THE MEDICARE HANDBOOK  1991

Including Information for Beneficiaries On

     o  Medicare Benefits
     o  Participating Physicians and Suppliers
     o  Health Insurance to Supplement Medicare
     o  Limits to Medicare Coverage
ABOUT THIS HANDBOOK

     Your Medicare handbook is designed to help you determine if
Medicare pays for the services you need and how payments are made. 
It is intended to be a handy reference to help you understand how
the Medicare program works and to know what your benefits are. 
There is an alphabetical index at the back to assist you in finding
information on specific subjects.  

     While Medicare pays for many of your health care expenses, it
does not cover all of them.  Therefore, it is important for you to
know what Medicare does and does not pay for.

Handbook Highlights
 
Medicare Peer Review Organizations (PROs) review the quality of
care provided by inpatient hospitals, hospital outpatient
departments and hospital emergency rooms; skilled nursing
facilities; home health agencies; ambulatory surgical centers; and
certain health maintenance organizations.  PROs are described on
page 2 and 3, and beginning on page 3, PROs are listed by state.

On pages 8 and 9 you will find a copy of An Important Message From
Medicare, a message that you get when you are admitted to a
Medicare participating hospital.  The message explains your rights.

Page 18 explains the assignment method of payment in which your
doctor or supplier agrees to accept Medicare's approved amount as
payment in full.

Information about other  insurance that pays before    Medicare
begins on page 25.

Pages 27 to 29 tell you what to do if you disagree with a Medicare
decision or the amount of payment on a claim.

Charts showing Medicare Part A and Part B benefits are on pages 32
and 33.


     If you have questions about whether you can get Medicare or
about how to enroll in Medicare, call Social Security.  You can
also call Social Security if you have questions about your Medicare
card or premium amounts.  But, if you have questions about what
Medicare Medical Insurance (Part B) covers or about your Medicare
Part B claims, call your Medicare carrier.  Carriers are the
insurance companies that process Medicare claims.  Carrier
telephone numbers are listed by state on pages 34 to 38 of this
handbook.

     People who can get Medicare because of kidney disease may get
a copy of Medicare Coverage of Kidney Dialysis and Kidney
Transplant Services from the Consumer Information Center (see
inside back cover).
                                
     Many doctors and suppliers have agreed to be part of
Medicare's participating physician and supplier program.  They
accept assignment on all Medicare claims.  If you get your medical
services from one of these participating doctors or suppliers, you
can often save money.  See page 18 and 19 for more information
about the assignment method of payment, and what you can do to find
a participating doctor or supplier.

     This handbook is meant to explain the Medicare program but is
not a legal document.  The official Medicare program provisions are
contained in the relevant laws, regulations and rulings.

p.p i
                             CONTENTS

GENERAL INFORMATION ABOUT MEDICARE
     What is Medicare? p.p 1
     Coordinated Care: Prepaid Health Care Organizations p.p 10
     Buying Health Insurance to Supplement 
       Medicare (Medigap) 10
     Fraud and Abuse 11
     Assistance for Low-Income Beneficiaries 11
MEDICARE HOSPITAL INSURANCE (Part A)
     What Medicare Part A Includes 12
     When You Are A Hospital Inpatient 12
     Skilled Nursing Facility Care 14
     Home Health Care  16
     Hospice Care 17
MEDICARE MEDICAL INSURANCE (Part B)
     What Medicare Part B Includes 17
     Deductible and Coinsurance Amounts 18   
     Assignment 18
     Participating Doctors and Suppliers 19
     Participating Providers 19
     Approved or "Reasonable" Charges 19 
     Covered Doctors' Services 20
     Second Opinion Before Surgery 21
     Services of Special Practitioners 21
     Outpatient Hospital Services 21
     Other Covered Services and Supplies 22
     Drugs and Biologicals 24
     Medicare Payments for Outpatient Treatment of Mental Illness
     24
MEDICARE MEDICAL INSURANCE (PART B) CLAIMS
     A New Rule 25
     Claims Submission for Services on or After 
       September 1, 1990  25
     Claims For a Person Who Has Died 25
     When Other Insurance Pays Before Medicare 25
     Explanation of Medicare Benefits Notice 27
YOUR RIGHT OF APPEAL
      Appealing Decisions Made by Providers of Part A
       Services  27
      Appealing Decisions Made by Peer Review 
       Organizations (PROs) 28
      Appealing Decisions Made by Medicare Intermediaries 
       on Part A Claims 28
      Appealing Decisions Made by Carriers on Part B 
       Claims 28
      Appealing Decisions Made by Health Maintenance Organiza-
       tions (HMOs) or Competitive Medical Plans (CMPs) 29

p.p ii
WHAT MEDICARE DOES NOT PAY FOR
      Custodial Care 29
      Care Not Reasonable And Necessary Under Medicare 
      Program Standards 29
      Services Medicare Does not Pay For 29
      Limitation of Liability  29
GETTING THE PART OF MEDICARE YOU DO NOT HAVE
      Getting Medicare Medical Insurance (Part B) 30
      Getting Medicare Hospital Insurance (Part A) 30
      Special Enrollment Period 30
EVENTS THAT CAN CHANGE YOUR MEDICARE PROTECTION
      When Protection Ends for People 65 and Older  31
      When Protection Ends for the Disabled 31
      When Protection Ends for those with Kidney 
      Failure 31
OTHER IMPORTANT INFORMATION
     Medicare Benefit Charts 32
     Medicare Carriers 34
     Index 39
p.p 1
GENERAL INFORMATION ABOUT MEDICARE
WHAT IS MEDICARE?

     The Medicare program is a federal health insurance program
for people 65 or older and certain disabled people.  It is run by
the Health Care Financing Administration of the U.S. Department of
Health and Human Services.  Social Security Administration offices
across the country take applications for Medicare and provide
general information about the program.

The Two Parts of Medicare

     There are two parts to the Medicare program.  Hospital
Insurance (Part A) helps pay for inpatient hospital care, inpatient
care in a skilled nursing facility, home health care and hospice
care.  Medical Insurance (Part B) helps pay for doctors' services,
outpatient hospital services, durable medical equipment, and a
number of other medical services and supplies that are not covered
by the hospital insurance part of Medicare. Throughout this
handbook, Medicare Hospital Insurance will be referred to as Part
A and Medicare Medical Insurance will be referred to as Part B.

     Part A has deductibles and coinsurance, but most people do
not have to pay premiums for Part A (see page 30).  Part B of
Medicare has premiums, deductibles, and coinsurance amounts that
you must pay yourself or through coverage by another insurance
plan.  Premium, deductible and coinsurance amounts are set each
year according to formulas established by law.  New payment amounts
begin each January 1.  When amounts increase, you will be notified. 
For 1991 deductible, premium and coinsurance amounts, see the
Medicare Benefit Charts on pages 32 and 33 of this handbook.
Who Can Get Medicare Hospital Insurance (Part A)?

     Generally, people age 65 and over can get premium-free
Medicare Part A benefits, based on their own or their spouses'
employment.  (Premium-free means there are no monthly premiums. 
Most people do not pay premiums for Medicare Part A.) You can get
premium-free Medicare Part A if you are 65 or over and:

Receive benefits under the Social Security or Railroad Retirement
system, 

Could receive benefits under Social Security or the Railroad
Retirement system but have not filed for     them, or

You or your spouse had certain government employment.

     If you are under 65 you can get premium-free Medicare Part A
benefits if you have been a disabled beneficiary under Social
Security or the Railroad Retirement Board for more than 24 months.

     Certain government employees and certain members of their
families can also get Medicare when they are disabled for more than
29 months.  They should apply with the Social Security
Administration as soon as they become disabled.
     Or, you may be able to get premium-free Medicare Part A
benefits if you receive continuing dialysis for permanent kidney
failure or if you have had a kidney transplant.

     Check with Social Security to see if you have worked long
enough under Social Security, Railroad Retirement, as a government
employee, or a combination of these systems to be able to get
Medicare Part A benefits.  Generally, if either you or your spouse
worked for 10 years, you may be able to get premium-free Medicare
Part A benefits.  

Who Can Get Medicare Medical Insurance (Part B)?

     Any person who can get premium-free Medicare Part A benefits
based on work as described above can enroll for Part B, pay the
monthly Part B premiums, (in 1991, $29.90 for most beneficiaries)
and get Part B benefits.  In addition, most United States residents
age 65 or over can enroll in Part B. 

Buying Medicare Part A and Part B

     If you do not have enough work credits to be able to get
Medicare Part A benefits and you are 65 or over, you may be able
to buy Medicare Parts A and B--or just Medicare Part B--by paying
monthly premiums.  Also, you may be able to buy Medicare Parts A
and B if you are disabled and lost your premium-free Part A solely
because you are working.  See page 30 for more information.

Enrollment in Medicare

     If you are already getting Social Security or Railroad
Retirement benefit payments when you turn 65, you will
automatically get a Medicare card in the mail.  The card will show
that you can get both Medicare Hospital Insurance (Part A) and
Medical 

p.p 2 Insurance (Part B) benefits.  If you do not want Part B,
follow the instructions that come with the card.

     The above process also applies when you have been a disability
beneficiary under Social Security or Railroad Retirement for 24
months.  A Medicare card will come in the mail.

     Some people do not automatically get a Medicare card.  They
must file an application to get Medicare benefits. If you have not
applied for Social Security or Railroad Retirement benefits, or if
government employment is involved, or if you have kidney disease,
you must file an application for Medicare.  Check with Social
Security if you are able to get Medicare under the Social Security
system or based on certain government employment; check with the
Railroad Retirement office if you are able to get Medicare under
the Railroad Retirement system.

     If you must file an application for Medicare, you should do
so during your initial enrollment period, to avoid late enrollment
penalties under Medicare Part B.  Your initial enrollment period
is a seven-month period that starts three months before the month
you first meet the requirements for Medicare.  If you do not sign
up for Medicare during the first three months of your initial
enrollment period, there will be a delay in starting your Part B
coverage.  Your coverage will be delayed from one to three months
after enrollment.  

     If you do not enroll for Medicare Part B at any time during
your initial enrollment period, you will not get another chance to
enroll until the next general enrollment period.  A general
enrollment period is held each year from January 1 through March
31.  You may also be charged a premium penalty for late enrollment
(unless you qualify for a special enrollment period as described
on page 30).

     The enrollment period requirements and penalties for late
enrollment also apply to Part A, if you do not meet the
requirements for premium-free Part A and want to enroll and pay
the premiums for the Part A coverage.

Your Medicare Card

     The Medicare card shows the Medicare coverage you have
(Hospital Insurance (Part A), Medical Insurance (Part B), or both)
and the date your protection started.  If you do not have both
parts of Medicare, see page 30 for information on how you can get
the part you don't have.

     Your Medicare card also shows your health insurance claim
number.  Sometimes this claim number is referred to as your
Medicare number.  The claim number has nine digits and a letter. 
There may also be another number after the letter. Your full claim
number must always be included on all Medicare claims and
correspondence.  When a husband and wife both have Medicare, each
receives a separate card and claim number.  Each spouse must use
the exact name and claim number shown on his or her card.

It is important that you remember to:

Use your Medicare card only after the effective date shown on it.

Keep your card handy.  And be sure to carry your card with you
whenever you are away from home.  

Always show your Medicare card when you receive services that
Medicare helps pay for.

Always write your health insurance claim number (including the
letter) on all checks for Medicare premium payments or any
correspondence about Medicare.  Also, you should have your Medicare
card available when you make a telephone inquiry. 

Immediately ask Social Security to get you a new card if you lose
yours.

Never let anyone else use your Medicare card.

Intermediaries and Carriers

     The federal government contracts with private insurance
organizations called intermediaries and carriers to process claims
and make Medicare payments.  Intermediaries handle claims submitted
on your behalf by hospitals, skilled nursing facilities, home
health agencies, hospices and other providers of services.  You
will not usually need to deal directly with intermediaries.

     Carriers handle claims for services by doctors and other
suppliers covered under Medicare's Part B program.  If you have
questions about Medicare Part B claims, you can contact your
Medicare carrier.  The addresses and phone numbers of carriers are
on pages 34 to 38.

Peer Review Organizations

     Peer Review Organizations (PROs) are groups of practicing
doctors and other health care professionals who are paid by the
federal government to review the care given to Medicare patients. 
Each state has a PRO that decides, for Medicare payment purposes,
whether care is reasonable and necessary, is provided in the
appropriate setting, and meets the standards of quality accepted
by the medical 

p.p 3 
profession.  

     PROs have the authority to deny payments if care is not
medically necessary or not delivered in the most appropriate
setting.
     
     PROs respond to requests for review of notices of noncoverage
issued by hospitals to beneficiaries; and PROs respond to
beneficiary, physician, and hospital requests for reconsideration
of PRO decisions.  PROs also investigate individual patient
complaints about the quality of care.  

     If you are admitted to a Medicare participating hospital, you
will receive An Important Message From Medicare which explains your
rights as a hospital patient and provides the name, address, and
phone number of the PRO for your state.   A copy of the message is
printed on pages 8 and 9.

     If you feel that you are improperly refused admission to a
hospital or that you are forced to leave the hospital too soon,
ask for a written explanation of the decision.  Such a written
notice must fully explain how you can appeal the decision and it
must give you the name, address, and phone number of the PRO where
your appeal or request for review can be submitted.  (See page 27
for further discussion of your appeal rights under Medicare.)

     Beneficiary complaints: PROs are responsible for reviewing
beneficiary complaints about the quality of care provided by
inpatient hospitals, hospital outpatient departments and hospital
emergency rooms; skilled nursing facilities; home health agencies;
ambulatory surgical centers; and certain health maintenance
organizations.

     If you believe that you have received poor quality care
provided by one of these facilities, you may complain to the PRO. 
The PRO will investigate written complaints from beneficiaries, or
their representatives, about the quality of Medicare services
received.

     Your complaint must be in writing.  The PRO will help you put
your complaint in writing if you wish.  If someone else makes a
complaint for you or on your behalf, you must give written
permission for that person to represent you in the complaint.

Medicare PROs for each state are listed here.

MEDICARE PEER REVIEW ORGANIZATIONS (PROs)

PROs can answer questions about hospital stays and other Hospital
Insurance (Part A) services.  Do not call the PRO with questions
about Medicare Medical Insurance (Part B).

ALABAMA
Alabama Quality Assurance Foundation
Suite 600
600 Beacon Parkway West
Birmingham, AL  35209-3154
1-800-288-4992
205-942-0785

ALASKA
Professional Review Organization for Washington 
(PRO for Alaska)
Suite 300
10700 Meridian Avenue, North
Seattle, WA  98133-9008
1-800-445-6941
206-364-9700
(in Anchorage dial 562-2252)


AMERICAN SAMOA/GUAM AND HAWAII
Hawaii Medical Service Association
 (PRO for American Samoa/Guam
  and Hawaii)
818 Keeaumoku Street
P.O. Box 860
Honolulu, HI  96808
808-944-3581

ARIZONA
Health Services Advisory Group, Inc.
301 East Bethany Home Road
Suite B-157
P.O. Box 16731
Phoenix, AZ  85012
1-800-626-1577
(in Arizona dial 1-800-359-9909)
602-264-6382

ARKANSAS
Arkansas Foundation for
 Medical Care, Inc.
P.O. Box 2424
809 Garrison Avenue
Fort Smith, AR  72902
1-800-824-7586
(in Arkansas dial 1-800-272-5528)
501-785-2471

p.p 4
CALIFORNIA
California Medical Review Inc.
Suite 500
60 Spear Street
San Francisco, CA  94105
1-800-841-1602 (in-state only)
1-415-882-5800 *PRO will accept collect calls from out of state on
this number.

COLORADO
Colorado Foundation for Medical Care
1260 South Parker Road 
P.O. Box 17300
Denver, CO  80217-0300                       
1-800-727-7086 (in-state only)
1-303-695-3333 *PRO will accept collect calls from out of state on
this number.

CONNECTICUT
Connecticut Peer Review Organization, Inc.
100 Roscommon Drive, Suite 200
Middletown, CT  06457
1-800-553-7590 (in-state only)
1-203-632-2008 *PRO will accept collect calls from out of state on
this number.

DELAWARE
West Virginia Medical Institute, Inc.
(PRO for Delaware)
3412 Chesterfield Ave. S.E.
Charleston, WV 25304
1-800-522-0446 (Delaware, District of Columbia, Maryland,        
                Pennsylvania and Virginia)
304-925-0461
(in Wilmington dial 655-3077)

DISTRICT OF COLUMBIA
Delmarva Foundation for
 Medical Care, Inc.
(PRO for D.C.)
341 B North Aurora Street
Easton, MD  21601
1-800-645-0011
(in Maryland dial 1-800-492-5811)
301-822-0697

FLORIDA
Professional Foundation for
 Health Care, Inc.
Suite 100
2907 Bay to Bay Blvd.
Tampa, FL  33629
1-800-634-6280 (in-state only)
813-831-6273

GEORGIA
Georgia Medical Care Foundation
Suite 200
57 Executive Park South
Atlanta, GA  30329
1-800-282-2614 (in-state only)
404-982-0411

HAWAII
Hawaii Medical Service Association
(PRO for American Samoa/Guam and Hawaii)
818 Keeaumoku Street
P.O. Box 860
Honolulu, HI  96808
1-808-944-3586 *PRO will accept collect calls from out of state on
this number
1-808-944-3581

IDAHO
Professional Review Organization for Washington
(PRO for Idaho)
Suite 300
10700 Meridian Avenue, North
Seattle, WA  98133-9008
1-800-445-6941
206-364-9700
1-208-343-4617*  (local Boise and collect) PRO will accept collect
calls from out of state on this number.

