed podiatrist to treat injuries and diseases of the foot.

Examples of common problems include ingrown toenails, hammer

toe deformities, bunion deformities and heel spurs.

Medicare generally does not pay for routine foot care such

as cutting or removal of corns and calluses, trimming of nails,

and other hygienic care. But, Medicare does help pay for some

routine foot care if you are being treated by a medical doctor

for a medical condition affecting your legs or feet (such as

diabetes or peripheral vascular disease) which requires that

the routine care be performed by a podiatrist or by a doctor of

medicine or osteopathy.

Dentists' Services

Medicare Part B generally does not pay for care in

connection with the treatment, filling, removal, or replacement

of teeth; root canal therapy; surgery for impacted teeth; or

other surgical procedures involving the teeth or structures

directly supporting the teeth. However, Medicare does help pay

for services of a dentist in certain cases when the medical

problem is more extensive than the teeth or structures directly

supporting them. (If you need to be hospitalized because of the

severity of a dental procedure, Medicare Part A may pay for

your inpatient hospital stay even if the dental care itself is

not covered by Medicare.)

Optometrists' Services

Medicare helps pay for Medicare-covered vision care,

including the services of an optometrist if the optometrist is

legally authorized to perform those services by the state in

which he or she performs them. However, Medicare will not pay

for routine eye exams and usually will not pay for eyeglasses.

(Medicare will pay for cataract spectacles, cataract contact

lenses, or intraocular lenses that replace the natural lens of

the eye after cataract surgery. Medicare will also pay for one

pair of conventional eyeglasses or conventional contact lenses

if necessary after cataract surgery with insertion of an

intraocular lens.)

Second Opinion Before Surgery

Sometimes your doctor may recommend surgery for the

treatment of a medical problem. In some cases, surgery is

unavoidable. But there is increasing evidence that many

conditions can be treated equally well without surgery. Because

even minor surgery involves some risk, we recommend that you

get an opinion from a second doctor to help you decide about

surgery. Medicare will help pay for a second opinion. Medicare

will also help pay for a third opinion if the first and second

opinions contradict each other.

Your own doctor is the best source for referral to another

doctor. But, if you wish, you can call your Medicare Part B

carrier for the names and phone numbers of doctors in your area

who provide second opinions. (Medicare carriers are listed on

pages 39 to 44.)

Services of Special Practitioners

Medicare Part B helps pay for covered services you receive

from certain specially qualified practitioners who are not

physicians. The practitioners must be approved by Medicare.

Medicare-approved practitioners are listed below:

* Certified registered nurse anesthetist.

* Certified nurse midwife.

* Clinical psychologist.

* Clinical social worker (other than in a hospital).

* Physician assistant. (A physician assistant can furnish

certain services in a hospital or certain other

facilities, can serve as an assistant-at-surgery, and can

furnish services in any location that is designated as a

rural health professional shortage area.)

* Nurse practitioner and clinical nurse specialist in

collaboration with a physician. (A nurse practitioner can

furnish services in a skilled nursing facility or a

Medicaid nursing facility in any area. In addition, a

nurse practitioner or clinical nurse specialist can

furnish services in a rural area.)

Outpatient Hospital Services

Medicare Part B helps pay for covered services you receive

as an outpatient from a participating hospital for diagnosis or

treatment of an illness or injury. Under certain conditions,

Medicare helps pay for emergency outpatient care you receive

from a non-participating hospital.

When you get outpatient hospital services, you are

responsible for the annual Medicare Part B deductible. In

addition to the deductible, you are responsible for a

coinsurance of 20 percent of the hospital's charge above the

deductible.

When you go to a hospital for outpatient services, you are

sometimes asked how much of your Part B deductible you have

met. One easy way to answer that question is to show your most

recent Explanation of Your Medicare Part B Benefits notice.

From this form, hospital staff can usually tell how much of the

$100 annual deductible you have met.

If the hospital cannot tell how much of the $100

deductible you have met and the charge for the services you

received is less than $100, the hospital may ask you

to pay the entire bill. The amount you pay the hospital can be

credited toward any part of the deductible you have not met. If

you pay the hospital for deductible amounts you do not owe, the

hospital or the Medicare intermediary will refund the amount

you overpaid.

