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Medicare
Part A Coverage

Medicare
Part B
Coverage

Programs
That Help Low-Income Beneficiaries

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  Medicare Part B Coverage

Medicare Part B pays for a wide range of medical services and supplies, but perhaps most important, it helps pay doctor bills.

The medically necessary services of a doctor are covered no matter where you receive them, whether at home, in the doctor's office, in a clinic, in a nursing home, or in a hospital.

Part B also helps pay for:
· Outpatient hospital services.

· X-rays and laboratory tests.

· Ambulance transportation.

· Breast prostheses following a mastectomy.

· Physical and occupational therapy.

· Speech-language pathology services.

· Home health care, if you do not have Part A of Medicare.

· Blood, after the first three pints.

· Flu, pneumonia, and hepatitis B shots.

· Screening Pap smears to detect cervical cancer.

· Mammograms to screen for breast cancer.

· Outpatient mental health services.

· The services of practitioners such as clinical psychologists and clinical social workers

· Artificial limbs and eyes.

· One pair of eyeglasses after cataract surgery.

· Arm, leg, back, and neck braces.

· Durable medical equipment, including wheelchairs, walkers, hospital beds, and oxygen equipment prescribed for home use by a doctor.

· Kidney dialysis and kidney transplants. Under limited circumstances, heart, lung, and liver transplants in a Medicare-approved facility.

· Medical supplies and items such as ostomy bags, surgical dressings, splints, and casts.

Benefit Limits

Some Part B benefits have special requirements, and some are more strictly limited than others. Pap smears, for example, are generally covered once every 3 years, mammograms every 24 months, and therapeutic shoes once a year for people who have severe diabetic foot disease.

You can receive services from an independent, Medicare-approved physical or occupational therapist. But the maximum Medicare will pay for each type of therapy in 1997 is $720.

Durable Medical Equipment: Wheelchairs and other durable medical equipment are covered only when prescribed by a doctor for use at home and when provided by a supplier approved by Medicare. You can find out what equipment is covered, and whether a supplier is approved, by calling Medicare's durable medical equipment (DME) regional carrier for your area. A state-by-state listing of DME carriers begins on page 29.

Ambulance Services

The ambulance benefit is also strictly limited. Medicare will help pay for the service only if:

1. The ambulance, equipment, and personnel meet Medicare requirements, and;

2. Transportation in any other vehicle could endanger your health.

Coverage is generally restricted to transportation between your home and a hospital, your home and a skilled nursing facility, or a hospital and a skilled nursing facility.

What's Not Covered

Many medical services and items are not covered by Medicare. They include, but are not limited to, routine physicals, most dental care, dentures, routine foot care, hearing aids, and most prescription drugs. Eyeglasses are covered only if you need corrective lenses after a cataract operation.

What You Pay

When you use your Part B benefits, you are responsible for paying 20 percent of whatever the hospital charges, not 20 percent of a Medicare-approved amount. For some outpatient mental health services, your share is 50 percent of the Medicare-approved amount.

Besides having to pay Medicare's deductibles and coinsurance, you are responsible for all charges for services and supplies you receive that are not covered by Medicare.

What Is Assignment?

Always ask your doctors and medical suppliers whether they accept assignment. If they do, they will accept the amount Medicare approves for a particular service or supply and will not charge you more than the deductible and 20 percent coinsurance. That can mean savings for you.

Here's how. Let's suppose you go to a doctor who accepts assignment and that you have already paid the $100 Part B deductible for the year. Let's also assume that the Medicare-approved amount for the service you receive is $100.

Medicare would pay 80 percent of the $100 approved amount, or $80. You would be responsible for the other 20 percent, or $20. Medicare would pay its share of the bill directly to the doctor after the doctor filed your claim. The doctor could ask you to pay the $20 immediately but could not ask for more.

Here's what could happen if the doctor did not accept assignment. The doctor could charge $115, which is the $100 Medicare-approved amount plus the extra 15 percent that doctors who do not accept assignment are permitted to charge.

Medicare would pay 80 percent of $100, or $80 and you would be responsible for the remaining $35. But for doctors who do not accept Medicare assignment, Medicare will pay only its share of the bill, and the doctor could ask you to pay the $115 immediately. Medicare would send you a check for $80 after the doctor filed your claim.

Limiting Charge

Be aware that federal law prohibits a doctor who does not accept assignment from charging more than 15 percent above Medicare's approved amount. Any overcharges must be refunded. The following states offer stricter guidelines on limiting charges: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont. If you live in one of these states, check with your state's insurance counseling program for details. You will find the phone number in the resource directory at the back of this book.

Other Charge Limits

Doctors who do not accept assignment for elective surgery are required to give you a written estimate of your costs before the surgery if the total charge will be $500 or more. If you are not given a written estimate, you are entitled to a refund of any amount you paid in excess of the Medicare-approved amount for the surgery performed.

