9780872186477

All About Medicare 2004

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  • ISBN13:

    9780872186477

  • ISBN10:

    0872186474

  • Format: Paperback
  • Copyright: 2004-03-01
  • Publisher: Natl Underwriter Co
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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

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