Major outpatient hospital services covered by Part B:

* Services in an emergency room or outpatient clinic,

including same-day surgery

* Laboratory tests billed by the hospital.

* Mental health care in a partial hospitalization

psychiatric program, if a physician certifies that

inpatient treatment would be required without it.

* X-rays and other radiology services billed by the

hospital.

* Medical supplies such as splints and casts.

* Drugs and biologicals that cannot be selfadministered.

* Blood transfusions furnished to you as an outpatient.

Some outpatient hospital services not covered by Part B:

* Routine physical examinations and tests directly related

to such examinations (except some Pap smears and

mammograms, see page 25).

* Eye or ear examinations to prescribe or fit eyeglasses or

hearing aids.

* Immunizations (except pneumococcal pneumonia and hepatitis

B vaccinations, or immunizations required because of an

injury or immediate risk of infection).

* Most routine foot care.

Other Services and Supplies Covered by Medicare

Ambulatory Surgical Services

An ambulatory surgical center is a facility that provides

surgical services that do not require a hospital stay. Medicare

Part B will pay for the use of an ambulatory surgical center

for certain approved surgical procedures. However, by law

Medicare can only pay centers that have an agreement with

Medicare to participate in the Medicare program. If you do not

know whether an ambulatory surgical center participates in

Medicare, ask someone in the center's business office. If that

person does not know, contact Social Security and ask them to

check with the Health Care Financing Administration.

In addition to helping pay for the use of the ambulatory

surgical center, Medicare also helps pay for physician and

anesthesia services that are provided in connection with the

procedure.

Home Health Services

If you have both Medicare Part A and Part B, your Part A

pays for home health services. But Part B will pay for home

health services if you do not have Part A. Medicare home health

services are described on page 18.

Outpatient Physical and Occupational Therapy and Speech

Pathology Services

Medicare Part B helps pay for medically necessary

outpatient physical and occupational therapy or speech

pathology services, if all the following three conditions are

met:

1) Your doctor prescribes the service.

2) Your doctor or therapist sets up the plan of treatment.

3) Your doctor periodically reviews that plan.

You can receive physical therapy, occupational therapy or

speech pathology services as an outpatient of a participating

hospital or skilled nursing facility, or from a participating

home health agency, rehabilitation agency, or public health

agency. The provider of services may charge you only for any

part of the $100 annual deductible you have not met, 20

percent of the remaining approved amount, and any noncovered

services.

Also, you can receive services directly from an

independently practicing, Medicare-approved physical or

occupational therapist in his or her office or in your home if

such treatment is prescribed by a doctor. (Medicare does not

pay for services provided by independently practicing speech

pathologists.) But, the maximum amount Medicare pays for each

of these services provided by an independently practicing

physical or occupational therapist in 1993 is $600 a year.

(This is 80 percent of the maximum approved amount of up to

$750.) The Medicare payment would be less than $600 if charges

for these services are used to meet part or all of your $100

annual deductible.

Comprehensive Outpatient Rehabilitation Facility Services

Under certain circumstances, Medicare helps pay for

outpatient services you receive from a Medicareparticipating

comprehensive outpatient rehabilitation facility (CORF).

Covered services include physicians' services; physical,

speech, occupational and respiratory therapies; counseling; and

other related services. You must be referred by a physician who

certifies that you need skilled rehabilitation services. For

most CORF services, you are responsible only for the annual

deductible and 20 percent of the Medicare approved-charges.

Medicare helps pay for mental health treatment in a CORF; the

Medicare payment limit for mental health treatment in a CORF is

discussed on page 27.

Partial Hospitalization for Mental Health Treatment

Partial hospitalization (sometimes called day treatment)

is a program of outpatient mental health care. Under certain

conditions, Medicare Part B helps pay for these programs when

provided by hospital outpatient departments or by community

mental health centers. If you are considering mental health

treatment, check with the program you have chosen to see if it

meets the conditions for Medicare payment.