ILLINOIS
Crescent Counties Foundation for Medical Care
350 Shuman Boulevard, Suite 240
Naperville, IL  60563
1-800-647-8089
708-357-8770

INDIANA
Sentinel Medical Review Organization
2901 Ohio Boulevard
P.O. Box 3713
Terre Haute, IN  47803
1-800-288-1499
812-234-1499

IOWA
Iowa Foundation for Medical Care
Colony Park
3737 Woodland Avenue, Suite 500
West Des Moines, IA  50265
1-800-752-7014 (in-state only)
515-223-2900

p.p 5
KANSAS
The Kansas Foundation for Medical
 Care, Inc.
2947 S.W. Wanamaker Drive
Topeka, KS  66614
1-800-432-0407 (in-state only)
913-273-2552

KENTUCKY
Sentinel Medical Review Organization
10503 Timberwood Circle, Suite 200
P.O. Box 23540
Louisville, KY  40223
1-800-288-1499
502-339-7442

LOUISIANA
Louisiana Health Care Review
9357 Interline Avenue, Suite 200
Baton Rouge, LA  70809
1-800-433-4958 (in-state only)
504-926-6353

MAINE
Health Care Review, Inc.
(PRO for Maine)
Henry C. Hall Building
345 Blackstone Blvd.
Providence, RI  02906
1-800-541-9888 or 1-800-528-0700 (both numbers in Maine only)
401-331-6661
1-207-945-0244 *PRO will accept collect calls from out of state on
this number.

MARYLAND
Delmarva Foundation for Medical Care, Inc.
(PRO for Maryland)
341 B North Aurora Street
Easton, MD  21601
1-800-645-0011
(in Maryland dial 1-800-492-5811)
301-822-0697

MASSACHUSETTS
Massachusetts Peer Review Organization, Inc.
300 Bearhill Road
Waltham, MA  02154
1-800-252-5533 (in-state only)
617-890-0011 *PRO will accept collect calls from out of state on
this number.

MICHIGAN
Michigan Peer Review Organization
40500 Ann Arbor Road, Suite 200
Plymouth, MI  48170
1-800-365-5899
313-459-0900

MINNESOTA
Foundation for Health Care Evaluation
Suite 400
2901 Metro Drive
Bloomington, MN  55425
1-800-444-3423
612-854-3306

MISSISSIPPI
Mississippi Foundation for Medical Care, Inc.
P.O. Box 4665
735 Riverside Drive
Jackson, MS  39296-4665
1-800-844-0600 (in-state only)
601-948-8894

MISSOURI
Missouri Patient Care Review Foundation
505 Hobbs Lane, Suite 100
Jefferson City, MO  65109
1-800-347-1016
314-893-7900

MONTANA
Montana-Wyoming Foundation for Medical Care
21 North Main
Helena, MT  59601
1-800-332-3411 (in-state only)
1-406-443-4020 *PRO will accept collect calls from out of state on
this number.

NEBRASKA
Iowa Foundation for Medical Care 
(PRO for Nebraska)  
Colony Park, Suite 500
3737 Woodland Avenue
West Des Moines, IA  50265
1-800-247-3004 (in Nebraska only)
515-223-2900

NEVADA
Nevada Peer Review
675 East 2100 South, Suite 270
Salt Lake City, UT  84106-1864
1-800-558-0829 (in Nevada only)
801-487-2290
1-702-385-9933 *PRO will accept collect calls from out of state on
this number.

p.p 6
NEW HAMPSHIRE
New Hampshire Foundation for
 Medical Care
110 Locust Street
Dover, NH 03820
1-800-582-7174 (in-state only)
1-603-749-1641 *PRO will accept collect calls from out of state on
this number.

NEW JERSEY
The Peer Review Organization of New Jersey, Inc.
Central Division
Brier Hill Court, Building J
East Brunswick, NJ  08816
1-800-624-4557 (in-state only)
1-201-238-5570 *PRO will accept collect calls from out of state on
this number.

NEW MEXICO
New Mexico Medical Review Association
707 Broadway N.E., Suite 200
P.O. Box 9900
Albuquerque, NM  87119-9900
1-800-432-6824 (in-state only)
505-842-6236

NEW YORK
Island Peer Review Organization, Inc.
9525 Queens Blvd.
Rego Park, NY  11374-4511
1-800-331-7767 (in-state only)
1-718-896-7230 *PRO will accept collect calls from out of state on
this number.
(in metro area and New York City dial 275-9894)

NORTH CAROLINA
Medical Review of North Carolina
Suite 200
P.O. Box 37309
1011 Schaub Drive
Raleigh, NC  27627
1-800-682-2650 (in-state only)
803-731-8225

NORTH DAKOTA
North Dakota Health Care Review, Inc.
Suite 301
900 North Broadway
Minot, ND  58701
1-800-472-2902 (in-state only)
1-701-852-4231 *PRO will accept collect calls from out of state on
this number.

OHIO
Peer Review Systems, Inc.
Suite 250
3700 Corporate Drive
Columbus, OH  43231-4996
1-800-233-7337
614-895-9900

OKLAHOMA
Oklahoma Foundation for Peer Review, Inc.
Suite 400 The Paragon Building
5801 Broadway Extension
Oklahoma City, OK  73118-7489
1-800-522-3414 (in-state only)
405-840-2891

OREGON
Oregon Medical Professional Review Organization
Suite 200
1220 Southwest Morrison
Portland, OR  97205
1-800-344-4354 (in-state only)
503-279-0100 *PRO will accept collect calls from out of state on
this number.

PENNSYLVANIA
Keystone Peer Review Organization, Inc.
777 East Park Drive
P.O. Box 8310
Harrisburg, PA  17105-8310
1-800-322-1914 (in-state only)
717-564-8288

PUERTO RICO
Puerto Rico Foundation for Medical Care
Suite 605 Mercantile Plaza
Hato Rey, PR  00918
1-809-753-6705 *PRO will accept collect calls from out of state on
this number. or 1-809-753-6708 *PRO will accept collect calls from
out of state on this number.

RHODE ISLAND
Health Care Review, Inc.
Henry C. Hall Building
345 Blackstone Boulevard
Providence, RI  02906
1-800-221-1691 (New England-wide)
(in Rhode Island dial 1-800-662-5028)
1-401-331-6661 *PRO will accept collect calls from out of state on
this number.

p.p 7
SOUTH CAROLINA
Medical Review of North Carolina
(PRO for South Carolina)
P.O. Box 37309
1011 Schaub Drive, Suite 200
Raleigh, NC  27627
1-800-922-3089 (in-state only)
919-851-2955

SOUTH DAKOTA
South Dakota Foundation for Medical Care
1323 South Minnesota Avenue
Sioux Falls, SD  57105
1-800-658-2285
605-336-3505

TENNESSEE
Mid-South Foundation for Medical Care
Suite 400
6401 Poplar Avenue
Memphis, TN  38119
1-800-873-2273
901-682-0381

TEXAS
Texas Medical Foundation
Barton Oaks Plaza Two, Suite 200
901 Mopac Expressway South
Austin, TX  78746
1-800-777-8315 (in-state only)
512-329-6610

UTAH
Utah Peer Review Organization
675 East 2100 South
Suite 270
Salt Lake City, UT  84106-1864
1-800-274-2290
801-487-2290

VERMONT
New Hampshire Foundation for Medical Care
(PRO for Vermont)
110 Locust Street
Dover, NH  03820
1-800-642-5066 (in Vermont only)
603-749-1641
1-802-862-6447 *PRO will accept collect calls from out of state on
this number.

VIRGIN ISLANDS
Virgin Islands Medical Institute
P.O. Box 1566
Christiansted
St. Croix, U.S.A.  VI  00820-1566
1-809-778-6470 *PRO will accept collect calls from out of state on
this number.

VIRGINIA
Medical Society of Virginia Review Organization
1606 Santa Rosa Road, Suite 235
P.O. Box K 70
Richmond, VA  23288
1-800-545-3814 (DC, MD and VA)
804-289-5320
(in Richmond, dial 289-5320)

WASHINGTON
Professional Review Organization
 for Washington
Suite 300
10700 Meridian Avenue, North
Seattle, WA  98133-9008
1-800-445-6941
206-364-9700
(in Seattle, dial 368-8272)

WEST VIRGINIA
West Virginia Medical Institute, Inc.
3412 Chesterfield Avenue, S.E.
Charleston, WV  25304                        
1-800-642-8686
304-925-0461
(in Charlestown, dial 925-0461)

WISCONSIN
Wisconsin Peer Review Organization
2001 W. Beltline Highway
Madison, WI  53713
1-800-362-2320 (in-state only)
608-274-1940

WYOMING
Montana-Wyoming Foundation for Medical Care
21 North Main
Helena, MT  59601
1-800-826-8978 (in Wyoming only)
1-406-443-4020 *PRO will accept collect calls from out of state on
this number.

p.p 8
(Sample) AN IMPORTANT MESSAGE FROM MEDICARE

YOUR RIGHTS WHILE YOU ARE A MEDICARE HOSPITAL PATIENT

You have the right to receive all the hospital care that is
necessary for the proper diagnosis and treatment of your illness
or injury.  According to Federal law, your discharge date must be
determined solely by your medical needs, not by "DRGs" or Medicare
payments.

You have the right to be fully informed about decisions affecting
your Medicare coverage and payment for your hospital stay and for
any post-hospital services.

You have the right to request a review by a Peer Review
Organization of any written Notice of Noncoverage that you receive
from the hospital stating that Medicare will no longer pay for your
hospital care.  Peer Review Organizations (PROs) are groups of
doctors who are paid by the Federal Government to review medical
necessity, appropriateness and quality of hospital treatment
furnished to Medicare patients.  The phone number and address of
the PRO for your area are:

      _____________________
      _____________________
      _____________________

TALK TO YOUR DOCTOR ABOUT YOUR STAY IN THE HOSPITAL

You and your doctor know more about your condition and your health
needs than anyone else.  Decisions about your medical treatment
should be made between you and your doctor.  If you have any
questions about your medical treatment, your need for continued
hospital care, your discharge, or your need for possible
post-hospital care, don't hesitate to ask your doctor.  The
hospital's patient representative or social worker will also help
you with your questions and concerns about hospital services.

IF YOU THINK YOU ARE BEING ASKED TO LEAVE THE HOSPITAL TOO SOON

Ask a hospital representative for a written notice of explanation
immediately, if you have not already received one.  This notice is
called a "Notice of Noncoverage."  You must have this Notice of
Noncoverage if you wish to exercise your right to request a review
by the PRO.

The Notice of Noncoverage will state either that your doctor or
the PRO agrees with the hospital's decision that Medicare will no
longer pay for your hospital care.

If the hospital and your doctor agree, the PRO does not review your
case before a Notice of Noncoverage is issued.  But the PRO will
respond to your request for a review of your Notice of Noncoverage
and seek your opinion.  You cannot be made to pay for your hospital
care until the PRO makes its decision, if you request the review
by noon of the first work day after you receive the Notice of
Noncoverage.

If the hospital and your doctor disagree, the hospital may request
the PRO to review your case.  If it does make such a request, the
hospital is required to send you a notice to that effect.  In this
situation the PRO must agree with the hospital or the hospital
cannot issue a Notice of Noncoverage.  You may request that the PRO
reconsider your case after you receive a Notice of Noncoverage but
since the PRO has already reviewed your case once, you may have to
pay for at least one day of hospital care before the PRO completes
this reconsideration.

IF YOU DO NOT REQUEST A REVIEW, THE HOSPITAL MAY BILL YOU FOR ALL
THE COSTS OF YOUR STAY BEGINNING WITH THE THIRD DAY AFTER YOU
RECEIVE THE NOTICE OF NONCOVERAGE.  THE HOSPITAL, HOWEVER, CANNOT
CHARGE YOU FOR CARE UNLESS IT PROVIDES YOU WITH A NOTICE OF
NONCOVERAGE.

p.p 9
(Sample)  HOW TO REQUEST A REVIEW OF THE NOTICE OF NONCOVERAGE

If the Notice of Noncoverage states that your physician agrees with
the hospital's decision:
 
You must make your request for review to the PRO by noon of the
first work day after you receive the Notice of Noncoverage by
contacting the PRO by phone or in writing.

The PRO must ask for your views about your case before making its
decision.  The PRO will inform you by phone or in writing of its
decision on the review.

If the PRO agrees with the Notice of Noncoverage, you may be billed
for all costs of your stay beginning at noon of the day after you
receive the PRO's decision.

Thus, you will not be responsible for the cost of hospital care
before you receive the PRO's decision.

If the Notice of Noncoverage states that the PRO agrees with the
hospital's decision:

You should make your request for reconsideration to the PRO
immediately upon receipt of the Notice of Noncoverage by contacting
the PRO by phone or in writing.

The PRO can take up to three working days from receipt of your
request to complete the review.  The PRO will inform you in writing
of its decision on the review.

Since the PRO has already reviewed your case once, prior to the
issuance of the Notice of Noncoverage, the hospital is permitted
to begin billing you for the cost of your stay beginning with the
third calendar day after you receive your Notice of Noncoverage
even if the PRO has not completed its review.

Thus, if the PRO continues to agree with the Notice of Noncoverage,
you may have to pay for at least one day of hospital care.

NOTE: The process described above is called "immediate review." 
If you miss the deadline for this immediate review while you are
in the hospital, you may still request a review of Medicare's
decision to no longer pay for your care at any point during your
hospital stay or after you have left the hospital.  The Notice of
Noncoverage will tell you how to request this review.

POST-HOSPITAL CARE

When your doctor determines that you no longer need all the
specialized services provided in a hospital, but you still require
medical care, he or she may discharge you to a skilled nursing
facility or home care.  The discharge planner at the hospital will
help arrange for the services you may need after your discharge. 
Medicare and supplemental insurance policies have limited coverage
for skilled nursing facility care and home health care.  Therefore,
you should find out which services will or will not be covered and
how payment will be made.  Consult with your doctor, hospital
discharge planner, patient representative and your family in making
preparations for care after you leave the hospital.  Don't hesitate
to ask questions.

ACKNOWLEDGMENT OF RECEIPT - My signature only acknowledges my
receipt of this Message from (name of hospital) on (date) and does
not waive any of my rights to request a review or make me liable
for any payment.

                                                                 
          
Signature of beneficiary or                (Date of receipt)
person acting on behalf of beneficiary

p.p 10
COORDINATED CARE: PREPAID HEALTH CARE ORGANIZATIONS

     More and more Medicare beneficiaries are joining coordinated
care plans--often called prepaid health care plans or managed care
plans--such as health maintenance organizations (HMOs) and
competitive medical plans (CMPs).  Many beneficiaries find that
coordinated care plans are a good way to get more health care for
their dollar. 

     HMOs and CMPs provide or arrange for all Medicare covered
services, and generally charge you fixed monthly premiums and only
small coinsurance payments.  Therefore, if you join a coordinated
care plan and get all of your services through the HMO or CMP, it
makes your out-of-pocket costs more predictable.  Also, depending
on your health needs, those costs may be less than you would pay
if you were liable for the regular Medicare deductible and
coinsurance.

     Coordinated care plans may also offer benefits not covered by
Medicare for little or no additional cost.  Benefits may include
preventive care, dental care, hearing aids and eyeglasses.

     However, if you enroll in an HMO or CMP you will usually be
required to get all care from the HMO or CMP.  In most cases, if
you get services that are not authorized by the organization
(unless they are emergency services, or services you urgently need
when you are out of the organization's service area) neither the
organization nor Medicare will pay for the services.

     Most Medicare beneficiaries are eligible to enroll in HMOs
and CMPs.  HMOs and CMPs cannot screen their applicants to find
whether they are healthy, or delay coverage for pre-existing
conditions.  The only enrollment criteria for Medicare HMOs and
CMPs are:

You must be enrolled in Medicare Part B and continue to pay the
Part B premiums;

You must live in the plan's service area;

You cannot be receiving care in a Medicare-certified hospice; and

You cannot have chronic kidney disease.

     If you develop chronic kidney disease or choose hospice
coverage after joining a coordinated care plan, the plan will
provide or arrange for your care.

     To join a coordinated care plan, contact plans in your area
that have a contract with Medicare.  All HMOs and CMPs have an
advertised open enrollment period at least once a year.  You may
return to fee-for-service Medicare at any time.  To end your
enrollment in a coordinated care plan, send a signed request to
your plan or to your local Social Security or Railroad Retirement
Board Office.  You return to regular Medicare the first day of the
following month.

If you belong to a Medicare HMO or CMP and you are unhappy with
the quality of care, you can:

Follow your HMO's or CMP's grievance procedure, or

Complain to your Peer Review Organization (PRO).  PROs are groups
of practicing doctors and other health care professionals under
contract to Medicare to review the care provided to Medicare
patients.  (See page 2).

     If you believe that your HMO or CMP has made an incorrect
decision on coverage of benefits or payment of a claim, you can
exercise your appeal rights--rights that are similar to those
provided under traditional Medicare (See page 29).

     Medicare also contracts with some coordinated care plans that
only partially cover Medicare services.  These are called health
care prepayment plans (HCPPs).  Some HCPPs cover all Medicare Part
B services.  Other HCPPs cover only some Part B services.  HCPPs
do not cover Medicare Part A services.  Membership rules and
enrollment rules are different than for HMOs and CMPs.  Whether you
join an HMO/CMP or an HCPP, be sure to read your membership
materials carefully to learn your rights and coverage.

