GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE

GUIDE TO HEALTH INSURANCE FOR PEOPLE WITH MEDICARE

* WHAT MEDICARE PAYS AND DOESN'T PAY

* 10 STANDARD MEDIGAP INSURANCE PLANS

* YOUR RIGHT TO MEDIGAP INSURANCE

* TIPS ON SHOPPING FOR PRIVATE HEALTH INSURANCE

Developed jointly by the National Association of Insurance
Commissioners and the Health Care Financing
Administration of the U.S. Department
of Health and Human Services.

Publication No. HCFA-02110

-NOTICE -


Listed in the back of this booklet are the addresses and
telephone numbers of each of the state agencies on aging and
the state insurance departments. They are available to assist
you with any questions you may have about private insurance to
supplement Medicare.

Suspected violations of the laws governing the marketing
of insurance policies should generally be reported to your
state insurance department since states are responsible for the
regulation of insurance within their boundaries.

There are, however, federal penalties for certain
violations concerning Medicare supplement insurance ("Medigap")
policies. It is, for example, a federal offense for an
insurance agent to indicate that he or she represents the
Medicare program or any other federal agency in order to sell a
policy. It is also illegal for an insurance company or agent to
sell you a policy that duplicates coverage you already have.

The federal toll-free telephone number for filing
complaints is:

1-800-638-6833


TABLE OF CONTENTS


DEFINITIONS OF SOME MEDICARE TERMS

SOME BASIC THINGS YOU SHOULD KNOW

WHAT IS MEDICARE?

MEDICARE HOSPITAL INSURANCE (PART A)

MEDICARE MEDICAL INSURANCE (PART B)

MEDICARE BENEFIT CHARTS

TYPES OF PRIVATE HEALTH INSURANCE

Medigap
Your Right to Medigap Coverage
Medicare SELECT
Managed Care Plans
Employer Group Insurance
Association Group Insurance
Long-Term Care Insurance
Hospital Indemnity Insurance
Specified Disease Insurance

DO YOU NEED MORE INSURANCE?

Medicaid Recipients
Assistance for Low-Income Elderly
Federally Qualified Health Center Services

TIPS ON SHOPPING FOR HEALTH INSURANCE

LIST OF STANDARD MEDIGAP BENEFIT PLANS

CHART COMPARING STANDARD MEDIGAP BENEFIT PLANS

INSURANCE POLICY CHECK-LIST

INSURANCE COUNSELING TELEPHONE NUMBERS

STATE INSURANCE DEPARTMENTS AND AGENCIES ON AGING


DEFINITIONS OF SOME MEDICARE TERMS


Actual Charge: The amount a physician or supplier actually
bills for a particular medical service or supply.

Approved Amount: The amount Medicare determines to be
reasonable for a service that is covered under Part B of
Medicare. It may be less than the actual charge. For physician
services the approved amount is taken from a national fee
schedule that assigns a dollar value to all physician services
covered by Medicare.

Assignment: An arrangement whereby a physician or medical
supplier agrees to accept the Medicare-approved amount as the
total charge for services and supplies covered under Part B.
Medicare usually pays 80% of the approved amount directly to
the provider after the beneficiary meets the annual Part B
deductible of $100. The beneficiary pays the other 20%.

Benefit Period: A benefit period is a way of measuring a
beneficiary's use of hospital and skilled nursing facility
services covered by Medicare. A benefit period begins the day
the beneficiary is hospitalized and ends after the beneficiary
has been out of the hospital or skilled nursing facility for 60
days in a row. If the beneficiary is hospitalized after 60
days, a new benefit period begins and most Medicare Part A
benefits are renewed. There is no limit as to the number of
benefit periods a beneficiary can have.

Coinsurance: The portion or percentage of Medicare's
approved amounts for covered services that a beneficiary is
responsible for paying.

Deductible: The amount of expense a beneficiary must first
incur before Medicare begins payment for covered service's.

Excess Charge: The difference between the
Medicare-approved amount for a service or supply and the actual
charge, if the actual charge is more than the approved amount.

Limiting Charge: The maximum amount a physician may charge
a Medicare beneficiary for a covered physician service if the
physician does not accept assignment of the Medicare claim. The
limit is 15% more than the fee schedule amount for
nonparticipating physicians. Limiting charge information
appears on Medicare's Explanation of Medicare Benefits (EOMB)
form.

Medicare Carrier: An insurance organization under contract
to the federal government to process Medicare Part B claims
from physicians and other health care providers. The names and
addresses of the carriers and areas they serve are listed in
the back of The Medicare Handbook, available from any Social
Security Administration office.

Medicare Hospital Insurance: This is Part A of Medicare.
It helps pay for medically necessary inpatient care in a
hospital, skilled nursing facility or psychiatric hospital, and
for hospice and home health care.

Medicare Medical Insurance: This is Pan B of Medicare.
This pan helps pay for medically necessary physician services
and many other medical services and supplies not covered by
Part A.

Participating Physician and Supplier: A physician or
supplier who agrees to accept assignment on all Medicare
claims.