MEDICARE MEDICAL INSURANCE (PART B) BENEFITS

MEDICARE MEDICAL INSURANCE (PART B) BENEFITS


Part B helps pay for medically necessary physician
services no matter where you receive them--at home, in the
doctor's office, in a clinic, in a nursing home, or in a
hospital. It also covers related medical services and supplies,
medically necessary outpatient hospital services, X-rays and
laboratory tests. Coverage is also provided for certain
ambulance services and the use at home of durable medical
equipment, such as wheelchairs and hospital beds.

Additionally, Part B covers medically necessary physical
therapy, occupational therapy, and speech-language pathology
services in a doctor's office, as an outpatient, or in your
home. Mental health services are covered as are mammograms and
Pap smears. And if you qualify for home health care but do not
have Part A, then Part B pays for all covered home health
visits.

Outpatient prescription drugs generally are not covered by
Part B. The exceptions include certain drugs furnished to
hospice enrollees, non-self administrable drugs provided as
part of a physician's services, and special drugs, such as
drugs furnished during the first year after an organ
transplantation, erythropoetin for home dialysis patients, and
certain oral cancer drugs.

When you use your Part B benefits, you will be required to
pay the first $100 (the annual deductible) each calendar year.
The deductible must represent charges for services and supplies
covered by Medicare. It also must be based on the Medicare
approved amounts, not the actual charges billed by your
physician or medical supplier.

After you meet the deductible, Part B generally pays 80
percent of the Medicare-approved amount for covered services
you receive the rest of the year. You are responsible for the
other 20 percent. If you require home health services, you do
not have to pay a deductible or coinsurance. You do, however,
have to pay 20 percent of the Medicare-approved amount for any
durable medical equipment! supplied under the Medicare home
health benefit.

You may also have other out-of-pocket costs under Part B
if your physician or medical supplier does not accept
assignment of your Medicare claim and charges more than
Medicare's approved amount. The difference to be paid is called
the "excess charge" or "balance billing." You should be aware,
however, that there are certain charge limitations mandated by
federal law (discussed below) and that some states also limit
physician charges.


Medicare-Approved Amount


The Medicare-approved amount for physician services
covered by Part B is based on a national fee schedule. The
schedule assigns a dollar value to each physician service based
on work, practice costs and malpractice insurance costs. Under
this payment system, each time you go to a physician for a
service covered by Medicare, the amount Medicare will recognize
for that service will be taken from the national fee schedule.
Medicare generally pays 80 percent of that amount.

Because you cannot tell in advance whether the approved
amount and the actual charge for covered services and supplies
will be the same, always ask your physicians and medical
suppliers whether they accept assignment of Medicare claims.


Accepting Assignment


Those who take assignment on a Medicare claim agree to
accept the Medicare-approved amount as payment in full. They
are paid directly by Medicare, except for the deductible and
coinsurance amounts that you must pay.

For example, for your first annual visit, if you go to a
participating physician, or if you go to a nonparticipating
physician who accepts assignment, and the Medicare-approved
amount for the service you receive is $200, you will be billed
$120: $100 for the annual deductible plus 20 percent of the
remaining $100, or $20. Medicare would pay the other $80.
Having met the deductible for the year, the next time you used
Part B services furnished by a physician or medical supplier
who accepts assignment, you would be responsible for only 20
percent of the Medicare-approved amount.

Physicians and suppliers who sign Medicare participation
agreements accept assignment on all Medicare claims. Their
names and addresses are listed in The Medicare Participating
Physician/Supplier Directory, which is distributed to senior
citizen organizations, all Social Security and Railroad
Retirement Board offices, hospitals, and all state and area
offices of the Administration on Aging.

It also is available free by writing or calling the
insurance company that processes Medicare Pan B claims for your
area. Called a Medicare "carrier," the company's name, address
and telephone number are listed in the back of The Medicare
Handbook, available from any Social Security office.