     If you need more information about Medicare and coordinated
care plans, you can get a copy of Medicare and Coordinated Care
Plans from the Consumer Information Center (see inside back cover).
BUYING HEALTH INSURANCE TO SUPPLEMENT MEDICARE (MEDIGAP)

     Medicare provides basic protection against the high cost of
health care, but it will not pay all of your medical expenses, nor
most long term care expenses.  For this reason, many private
insurance companies sell insurance to supplement Medicare (Medigap
insurance) and separate long-term care 

p.p 11 
insurance.  The federal government does not sell or service such
insurance.

     If you are thinking about buying a new private insurance
policy or replacing an old policy to supplement your Medicare
protection or cover long-term care costs, you should shop
carefully.  You can get a pamphlet, Guide to Health Insurance for
People with Medicare, to help you make Medicare supplement
decisions. The guide explains how supplemental insurance works and
how to shop for it.  The guide also lists the names, addresses and
telephone numbers of the insurance department in your state and
your state Agency on Aging.  These offices can give you information
about insurance to supplement Medicare and some may have free
counseling services available.  You may order a copy of the guide
from the Consumer Information Center (see inside back cover). 

NOTE: Coordinated care plans (prepaid plans) can be an alternative
to traditional medigap insurance.  (See page 10 for more
information about coordinated care plans.)

     Insurance companies or agents selling health insurance to
supplement Medicare must avoid certain illegal practices.  Federal
criminal and civil penalties (fines) may be imposed against any
insurance company or agent who knowingly sells you a policy that
duplicates Medicare coverage or your private health insurance
coverage.  Penalties also apply if insurance agents tell you that
they are employees or agents of the Medicare program or of any
government agency.  There is also a penalty for making a false
statement about a policy's meeting legal standards for
certification when it does not, and for using the mails in a state
for delivering advertisements of health insurance policies to
supplement Medicare if the policies have not been approved for sale
in that state.

     If you suspect that you have been the victim of these or any
other illegal sales practices, you should contact the insurance
department in your state.  The telephone numbers to call are listed
in the back of the pamphlet, Guide to Health Insurance for People
with Medicare. (See above for how to get a copy of the guide.)  You
may also call this number:  1-800-638-6833. 


FRAUD AND ABUSE

     If you have reason to believe that a doctor, hospital, or
other provider of health care services is performing unnecessary
or inappropriate services or is billing Medicare for services you
did not receive, you should immediately report this to the Medicare
contractor.  The contractor is the intermediary or carrier that
handles your claims (see page 2).  The telephone number of the
Medicare intermediary or carrier is listed on the notice explaining
Medicare's decision on your Medicare claim.  Medicare carriers are
also listed on pages 34 to 38.  

     If the Medicare contractor does not respond adequately to your
report of Medicare fraud or abuse, you should call the Department
of Health and Human Services, Office of Inspector General toll-
free Hotline (1-800-368-5779).  There is no charge to you when you
call this number.

Be prepared to tell the operator:

The exact nature of the wrongdoing you suspect; the date it
occurred, and the name and address of the party involved.

The name and location of the Medicare contractor you reported it
to, and when you reported it.

The name of any contractor employee to whom you spoke and what
advice that person gave you.

You may also report this information to the Office of Inspector
General by writing to: OIG Hotline, P.O. Box 17303, Baltimore,
Maryland, 21203-7303.    Call or write your Medicare contractor
first for faster action.  Do not call the Inspector General Hotline
for Medicare policy questions or questions about delayed claims or
payments.


ASSISTANCE FOR LOW-INCOME BENEFICIARIES

     If you meet certain income and resource tests, your state's
medical assistance (Medicaid) program will assist you in paying
your share of Medicare costs.  To qualify:

Your annual income level must be near the national poverty
guidelines.  Poverty guidelines for 1991 are set at $6620 for one
person and $8880 for a family of two.

You cannot have resources such as bank accounts or stocks and bonds
worth more than $4,000 for an individual or $6,000 for a couple.

     State governments assist qualified Medicare beneficiaries by
paying the monthly Medicare premiums.  And, in most cases, state
governments also pay Medicare deductibles and coinsurance.  

     If you think you may qualify, you should contact your state
or local welfare, social service or public health agency.
p.p 12
MEDICARE HOSPITAL INSURANCE (PART A)
WHAT MEDICARE PART A INCLUDES

     Medicare Part A helps pay for four kinds of medically
necessary care:  

1) Inpatient hospital care 
2) Inpatient care in a skilled nursing facility following a
hospital stay 
3) Home health care 
4) Hospice care

     There is a limit on how many days of hospital or skilled
nursing facility care Medicare helps pay for in each benefit
period.  But, your Part A protection is renewed every time you
start a new benefit period.  (Benefit periods are described below.)

     Skilled nursing facility care is the only type of nursing home
care that Medicare covers.  Medicare does not pay for care that is
primarily custodial.  (See pages 29 for an explanation).
Benefit Periods

     A benefit period is a way of measuring your use of services
under Medicare Part A.  Your first benefit period starts the first
time you enter a hospital after your hospital insurance begins. 
A benefit period ends when you have been out of a hospital or other
facility primarily providing skilled nursing or rehabilitation
services for 60 days in a row (including the day of discharge.) 
If you remain in a facility (other than a hospital) that primarily
provides skilled nursing or rehabilitation services, a benefit
period ends when you have not received any skilled care there for
60 days in a row.

     There is no limit to the number of benefit periods you can
have for hospital and skilled nursing facility care.  However,
special limited benefit periods apply to hospice care (see page
17).

Here are two examples of how the benefit period works:

Example 1: Mrs. Jones enters the hospital on January 5th.  She is
discharged on January 15th.  She has used 10 days of her first
benefit period.  Mrs. Jones is not hospitalized again until July
20th.  Since more than 60 days elapsed between her hospital stays,
she begins a new benefit period, her Part A coverage is completely
renewed, and she will again pay the hospital deductible.

Example 2:  Mrs. Smith enters the hospital on August 14th.  She is
discharged on August 24th.  She also has used 10 days of her first
benefit period.  However, she is then readmitted to the hospital
on September 20th.  Since fewer than 60 days elapsed between
hospital stays, Mrs. Smith is still in her first benefit period and
will not be required to pay another hospital deductible.  This
means that the first day of her second admission is counted as the
11th day of hospital care in that benefit period.  Mrs. Smith will
not begin a new benefit period until she has been out of the
hospital (and has not received any skilled care in a skilled
nursing facility) for 60 consecutive days.   

How Medicare Pays for Part A Services

     Medicare Part A helps pay for most but not all of the services
you receive in a hospital or skilled nursing facility or from a
home health agency or hospice program.  There are covered services
and noncovered services under each kind of care.  Covered services
are services and supplies that Part A pays for.

     Hospitals, skilled nursing facilities, home health agencies
and hospices are called "providers" under the Medicare Part A
program.  Providers submit their claims directly to Medicare--you
cannot submit claims for their services. The provider will charge
you for any part of the Part A deductible you have not met and any
coinsurance payment you owe.

     When a hospital, skilled nursing facility, home health agency,
or hospice sends Medicare a Part A claim for payment, you get a
Notice of Utilization that explains the decision Medicare made on
the claim.  This notice is not a bill.  If you have any questions
about the notice, get in touch with the people who sent you the
notice.

WHEN YOU ARE A HOSPITAL INPATIENT

     Medicare Part A helps pay for inpatient hospital care if all
of the following four conditions are met:  

1) A doctor prescribes inpatient hospital care for treatment of
your illness or injury 

2) You require the kind of care that can be provided only in a
hospital

p.p 13 

3) The hospital is participating in Medicare (*Added footnote for
STAR: Under certain conditions, Medicare helps pay for emergency
inpatient care you receive in a non-participating hospital.  End
of STAR footnote.)

4) The Utilization Review Committee of the hospital, a Peer Review
Organization or an Intermediary does not disapprove your stay.

     If you meet these four conditions, Medicare will help pay for
up to 90 days of medically necessary inpatient hospital care in
each benefit period.**Added footnote for STAR: Medicare pays for
only limited care in an inpatient psychiatric hospital (see page
14).  The hospital can tell you about these limits. End of STAR
footnote.

     During 1991, from the 1st day through the 60th day in a
hospital during each benefit period, Part A pays for all covered
services except the first $628.  This is called the Part A
deductible.  (A deductible is an amount you owe before Medicare
begins paying for services and supplies covered by the program.) 
The hospital may charge you the deductible only for your first
admission in each benefit period.  If you are discharged and then
readmitted before the benefit period ends, you do not have to pay
the deductible again.  

     From the 61st through the 90th day in a hospital during each
benefit period, Part A pays for all covered services except for
$157 a day.  This daily amount is called Part A coinsurance. The
hospital charges you the $157. 

     Hospital reserve days (explained below) can help with your
expenses if you need more than 90 days of inpatient hospital care
in a benefit period.

     Medicare Part A does not pay for your doctor's services even
though you receive them in a hospital.  Instead, doctors' services
are covered under Medicare Part B.  A description of Medicare Part
B begins on page 17.
Major services covered when you are a hospital inpatient
Medicare Part A pays for these services:

A semiprivate room (2 to 4 beds in a room)

All your meals, including special diets

Regular nursing services

Costs of special care units, such as intensive care or coronary
care units

Drugs furnished by the hospital during your stay

Blood transfusions furnished by the hospital during your stay (see
page 14 for information about coverage of blood)

Lab tests included in your hospital bill X-rays and other radiology
services, including radiation therapy, billed by the hospital

Medical supplies such as casts, surgical dressings, and splints

Use of appliances, such as a wheelchair

Operating and recovery room costs

Rehabilitation services, such as physical therapy, occupational
therapy, and speech pathology services

Some services not covered when you are a hospital inpatient

Medicare Part A does not pay for these services:

Personal convenience items that you request such as a telephone or
television in your room

Private duty nurses

Any extra charges for a private room unless it is determined to be
medically necessary

NOTE:  If you disagree with a decision on the amount Medicare will
pay on a claim or whether services you receive are covered by
Medicare, you always have the right to appeal the decision. (See
page 27.)

Hospital Inpatient Reserve Days

     We said earlier that Medicare helps pay for your care in a
hospital for up to 90 days in each benefit period.  And Medicare
Part A includes an extra 60 hospital days you can use if you have
a long illness and have to stay in the hospital for more than 90
days.  These extra days are called reserve days.  Once you use a
reserve day you never get it back.  Reserve days are not renewable.

     During 1991, Medicare Part A pays for all covered services
except $314 a day for each reserve day you use.  You are
responsible for paying this $314.

     You have only 60 reserve days in your lifetime, and you can
decide when you want to use them.  After you have been in the
hospital 90 days, you can use all or some of your 60 reserve days
if you wish.  But you do not have to use your reserve days right
away if you do not want to.  All Medicare supplemental private
insurance plans pay at least 90 percent of Medicare hospital bills
for illnesses that keep beneficiaries in the hospital for more than
90 days, but they usually require you to use your reserve days
first.

     If you do not want to use your reserve days, you must tell
the hospital in writing before your 90th day in the hospital. 
Otherwise, the extra days you 

p.p 14
need to be in the hospital will automatically be taken from your
reserve days.

Coverage of Blood Under Part A

     Part A helps pay for blood (whole blood or units of packed
red blood cells), blood components, and the cost of blood
processing and administration. If you receive blood as an inpatient
of a hospital or skilled nursing facility, Part A will pay for
these blood costs, except for any nonreplacement fees charged for
the first 3 pints of whole blood or units of packed red cells per
calendar year.  (The nonreplacement fee is the charge that some
hospitals and skilled nursing facilities make for blood which is
not replaced.)

     You are responsible for the nonreplacement fees for the first
3 pints or units of blood furnished by a hospital or skilled
nursing facility.  If you are charged nonreplacement fees, you have
the option of either paying the fees or having the blood replaced. 
If you choose to have the blood replaced, you can either replace
the blood personally or arrange to have another person or an
organization replace it for you.  A hospital or skilled nursing
facility cannot charge you for any of the first 3 pints of blood
you replace or arrange to replace.  (If you have already paid for
or replaced blood under Medicare Part B during the calendar year,
you do not have to meet those costs again under Medicare Part A. 
See page 18 for an explanation of coverage of blood under Medicare
Part B.)

Care In A Psychiatric Hospital

     Part A helps pay for no more than 190 days of inpatient care
in a participating psychiatric hospital in your lifetime.  Once
you have used these 190 days, Part A does not pay for any more
inpatient care in a psychiatric hospital.

     Also, there is a special rule that applies if you are in a
participating psychiatric hospital at the time your Part A starts. 
Social Security can give you information about this special rule.

Care Outside the United States

     Medicare generally does not pay for hospital or medical
services outside the United States.  (Puerto Rico, the U.S. Virgin
Islands, Guam, American Samoa, and the Northern Mariana Islands are
considered part of the United States.)

     If you are planning to travel outside the United States, you
may want to buy special short-term health insurance for foreign
travel.

     There are rare emergency cases where Medicare can pay for care
in Canada or Mexico.  Medicare can sometimes also pay if a Mexican
or Canadian hospital is closer to your home than the nearest U.S.
hospital that can provide the care you need.  If you get emergency
treatment in a Canadian or Mexican hospital or if you live near a
Canadian or Mexican hospital, ask your Medicare
carrier/intermediary about your coverage.

Care in a Christian Science Sanatorium

     Medicare Part A helps pay for inpatient hospital and skilled
nursing facility services you receive in a participating Christian
Science sanatorium if it is operated or listed and certified by the
First Church of Christ, Scientist, in Boston.  (However, Medicare
Part B will not pay for the practitioner.)

The Prospective Payment System

      Medicare pays for most inpatient hospital care under the
Prospective Payment System (PPS).  Under PPS, hospitals are paid
a predetermined rate per discharge for inpatient services furnished
to Medicare beneficiaries.  The predetermined rates are based on
payment categories called Diagnosis Related Groups, or DRGs.  In
some cases, the Medicare payment will be more than the hospital's
costs; in other cases, the payment will be less than the hospital's
costs.  In special cases, where costs for necessary care are
unusually high or the length of stay is unusually long, the
hospital receives additional payment.  But even if Medicare pays
the hospital less than the cost of your care, you do not have to
make up the difference.

     It is important to remember that the PPS system does not
change your Medicare Part A protection as described in this
handbook.  PPS does not determine the length of your stay in the
hospital or the extent of care you receive.  The law requires
participating hospitals to accept Medicare payments as payment in
full, and those hospitals are prohibited from billing the Medicare
patient for anything other than the applicable deductible and
coinsurance amounts, plus any amounts due for noncovered items or
services, such as television, telephone or private duty nurses.

SKILLED NURSING FACILITY CARE

     Medicare Part A can help pay for certain inpatient care in a
Medicare-participating skilled nursing facility following a
hospital stay.  Your condition must require daily skilled nursing
or skilled rehabilitation services which, as a practical matter,

p.p 15
can only be provided in a skilled nursing facility, and the skilled
care you receive must be based on a doctor's orders.


     The only type of "nursing home" care Medicare helps pay for
is skilled nursing facility care.

     A skilled nursing facility is a specially qualified facility
that specializes in skilled care:

A skilled nursing facility has the staff and equipment to provide
skilled nursing care or skilled rehabilitation services and other
related health services.  Skilled nursing care means care that can
only be performed by, or under the supervision of, licensed nursing
personnel.  Skilled rehabilitation services may include such
services as physical therapy performed by, or under the supervision
of, a professional therapist. 

Most nursing homes in the United States are not skilled nursing
facilities that participate in Medicare. In some facilities, only
certain portions participate in Medicare.  

If you are not sure whether a facility participates in Medicare as
a skilled nursing facility, ask someone in the facility's business
office.  If staff at the facility cannot tell you, ask Social
Security to check with the Health Care Financing Administration.

Medicare does not pay for custodial care when that is the only kind
of care you need.

     Care is considered custodial when it is primarily for the
purpose of helping the patient with daily living or meeting
personal needs and could be provided safely and reasonably by
people without professional skills or training.  For example,
custodial care includes help in walking, getting in and out of bed,
bathing, dressing, eating, and taking medicine.  

When can Medicare pay?

     Medicare Part A can help pay for your care in a Medicare-
participating skilled nursing facility if you meet all of these
six conditions:

1)   Your condition requires daily skilled nursing or skilled
     rehabilitation services which, as a practical matter, can only
     be provided in a skilled nursing facility, and

2)   You have been in a hospital at least three days in a row (not
     counting the day of discharge) before you are admitted to a
     participating skilled nursing facility, and
3)   You are admitted to the facility within a short time
     (generally within 30 days) after you leave the hospital, and
4)   Your care in the skilled nursing facility is for a condition
     that was treated in the hospital, or for a condition that
     arose while you were receiving care in the skilled nursing
     facility for a condition which was treated in the hospital,
     and
5)   A medical professional certifies that you need, and you
     receive, skilled nursing or skilled rehabilitation services
     on a daily basis, and 
6)   The Medicare intermediary does not disapprove your stay.

     All six conditions must be met.  Remember, you must need
skilled nursing care or skilled rehabilitation services on a daily
basis.  Part A will not pay for your stay if you need skilled
nursing or rehabilitation services only occasionally, such as once
or twice a week, or if you do not need to be in a skilled nursing
facility to get skilled services.  Also, Part A will not pay for
your stay if you are in a skilled nursing facility mainly because
you need custodial care.

     When your stay in a skilled nursing facility is covered by
Medicare, Part A helps pay for a maximum of 100 days each benefit
period, but only if you need daily skilled nursing care or
rehabilitation services for that long.