Rural Health Clinic Services

Medicare Part B helps pay for services of physicians,

nurse practitioners, physician assistants, nurse midwives,

visiting nurses (under certain conditions), clinical

psychologists, and clinical social workers furnished by a rural

health clinic. You are responsible only for the annual Medicare

Part B deductible plus 20 percent of the Medicare-approved

charge for the clinic.

Federally Qualified Health Center Services

Federally qualified health centers are located in both

rural and urban areas and any Medicare beneficiary may seek

services at them. As part of the "federally qualified health

center benefit," Medicare Part B helps pay for services of

physicians, nurse practitioners, physician assistants, nurse

midwives, visiting nurses (under certain conditions), clinical

psychologists, and clinical social workers. Also, as part of

the federally qualified health center benefit, Medicare helps

pay for certain preventive health services. The center can tell

you what services are part of the federally qualified health

center benefit.

You do not have to pay the Medicare Part B annual

deductible for services provided under the federally qualified

health center benefit. You are responsible for 20 percent of

the Medicare-approved charge for the clinic. (There are some

cases, under Public Health Service guidelines, when the

federally qualified health center may waive all or part of the

20 percent Part B coinsurance which is applicable for center

services.)

Federally qualified health centers often provide services

in addition to those offered under the Medicare federally

qualified health center benefit. Examples of these services are

X-rays and equipment like crutches and canes. As long as the

center meets Medicare requirements to provide these services,

Medicare Part B can help pay for them. You are responsible for

any unmet part of the annual Medicare Part B deductible plus 20

percent of the Medicare-approved charge for the service.

Laboratory Services

All laboratories must be certified under the Clinical

Laboratory Improvement Amendments to perform laboratory

testing. Medicare Part B pays the full approved fee for covered

clinical diagnostic tests provided by certified laboratories

that are participating in Medicare. The laboratory can be

independent, part of a hospital outpatient department or in a

doctor's office. The laboratory must accept assignment for the

tests. (See page 28 for an explanation of assignment.) It may

not bill you for the tests.*

* In the state of Maryland only, you may be charged 20

percent coinsurance for hospital outpatient tests.

Some laboratories are approved only for certain kinds of

tests. Your doctor can usually tell you which laboratories are

approved and whether the tests he or she is ordering from an

approved laboratory are covered by Medicare. If your doctor can

not tell you, call your Part B carrier. (Carriers are listed on

pages 39 to 44.)

Portable Diagnostic X-ray Services

Medicare Part B helps pay for portable diagnostic X-ray

services you receive in your home or other locations if they

are ordered by a doctor and if they are provided by a

Medicare-approved supplier. You can ask your Part B carrier

whether the supplier is Medicare-approved. (Carriers are listed

on pages 39 to 44.)

Other Diagnostic Tests

Medicare Part B also helps pay for other diagnostic tests,

including X-rays, that your doctor orders to evaluate your

medical problems.

Pap Smear Screening

Medicare Part B helps pay once every three years for Pap

smears to screen for cervical cancer. Medicare helps pay more

frequently for certain women at high risk.

Medicare also pays for diagnostic Pap smears as needed

when symptoms are present.

Breast-Cancer Screening (Mammography)

Medicare Part B helps pay for X-ray screenings for the

detection of breast cancer, if they are provided by a

Medicare-approved supplier. Women 65 or older can use the

benefit every other year. Some younger women covered by

Medicare can use the screening benefit more frequently. Your

Medicare carrier can tell you how often Medicare will pay for a

screening mammogram for you. Medicare also pays for diagnostic

mammograms as needed when symptoms are present.

For accurate up-to-date information on cancer prevention,

detection, diagnosis, and treatment for patients, their

families, and the general public, call the Cancer Information

Service at 1-800-4-CANCER.

Radiation Therapy

Medicare Part B helps pay for outpatient radiation therapy

given under the supervision of your doctor.

Kidney Dialysis and Transplants

Medicare Part B helps pay for kidney dialysis and

transplants. For detailed information on this coverage, you can

get a copy of Medicare Coverage of Kidney Dialysis and Kidney

Transplant Services from the Consumer Information Center (see

inside back cover).