Even if your physician or supplier does not participate in
Medicare, ask before receiving any services or supplies whether
he or she will accept assignment of your Medicare claim. Many
physicians and suppliers accept assignment on a case-by-case
basis. If your physician or supplier will not accept
assignment, you are responsible for paying all permissible
charges.

Medicare will then reimburse you its share of the approved
amount for the services or supplies you received. Regardless of
whether your physician or supplier accepts assignment, they are
required to file your Medicare claim for you.

In certain situations nonparticipating providers of
services are required by law to accept assignment. For
instance, all physicians and qualified laboratories must accept
assignment for Medicare-covered clinical diagnostic laboratory
tests. Physicians also must accept assignment for covered
services provided to beneficiaries with incomes low enough to
qualify for Medicaid payment of their Medicare cost-sharing
requirements (see page 18).


Physician Charge Limits


While physicians who do not accept assignment of a
Medicare claim can charge more than physicians who do, there is
a limit as to the amount they can charge you for services
covered by Medicare. Under the law, they are not permitted to
charge more than 115 percent of the Medicare-approved amount
for the service. Physicians who knowingly, willfully, and
repeatedly charge more than the legal limit are subject to
sanctions. If you think you have been overcharged, or you want
to know what the limiting charge is for a particular service,
contact the Medicare carrier for your area. Limiting charge
information also appears on the Explanation of Medicare
Benefits (EOMB) form that you generally receive from the
Medicare carrier when you go to a physician for a
Medicare-covered service. You do not have to pay charges that
exceed the legal limit.

If you think your physician has exceeded the charge limit,
you should contact the physician and ask for a reduction in the
charge, or a refund, if you have paid more than the charge
limit. If you cannot resolve the issue with the physician, you
can call your Medicare carrier and ask for assistance.


More Charge Limits


Another federal law requires physicians who do not accept
assignment for elective surgery to give you a written estimate
of your costs before the surgery if the total charge will be
$500 or more. If the physician did not give you a written
estimate, you are entitled to a refund of any amount you paid
in excess of the Medicare-approved amount. Any nonparticipating
physician who provides you with services that he or she knows
or has reason to believe Medicare will determine to be
medically unnecessary and thus will not pay for, is required to
so notify you in writing before performing the service. 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.


Gaps in Medicare Coverage for Doctors and Medical Suppliers

* You pay $100 annual deductible.

* Generally, you pay 20% coinsurance.

* You pay legally permissible charges in excess of the
Medicare-approved amount for unassigned claims (see page
6).

* You pay 50% of approved charges for most outpatient mental
health treatment.

* You pay all charges in excess of Medicare's maximum yearly
limit of $900 for independent physical or occupational
therapists.

* No coverage for most services that are not reasonable and
necessary for the diagnosis or treatment of an illness or
injury.

* No coverage for most self-administerable prescription
drugs or immunizations, except for pneumococcal, influenza
and hepatitis B vaccinations.

* No coverage for routine physicals and other screening
services, except for mammograms and Pap smears.

* Generally, no coverage for dental care or dentures.

* No coverage for acupuncture treatment.

* No coverage for hearing aids or routine hearing loss
examinations.

* No coverage for care received outside the United States
and its territories, except under limited circumstances in
Canada and Mexico.

* No coverage for routine foot care except when a medical
condition affecting the lower limbs (such as diabetes)
requires care by a medical professional.

* No coverage for services of naturopaths, Christian Science
practitioners, immediate relatives, or charges imposed by
members of your household.

* No coverage for the first 3 pints of whole blood or units
of packed cells used in each year in connection with
covered services. To the extent the 3-pint blood
deductible is met under Part A, it does not have to be met
under Part B.

* No coverage for routine eye examinations or eyeglasses,
except prosthetic lenses, if needed, after cataract
surgery.


Medicare Benefit Charts


The charts on pages 8 and 9 describe Medicare benefits
only. The "You Pay" column itemizes expenses you are
responsible for and must pay out of your own pocket or through
the purchase of some type of private insurance as described in
this booklet.