      If you leave a skilled nursing facility and are readmitted
within 30 days, you do not have to have a new three day stay in
the hospital for your care to be covered.  If you have some of your
100 days left and you need skilled nursing or rehabilitation
services on a daily basis for further treatment of a condition
treated during your previous stay in the facility, Medicare will
help pay.

     In each benefit period, Part A pays for all covered services
for the first 20 days you are in a skilled nursing facility. 
During 1991, for the 21st through the 100th day, Part A pays for
all covered services except for $78.50 a day.  You may be charged
up to this daily coinsurance amount by the skilled nursing
facility.

     Medicare Part A does not cover your doctor's services while
you are in a skilled nursing facility.  Medicare Part B covers
doctors' services.  A description of Medicare Part B begins on page
17.

Major services covered when you are in a skilled nursing facility
Medicare Part A pays for these services:

A semiprivate room (2 to 4 beds in a room)
All your meals, including special diets
p.p 16
Regular nursing services

Physical, occupational, and speech therapy

Drugs furnished by the facility during your stay

Blood transfusions furnished during your stay (see page 14 for
information about coverage of blood)

Medical supplies such as splints and casts furnished by the
facility

Use of appliances such as a wheelchair furnished by the facility

Some services not covered when you are in a skilled nursing
facility
     
Medicare Part A does not pay for these services:

Personal convenience items that you request such as a television
in your room

Private duty nurses

Any extra charges for a private room, unless it is determined to
be medically necessary 


NOTE: If you disagree with a decision on the amount Medicare will
pay on a claim or whether services you receive are covered by
Medicare, you always have the right to appeal the decision. (See
page 27.)

HOME HEALTH CARE 

     If you need skilled health care in your home for the treatment
of an illness or injury, Medicare pays for covered home health
services furnished by a participating home health agency.  A home
health agency is a public or private agency that specializes in
giving skilled nursing services and other therapeutic services,
such as physical therapy in your home.  (A hospital or other
facility that mainly provides skilled nursing or rehabilitation
services cannot be considered your home.)

     Medicare pays for home health visits only if all four of the
following conditions are met: 
1)   The care you need includes intermittent skilled nursing care,
     physical therapy, or speech therapy, and
2)   You are confined to your home (homebound), and
3)   You are under the care of a physician who determines you need
     home health care and sets up a home health plan for you, and
4)   The home health agency providing services is participating in
     Medicare.

     Once these conditions are met, either Medicare Part A or
Medicare Part B will pay for all medically necessary home health
services.  When you no longer need intermittent skilled nursing
care, physical therapy, or speech therapy, Medicare will pay for
home health services if you continue to need occupational therapy. 

     Medicare home health services do not include coverage for
general household services such as laundry, meal preparation,
shopping, or other home care services furnished mainly to assist
people in meeting personal, family, or domestic needs.

     To determine whether you can get services under the Medicare
home health benefit, ask your physician to refer you to a Medicare
participating home health agency.  The home health agency will
evaluate your case to advise you about whether you meet the
requirements for Medicare coverage.  Home health agencies do not
charge for this evaluation.

Home health services covered by Medicare
     Medicare pays for these services:
Part-time or intermittent skilled nursing care (This can include
eight hours of reasonable and necessary care per day for up to 21
consecutive days--or longer in certain circumstances.)

Physical therapy
Speech therapy

     If you need intermittent skilled nursing care, or physical or
speech therapy, Medicare also pays for:
Occupational therapy
Part-time or intermittent services of home health aides
Medical social services
Medical supplies
Durable medical equipment (80 percent of approved amount)

Home health services not covered by Medicare
     Medicare does not pay for these services:
24-hour-a-day nursing care at home
Drugs and biologicals
Meals delivered to your home
Homemaker services
Blood transfusions

     Medicare pays the full approved cost of all covered home
health visits.  You may be charged only for any services or costs
that Medicare does not cover.  However, if you need durable medical
equipment, you are responsible for a 20 percent coinsurance payment
for the equipment.

     The home health agency will submit the claim for payment. 
You do not have to send in any bills yourself.

p.p 17
NOTE: If you disagree with a decision on the amount Medicare will
pay on a claim or whether services you receive are covered by
Medicare, you always have the right to appeal the decision.  (See
page 27.)

HOSPICE CARE

     A hospice is a public agency or private organization that is
primarily engaged in providing pain relief, symptom management and
supportive services to terminally ill people.

     Hospice care is a special type of care for people who are
terminally ill.  It includes both home care and inpatient care,
when needed, and a variety of services not otherwise covered under
Medicare.  Under the Medicare hospice benefit, Medicare pays for
services every day and permits a hospice to provide appropriate
custodial care, including homemaker services and counseling.

     Medicare Part A helps pay for hospice care if all three of
these conditions are met: 
1)   A doctor certifies that the patient is terminally ill, and 
2)   The patient chooses to receive care from a hospice instead of
     standard Medicare benefits for the terminal illness, and 
3)   Care is provided by a Medicare-participating hospice program.

     Special benefit periods apply to hospice care.  Part A pays
for two 90-day periods, followed by a 30-day period, and--when
necessary--an extension period of indefinite duration. Hospice
benefit periods may be consecutive.  And, a beneficiary may
disenroll from the hospice during any benefit period, return to
regular Medicare coverage, then later re-elect the hospice benefit
if another benefit period is available.  (But the remainder of the
benefit period in effect at the time of disenrollment is lost.)

     There are no deductibles under the hospice benefit. The
beneficiary does not pay for Medicare-covered services for the
terminal illness, except for small coinsurance amounts for
outpatient drugs and inpatient respite care. (The hospice respite
care benefit is described below).  The patient is responsible for
five percent of the cost of outpatient drugs or $5 toward each
prescription, whichever is less.  For inpatient respite care, the
patient pays five percent of the Medicare-allowed rate
(approximately $4.34 per day in 1991).  The rate varies slightly
depending on the area of the country.

     Respite care under the hospice program is a short-term
inpatient stay in a facility.  The Medicare beneficiary's inpatient
stay gives temporary relief--a respite--to the person who regularly
assists with home care.  Each inpatient respite care stay is
limited to no more than five days in a row.

     While receiving hospice care, if a patient requires treatment
for a condition not related to the terminal illness, Medicare
continues to help pay for all necessary covered services under the
standard Medicare benefit program.

Services covered when provided by a hospice
Medicare Part A pays for these services for beneficiaries as part
of hospice care:
Nursing services
Doctors' services
Drugs, including outpatient drugs for pain relief and symptom
management
Physical therapy, occupational therapy and speech-language
pathology
Home health aide and homemaker services
Medical social services
Medical supplies and appliances
Short-term inpatient care, including respite care 
Counseling

     The Medicare Part A hospice benefit does not pay for
treatments other than for pain relief and symptom management of a
terminal illness.
NOTE: If you disagree with a decision on the amount Medicare will
pay on a claim or whether services you receive are covered by
Medicare, you always have the right to appeal the decision. (See
page 27)

MEDICARE MEDICAL INSURANCE (PART B)
WHAT MEDICARE PART B INCLUDES
     Medicare Part B helps pay for: 
1) Doctor's services
2) Outpatient hospital care
3) Diagnostic tests
4) Durable medical equipment
5) Ambulance services
6) Many other health services and supplies which are not covered
by Medicare Part A

     The following sections tell you more about these different
kinds of care, the services that are and are not covered by
Medicare Part B, and what part of your medical expenses Medicare
will pay.

p.p 18
DEDUCTIBLE AND COINSURANCE AMOUNTS UNDER MEDICARE PART B
The Annual Deductible

     You must pay the first $100 in approved charges for covered
medical expenses in 1991.  This is called the Medicare Part B
annual deductible.  You need to meet this $100 deductible only once
during the year, and the deductible can be met by any combination
of covered expenses.  You do not have to meet a separate deductible
for each different kind of covered service you receive.

The Blood Deductible

     You must pay any nonreplacement fees charged for the first
three pints or units of blood and blood components you use each
year.  (The nonreplacement fee is the charge that some
practitioners and facilities make for blood which is not replaced.) 
This is called the Medicare Part B blood deductible.  After you
have replaced or paid for the first three pints of blood and you
have met the $100 annual deductible, Medicare will pay 80 percent
of the approved charges for blood, starting with the fourth pint. 
(If you have already paid for or replaced some units of blood under
Medicare Part A during the calendar year, you do not have to pay
for or replace that number of units again under Medicare Part B.)
Coinsurance 

     After you pay the annual deductible, you will owe a share of
the Medicare-approved charges for most services and supplies.  This
share is called coinsurance.  Usually, your coinsurance share is
20 percent of the Medicare-approved charge.

     Medicare determines the "approved" or "reasonable" charge for
each service you receive.  If your services were provided "on
assignment" (see this page for an explanation of assignment) you 
pay only the coinsurance.  

     If your services were not provided "on assignment," and the
charges for your services were more than the Medicare-approved
amount, you usually owe the Medicare coinsurance plus charges above
the Medicare-approved amount.  
NOTE: This explanation of your deductible and coinsurance amounts
describes Medicare's payment system for most services covered by
Medicare Part B.  In cases where payment for services is handled
in a different way, you will be given an explanation along with
the description of services covered.

THE ASSIGNMENT PAYMENT METHOD

     Under the assignment method, your doctor or supplier agrees
to accept the charge approved by the Medicare carrier as total
payment for covered services: the doctor or supplier agrees to
"take assignment." 

     The assignment method can save you money.  The doctor or
supplier sends the claim to Medicare.  Medicare pays your doctor
or supplier 80 percent of the Medicare-approved charge, after
subtracting any part of the $100 annual deductible you have not
met.  The doctor or supplier can charge you only for the part of
the $100 annual deductible you have not met and for the
coinsurance, which is the remaining 20 percent of the approved
charge.  Of course, your doctor or supplier also can charge you
for services that Medicare does not cover. 

     Doctors and certain other practitioners and suppliers must
take assignment on all claims for physician services furnished to
Medicare beneficiaries who are eligible for medical assistance
through their state Medicaid program, including qualified Medicare
beneficiaries.  (The qualified Medicare beneficiary program is
discussed on page 11.)

When Your Doctor or Supplier Does Not Accept Assignment

     If your doctor or supplier does not accept assignment, you
must pay the doctor or supplier directly.  You are responsible for
any part of your bill that is more than the Medicare-approved
amount since your doctor or supplier did not agree to accept the
Medicare-approved amount as payment in full.  In this case Medicare
pays you 80 percent of the approved charge, after subtracting any
part of the $100 annual deductible you have not met.   

     Even though a doctor does not accept assignment, there are
limits in the amount that he or she can actually charge you.  In
1991, for office and hospital visits, that amount is 140 percent
of the Medicare approved amount.  For most other services (surgery,
for example) the limit is 125 percent of the approved amount. 
Physicians who knowingly charge more than these amounts are subject
to severe sanctions.  If you think you have been charged more than
the acceptable level, please contact the carrier.

     All doctors and suppliers must fill out claim forms for you
and send them to Medicare--whether or not they take assignment. 
But if your doctor or supplier fails to send in an unassigned claim
you can submit the claim yourself (see page 24).

p.p 19
PARTICIPATING DOCTORS AND SUPPLIERS

     Doctors and suppliers may sign agreements to become
Medicare-participating.  Medicare-participating doctors and
suppliers  have agreed in advance to accept assignment on all
Medicare claims.  Doctors and suppliers are given the opportunity
to sign participation agreements each year.  Medicare-participating
doctors and suppliers can display emblems or certificates which
show that they accept assignment on all Medicare claims.

     The names and addresses of Medicare-participating doctors and
suppliers are listed (by geographic area) in the
"Medicare-Participating Physician/Supplier Directory."  You can
get the directory for your area free of charge from your Medicare
carrier (see pages 34 to 38); or you can call your carrier and ask
for names of some participating doctors in your area.  Also, this
directory is available for you to look at in Social Security
offices, state and area offices of the Administration on Aging,
and in most hospitals.  

     Many doctors and suppliers who do not take assignment on all
claims, may take assignment on some or most claims.  Ask your
doctor or supplier whether he or she will take assignment on your
claims.

PARTICIPATING PROVIDERS

     Hospitals, skilled nursing facilities, home health agencies,
hospices, comprehensive outpatient rehabilitation facilities, and
providers of outpatient physical and occupational therapy and
speech pathology services are all participating providers under
Medicare Part B.  They submit their claims to Medicare and must
accept the Medicare approved amount as payment in full for covered
services.  Medicare subtracts any deductible you have not met and
the coinsurance amount and pays the provider.  The provider then
bills you for only those deductible and coinsurance amounts.

APPROVED OR "REASONABLE" CHARGES
     Medicare Part B payments are based for the most part on what
the law defines as "reasonable charges" or the amounts approved by
the Medicare carrier.  Because of the way the approved amounts are
determined and because of high rates of inflation in medical care
prices, the charges approved are often less than the actual charges
billed by doctors and suppliers.  Part B usually pays only 80
percent of the approved charge even if it is less than the actual
charge.

     When a Part B claim is submitted that is payable on a
reasonable charge basis, the carrier compares the actual charge
shown on the claim with the customary and prevailing charges for
that service.  The charge approved by the carrier will be the
lowest of: 1) the customary charge (the charge most frequently made
by the doctor or supplier for each item or service); or 2) the
prevailing charge (based on all the customary charges in the
locality for each type of service); or 3) the actual charge. 

     Below are examples of two payments for the same service.  Dr.
A accepts assignment.  Dr. B does not accept assignment.  In both
examples, the beneficiary has already met the $100 deductible.

TWO PAYMENT EXAMPLES

Doctor  A Accepts assignment; Actual charge $500;  Medicare
approved charge $400; Medicare pays $320 (80% of approved charge);
Beneficiary is responsible for $80 (20% approved charge).        
        
Doctor B Does not accept Assignment; Actual charge $500; Medicare
approved charge $400; Medicare pays $320 (80% of approved charge);
Beneficiary responsible for $180 (difference between actual charge
and Medicare payment).                              
*There are certain limits to charges of doctors who do not accept
assignment, (see page 18); and there is a special rule for doctors
performing elective surgery (see NOTE, page 21).

p.p 20
COVERED DOCTORS' SERVICES

     Medicare Part B helps pay for covered services you receive
from your doctor in his or her office, in a hospital, in a skilled
nursing facility, in your home, or any other location.
Major doctors' services covered by Medicare
Medicare Part B helps pay for these services:
Medical and surgical services, including anesthesia
Diagnostic tests and procedures that are part of your treatment
Radiology and pathology services by doctors while you are a
hospital inpatient or outpatient
Treatment of mental illness (Medicare payments for      outpatient
treatment are limited.  See page 24)
Other services such as:
     --X-rays
     --Services of your doctor's office nurse
     --Drugs and biologicals that cannot be      self-administered
     --Transfusions of blood and blood components
     --Medical supplies
     --Physical/occupational therapy and speech pathology    
     services
Some doctors' services not covered by Medicare
     Medicare Part B does not pay for these services:
Routine physical examinations and tests directly related to such
examinations (except some pap smears and mammograms)

Most routine foot care and dental care

Examinations for prescribing or fitting eyeglasses (except after
cataract surgery) or hearing aids

Immunizations (except pneumococcal pneumonia vaccinations or
immunizations required because of an injury or immediate risk of
infection, and hepatitis B for certain persons at risk)

Cosmetic surgery, unless it is needed because of accidental injury
or to improve the function of a malformed part of the body
Types of Doctors

     Most doctors' services are furnished by a doctor of medicine
(MD) or a doctor of osteopathy (DO).  Other "physicians" that can
furnish some covered services include chiropractors, doctors of
podiatric medicine (podiatrists), doctors of dental surgery or of
dental medicine (dentists), and doctors of optometry
(optometrists).

Chiropractors' services

     Medicare helps pay for only one kind of treatment furnished
by a licensed chiropractor: manual manipulation of the spine to
correct a subluxation that can be demonstrated by X-ray.  Medicare
Part B does not pay for any other diagnostic or therapeutic
services, including X-rays, furnished by a chiropractor.  

Podiatrists' services

     Medicare Part B helps pay for any covered services of a
licensed podiatrist to treat injuries and diseases of the foot. 
Examples of common problems include ingrown toenails, hammer toe
deformities, bunion deformities and heel spurs.

     Medicare generally does not pay for routine foot care such as
cutting or removal of corns and calluses, trimming of nails, and
other hygienic care.  But, Medicare does help pay for some routine
foot care if you are being treated by a medical doctor for a
medical condition affecting your legs or feet (such as diabetes or
peripheral vascular disease) which requires that the routine care
be performed by a podiatrist or by a doctor of medicine or
osteopathy.

Dentists' services

     Medicare Part B generally does not pay for care in connection
with the treatment, filling, removal, or replacement of teeth; root
canal therapy; surgery for impacted teeth; and other surgical
procedures involving the teeth or structures directly supporting
the teeth.  However, Medicare does help pay for services of a
dentist in certain cases when the medical problem is more extensive
than the teeth or structures directly supporting them.  (If you
need to be hospitalized because of the severity of a dental
procedure, Medicare Part A will pay for your in-patient hospital
stay even if the dental care itself is not covered by Medicare.)
Optometrists' services

     Medicare helps pay for Medicare-covered services from an
optometrist if the optometrist is legally authorized to perform
those services by the state in which he or she performs them. 
However, Medicare will not pay for routine eye exams, and it will
usually not pay for eyeglasses.  (Medicare  will pay for
intraocular lenses to replace the natural lens of the eye after
cataract surgery.  Medicare will also pay for one pair of
eyeglasses or contact lenses furnished after insertion of the
intraocular lens.) 

p.p 21
NOTE: Medicare law requires doctors who do not take 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 doctor did not give you a written estimate, you are entitled
to a refund of any amount you paid him or her over the Medicare
approved amount.