Heart and Liver Transplants

Under certain limited conditions, Medicare Part B helps

pay for heart and liver transplants in a Medicare-approved

facility. If you are considering a heart or liver transplant,

you and your physician can find out about Medicare coverage by

contacting your Medicare carrier. If you belong to an HMO, the

HMO will give you the information you need about Medicare

coverage.

Ambulance Transportation

Medicare Part B helps pay for medically necessary

ambulance transportation, including air ambulance, but only if:

* The ambulance, equipment and personnel meet Medicare

requirements.

* Transportation in any other vehicle could endanger your

health.

Under these conditions, Medicare helps pay for ambulance

transportation but only to a hospital or skilled nursing

facility, or from a hospital or skilled nursing facility to

your home. Medicare does not pay for ambulance use from your

home to a doctor's office or to a dialysis facility that is not

in or next to a hospital.

Medicare usually helps pay only if the ambulance

transportation is in your local area. But, if there are no

local facilities equipped to provide the care you need,

Medicare helps pay for necessary ambulance transportation to

the closest facility outside your local area that can provide

the necessary care. If there is a local facility equipped to

provide the care you need but you choose to go to another

institution that is farther away, Medicare payment is based on

the charge for transportation to the closest facility that can

provide the necessary care.

Durable Medical Equipment

Medicare Part B helps pay for durable medical equipment

such as oxygen equipment, wheelchairs, and other medically

necessary equipment that your doctor prescribes for use in your

home. (A hospital or facility that mainly provides skilled

nursing or rehabilitation services cannot be considered your

home.)

To be considered durable medical equipment, the equipment

must be able to be used over again by other patients, must

primarily serve a medical purpose, must not be useful to people

who are not sick or injured, and must be appropriate for use in

your home. Not all types of equipment that you might find

useful can meet all four of these requirements.

Only your own doctor should prescribe medical equipment

for you. An equipment supplier should not take any of the

following actions:

* Contact you first, either by phone or by mail, and offer

to get your doctor or Medicare to approve an item. (It is

all fight for the supplier to contact you in response to

calls from your doctor or other health care workers.)

* Say he or she works for, or represents, Medicare.

* Deliver equipment to your home that neither you nor your

doctor ordered.

* Send you used items, while billing Medicare for new ones.

Some of these actions may be against the law. If you

believe a supplier has taken any of these actions, you should

alert Medicare. First, ask your doctor whether he or she

ordered the item. If your doctor did not order the item, you

should file a complaint with your Medicare carrier. You can

file a complaint by phone, in person or in writing. Your

carrier will investigate.

It is also illegal for a supplier to offer you items at no

cost to you or offer to pay the Medicare coinsurance on items.

If a supplier makes one of these offers, file a complaint with

your Medicare carrier as described above.

NOTE: The durable medical equipment supplier must have

your doctor's prescription before delivering any of the

following items: seat lift chairs, power-operated vehicles,

equipment for care of pressure sores, or transcutaneous

electrical nerve stimulators. In the case of seat lift chairs,

Medicare covers only the lift mechanism, not the chair itself.

Medicare pays for different kinds of durable medical

equipment in different ways; some equipment must be rented,

other equipment must be purchased, and for some equipment you

may choose rental or purchase. Your Medicare carrier will be

able to provide more specific guidance on which method will be

used for a particular item. (Carriers are listed on pages 39 to

44.)

Prosthetic Devices

Medicare Part B helps pay for prosthetic devices needed to

replace an internal body organ. These include Medicare-approved

corrective lenses needed after a cataract operation, ostomy

bags and certain related supplies, and breast prostheses

(including a surgical brassiere) after a mastectomy. Medicare

also helps pay for artificial limbs and eyes, and for arm, leg,

back, and neck braces. Medicare does not pay for orthopedic

shoes unless they are an integral part of leg braces and the

cost is included in the charge for the braces. Medicare does

not pay for dental plates or other dental devices.

Medical Supplies

Medicare Part B helps pay for surgical dressings, splints,

and casts ordered by a doctor in connection with your medical

treatment. This does not include adhesive tape, antiseptics, or

other common first-aid supplies.