Additionally, any doctor who does not participate in Medicare and who provides you with a service that he or she knows or has reason to believe Medicare will determine to be medically unnecessary must tell you that in writing before performing the service. This is because Medicare will not pay for services it judges to be medically unnecessary. If written notice is not given, and you did not know that Medicare would not pay, you cannot be held liable to pay for that service. However, if you did receive written notice and signed an agreement to pay for the service, you will be held liable to pay.

Participating Doctors and Suppliers

To avoid excess charges, go to doctors and medical suppliers who accept assignment. Some do on a case-by-case basis. Others sign agreements to accept assignment of all Medicare claims. They are called participating doctors and suppliers. You can get the names, addresses, and telephone numbers of participating doctors and suppliers by calling your Medicare carrier. You will find the phone number for your state's carrier in the resource directory of this book.

Part B Claims

Carriers are private insurance companies that contract with the federal government to process Medicare claims and make payments for services and supplies covered by Part B.

Every time you go to the doctor for a service covered by Medicare, the doctor is required by law to send the claim for payment to the carrier for the area where the service was provided. After processing your claim, the carrier usually will send you a notice about your benefits. It shows what was billed, the amount Medicare approved, and what you owe. It also tells you how to file an appeal if you disagree with a payment decision. Contact the carrier with any questions about a Part B claim. The carrier's name and telephone number are printed on the benefit notice. A state-by-state listing of Medicare carriers begins on page 29.

If you get Medicare under the Railroad Retirement system, your claims are processed by the United Health Care office that serves your region. You can get the telephone number from any Railroad Retirement Board office.

Getting A Second Opinion

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, you may want to get the opinion of another doctor before making a decision.

Medicare pays the same way for a second opinion as it pays for other doctor services as long as you are seeking advice for the treatment of a medical condition covered by Medicare. If the first two opinions contradict each other, Medicare will help pay for a third opinion. You can ask your own doctor to refer you to another doctor for a second opinion. Or, you can call your Medicare carrier and ask for the names and phone numbers of doctors in your area who provide second opinions.

Health Care Outside The United States

In general, Medicare will not pay for health care obtained outside the United States and its territories. Medicare can pay for inpatient hospital services that you get in Canada or Mexico if:

· You are in the United States when a medical emergency occurs and the Canadian or Mexican hospital is closer than the nearest U.S. hospital that can treat the emergency.

· You are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency.

· You live in the United States and a Canadian or Mexican hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.

Medicare also pays for doctor and ambulance services furnished in Canada or Mexico in connection with a covered inpatient hospital stay. When in doubt about whether Medicare will pay for health care services, ask your Medicare carrier.

Medicare And Other Health Care Providers

Special Health Care Facilities

Besides helping to pay for care in a hospital or skilled nursing facility, Medicare covers a variety of services provided at special types of health care facilities.

Ambulatory Surgical Center: Part B helps pay for certain types of surgery performed at a Medicare-approved ambulatory surgical center. This type of surgery does not require a hospital stay.

Rural Health Clinic
Various services provided at rural health clinics are also covered by Medicare. These clinics serve areas where few people live. Medicare pays for services provided by the doctors, nurse practitioners, doctor assistants, nurse midwives, clinical psychologists, and social workers that are part of the clinic.

Comprehensive Outpatient Rehabilitation Facility
Part B pays for services provided at a comprehensive outpatient rehabilitation facility if they were prescribed by a doctor and the facility participates in Medicare.

Community Mental Health Center
Under certain conditions, Part B helps pay for partial hospitalization programs provided by community mental health centers or hospital outpatient departments. These specialized programs provide acute mental health care to outpatients. Your doctor must order the care, and the program must participate in Medicare.

Federally Qualified Health Center
A full range of services can be obtained at federally qualified health centers. These facilities are mainly community health centers, Indian health clinics, migrant worker health centers, and health centers for the homeless. They are generally located in inner-city and rural areas, and they are open to all Medicare beneficiaries.

Certified Medical Laboratory
Laboratory clinical diagnostic tests are covered when provided by a certified medical laboratory that participates in Medicare. The laboratory must accept assignment of your Medicare claim and cannot bill you. Part B pays all charges. (In Maryland only, you can be billed for 20 percent coinsurance for hospital outpatient tests.)

Other Health Professionals

Most of the doctor services covered by Medicare must be provided by either a doctor of medicine or a doctor of osteopathy. Medicare generally does not pay for the routine services provided by optometrists, podiatrists, dentists, or chiropractors. However, in some cases, Medicare will pay for some of the services provided by these professionals. Since the rules are complicated, you should check with your Medicare carrier to see what services are covered.

The carrier can also tell you whether Medicare will pay for services provided by a medical professional who is not a doctor. In some cases, Medicare covers the services of certified registered nurse anesthetists, clinical nurse specialists,certified midwives, nurse practitioners, physical and occupational therapists, physician assistants, clinical social workers, and clinical psychologists. The coverage is limited, so call your Medicare carrier to find out whether Medicare will pay for the kind of service you need.