SECOND OPINION BEFORE SURGERY

     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, we recommend that you get a second doctor's opinion to
help you decide about surgery.  Medicare will help pay for a second
opinion.  

     Your own doctor is the best source for referral to another
doctor.  But, if you wish, you can call your Medicare Part B
carrier for the names and phone numbers of doctors in your area
who provide second opinions.  Medicare carriers are listed on pages
34 to 38.

SERVICES OF SPECIAL PRACTITIONERS

     Medicare Part B helps pay for covered services you receive
from certain specially qualified practitioners who are not
physicians.  The practitioners must be approved by Medicare. 
Medicare-approved practitioners are listed below:
Certified registered nurse anesthetist
Certified nurse midwife
Clinical psychologist
Clinical social worker (in certain settings)

Physician assistant (A physician assistant can furnish certain
services in a hospital or certain other facilities; can serve as
an assistant-at-surgery; and can furnish services in any location
that is designated as a rural health manpower shortage area)

Nurse practitioner and clinical nurse specialist (in collaboration
with a physician in a rural area. In addition, a nurse practitioner
can furnish services in a skilled nursing facility or a Medicaid
Nursing Facility in an urban area.) 

OUTPATIENT HOSPITAL SERVICES

     Medicare Part B helps pay for covered services you receive as
an outpatient from a participating hospital for diagnosis or
treatment of an illness or injury.  Under certain conditions,
Medicare helps pay for emergency outpatient care you receive from
a non-participating hospital.

     When you go to a hospital for outpatient services, you are
sometimes asked how much of your Part B deductible you have met. 
One easy way to answer that question is to show your most recent
Explanation of Medicare Benefits notice.  From this form, hospital
staff can usually tell how much of the $100 annual deductible you
have met.

     If the hospital cannot tell how much of the $100 deductible
you have met and the charge for the services you received is less
than $100, the hospital may ask you to pay the entire bill.  The
amount you pay the hospital can be credited toward any part of 
the deductible you have not met.  If you pay the hospital for
deductible amounts you do not owe, the hospital or the Medicare
intermediary will refund the amount you overpaid.

Major outpatient hospital services covered by Part B
Medicare Part B helps pay for these services:

Services in an emergency room or outpatient clinic, including same
day surgery

Laboratory tests billed by the hospital
Mental health care in a partial hospitalization psychiatric
program, if a physician certifies that inpatient treatment would
be required without it

X-rays and other radiology services billed by the hospital

Medical supplies such as splints and casts

Drugs and biologicals that cannot be self-administered

Blood transfusions furnished to you as an outpatient

Some outpatient hospital services not covered by Part B
Medicare Part B does not pay for these services:
Routine physical examinations and tests directly related to such
examinations (except some pap smears and mammograms)

Eye or ear examinations to prescribe or fit eyeglasses (except
after cataract surgery) or hearing aids

Immunizations (except pneumococcal pneumonia and Hepatitis B
vaccinations, or immunizations required because of an injury or
immediate risk of infection)

Most routine foot care

p.p 22
OTHER COVERED SERVICES AND SUPPLIES
Ambulatory surgical services

     An ambulatory surgical center is a facility that provides
surgical services that do not require a hospital stay.  Medicare
Part B will pay for the use of an ambulatory surgical center for
certain approved surgical procedures.  However, by law Medicare
can only pay centers that have an agreement with Medicare to
participate in the Medicare program.  If you do not know whether
an ambulatory surgical center participates in Medicare, ask someone
in the center's business office.  If that person does not know,
contact Social Security and ask them to check with the Health Care
Financing Administration.  

     In addition to helping pay for the use of the ambulatory
surgical center, Medicare also helps pay for physician and
anesthesia services that are provided in connection with the
procedure.
Home Health Services

     If you have both Medicare Part A and Part B, your Part A pays
for home health services.  But Part B will pay for home health
services if you do not have Part A.  Medicare home health services
are described on page 16.
Outpatient physical and occupational therapy and speech pathology
services

     Medicare Part B helps pay for medically necessary outpatient
physical and occupational therapy or speech pathology services, if
all the following three conditions are met:
1)   Your doctor prescribes the service,
2)   Your doctor or therapist sets up the plan of treatment, and
3)   Your doctor periodically reviews that plan.

     You can receive physical therapy, occupational therapy or
speech pathology services as an outpatient of a participating
hospital or skilled nursing facility, or from a participating home
health agency, rehabilitation agency, or public health agency.  The
provider of services may charge you only for any part of the $100
annual deductible you have not met, 20 percent of the remaining
approved amount, and any noncovered services.

     Also, you can receive services directly from an independently
practicing, Medicare-approved physical or occupational therapist
in his or her office or in your home if such treatment is
prescribed by a doctor.  But, the maximum amount Medicare pays for
each of these services provided by an independently practicing
physical or occupational therapist in 1991 is $600 a year. (This
is 80 percent of the maximum approved amount of up to $750.)  The
Medicare payment would be less than $600 if charges for these
services are used to meet part or all of your $100 annual
deductible. 

Comprehensive outpatient rehabilitation facility services

     Under certain circumstances, Medicare helps pay for outpatient
services you receive from a Medicare-participating comprehensive
outpatient rehabilitation facility (CORF).  Covered services
include physicians' services; physical, speech, occupational and
respiratory therapies; counseling; and other related services.  You
must be referred by a physician who certifies that you need skilled
rehabilitation services.  For most CORF services, you are
responsible only for the annual deductible and 20 percent of the
Medicare approved charges.  Medicare helps pay for mental health
treatment in a CORF; the Medicare payment limit for mental health
treatment in a CORF is discussed on page 24.

Rural Health Clinic Services

     Medicare Part B helps pay for services of physicians, nurse
practitioners, physician assistants, nurse midwives, visiting
nurses (under certain conditions), clinical  psychologists, and
clinical social workers furnished by a rural health clinic.   You
are responsible only for the annual Medicare Part B deductible plus
20 percent of the Medicare approved charge for the clinic.

Independent Laboratory Services

     Medicare Part B pays the full approved fee for covered
clinical diagnostic tests provided by independent laboratories that
are approved to perform them.  The laboratory must accept
assignment for these tests. (See page 18 for an explanation of
assignment.)  It may not bill you for the tests.

     Not all laboratories are approved by Medicare and some
laboratories are approved only for certain kinds of tests.  If a
doctor prescribes tests which the laboratory is not approved to
perform, Medicare does not pay for the tests, and you can be
required to pay for them.  Your doctor can usually tell you which
laboratories are approved and whether the tests he or she is
prescribing from an approved laboratory are covered by Medicare. 
If your doctor can not tell you, call your Part B carrier. 
Carriers are listed on pages 34 to 38.  

p.p 23
     Your doctor must accept assignment for covered clinical
diagnostic laboratory tests which he or she furnishes.  He or she
is not allowed to bill you for them.  (See page 18 for an
explanation of assignment.)

Portable Diagnostic X-ray Services

     Medicare Part B helps pay for portable diagnostic X-ray
services you receive in your home or other locations if they are
ordered by a doctor and if they are provided by a Medicare-approved
supplier.  You can ask your Part B carrier whether the supplier is
Medicare-approved.  Carriers are listed on pages 34 to 38.
Other Diagnostic Tests

     Medicare Part B also helps pay for other diagnostic tests,
including X-rays, that your doctor orders to evaluate your medical
problems.

Pap Smear Screening 

     Medicare Part B helps pay for pap smears to screen for
cervical cancer that are performed every 3 years, or more
frequently for certain women at high risk.  Medicare also pays for
diagnostic pap smears as needed when symptoms are present.
Breast-Cancer Screening (Mammography)

     Medicare Part B helps pay for X-ray screenings for the
detection of breast cancer.  Women 65 or older can use the benefit
every other year.  Younger disabled women covered by Medicare can
use the screening benefit more frequently.  Medicare also pays for
diagnostic mammograms as needed when symptoms are present.

For accurate up-to-date information on cancer prevention,
detection, diagnosis, and treatment for patients, their families,
and the general public, call the Cancer Information Service at 1-
800-4-CANCER.

Radiation Therapy

     Medicare Part B helps pay for radiation therapy given under
the supervision of your doctor.

Kidney Dialysis and Transplants

     Medicare Part B helps pay for kidney dialysis and transplants. 
For detailed information on this coverage, you can get a copy of
Medicare Coverage of Kidney Dialysis and Kidney Transplant Services
from the Consumer Information Center (see inside back cover).
Heart Transplants

     Under certain limited conditions, Medicare Part B helps pay
for heart transplants.  If you are considering a heart transplant,
you and your physician can find out about Medicare coverage by
contacting your Medicare carrier.

Ambulance transportation

     Medicare Part B helps pay for medically necessary ambulance
transportation but only if:

The ambulance, equipment and personnel meet Medicare requirements,
and 

Transportation in any other vehicle could endanger your health.

     Under these conditions, Medicare helps pay for ambulance
transportation but only to a hospital or skilled nursing facility,
or from a hospital or skilled nursing facility to your home. 
Medicare does not pay for ambulance use from your home to a
doctor's office.

     Medicare usually helps pay only if the ambulance
transportation is in your local area.  But, if there are no local
facilities equipped to provide the care you need, Medicare helps
pay for necessary ambulance transportation to the closest facility
outside your local area that can provide the necessary care.  If
you choose to go to another institution that is farther away,
Medicare payment is based on the reasonable charge for
transportation to the closest facility that can provide the
necessary care.

Durable Medical Equipment

     Medicare Part B helps pay for durable medical equipment such
as oxygen equipment, wheelchairs, and other medically necessary
equipment that your doctor prescribes for use in your home.  (A
hospital or facility that mainly provides skilled nursing or
rehabilitation services cannot be considered your home.) 

     To be considered durable medical equipment, the equipment must
be able to be used over again by other patients, must primarily
serve a medical purpose, must not be useful to people who are not
sick or injured, and must be appropriate for use in your home.  Not
all types of equipment that you might find useful can meet all four
of these requirements.  

NOTE: The durable medical equipment supplier must have your
doctor's prescription before delivering any of the following items: 
seat lift chairs, power-operated vehicles, equipment for care of
pressure sores, or transcutaneous electrical nerve stimulators.  

p.p 24
In the case of seat lift chairs, Medicare covers only the lift
mechanism, not the chair itself.

     Medicare uses three methods of payment for durable medical
equipment: lease-purchase, lump-sum payment for purchase, or rental
charges.  Your Medicare carrier will be able to provide more
specific guidance on which method will be used for a particular
item.  (Carriers are listed on pages 34 to 38)

Prosthetic devices

     Medicare Part B helps pay for prosthetic devices needed to
substitute for an internal body organ.  These include
Medicare-approved corrective lenses needed after a cataract
operation, ostomy bags and certain related supplies, and breast
prostheses (including a surgical brassiere) after a mastectomy. 
Medicare also helps pay for artificial limbs and eyes, and for arm,
leg, back, and neck braces.  Medicare does not pay for orthopedic
shoes unless they are an integral part of leg braces and the cost
is included in the charge for the braces.  Medicare does not pay
for dental plates or other dental devices.

Medical supplies

     Medicare Part B helps pay for surgical dressings, splints,
and casts ordered by a doctor in connection with your medical
treatment.  This does not include adhesive tape, antiseptics, or
other common first-aid supplies.

DRUGS AND BIOLOGICALS
Pneumococcal Pneumonia Vaccine

     Medicare Part B pays the full approved charges for
pneumococcal pneumonia vaccine and its administration.  Neither
the $100 annual deductible nor the 20 percent coinsurance apply to
this service. 

Hepatitis B Vaccine

     Medicare Part B helps pay for hepatitis B vaccine administered
to beneficiaries considered to be at high or intermediate risk of
contracting the disease.
Hemophilia Clotting Factors

     Medicare Part B helps pay for blood clotting factors and items
related to their administration for hemophilia patients who are
able to use them to control bleeding without medical or other
supervision.  The amount of clotting factors necessary to have on
hand for a specific period is determined for each patient
individually.

Blood
     Medicare Part B helps pay for blood and blood components you
receive as a hospital outpatient or as part of other services. 
(See page 18 for an explanation of the blood deductible.)
Antigens

     Under certain circumstances, Medicare Part B helps pay for
antigens prepared for you by your doctor.  You can check with your
Medicare carrier to see if Medicare will pay for your antigens. 
Carriers are listed on pages 34 to 38.  

Immunosuppressive Drugs

     Immunosuppressive drugs are often given to prevent rejection
of transplanted organs.  Medicare Part B helps pay for drugs used
in immunosuppressive therapy for one year beginning with the date
of discharge from the inpatient hospital stay during which a
Medicare-covered organ transplant was performed.

MEDICARE PAYMENTS FOR OUTPATIENT TREATMENT OF MENTAL ILLNESS

     Medicare helps pay for services you receive for outpatient
treatment of a mental illness.  You may get the services from
doctors, comprehensive outpatient rehabilitation facilities
(CORFs), physician assistants, psychologists and clinical social
workers.  

     These services for outpatient treatment of a mental illness
are subject to a special payment rule.  In effect, once the annual
deductible is met, Medicare Part B pays only 50 percent (not 80
percent) of approved charges for these services, and beneficiaries
are required to pay the remaining 50 percent.  

     Hospital outpatient treatment (including partial
hospitalization psychiatric programs) of mental illness is not
subject to this special payment rule.

MEDICARE MEDICAL INSURANCE (PART B) CLAIMS

A NEW RULE

     On September 1, 1990, a new rule took effect.  For covered
Part B services you receive on or after September 1, 1990, doctors,
suppliers and other providers of services must submit Medicare
claims for you, even if they do not take assignment.  They must
submit the claims within 1 year of providing the service to you or
be subject to certain penalties.  
     You should notify your Medicare carrier if your doctor or
supplier refuses to submit a Part B Medicare 

p.p. 25
claim for services furnished on or after September 1, 1990 if you
believe the services may be covered by Medicare.  Phone numbers
and addresses of carriers are listed on pages 34 to 38.

     You may continue to file your own unassigned Part B claims
for:
Services provided before September 1, 1990

Services not covered by Medicare for which you want a formal Part
B coverage determination

Services provided on or after September 1, 1990, that your doctor
or supplier refuses to submit for you, even though it is required
by law

Services provided outside the United States (Medicare coverage of
services outside the United States is very limited and must meet
special rules)

Used durable medical equipment purchased from a private source.

     If you need to file your own claim you can get the proper
form, the HCFA-1490S, by calling or writing your Medicare carrier. 
Carrier addresses and phone numbers are listed on pages 34 to 38. 


Time Limits

     Under the law, there are some time limits for submitting
Medicare Part B claims.  For Medicare to make payments on your
claims, you must send in your claims within these time limits. 
You always have at least 15 months to submit claims.  The table
below tells you exactly what the time limits are.

(STAR note:  This has been rewritten for easier reading.  Claimant
is looking at a chart.)

For service you get between Oct 1, 1989 & Sept 30, 1990, your claim
must be submitted by Dec 31, 1991

For service you get between Oct 1, 1990 & Sept 30, 1991, your claim
must be submitted by Dec 31, 1992

For service you get between Oct 1, 1991 & Sept 30, 1992, your claim
must be submitted by Dec 31, 1993.

CLAIMS SUBMISSION FOR SERVICES ON OR AFTER SEPTEMBER 1, 1990

     Your doctor or supplier must submit a form, called a HCFA-
1500, requesting that Medicare Part B payment be made for your
covered services, whether or not assignment is taken.  The doctor
or supplier should complete the HCFA-1500 form and send it to the
proper Medicare carrier.  Names, addresses and telephone numbers
of the Medicare carriers are listed on pages 34 to 38.

     If the claim is for the rental or purchase of durable medical
equipment, a doctor's prescription must be included with the claim. 
The prescription must show the equipment you need, the medical
reason for the need, and an estimate of how long the equipment will
be medically necessary. 

     If you are enrolled in a coordinated care plan--a prepaid
health care organization, such as an HMO or CMP--a claim will
seldom need to be submitted on your behalf.  Medicare pays the HMO
or CMP a set amount and the HMO or CMP provides your medical care. 
In most cases you are required to receive all non-emergency care
through your HMO or CMP or through arrangements they make before
you receive care.  However, if you get an out-of-plan service, the
claim should be submitted directly to your HMO or CMP.  If your
doctor or supplier needs an address, consult your HMO/CMP
membership handbook, or contact the HMO/CMP.

     If you get Medicare under the Railroad Retirement system, the
doctor or supplier must submit your claims to The Travelers
Insurance Company office that serves your region.  Regional offices
of The Travelers are listed in Your Medicare Handbook for Railroad
Retirement Beneficiaries, which is available at any railroad
retirement office.

CLAIMS FOR A PERSON WHO HAS DIED

     When a Medicare beneficiary dies, any Part A payments due will
be paid directly to the hospital, skilled nursing facility, home
health agency or hospice that provided covered services.
     For services covered under Medicare Part B, some special rules
apply, depending on whether the doctor's or supplier's bill has
been paid.

     If the bill was paid by the patient or with funds from the
patient's estate, payment will be made either to the estate
representative or to a surviving member of the patient's immediate
family.  If someone other than the patient paid the bill, payment
may be made to that person.