Drugs and Biologicals

Pneumococcal Pneumonia Vaccine

Medicare Part B pays the full approved charges for

pneumococcal pneumonia vaccine and its administration. Neither

the $100 annual deductible nor the 20 percent coinsurance

applies to this service.

Hepatitis B Vaccine

Medicare Part B helps pay for hepatitis B vaccine

administered to beneficiaries considered to be at high or

intermediate risk of contracting the disease.

Hemophilia Clotting Factors

Medicare Part B helps pay for blood clotting factors and

items related to their administration for hemophilia patients

who are able to use them to control bleeding without medical or

other supervision. The amount of clotting factors necessary to

have on hand for a specific period is determined for each

patient individually.

Blood

Medicare Part B helps pay for blood and blood components

you receive as a hospital outpatient or as part of other

services. (See page 21 for an explanation of the blood

deductible.)

Antigens

Under certain circumstances, Medicare Part B helps pay for

antigens prepared for you by your doctor. You can check with

your Medicare carrier to see if Medicare will pay for your

antigens. (Carriers are listed on pages 39 to 44.)

Immunosuppressive Drugs

Immunosuppressive drugs are often given to prevent

rejection of transplanted organs. Medicare Part B helps pay for

drugs used in immunosuppressive therapy for one year beginning

with the date of discharge from the inpatient hospital stay

during which a Medicare-covered organ transplant was performed.

Epoetin Alfa

Medicare Part B may help pay for the drug Epoetin alfa

when used to treat Medicare beneficiaries with anemia related

to chronic kidney failure, or related to use of AZT in

HIV-positive beneficiaries or for other uses that a Medicare

carrier finds medically appropriate. (The kidney failure

patients are not required to be on dialysis.) The Epoetin alfa

must be administered incident to the services of a doctor in

the office or in a hospital outpatient department. Part B also

helps pay for Epoetin alpha that is self-administered by home

dialysis patients or administered by their caregivers.

Medicare Payments for Outpatient Treatment of Mental Illness

Medicare helps pay for outpatient mental health services

you receive from professionals such as physicians, clinical

psychologists, clinical social workers and other nonphysician

practitioners. These professionals furnish services in various

settings, for example, hospitals, comprehensive outpatient

rehabilitation facilities, community mental health centers, and

skilled nursing facilities.

When furnished on an outpatient basis, mental health

treatment services are subject to a payment limitation that is

called the "outpatient mental health limitation." In effect,

once the annual deductible is met, Medicare Part B pays only 50

percent (not 80 percent) of the approved amount for these

services. On assigned claims, beneficiaries are responsible for

paying the remaining 50 percent. For unassigned claims,

beneficiaries may have to pay more. (See page 28 for

information about assignment.)

Partial hospitalization services (except those furnished

by a physician) for treatment of mental illness are not subject

to this payment limitation. Also, brief office visits for the

sole purpose of monitoring or changing drug prescriptions used

in the treatment of mental illness are not subject to this

payment limitation. (See page 24 for more information about

partial hospitalization services.)

Medicare Medical Insurance (Part B) Payments

The Assignment Payment Method

Under the assignment method, your doctor or supplier

agrees to accept the amount approved by the Medicare carrier as

total payment for covered services: the doctor or supplier

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 Medicareapproved 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 Aging, 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 Medicareapproved 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 Aging

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 Aging

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 Aging and Disabilities

103 South Main Street

Waterbury, VT 05676

1-800-642-5119

New York:

State Office for the Aging

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 organization 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 Travelers

Insurance Company office that serves your region. Regional

offices of The Travelers 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 touchtone 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 enrollment period. A general enrollment period is

held January 1 through March 31 each year. Your protection will

begin July 1 of the year you enroll. If you enroll during a

general enrollment 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

enrollment period: January 1 through March 31 each year. If you

enroll during a general enrollment 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 enroll. (Also

see this page for information on the special enrollment

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 Enrollment 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

enrollment in Medicare Medical Insurance (Part B) or premium

Hospital Insurance (Part A) without premium penalty and without

waiting for a general enrollment period to enroll. Delayed

enrollment 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 enroll 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 enrollment 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 enroll 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 enrollment 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 enrollment 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

enroll 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 enroll during your initial enrollment 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 enroll during this

initial enrollment period, you may enroll in a subsequent

general enrollment period (January through March of each year)

or during a special enrollment 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 organizations,

intermediaries, carriers and health maintenance organizations

are discussed below.

