All About Medicare 2004

by Fenton, John H.; Stenken, Joseph F.

• ISBN13: 9780872186477
• ISBN10: 0872186474
• Format: Paperback
• Copyright: 2004-03-01
• Publisher: Natl Underwriter Co

Table of Contents

INTRODUCTION	1	(14)
Medicare Defined	A-1
Administration of Medicare	A-2
Hospital Insurance Protection	A-3
Medical Insurance Protection	A-4
Providers of Services and Supplies	A-5
Hospital Insurance	A-6
Medical Insurance	A-7
Home Health Coverage	A-8
Limit on Benefits	A-9
Availability of Benefits	A-10
Medicare Card	A-11
Care Not Covered by Medicare	A-12
Quality Improvement Organizations	A-13
Fraud and Abuse Hotline	A-14
Fee-for-Service System Versus Medicare Advantage	A-15
PART A: HOSPITAL INSURANCE	15	(38)
ELIGIBILITY	15	(10)
Who Is Eligible	B-1
End-Stage Renal Disease	B-2
Government Employees	B-3
Medicare as Secondary Payer	B-4
Persons Who Do Not Qualify for Social Security	B-5
Special Enrollment Premium	B-6
ADMINISTRATION	25	(2)
Centers for Medicare & Medicaid Services	B-7
Prospective Payment System	B-8
Compulsory Nature of Plan	B-9
FINANCING HOSPITAL INSURANCE	27	(1)
Hospital Insurance Tax	B-10
BENEFITS	28	(1)
Generally	B-11
QUALIFIED MEDICARE BENEFICIARIES	28	(2)
Medicare Costs Paid by State	B-12
How to Qualify	B-13
Income Above Poverty Level	B-14
Applying for Assistance	B-15
INPATIENT HOSPITAL SERVICES	30	(6)
Services Covered	B-16
Care in Psychiatric Hospital	B-17
Religious Nonmedical Health Care Institutions	B-18
Selecting a Hospital	B-19
Certification by Doctor	B-20
Hospital Agreement with Medicare	B-21
HOSPICE CARE	36	(3)
Hospice Care Defined	B-22
How Hospice Care is Covered	B-23
Hospice Benefit Period	B-24
Cost to Patient	B-25
Respite Care	B-26
SKILLED NURSING FACILITY CARE	39	(5)
Definition	B-27
Services Covered	B-28
Cost to Patient	B-29
When Payment is Made	B-30
HOME HEALTH CARE	44	(6)
When Services Are Covered	B-31
Conditions for Coverage	B-32
Services Covered by Medicare	B-33
How Medicare Pays the Cost	B-34
GENERAL INFORMATION	50	(3)
Outpatient Hospital Services	B-35
Financial Need	B-36
Increases in Deductible and Coinsurance Amounts	B-37
Living Will and Durable Power of Attorney	B-38
PART B: MEDICAL INSURANCE	53	(30)
ELIGIBILITY	53	(4)
Who Is Eligible	C-1
How to Enroll	C-2
Failure to Enroll During Automatic Enrollment Period	C-3
Federal-State Agreement	C-4
Special Enrollment Period for Certain Disabled Workers	C-5
Terminating Coverage	C-6
FINANCING MEDICAL INSURANCE	57	(7)
How Program is Financed	C-7
Qualified Medicare Beneficiary	C-8
How Premiums are Paid	C-9
Determining "Approved Charges"	C-10
How Payments are Made	C-11
Medicare-Participating Doctors	C-12
Medicare Supplier	C-13
Cost Paid By Patient	C-14
How Patient Finds Out How Much Medicare Will Pay	C-15
BENEFITS	64	(16)
Doctors' Services	C-16
Outpatient Hospital Services	C-17
Outpatient Physical Therapy and Speech Pathology Services	C-18
Partial Hospitalization Services	C-19
Certified Nurse-Midwife Services	C-20
Dental Work	C-21
Medical Equipment	C-22
Ambulance Service	C-23
Outpatient Treatment of Mental Illness	C-24
Vaccines	C-25
Antigens	C-26
Liver Transplant	C-27
Comprehensive Outpatient Rehabilitation Facility	C-28
Home Health Services	C-29
Independent Clinical Laboratory Services	C-30
Screening Pap Smears	C-31
Breast Cancer Screening	C-32
Prostate Screening	C-33
Colorectal Screening	C-34
Diabetes Benefits	C-35
Bone Mass Measurements	C-36
Osteoporosis	C-37
Eyeglasses	C-38
Nurse Practitioners	C-39
Lung and Heart-Lung Transplants	C-40
Immunosuppressive Drugs	C-41
Ambulatory Surgical Services	C-42
Rural Health Clinic Services	C-43
Telehealth Services	C-44
Federally Qualified Health Center Services	C-45
Other Benefits	C-46
Services Covered With No Cost Sharing	C-47
MEDICARE COVERAGE OF BLOOD	80	(1)