     If the bill has not been paid and the doctor or supplier does
not accept assignment, the Medicare payment can be made to the
person who has or assumes legal obligation to pay the bill for the
deceased patient.  

     Your Medicare carrier can provide additional information about
how to claim a Medicare Part B payment after a patient dies.

WHEN OTHER INSURANCE PAYS BEFORE MEDICARE

     If any of the following insurance situations applies to you,
please notify your doctor, hospital, or other provider of services. 

p.p 26
When You or Your Spouse Continue To Work

     Medicare has special rules that apply to beneficiaries who
have employer group health plan coverage through their employment
or the employment of a spouse.

     Group health plans of employers with 20 or more employees are
required to offer workers age 65 or over, and workers' spouses who
are age 65 or over, the same health insurance benefits under the
same conditions offered to younger workers and spouses.  In such
situations you and your spouse have the option to accept or reject
your employer's health plan.  If you accept your employer's health
plan, it will pay first on your health claims: Medicare will become
the secondary payer.  If you reject your employer's health plan,
Medicare will remain the primary health insurance payer.  If you
elect Medicare to be the primary payer, your employer plan cannot
offer you coverage that supplements Medicare.  If your employer
plan denies you coverage, offers you different coverage, or pays
benefits that are secondary to Medicare, notify the carrier that
handles your Medicare claims.

     For more information, contact your employer or ask Social
Security for a copy of Medicare and Employer Health Plans.  The
publication is also available from the Consumer Information Center
(see inside back cover).

If You Are Disabled and Under Age 65

     Medicare is the secondary payer for certain disabled people
who have premium-free Medicare Part A and are covered under an
employer's health plan or the employer health plan of an employed
family member.  This secondary payer provision applies to group
health plans of employers that employ 100 or more people.  Under
certain conditions, the secondary payer provision also applies to
group health plans of employers with fewer than 100 employees.

     For more information, contact your employer or ask Social
Security for a copy of Medicare and Employer Health Plans.  The
publication is also available from the Consumer Information Center
(see inside back cover).

Other Situations Where Medicare is the Secondary Payer

     If you have a work related illness or injury, services
provided as treatment of that illness or injury should be covered
by workers' compensation or federal black lung benefits.  It is
important that your Medicare claim form note that the treatment is
related to a work related illness or injury, even if the injury or
illness occurred in the past.

     Medicare is a secondary payer for up to 18 months for
beneficiaries who have Medicare solely on the basis of permanent
kidney failure, if they have employer group health plan coverage.

     Medicare also serves as the secondary payer in cases where no
fault insurance or liability insurance is available as the primary
payer.

     Although Medicare benefits are secondary to benefits paid by
liability insurers, Medicare may make a conditional payment if it
receives a claim for services covered by liability insurance.  In
those cases, Medicare pays the claim and then, when a liability
settlement is reached, Medicare recovers its conditional payment
from the settlement amount.

If You Have or Can Get Both Medicare and Veterans Benefits

     If you have or can get both Medicare and veterans benefits,
you may choose to get treatment under either program.  But,
Medicare:
     o    Cannot pay for services you receive from Veterans Affairs
          (VA) hospitals or other VA facilities, except for certain
          emergency hospital services; and
     o    Generally cannot pay if the VA pays for VA-authorized
          services that you get in a non-VA hospital or from a
          non-VA physician.

     Since July 1986, the VA has been charging coinsurance payments
to some veterans who have non-service connected conditions for
treatment in a VA hospital or medical facility, or for VA
authorized treatment by non-VA sources.  The VA charges coinsurance
payments when the veteran's income exceeds a particular level.  If
the VA charges you a coinsurance payment for VA authorized care by
a non-VA physician or hospital, Medicare may be able to reimburse
you, in whole or in part, for your VA coinsurance payment
obligation.

NOTE:  Medicare cannot reimburse you for VA coinsurance payments
for services furnished by VA hospitals and facilities, unless the
services are emergency inpatient or outpatient hospital services. 
Then, the Medicare payment is subject to Medicare deductible and
coinsurance amounts.

     If you have questions about whether the VA or Medicare should
pay for your doctor and other Medicare medical services, contact
your Medicare carrier.  If you have questions about whether the VA

p.p 27
or Medicare should pay for hospital or other Medicare Part A
services, ask the provider of services to check with the Medicare
intermediary.

The Data Match

     Congress recently passed a law that will help Medicare get
back an estimated $1 billion in taxpayer money.  The law will
enable Medicare to get accurate information about beneficiaries'
health insurance.  

     The new law authorizes the Health Care Financing
Administration (the agency that administers the Medicare program),
the Internal Revenue Service, and the Social Security
Administration to share information about whether Medicare
beneficiaries or their spouses are working and whether they have
employment-related health insurance.  

     The process for sharing information from other agencies is
called the Data Match.  The Data Match will help Medicare find
cases where another insurer should have paid first on Medicare
beneficiaries' health care claims.  A designated Medicare
contractor will contact employers to confirm health insurance
coverage information.

Your Rights under the Data Match

     When the government collects or uses information about you,
it must act under specific guidelines to protect your privacy. 
The government must:
     o    Tell you, at the time the information is collected, why
          the information is needed and how it will be used;
     o    Make sure personal information is used only for the
          reasons given, or seek your permission when another
          purpose for its use is considered necessary or desirable;
     o    Allow you to see the records kept on you; and
     o    Provide you with the opportunity to correct inaccuracies
          in the records kept about you.

EXPLANATION OF MEDICARE BENEFITS NOTICE

     After your doctor, provider, or supplier sends in a Part B
claim, Medicare will send you a notice called Explanation of
Medicare Benefits to tell you the decision on the claim.  

     For services of a physician, this notice shows what services
were covered, what charges were approved, how much was credited
toward your $100 annual deductible, and the amount Medicare paid. 
For other Part B services the notice shows similar information. 
Please examine the notice carefully.  If you believe payment was
made for a service or supply you didn't receive, or the payment is
otherwise questionable, call or write the carrier that handled your
claim.  

     The address and toll-free telephone number you can use to
contact your carrier is printed on the Explanation of Medicare
Benefits form.  Carriers are also listed on pages 34 to 38 of this
handbook.

Calling Your Medicare Carrier
     Many carriers have installed an automated telephone answering
system to help make their response to you faster and more accurate. 
When you call, if your carrier has a system of this type, you will
be connected to a special automated voice system.  If you have a
touch-tone telephone, follow the instructions you receive over the
phone to get information about the status of your claims.

     If you need other information or want to talk about a claim,
you can ask the system to connect you with a customer service
representative at any time.  If you do not have a touch-tone
telephone, stay on the line after you dial and you will be
connected to a customer service representative.

YOUR RIGHT OF APPEAL

     If you disagree with a decision on the amount Medicare will
pay on a claim or whether services you received are covered by
Medicare, you have the right to appeal the decision.  The notice
you receive from Medicare tells you the decision made on the claim
and also tells you exactly what appeal steps you can take.  If you
ever need more information about your right to appeal and how to
request it, call Social Security, or the Medicare intermediary or
carrier in your state.  If you need more information about your
right to appeal a Peer Review Organization (PRO) decision, you can
call the PRO in your state.  (The number of the Medicare
intermediary or carrier is listed on the notice explaining
Medicare's decision on the claim.  Medicare carriers are also
listed on pages 34 to 38.  PROs are listed on pages 3 to 7)

APPEALING DECISIONS MADE BY PROVIDERS OF PART A SERVICES 

     In many cases the first written notice of noncoverage you
receive will come from the provider of the services (for example,
a hospital, skilled nursing facility, home health agency or
hospice).  

p.p 28
This notice of noncoverage from the provider should explain why
the provider believes Medicare will not pay for the services.  This
notice is not an official Medicare determination, but you can ask
the provider to get an official Medicare determination.  If you ask
for an official Medicare determination, the provider must file a
claim on your behalf to Medicare.  Then you will receive a Notice
of Utilization, which is the official Medicare determination.  If
you still disagree, you can appeal by following the instructions
on the Notice of Utilization.

APPEALING DECISIONS MADE BY PEER REVIEW ORGANIZATIONS (PROs)

     When you are admitted to a Medicare participating hospital,
you will be given a notice called An Important Message From
Medicare (see page 8 and 9 for a copy of this notice).  The notice
contains a brief description of PROs, and the name, address, and
phone number of the PRO in your state.  Also, it describes your
appeal rights.

     PROs make determinations about hospital care and ambulatory
surgical center care.  The PROs decide whether care provided to
Medicare patients is medically necessary, provided in the most
appropriate setting, and is of good quality.  When you disagree
with a PRO decision about your case, you can appeal by requesting
a reconsideration.  Then, if you disagree with the PRO's
reconsideration decision, and the amount remaining in question is
$200 or more, you can request a hearing by an Administrative Law
Judge.  Cases involving $2,000 or more can eventually be appealed
to a Federal Court.
NOTE:  In the case of elective (non-emergency) surgery, either the
hospital or the PRO may be involved in pre-admission decisions. 
If the hospital believes that your proposed stay will not be
covered by Medicare, it may recommend, without consulting the PRO,
that you not be admitted to the hospital.  If this is the case, the
hospital must give you its decision in writing.  If you or your
physician disagree with the hospital's decision, you should make
a request to the PRO for immediate review.  If you want an
immediate review, you must make your request, by telephone or in
writing, within three calendar days after receipt of the notice.

APPEALING DECISIONS MADE BY INTERMEDIARIES ON PART A CLAIMS

     Appeals of decisions on most other services covered under
Medicare Part A (skilled nursing facility care, home health care,
hospice services, and a few inpatient hospital matters not handled
by PROs) are handled by Medicare intermediaries.  If you disagree
with the intermediary's initial decision, you have 60 days from the
date you receive the initial decision to request a reconsideration. 
The request can be submitted directly to the intermediary or
through Social Security.  If you disagree with the intermediary's
reconsideration decision and the amount remaining in question is
$100 or more, you have 60 days from the date you receive the
reconsideration decision to request a hearing by an Administrative
Law Judge.  Cases involving $1,000 or more can eventually be
appealed to a Federal Court.

APPEALING DECISIONS MADE BY CARRIERS ON PART B CLAIMS

     Your doctor must provide you with a written notice if he or
she knows or believes that Medicare will not consider a particular
service reasonable and necessary and will not pay for it.  This
written notice must be given to you before the service is performed
and must clearly state the reasons your doctor believes Medicare
will not pay.  If your doctor does not give you this written notice
and you did not know that Medicare would not pay for the services
you received, you cannot be held liable to pay for them.  However,
if you did receive written notice and signed an agreement to pay
for the services yourself so you could be treated, you will be held
liable to pay.

     This written notice is not an official Medicare determination. 
If you disagree with it, you may ask your doctor to submit a claim
for payment to the Medicare carrier to get an official Medicare
determination.  The claim must be filed within 15 months (see page
25 for specific time periods.)  If you receive an adverse decision
from Medicare and you still disagree, you have the right to appeal
that decision.  You have six months from the date of the decision
to ask the carrier to review it.  Then, if you disagree with the
carrier's written explanation of its review decision and the amount
remaining in question is $100 or more, you have six months from the
date of the review decision to request a hearing before a carrier
hearing officer.  

     If you disagree with the carrier hearing officer's decision
and the amount remaining in question is $500 or more, you have 60
days from the date you receive the decision to request a hearing
before an Administrative Law Judge.  Cases involving $1,000 or more
can eventually be appealed to a Federal Court.

p.p 29
APPEALING DECISIONS MADE BY HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
AND COMPETITIVE MEDICAL PLANS (CMPs)

     If you have Medicare coverage through an HMO or CMP, decisions
about coverage and payment for services will usually be made by
your HMO/CMP.  Your appeal rights are similar to the rights of
Medicare beneficiaries under regular fee-for-service Medicare. 
Also, federal law requires HMOs and CMPs under contract to Medicare
to provide a full, written explanation of appeal rights to all
members at the time of enrollment, and at least once a year after
that.  If you are a member of an HMO or CMP and you have not
received a written explanation of your appeal rights, you should
request one from your HMO or CMP membership office.

WHAT MEDICARE DOES NOT PAY FOR 

CUSTODIAL CARE

     Medicare does not pay for custodial care when that is the only
kind of care you need.  Care is considered custodial when it is
primarily for the purpose of helping you with daily living or
meeting personal needs and could be provided safely and reasonably
by people without professional skills or training.  Much of the
care provided in nursing homes to people with chronic, long-term
illnesses or disabilities is considered custodial care.  For
example, custodial care includes help in walking, getting in and
out of bed, bathing, dressing, eating, and taking medicine.  Even
if you are in a participating hospital or skilled nursing facility,
Medicare does not cover your stay if you need only custodial care.

CARE NOT REASONABLE AND NECESSARY UNDER MEDICARE PROGRAM STANDARDS

     Medicare does not pay for services that are not reasonable
and necessary for the diagnosis or treatment of an illness or
injury.  These services include drugs or devices that have not been
approved by the Food and Drug Administration (FDA); medical
procedures and services performed using drugs or devices not
approved by FDA;(*some services are not covered by Medicare even
when FDA has approved them) and services, including drugs or
devices, not considered safe and effective because they are
experimental or investigational.

     If a doctor admits you to a hospital or skilled nursing
facility when the kind of care you need could be provided
elsewhere, (for example, at home or in an outpatient facility) your
stay will not be considered reasonable and necessary.  So Medicare
will not pay for your stay.  If you stay in a hospital or skilled
nursing facility longer than you need to be there, Medicare
payments will end when inpatient care is no longer reasonable and
necessary.
     
     If a doctor (or other practitioner) comes to treat you--or
you visit him or her for treatment--more often than is medically
necessary, Medicare will not pay for the "extra" visits.  Medicare
will not pay for more services than are reasonable and necessary
for your treatment.  

     Medicare always bases decisions about what is reasonable and
necessary on professional medical advice.

SERVICES MEDICARE DOES NOT PAY FOR

     Medicare, by law, cannot pay for certain services.  These
include services performed by immediate relatives or members of
your household, and services paid for by another government
program.  If you have a question about whether Medicare pays for
a particular service, ask your Medicare carrier.  (See pages 34 to
38 for the name and telephone number of your carrier.)

LIMITATION OF LIABILITY

     Under Medicare law you will not be held responsible for
payment of the cost of certain health care services for which you
were denied Medicare payment if you did not know or you could not
reasonably be expected to know (that is, you had not received a
written notice) that the services were not covered by Medicare. 
This provision is called limitation of liability and is often
referred to as a "waiver of liability."  This protection from
financial liability applies only when the care was denied because
it was: 

Custodial care; 

Not "reasonable and necessary" under Medicare program standards
for diagnosis or treatment; or 

For home health services, the patient was not homebound or not
receiving skilled nursing care on an intermittent basis.
p.p 30
     This limitation of liability provision does not apply to
Medicare Part B services provided by a non-participating physician
or supplier who did not accept assignment of the claim.
In certain situations Medicare law also protects you from paying
for services provided by a non-participating physician on a non-
assigned basis that are denied as "not reasonable and necessary." 
If your physician knows or should know that Medicare will not pay
for a particular service as "not reasonable and necessary," he or
she must give you written notice--before performing the service-
-of the reasons why he or she believes Medicare will not pay.  The
physician must get your written agreement to pay for the services. 
If you did not receive this notice, you are not required to pay for
the service.  If you did pay, you may be entitled to a refund.

GETTING THE PART OF MEDICARE YOU DO NOT HAVE

GETTING MEDICARE MEDICAL INSURANCE (PART B)

     If you have Medicare premium-free Hospital Insurance but do
not have Medicare Part B, you can sign up for Part B during a
general enrollment period.  A general enrollment period is held
January 1 through March 31 each year.  Your protection will begin
July 1 of the year you enroll.  If you enroll during a general
enrollment period, your monthly premium may be increased by 10
percent for each 12-month period you could have had Part B but were
not enrolled.   

GETTING MEDICARE HOSPITAL INSURANCE (PART A)

     Some people 65 or older have Medicare Medical Insurance (Part
B), but do not meet the requirements for premium-free Part A. 
Also, certain disabled people under age 65 will lose premium-free
Part A solely because they are working.  If you are in either of
these categories, you can get Part A by paying a monthly premium. 
This is called "premium hospital insurance."  The Part A premium
is $177 a month through December 31, 1991.  (This amount will
change January 1, 1992.)

     You can sign up for premium Part A during a general enrollment
period: January 1 through March 31 each year.  If you enroll during
a general enrollment period that begins more than one year after
you became eligible to buy Part A, your monthly premium may be 10
percent higher than the basic premium amount.  Your protection will
begin July 1 of the year you enroll.  (Also see this page for
information on the special enrollment period.)

     Beginning February 1, 1991, if you have been covered under an
HMO or CMP, you can sign up for premium Part A at any time while
you are in the HMO or CMP and up to 8 months after the HMO/CMP
coverage has ended. The premium penalty, if any, may be reduced
because of the coverage under the HMO or CMP. 

     For more information about premium amounts, premium
surcharges, and how to get the part of Medicare you do not have,
contact Social Security.

SPECIAL ENROLLMENT PERIOD

     If you are covered by an employer group health plan based on
your own or your spouse's current employment (not a plan for
retired people and their spouses), you may be able to delay
enrollment in Medicare's Medical Insurance (Part B) or premium
Hospital Insurance (Part A) without premium penalty and without
waiting for a general enrollment period to enroll.  Delayed
enrollment without penalty or wait is usually available only if
you are covered by an employer group health plan at the time you
were first able to get Medicare.