Preventive Care Under Medicare

Medicare helps pay for a limited number of preventive services.

Medicare helps pay for flu and pneumonia shots. The flu shot is given each year before flu season, generally between October and December. The pneumonia shot can be given at any time. Most people need to get the pneumonia shot only once. Your doctor can tell you if you have any health conditions that will make revaccination necessary at a later date.

Flu and pneumonia shots are important in preventing illnesses that could lead to hospitalization or death. If you are not sure if you had a pneumonia shot, ask your doctor. You can get the pneumonia shot when you get your next flu shot.

Medicare also helps pay for the hepatitis B vaccine if you are at high risk of contracting hepatitis B. The shot must be ordered by your doctor.

Medicare helps pay for X-ray screenings for the detection of breast cancer and for Pap smears to detect cervical cancer. Women 65 or older can use the breast cancer screening benefit every 24 months, while women at high risk for breast cancer can use the benefit more frequently.

Joining and Leaving a Managed Care Plan

Enrolling in A Plan

Most Medicare beneficiaries can enroll in a managed care plan. To enroll:

1. You must have Medicare Part B and continue paying Part B premiums.

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

3. You cannot be receiving care in a Medicare-certified hospice at the time of enrollment.

4. You cannot have permanent kidney failure at the time of enrollment.

The names of the plans in your area are available by calling your state insurance counseling office. (See state-by-state listing) Insurance counselors will give you information about the plans in your state to help you decide whether managed care is right for you.

All plans that have contracts with Medicare must have an advertised open enrollment period of at least 30 days once a year. Plans must enroll Medicare beneficiaries in the order of application. You cannot be rejected because of poor health.

If your area is served by more than one plan, compare the doctors' qualifications, facilities, premiums, copayments, and benefits to determine which plan best suits your needs at a price you can afford. Determine whether the plan's providers are in a location convenient to you and whether transportation is available at all hours to get you to them.

Carefully weigh the advantages and disadvantages of plan membership if you travel a lot or live part of the year in another state. Plans must provide coverage for the first 90 days when you travel.

Also keep in mind that if you enroll in a plan and later move out of the plan's service area, you will have to disenroll and either return to fee-for-service Medicare or enroll in a plan that serves your new location. Because each plan is different, your benefits and premiums probably will not be exactly the same if you enroll in another plan.

Leaving A Plan

You can stay in a managed care plan as long as it has a Medicare contract or you can leave at any time to join another plan or to return to fee-for-service Medicare.

To end your enrollment, send a signed request to the plan or to your local Social Security Administration office or, if appropriate, the Railroad Retirement Board. You will return to fee-for-service Medicare the first day of the next month after the plan receives your request to disenroll.

Changing from one managed care plan to another is simple if both plans have a Medicare contract. When you enroll in a new plan you are automatically disenrolled from the first plan.

Medigap insurance is another matter that you should consider if you are thinking about enrolling in a plan or if you are already in a plan and are thinking about disenrolling.

If you have a Medigap policy and decide to join a managed care plan, you may want to keep your Medigap policy for a short amount of time while deciding if you like managed care. You generally do not need a Medigap policy if you are in a managed care plan, but keeping your Medigap policy could help you if you decide to leave managed care and go back to fee-for-service Medicare. If you had a medigap policy but dropped it when you joined a managed care plan, you may not be able to get the same Medigap policy back, especially if you have a health problem.

Protection from Discrimination

The Department of Health and Human Services has an Office for Civil Rights that is responsible for enforcing laws that ban discrimination on the basis of race, color, sex, national origin, disability, or age. Every facility or agency that participates in Medicare must comply with the law. If you believe that you have been discriminated against based on any of these categories, contact one of the offices listed below.

Use this table to find the Office for Civil Rights for your state.

Medicare Hospital Insurance (Part A)
Covered Services for 1997

MEDICAL EXPENSES
Physician's services, inpatient and outpatient medical and surgical services and supplies, physical, occupational and speech therapy, diagnostic tests, and durable medical equipment.

* You pay the $100 Part B deductible only once each year.
** Federal law limits charges for physician services (see here)

CLINICAL LABORATORY SERVICES
Blood tests, urinalysis, and more.

HOME HEALTH CARE***
Part-time or intermittent skilled care, home health aide services, durable medical equipment and supplies and other services. Part B pays for home health care only if you do not have Part A of Medicare.

OUTPATIENT HOSPITAL SERVICES
Services for the diagnosis or treatment of an illness or injury.

* You pay the $100 Part B deductible only once each year.

BLOOD

**** To the extent any of the three pints of blood are paid for or replaced under one part of Medicare during the calendar year, they do not have to be paid for or replaced under the other part.

Last Updated December 22, 1997