How Medicare Helps Pay Cost of Blood	C-48
PRIVATE CONTRACTS	81	(2)
Private Contracts with Physicians	C-49
PART C: MEDICARE ADVANTAGE	83	(12)
DEFINITION	83	(2)
Medicare Advantage Defined	D-1
Health Maintenance Organization	D-2
Private Fee-For-Service Plan	D-3
Provider-Sponsored Organization	D-4
Religious Fraternal Benefit Society Plan	D-5
ELIGIBILITY, ELECTION, AND ENROLLMENT	85	(2)
Enrollment Process	D-6
Enrollment Periods	D-7
Beneficiary Information	D-8
BENEFITS AND BENEFICIARY PROTECTIONS	87	(3)
Basic Benefits	D-9
Standards of Protection	D-10
Antidiscrimination Rules	D-11
Disclosure to Enrollees	D-12
Access to Services	D-13
Quality Assurance Program	D-14
Grievances	D-15
Provider Participation Rules	D-16
Billing Limits	D-17
PREMIUMS	90	(1)
Proposed Premiums	D-18
Other Premium Rules	D-19
CONTRACTS WITH MEDICARE ADVANTAGE ORGANIZATIONS	91	(1)
Contracts with Health Care Financing Administration	D-20
MEDIGAP INSURANCE PROGRAM	92	(3)
Medigap Insurance Rules	D-21
Special Protections	D-22
PART D: PRESCRIPTION DRUG INSURANCE	95	(4)
Prescription Drug Insurance Defined	E-1
Effective Date	E-2
Who Is Eligible	E-3
Benefits of Medicare Drug Discount Card	E-4
Cost of Medicare Drug Discount Card	E-5
Benefits of Prescription Drug Insurance	E-6
Cost of Prescription Drug Insurance	E-7
MEDIGAP INSURANCE	99	(14)
Defined	F-1
Open Enrollment Period	F-2
Medigap Insurance for Medicaid Recipients	F-3
Federal Standards for Medigap Insurance	F-4
Additional Benefits	F-5
Twelve Standard Policies	F-6
Medicare SELECT Policies	F-7
Choosing the Right Policy	F-8
Medicare Advantage Program	F-9
Rules for Selling Medigap Insurance	F-10
Shopping for Medigap Insurance	F-11
HOW TO SUBMIT CLAIMS AND APPEALS	113	(32)
CLAIMS PROCEDURE	113	(3)
Hospital Insurance Services	G-1
How to Submit Medical Insurance Claims	G-2
Itemized Bills	G-3
Death of Person Filing Claim	G-4
Time Limit for Filing Claim	G-5
Where to Send Claims	G-6
Prompt Payment	G-7
APPEALS PROCEDURE	116	(7)
Right to Appeal Decision on Claim	G-8
How to Appeal Medical Insurance Claim Decision	G-9
Review by Medicare Carrier	G-10
Hearing with Medicare Carrier	G-11
How to Appeal Hospital Insurance Claim Decision	G-12
How to Appeal All Other Hospital Insurance Claims	G-13
How to Appeal HMO Decisions	G-14
Protection if Organization Ceases To Provide Benefits	G-15
MEDICAID	123	(1)
OVERVIEW	123	(2)
Medicaid Defined	H-1
Expenses Paid by Federal Government	H-2
MEDICAID ELIGIBILITY	125	(3)
Groups Covered by States	H-3
SSI States	H-4
Optional Coverage	H-5
MEDICAID SERVICES	128	(3)
Basic Services	H-6
AIDS	H-7
Optional Services	H-8
PAYMENT UNDER MEDICAID	131	(2)
How Providers are Paid	H-9
Amount and Duration of Services	H-10
Medicare Coverage	H-11
LONG-TERM CARE	133	(1)
Medicaid Coverage	H-12
EXEMPT INCOME AND RESOURCES	133	(2)
Income and Resources Recipient Can Keep	H-13
SPOUSAL IMPOVERISHMENT	135	(2)
Income	H-14
Resources	H-15
Income Eligibility Requirements	H-16
Post-eligibility Treatment of Income	H-17
MEDICAID TRANSFER RULES	137	(1)
Transfer of Property to Meet Eligibility Requirements	H-18
TRUSTS	138	(3)
Use of Trusts	H-19
Exceptions to Trust Rule	H-20
ESTATE RECOVERIES	141	(1)
State Recovery of Medicaid Expenses	H-21
DISCRIMINATION	142	(1)
Nursing Homes	H-22
MANAGED CARE	142	(3)
Changes to Medicaid Program	H-23
APPENDICES	145
Appendix A - Table of Medicare Benefits	145	(2)
Appendix B - What Medicare Does Not Cover	147	(2)
Appendix C - Example of Medicare Benefits	149	(2)
Appendix D - Medicare Carriers	151	(2)
Appendix E - Medicare Quality Improvement Organizations (QIOs)	153	(2)
Appendix F - Durable Medical Equipment Regional Carriers	155	(2)
Appendix G - Insurance Counseling - General Information	157	(2)
Appendix H - Centers for Medicare & Medicaid Services	159