     In general, if you are 65 or over, you may enroll in Medicare
Part B during the 7-month period beginning with the month:
     o    Your or your spouse's current employment ends, or
     o    Your coverage under the employer group health plan ends,
whichever comes first.

     If you are disabled and covered by an employer group health
plan, you are also given a special enrollment period in certain
circumstances.  If you are covered under a group health plan based
on current employment status when you are first able to get
Medicare, you may enroll in Medicare Part B during the 7-month
period that begins:

When the employment status ends,

When the plan is no longer classifiable as a large group health
plan (one that covers 100 or more employees), or 

When the plan coverage is terminated.

     Contact Social Security as soon as employment ends, or the
plan coverage ends or changes, to be sure that you get the
information you need about enrolling in Medicare's Part B.

p.p 31
EVENTS THAT CAN CHANGE YOUR MEDICARE PROTECTION

WHEN PROTECTION ENDS FOR PEOPLE 65 AND OLDER

     If you have Medicare Hospital Insurance (Part A) based on your
spouse's work record, your protection will end if you and your
spouse divorce before your marriage has lasted 10 years.  But if
you have Part A based on your own work record, your protection will
continue as long as you live.

     Your Medicare Part B protection will stop if your premiums
are not paid or if you voluntarily cancel.  If you are thinking
about cancelling your Part B, remember that you may not be able to
get private insurance that offers the same protection.  If you
cancel your Part B and then later decide to re-enroll, you can only
re-enroll during a general enrollment period (January 1 through
March 31 of each year).  Also, your premium may be higher and your
protection will not begin again until July 1 of the year you
re-enroll (unless you qualify for a special enrollment period as
described on page 30).  

     If you are buying Medicare Part A by paying monthly premiums
(see page 30), you will lose it if you cancel your Medicare Part
B.  People who buy Medicare Part A must enroll and pay the premium
for Part B.  But, you can cancel Part A and still continue to buy
your Part B.
     If you want more information about cancelling your Medicare
protection, get in touch with Social Security.

WHEN PROTECTION ENDS FOR THE DISABLED

     If you have Medicare because you are disabled, your protection
will end if you recover from your disability before you are 65. 
If you go to work but are still disabled, your premium-free Part
A protection will continue for at least 48 months after you begin
working. Your Part B will also continue for at least 48 months if
you continue to pay the monthly premiums.  

     If you remain disabled and lose your premium-free Part A
solely because you are working, you may buy Part A only or both
Part A and Part B.  (You cannot buy Part B only.)  You can continue
to buy Medicare for as long as you remain disabled.  

     You may enroll during your initial enrollment period which
begins with the month you are notified you are no longer eligible
for premium-free Part A and continues for 7 full months after that
month.  If you do not enroll during this initial enrollment period,
you may enroll in a subsequent general enrollment period (January
through March of each year).

     If you ever want to cancel the Medicare protection for which
you pay premiums, get in touch with Social Security.  

WHEN PROTECTION ENDS FOR THOSE WITH PERMANENT KIDNEY FAILURE

     If you have Medicare because of permanent kidney failure, your
protection will end 12 months after the month maintenance dialysis
treatment stops or 36 months after the month you have a successful
kidney transplant.

     Your Medicare Part B protection could stop before that if you
fail to the pay premiums, or if you decide to cancel.  Call Social
Security if you ever want to cancel your Part B protection.

     If you need more information about Medicare coverage of
permanent kidney failure, you can get a copy of Medicare Coverage
of Kidney Dialysis and Kidney Transplant Services from Social
Security or the Consumer Information Center (see inside back
cover).

p.p 32
MEDICARE (PART A):  HOSPITAL INSURANCE-COVERED SERVICES PER
CALENDAR YEAR
(STAR note:  This is a four column chart that has been rearranged
for easier reading with your adaptive devices.  The printed chart
contains four columns.  The headings are:  Services, Benefit,
Medicare Pays, and You Pay. There are asterisks after some of the
entries.  Use your WordPerfect Search for the search string
"Asterisk Part A", and read the asterisks immediately below.)

Hospitalization Services per benefit period(1) - This includes
Semi-private room and board, general nursing and miscellaneous
hospital services and supplies.
     
Benefit for the first 60 days - Medicare pays** all but $628. You
pay** $628.

Benefit for the 61st to 90th day - Medicare pays** all but $157 a
day.  You pay** $157 a day.

Benefit for the 91st to 150th day* - Medicare pays** all but $314
a day.  You pay** $314 a day.

Benefit beyond 150 days - Medicare pays** nothing.  You pay** all
costs.

Post hospital Skilled Nursing Facility Care servicesper benefit
period (1) You must have been in a hospital for at least 3 days
and enter a Medicare-approved facility generally within 30 days
after hospital discharge. (2)

Benefit for the first 20 days - Medicare pays** 10% of approved
amount.  You pay** nothing.

Benefit for additional 80 days.  Medicare pays** all but $78.50 a
day.  You pay** $78.50 a day.

Benefit beyond 100 days - Medicare pays** nothing.  You pay** all
costs.

Home Health Care services

Benefit - Visits limited to medically necessary skilled care.
Medicare pays** full cost of services; 80% of approved amount for
durable medical equipment.  You pay** nothing for services; 20% of
approved amount for durable medical equipment.

Hospice Care services

Benefit - As long as doctor certifies.  Medicare pays** all but
limited costs for outpatient drugs and inpatient respite care. 
You pay** limited cost sharing for outpatient drugs and inpatient
respite care.

Blood services

Benefit - Blood  Medicare pays** all but first 3 pints per calendar
year.  You pay** for first 3 pints.***

1991 Part A Monthly Premium - None for most beneficiaries.  $177
if you must buy Part A (Premium may be higher if you enroll late).

Asterisk Part A

*60 reserve days may be used only once;  days used are not
renewable.

**These figures are for 1991 and are subject to change each year.

***To the extent the blood deductible is met under one part of
Medicare during the calendar year, it does not have to be met under
the other part.

(1)A benefit period begins on the first day you receive service as
an inpatient in a hosptial and ends after you have been out of the
hosptial or skilled nursing facility for 60 days in a row.

(2)Medicare and private insurance will not pay for most nursing
home care.

p.p 33

MEDICARE (PART B):  MEDICAL INSURANCE COVERED SERVICES PER CALENDAR
YEAR      

(STAR note:  This is a four column chart that has been rearranged
for easier reading with your adaptive devices.  The printed chart
contains four columns.  The headings are:  Services, Benefit,
Medicare Pays, and You Pay. There are asterisks after some of the
entries.  Use your WordPerfect Search for the search string
"Asterisk Part B", and read the asterisks immediately below.)

Medical Expense Services - Physician's services, inpatient and
outpatient medical services and supplies, physical and speech
therapy, ambulance, etc.

Benefit - Medicare pays for medical services in or out of the
hospital.  Medicare pays for 80% of approved amount (after $100
deductible).  You pay $100 deductible* plus 20% of approved charge
amount (plus any charge above the approved amount).**

Home Health Care services - 

Benefit - Visits limited to medically necessary skilled care. 
Medicare pays full cost of services; 80% of approved amount for
durable medical equipment.  You pay nothing for services; 20% of
approved amount for durable medical equipment.

Outpatient Hospital Treatment Services

Benefit - Unlimited if medically necessary.  Medicare pays 80% of
approved amount (after $100 deductible).  You pay subject to
deductible plus 20% of approved amount.

Blood Services

Benefit - Blood.  Medicare pays 80% of approved amount (after $100
deductible and starting with 4th pint).  You pay for the first 3
pints plus 20% of approved amount (after $100 deductible).***

1991 Part B Monthly Premiums:  $29.90 (Premium may be higher if
you enroll late).

Asterisk Part B

*Once you have had $100 of expense for covered services in 1991,
the Part B deductible does not apply to any further covered
services you receive for the rest of the year.

**You pay for charges higher than the amount approved by Medicare
unles the doctor or supplier agrees to accept Medicare's approved
amount as full payment for services rendered. 

***To the extent the blood deductible is met under one part of
Medicare during the calendar year, it does not hae be met under
the other part.

p.p 34
MEDICARE CARRIERS
Carriers can answer questions about Medical Insurance (Part B)

Note: The toll-free or 800 numbers listed below can be used only
in the states where the carriers are located.  Also listed are the
local commercial numbers for the carriers.  Out-of-state callers
must use the commercial numbers.
          
These carrier toll-free numbers are for beneficiaries to use and
should not be used by doctors and suppliers.  

Many carriers have installed an automated telephone answering
system.  If you have a touch-tone telephone, you can follow the
system instructions to find out about your latest claims and get
other information.  If you do not have a touch-tone telephone, stay
on the line and someone will help you.

ALABAMA
Medicare/Blue Cross-Blue Shield of Alabama
P.O. Box 830-140
Birmingham, Alabama  35283-0140
1-800-292-8855
205-988-2244

ALASKA
Medicare/Aetna Life & Casualty
200 S.W. Market St., P.O. Box 1997
Portland, Oregon 97207-1997
1-800-547-6333
503-222-6831 (customer service site actually in Oregon)

ARIZONA
Medicare/Aetna Life & Casualty
P.O. Box 37200
Phoenix, Arizona 85069
1-800-352-0411
602-861-1968

ARKANSAS
Medicare/Arkansas Blue Cross and Blue Shield
A Mutual Insurance Company
P.O. Box 1418
Little Rock, Arkansas 72203-1418
1-800-482-5525
501-378-2320

CALIFORNIA
Counties of: Los Angeles, Orange, San Diego, Ventura, Imperial,
San Luis Obispo, Santa Barbara
Medicare/Transamerica Occidental Life Insurance Co.
Box 50061
Upland, California  91785-5061
1-800-675-2266
213-748-2311
Rest of state: Medicare Claims Dept.
Blue Shield of California
Chico, California 95976
(In area codes 209, 408,415, 707, 916)
1-800-952-8627
916-743-1587
(In the following area codes--other than Los Angeles, Orange, San
Diego, Ventura, Imperial, San Luis Obispo, and Santa Barbara
counties--213, 619, 714, 805, 818)
1-800-848-7713
714-824-0900

COLORADO
Medicare/Blue Cross and Blue Shield of Colorado
Claims:
P.O. Box 173560
Denver, Colorado  80217
Correspondence/Appeals:
P.O. Box 173500
Denver, Colorado  80217
(Metro Denver) 303-831-2661
(In Colorado, outside of metro area) 1-800-332-6681

CONNECTICUT
Medicare/The Travelers Ins. Co.
538 Preston Avenue
P.O. Box 9000
Meriden, Connecticut  06454-9000
1-800-982-6819
(In Hartford) 203-728-6783
(In the Meriden area) 203-237-8592

DELAWARE
Medicare/Pennsylvania Blue Shield
P.O. Box 890200
Camp Hill, Pennsylvania  17089-0200
1-800-851-3535

DISTRICT OF COLUMBIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124

FLORIDA
Medicare/Blue Shield of Florida, Inc.
P.O. Box 2525
Jacksonville, Florida 32231
     For fast service on simple inquiries including requests for
copies of Explanation of Medicare Benefits notices, requests for
Medpard directories, brief claims inquiries (status or verification
of receipt), and address changes: 
1-800-666-7586
For all your other Medicare needs:
1-800-333-7586
904-355-3680
p.p 35
GEORGIA
Medicare/Aetna Life & Casualty
P.O. Box 3018
Savannah, Georgia 31402-3018
1-800-727-0827
912-920-2412

HAWAII
Medicare/Aetna Life & Casualty
P.O. Box 3947
Honolulu, Hawaii  96812
1-800-272-5242
808-524-1240

IDAHO
Connecticut General Life Insurance Company
3150 N. Lakeharbor Lane, Suite 254
P.O. Box 8048
Boise, Idaho  83707-6219
1-800-627-2782
208-342-7763

ILLINOIS
Medicare Claims
Blue Cross & Blue Shield of Illinois
P.O. Box 4422
Marion, Illinois  62959
1-800-642-6930
312-938-8000

INDIANA
Medicare Part B
Associated Ins. Companies, Inc.
P.O. Box 7073
Indianapolis, Indiana 46207
1-800-622-4792
317-842-4151

IOWA
Medicare
IASD Health Services Inc.
(d/b/a Blue Cross & Blue Shield of Iowa)
636 Grand
Des Moines, Iowa 50309
1-800-532-1285
515-245-4785

KANSAS
Counties of:  Johnson, Wyandotte
Medicare/Blue Shield of Kansas City
P.O. Box 419840
Kansas City, Missouri 64141-6840
1-800-892-5900
816-561-0900
Rest of state:  Medicare/Blue Cross and Blue Shield of Kansas
P.O. Box 239
Topeka, Kansas 66601
1-800-432-3531
913-232-3773

KENTUCKY
Medicare-Part B
Blue Cross & Blue Shield of Kentucky
100 East Vine St.
Lexington, Kentucky 40507
1-800-999-7608
606-233-1441

LOUISIANA
Arkansas Blue Cross & Blue Shield 
Medicare Administration
P.O. Box 95024
Baton Rouge, Louisiana 70895-9024
1-800-462-9666
(In New Orleans) 504-529-1494
(In Baton Rouge) 504-927-3490

MAINE
Medicare/Blue Shield of
Massachusetts/Tri-State
P.O. Box 1010
Biddeford, Maine 04005
1-800-492-0919
207-282-5689

MARYLAND
Counties of: Montgomery, Prince Georges
Medicare/Pennsylvania Blue Shield
P.O. Box 890100
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
Rest of state:  Maryland Blue Shield, Inc.
1946 Greenspring Drive
Timonium, Maryland 21093
1-800-492-4795
301-561-4160

MASSACHUSETTS
Medicare/Blue Shield of Massachusetts, Inc.
1022 Hingham Street
Rockland, Massachusetts 02371
1-800-882-1228
617-956-3994

MICHIGAN
Medicare Part B
Michigan Blue Cross & Blue Shield
P.O. Box 2201
Detroit, Michigan 48231-2201
(In area code 313) 1-800-482-4045
(In area code 517) 1-800-322-0607
(In area code 616) 1-800-442-8020
(In area code 906) 1-800-562-7802
(In Detroit) 313-225-8200
p.p 36
MINNESOTA
Counties of:  Anoka, Dakota, Fillmore,
Goodhue, Hennepin, Houston, Olmstead,
Ramsey, Wabasha, Washington, Winona
Medicare/The Travelers Ins. Co.
8120 Penn Avenue South
Bloomington, Minnesota 55431
1-800-352-2762
612-884-7171
Rest of state:  Medicare
Blue Shield of Minnesota
P.O. Box 64357
St. Paul, Minnesota 55164
1-800-392-0343
612-456-5070

MISSISSIPPI
Medicare/The Travelers Ins. Co.
P.O. Box 22545
Jackson, Mississippi 39225-2545
(In Mississippi) 1-800-682-5417
(Outside of Mississippi) 1-800-227-2349
601-956-0372

MISSOURI
Counties of:  Andrew, Atchison, Bates,
Benton, Buchanan, Caldwell, Carroll, Cass,
Clay, Clinton, Daviess, DeKalb, Gentry,
Grundy, Harrison, Henry, Holt, Jackson, Johnson, Lafayette,
Livingston, Mercer, Nodaway, Pettis, Platte, Ray, St. Clair,
Saline, Vernon, Worth
Medicare/Blue Shield of Kansas City
P.O. Box 419840
Kansas City, Missouri 64141-6840
1-800-892-5900
816-561-0900
Rest of state:  Medicare
General American Life Insurance Co.
P.O. Box 505
St. Louis, Missouri 63166
1-800-392-3070
314-843-8880

MONTANA
Medicare
Blue Cross and Blue Shield of Montana
2501 Beltview
P.O. Box 4310
Helena, Montana 59604
1-800-332-6146
406-444-8350    

NEBRASKA
The carrier for Nebraska is Blue Shield of Kansas.  Claims should
be sent to:
Medicare Part B
Blue Cross/Blue Shield of Nebraska 
P.O. Box 3106
Omaha, Nebraska 68103-0106
1-800-633-1113
913-232-3773 (customer service site in Kansas)

NEVADA
Medicare/Aetna Life and Casualty
P.O. Box 37230
Phoenix, Arizona 85069
1-800-528-0311
602-861-1968

NEW HAMPSHIRE
Medicare
Blue Shield of Massachusetts/Tri-State
P.O. Box 1010
Biddeford, Maine 04005
1-800-447-1142
207-282-5689

NEW JERSEY
Medicare/Pennsylvania Blue Shield
P.O. Box 400010
Harrisburg, Pennsylvania 17140-0010
1-800-462-9306
717-763-3601

NEW MEXICO
Medicare/Aetna Life and Casualty
P.O. Box 25500
Oklahoma City, Oklahoma 73125-0500
1-800-423-2925
(In Albuquerque) 505-843-7771

NEW YORK
Counties of:  Bronx, Kings, New York, Richmond
Medicare B/Empire Blue Cross and Blue Shield
P.O. Box 2280
Peekskill, New York 10566
516-244-5100
Counties of:  Columbia, Delaware, Dutchess,
Greene, Nassau, Orange, Putnam, Rockland,
Suffolk, Sullivan, Ulster, Westchester
Medicare B/Empire Blue Cross and Blue Shield
P.O. Box 2280
Peekskill, New York 10566
1-800-442-8430
516-244-5100
County of:  Queens
Medicare/Group Health, Inc.
P.O. Box 1608, Ansonia Station
New York, New York 10023
212-721-1770
Rest of state:  Medicare
Blue Shield of Western New York
7-9 Court Street
Binghamton, New York 13901-3197
607-772-6906
1-800-252-6550
p.p 37
NORTH CAROLINA
Connecticut General Life Insurance Company
P.O. Box 671
Nashville, Tennessee 37202
1-800-672-3071
919-665-0348