Appealing Decisions Made by Providers of Part A Services

In many cases the first written notice of noncoverage 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 noncoverage 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

Utilization, which is the official Medicare determination. If

you still disagree, you can appeal by following the

instructions on the Notice of Utilization.

Appealing Decisions Made by Peer Review Organizations (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 center 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

organization (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 Organizations

(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 favor, 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

Organization (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 touchtone 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 Travelers 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 Travelers 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 Travelers 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 Travelers 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 Organization 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 Sweet

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 Organization, 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 Organization 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 Organization

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 Organization

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 Organization, Inc.

300 Bearhill Road

Waltham, MA 02154

1-800-252-5533 (in-state only)

1-617-890-0011*

MICHIGAN

Michigan Peer Review Organization

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 Organization 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 Organization, 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 Organization

Suite 200

1220 Southwest Morrison

Portland, OR 97205

1-800-344-4354 (in-state only)

503-279-0100*

PENNSYLVANIA

Keystone Peer Review Organization, 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 Organization

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 Organization

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 Organization 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 Organization

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 Organizations,

Advance directives,

Ambulance services,

Ambulatory surgical services,

Annual Part B deductible,

Antigens,

Appeal fights,

Appealing claims decisions

by carriers,

by health maintenance organizations,

by intermediaries,

by Peer Review Organizations,

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,

hemophilia 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 anesthetist,

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 organizations.

Coinsurance, Competitive medical plans (CMPs).

See Coordinated health care organizations.

Complaints

fraud and abuse hot line,

Medigap fraud,

review process,

skilled nursing facility,

Comprehensive Outpatient Rehabilitation

Facility (CORF),

Coordinated Health Care Organizations (HMOs, CMPs)

appealing decisions,

enrollment and coverage,

fraud,

quality of care,

Cosmetic surgery,

Counseling,

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,

enrollment process,

Doctors

participating,

services covered,

Doctors of osteopathy,

DRGs. See Diagnosis Related Groups.

Drugs and biologicals

coverage under Part A,

coverage under Part B,

hemophilia 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,

Enrollment, Medicare cards,

Enrollment 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 center,

Financial assistance for

low-income beneficiaries,

Foot care,

Foreign hospital care,

Fraud and abuse,

HCFA 1500, form,

Health maintenance organizations (HMOs).

See Coordinated health care organizations.

Heart transplants,

Hemophilia clotting factors,

Hepatitis B vaccine,

HMOs. See Coordinated health care organizations.

Home health agencies,

Home health aides,

Home health care

Part A coverage,

Part B coverage,

Homemaker services,

Hospice care

and coordinated health care organizations,

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,

enrollment process,

noncoverage, notice of,

patient fights,

premiums, premium-free,

prospective payment system,

Hospital outpatient care,

Hot line, fraud and abuse,

Medigap fraud,

Immunizations,

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 organizations,

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 organizations.

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, enrollment 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, hotline,

Mental illness, outpatient treatment,

Noncoverage

notice of,

what Medicare does not cover,

Notice of Utilization,

Nurse anesthetists, midwives, practitioners, and specialists,

clinical,

Nursing home. See Skilled nursing facility.

Occupational therapy. See Therapy.

Open enrollment 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 hospitalization 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 Organizations (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 organizations.

See Coordinated health care organizations.

Prescription drugs. See Drugs and biologicals.

Privacy Act,

Private duty nurses,

Private insurance organizations,

Also see Intermediaries and carriers.

PROs. See Peer Review Organizations.

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 Organizations.

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,

enrollment, cards, premium amounts, questions,

Social worker, clinical,

Special enrollment 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 Organizations,

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,