NORTH DAKOTA
Medicare/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-247-2267
701-282-0691

OHIO
Medicare/Nationwide Mutual Ins. Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-282-0530
614-249-7157

OKLAHOMA
Medicare/Aetna Life and Casualty
701 N.W. 63rd St.
Oklahoma City, Oklahoma 73116-7693
1-800-522-9079
405-848-7711

OREGON
Medicare/Aetna Life and Casualty
200 S.W. Market St.
P.O. Box 1997
Portland, Oregon 97207-1997
1-800-452-0125
503-222-6831

PENNSYLVANIA
Medicare/Pennsylvania Blue Shield
P.O. Box 890065
Camp Hill, Pennsylvania 17089-0065
1-800-382-1274

RHODE ISLAND
Medicare/Blue Shield of Rhode Island
444 Westminster Street
Providence, Rhode Island 02901
1-800-662-5170
401-861-2273

SOUTH CAROLINA
Medicare Part B
Blue Cross and Blue Shield of South Carolina
Fontaine Road Business Center
300 Arbor Lake Drive, Suite 1300
Columbia, South Carolina 29223
1-800-868-2522
803-754-0639

SOUTH DAKOTA
Medicare Part B/Blue Shield of North Dakota
4510 13th Avenue, S.W.
Fargo, North Dakota 58121-0001
1-800-437-4762
701-282-0691

TENNESSEE
Connecticut General Life Insurance Company
P.O. Box 1465
Nashville, Tennessee 37202
1-800-342-8900
615-244-5650

TEXAS
Medicare
Blue Cross & Blue Shield of Texas, Inc.
P.O. Box 660031
Dallas, Texas 75266-0031
1-800-442-2620
214-235-3433

UTAH
Medicare/Blue Shield of Utah
P.O. Box 30269
Salt Lake City, Utah 84130-0269
1-800-426-3477
801-481-6196

VERMONT
Medicare
Blue Shield of Massachusetts/Tri-State
P.O. Box 1010
Biddeford, Maine 04005
1-800-447-1142
207-282-5689

VIRGINIA
Counties of:  Arlington, Fairfax;
Cities of:  Alexandria, Falls Church, Fairfax
Medicare/Pennsylvania Blue Shield
P.O. Box 890100 
Camp Hill, Pennsylvania 17089-0100
1-800-233-1124
Rest of state:  Medicare/The Travelers Ins. Co.
P.O. Box 26463
Richmond, Virginia 23261
1-800-552-3423
804-254-4130

p.p 38
WASHINGTON
Medicare
Mail to your local Medical Service Bureau.
If you do not know which bureau handles your
claim, mail to:
King County Medical Blue Shield
P.O. Box 21248
Seattle, Washington 98111-3248
(In King County)    1-800-422-4087
                    206-464-3711
(In Spokane)        1-800-572-5256
                    509-536-4550
(In Kitsap)         1-800-552-7114
                    206-377-5576
(In Pierce)         206-597-6530
(In Thurston)       206-352-2269
Others:  Collect if out of call area.

WEST VIRGINIA
Medicare/Nationwide Mutual Insurance Co.
P.O. Box 57
Columbus, Ohio 43216
1-800-848-0106
614-249-7157

WISCONSIN
Medicare/WPS
Box 1787
Madison, Wisconsin 53701
1-800-362-7221
(In Madison)   608-221-3330
(In Milwaukee) 414-931-1071

WYOMING
Blue Cross/Blue Shield of Wyoming
P.O. Box 628
Cheyenne, Wyoming 82003
1-800-442-2371
307-632-9381

AMERICAN SAMOA
Medicare/Hawaii Medical Services Assn.
P.O. Box 860
Honolulu, Hawaii 96808
808-944-2247

GUAM
Medicare/Aetna Life and Casualty
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240

NORTHERN MARIANA ISLANDS
Medicare/Aetna Life & Casualty
P.O. Box 3947
Honolulu, Hawaii 96812
808-524-1240

PUERTO RICO
Medicare/Seguros De Servicio De
Salud De Puerto Rico
Call Box 71391 
San Juan, Puerto Rico 00936
(In Puerto Rico)              800-462-7015
(In U.S. Virgin Islands)      800-474-7448
(In Puerto Rico metro area)   809-749-4900

VIRGIN ISLANDS
Medicare/Seguros De Servicio De
Salud De Puerto Rico
Call Box 71391 
San Juan, Puerto Rico 00936
(In U.S. Virgin Islands)      800-474-7448
p.p 39
INDEX
Address lists 
  Medicare carriers, 34-38 
  Peer Review Organizations, 3-7 
Ambulance services, 23 
Ambulatory surgical services, 22 
Annual Part B deductible, 18, 33 
Antigens, 24 
Appeal rights, 27 
Appealing claims decisions 
  by carriers, 28 
  by coordinated care organizations, 29
  by intermediaries, 28 
  by Peer Review Organizations, 28 
  by providers of services, 27 
Appliances. See Medical appliances 
Application process, 1 
Approved or "reasonable" charges, 19 
Assignment payment method, 18 
Assistance for low-income beneficiaries, 11
 
Benefit periods 
  hospice care, 17 
  hospital and skilled nursing facility, 12 
Black lung benefits, 26 
Blood 
  deductible amount, 14, 18, 32, 33 
  hemophilia clotting factors, 24 
  home health care, transfusions, 16 
  hospital inpatient, transfusions, 13
  payment for, 14, 18, 24, 32, 33
  skilled nursing facility, transfusions, 16
 
Care not covered, 29 
Chiropractors, services covered, 20 
Christian Science sanatorium, 14
Claim number, 2 
Claims 
  benefits explanation notice, 27 
  claim number, 2 
  deceased beneficiary, 25                          
  insurance other than Medicare, 25 
  intermediaries and carriers role, 2 
  Railroad Retirement system, 1 
  submission, for home health care, 16 
  submission process, 24 
  time limit, 25
Clinical nurse specialists, psychologists, social workers, 21
CMPs. See Coordinated care organizations 
Coinsurance, 1, 13, 15, 18, 32, 33 
Competitive medical plans (CMPs). See Prepaid health care 
    organizations 
Complaints 
  fraud and abuse hot line, 11 
  Medigap fraud, 11 
  review process, 3 
Comprehensive Outpatient Rehabilitation Facility (CORF), 
    22 
Coordinated Health Care Organizations (HMOs, CMPs)
  appealing decisions, 29 
  coverage, 10
Cosmetic surgery, 20 
Counseling, 17 
Custodial care, 15, 29
 
Deductibles 
  annual, 18, 33
  blood, 14, 18, 32, 33
  hospital insurance (Part A), 13, 32
  medical insurance (Part B), 18, 33 
Dentists, services covered, 20 
Diagnosis Related Groups (DRGs), 14
Diagnostic tests, 22-23 
Dialysis. See Kidney disease 
Disabled people 
  cancelling or losing Medicare protection, 22 
  eligibility for coverage, 1 
  enrollment process, 2, 21-22 
Doctors 
  participating, 17 
  services covered, 12-13 
Doctors of osteopathy, 12 
DRGs. See Diagnosis Related Groups 
Drugs and biologicals 
  hemophilia clotting factors, 16 
  hepatitis B vaccine, 16 
  home health care, 10 
  hospice care, 11 
  immunosuppressive drugs, 16 
  inpatient, 7                
  pneumococcal pneumonia vaccine, 16 
  skilled nursing facility, 9 
Durable medical equipment 
  coinsurance for, 10 
  description, 15-16 
 
Elective surgery, written estimate of costs, 2 
Emergency room services, 14 
Enrollment, Medicare cards, 4 
p.p 40
Enrollment process 
  hospital insurance (Part A), 1-2, 30 
  medical insurance (Part B), 1-2, 30 
Equipment. See Durable medical equipment; Medical appliances 
Explanation of Medicare Benefits, 27 
Eye examinations, 20 
 
Financial assistance for low-income beneficiaries, 11
Foot care, 20 
Foreign hospital care, 14
Form 1490S, 25 
Fraud and abuse hot line, 1 
 
Guide to Health Insurance for People with Medicare, 10
 
Health maintenance organizations (HMOs). See Coordinated 
    care organizations 
Hemophilia clotting factors, 24 
Hepatitis B vaccine, 24 
HMOs. See Coordinated care organizations 
Home health agencies, 16 
Home health aides, 16, 
Home health care 
  description, 16
  services covered, 16
Homemaker services, 16   
Hospice care 
  description, 17 
  and coordinated care organizations, 10
  services covered, 17 
Hospital inpatient care, 12-14
Hospital insurance (Part A) 
  appealing decisions, 28 
  benefit periods, 12,17 
  buying, 1, 30 
  cancelling or losing protection, 31 
  coinsurance, 1, 13, 15, 32
  coverage, 12-17
  deductible, 13, 32 
  eligibility, 1 
  enrollment process, 1, 30 
  noncoverage, notice of, 27-28
  patient rights, 2-3, 8-9
  premium-free, 1, 30
  premiums, 1, 30
  prospective payment system, 14
Hospital outpatient care, 21
Hot line, fraud and abuse, 11
 
Immunizations, 24 
Immunosuppressive drugs, 24 
An Important Message From Medicare, 3, 8-9
Inpatient care 
  blood, payment for, 14, 32
  Christian Science sanatorium, 14
  conditions for payment, 12-13
  foreign hospitals, 14
  psychiatric, 14
  reserve days, 13
  services covered, 13
Insurance. See also Hospital insurance (Part A); Medical 
  insurance (Part B); 
  illegal sales practices, penalties and fines, 11 
  other than Medicare, claims submission, 25 
  supplemental, 10-11
Intermediaries and carriers 
  appealing decisions by, 28 
  description, 2 
 
Kidney disease 
  cancelling or losing Medicare protection, 31 
  and coordinated care organizations, 10  
  coverage booklet, 23, 31 
  dialysis and transplants, 23 
  eligibility for and enrollment in Medicare, 1-2 
  Medicare as secondary payer, 26 

 
Laboratory services 
  independent laboratory, 22-23
  inpatient, 13
  portable X-ray, 23 
Limitation of liability, 29 
Low-income assistance, 11
Mammography screening, 23
Medical appliances 
  hospice care, 17 
  inpatient care, 13
  skilled nursing facility, 16
Medical insurance (Part B) 
  appealing decisions, 28 
  approved or "reasonable" charges, 19 
  assignment payment method, 18 
  benefits explanation notice, 27 
  buying, 1, 30 
  cancelling or losing protection, 31 
  claims, 24-27
  coverage, 17-24 
  deductible and coinsurance amounts, 18, 33
  doctors and suppliers, participating, 19 
  eligibility, 1 
  enrollment process, 1-2, 30
  premium amount, 1
  providers, participating, 19 
  "reasonable" charges, 19 
p.p 41
Medical supplies 
  description, 24 
  home health care coverage, 16 
  hospice care coverage, 17 
  inpatient coverage, 13
  skilled nursing facility coverage, 16
Medicare, Part A. See Hospital insurance (Part A) 
Medicare, Part B. See Medical insurance (Part B) 
Medicare and Employer Health Plans, 26 
Medicare cards, 2 
Medicare Coverage of Kidney Dialysis and Kidney Transplant 
    Services, 23, 31 
Medicare Participating Physician/Supplier Directory, 19 
Medigap insurance. See Supplemental insurance 
Mental illness, outpatient treatment, 24 
 
Noncoverage 
  notice of, 27-28
  what Medicare does not cover, 29 
Notice of Utilization, 12, 28
Nurse anesthetists, 21 
Nurse midwives, 21
Nurse practitioners, 21
Nurse specialists, clinical, 21
Nursing home. See Skilled nursing facility 
 
Occupational therapy. See Therapy 
Optometrists, services covered, 20 
Outpatient hospital care 
  emergency care, nonparticipating hospital, 21 
  overpayments, 21 
  services covered, 21 
Overpayments, 21 
Oxygen equipment. See Durable medical equipment 
 
Pap smears, 23
Part A. See Hospital insurance (Part A) 
Part B. See Medical insurance (Part B) 
Participating doctors and suppliers, 19 
Participating providers, 19 
Patient's Request for Medicare Payment (Form 1490S), 25 
Payments. See also Deductibles 
  assignment payment method, 18 
  for blood.  See Blood
  for durable medical equipment, 16 
  inpatient care, conditions, 12-13
  limitation of liability, 29 
  overpayments, 21 
  prospective payment system, 14
Peer Review Organizations (PROs). See also Appeal rights 
  address and telephone number list, 3-7 
  appealing decisions, 3, 28
  complaints review process, 3 
  description, 2-3
Physical examinations, routine, 20, 21 
Physical therapy. See Therapy 
Physician assistants, 21 
Physicians 
  participating, 19 
  services covered, 20-21 
Pneumococcal pneumonia vaccine, 24 
Podiatrists, services covered, 20 
PPS. See Prospective payment system 
Premium-free eligibility, 1 
Prepaid health care organizations.  See Coordinated health care 
organizations 
  
Prescription drugs. See Drugs and biologicals 
Private duty nurses, 13, 16
Private insurance organizations. See Intermediaries and 
    carriers 
PROs. See Peer Review Organizations 
Prospective payment system (PPS), 14
Prosthetic devices, 24 
Psychiatric care. See also Mental illness 
  psychiatric hospital care, 14
Psychologists, clinical, 21 
 
Quality of care. See also Appeal rights; Peer Review 
    Organizations;  
  complaints, 3 
  fraud and abuse hot line numbers, 11

Radiation therapy, 23 
"Reasonable" charges, 19 
Rehabilitative services. See Therapy 
Relatives, services by, 29 
Reserve days, 13-14
Respiratory therapy. See Therapy 
Respite care, 17 
Routine physical examinations, 20, 21 
Rural health clinic services, 22 
 
Seat lift chairs. See Durable medical equipment 
Second opinion before surgery, 21 
Secondary payer, 25-26
Services not covered, 29 
Skilled nursing facility 
  inpatient care, 14-16
  services covered, 15-16
Social Security Administration 
  disability eligibility, 1 
  enrollment, cards, premium amounts, questions, 1
p.p 42
Social worker, clinical, 21 
Special enrollment period, 30 
Special practitioners, 21 
Speech pathology, 13, 17, 22
Speech therapy. See Therapy 
Supplemental insurance, buying, 10
Supplies. See Medical supplies 
Surgery 
  ambulatory, 22 
  cosmetic, 20 
  elective, 21
  second opinion, 21 
 
Telephone numbers, toll-free
  hot line, fraud and abuse, 11
  Medicare carriers, 34-38
  Medigap, fraud, 11 
  Peer Review Organizations, 3-7 
  second opinion, referral, 21 
Terminal illness. See Hospice care 
Tests, diagnostic, 22, 23
Therapy 
  Comprehensive Outpatient Rehabilitation Facility services, 
      22 
  doctors' services, coverage, 20 
  home health care, coverage, 16 
  hospice care, coverage, 17 
  inpatient, coverage, 13
  occupational, 13, 16, 17, 22
  outpatient, coverage, 22 
  physical, 13, 16, 17, 22
  radiation, coverage, 23
  respiratory, 22 
  skilled nursing facility, coverage, 16
  speech, 16, 22 
Time limit for claims submission, 25 
Toll-free telephone numbers.  See Telephone numbers
 
Vaccines, 24 
Veterans benefits, 26-27
 
Wheelchairs. See Durable medical equipment 
Workers' compensation benefits, 26 
 
X-ray services, 13, 23 
 (this is cover 3)

                OTHER PUBLICATIONS ABOUT MEDICARE
Guide to Health Insurance for People with Medicare (507-X) 
     Discusses what Medicare pays and does not pay, types of 
private health insurance to supplement Medicare and gives hints on
shopping for private health insurance. (HCFA-02110)
Hospice Benefits Under Medicare (508-X)
     Describes the scope of medical and support services available
to Medicare beneficiaries with terminal illnesses. (HCFA-02154)
Medicare and Coordinated Care Plans (509-X)
     Describes the health services available to beneficiaries from
HMOs and CMPs. (HCFA-02143)
Getting a Second Opinion (536-X)
     Explains the importance of getting a second opinion for
non-emergency surgery, describes Medicare coverage of costs, and
gives suggestions for locating a specialist in your area.
(HCFA-02114)
Medicare and Employer Health Plans (586-X)
     Explains the special rules that apply to Medicare
beneficiaries who have employer group health plan coverage.
(HCFA-02150)
Medicare Coverage of Kidney Dialysis and Kidney Transplant
Services: A Supplement to Your Medicare Handbook (587-X)
     Describes Medicare benefits for people with chronic kidney 
disease. (HCFA-10128)

To order a copy of one or more of these free publications, fill
out and mail the order form at the bottom of the page to:

                   Consumer Information Center
                          Department 59
                        Pueblo, CO  81009

Supplies may be limited.  Allow 6 to 8 weeks for delivery.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
 Check the booklets you want, fill in your name and address, and
send this order form to:  Consumer Information Center, Department
59, Pueblo, CO  81009.

Guide to Health Insurance for People with Medicare (507-X)
Hospice Benefits Under Medicare (508-X)
Medicare and Coordinated Care Plans (509-X)
Getting a Second Opinion (536-X)
Medicare and Employer Health Plans (586-X)
Medicare Coverage of Kidney Dialysis and Kidney Transplant Services
(587-X)

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