HEARING - U.S. Senate Special Committee on Aging

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WHAT MEDICARE PART A PAYS 195 MEDICARE HOSPITAL INSURANCE BENEFITS (PART A) When att program recrents we met, Medicare Part A wilt help pay for medicaly necessary ks-hospital cae, for medicaly necessary Inpatient care In a skilted nwsuig facilty after a hospital stay, and for hospice care. In addition, Part A pays the hdt cost of modFally necessary home health care. Part A covers all services customarily nshed by hospitals and sklled rmsrig facffties. Part A does not cover private duty nursing. dwges for a prrvate room unless medicaty necessary, or convenience items such as telephones or tesion. Part A also does not cover the fa'st 3 pints of blood you receive dun an inpatient stay Mbut you cannot be charged for blood t it is replaced by a blood pVan or through a blood donation In your behaf. 8ENEFtT PERIODS Medicare Pan A benefits are paid on the basis of benefit periods. A benefit period begrrs the first day you receive Medicare covered service in a hosptal and ends when you have been out of a hospital or skilled nursing facility for 60 days in a row. if you enter a hospital again after 60 days, a new benefit period begins. AP Part A benefits (except for lifetime reserve days you have used) are renewed. There is no lirrt to the number of benefit periods you can have for hospital or skilled nursing facility care. However, spedial limited benefit periods apply to hospice care. INPATIENT HOSPITAL CARE Part A pays for an covered services for the first 60 days of inpatient hospital care in a benefit period except for $520. the 1987 Part A dedtctile. For the next 30 days, Part A pays for all covered services except for $130 a day. Every person enrolled in Part A also has a 60-day reserve for Inpatient hospital care which can be drawn from it more than 90 days are needed in a banefit period. When reserve days are used, Part A pays for all covered services except for $260 a day. Once used, reserve days are not renewable. SKILLED NURSING FACIliTY CARE A skilled nursing facility is a special knd of facility which Pirnanly furnishes skilled nurs"ng and rehabilitation services. It may be a separate facility or a part of Page 4 a hospital. Medicare benefits are payable only If the skiled rsing facitty is certified by Medicare. Most nursing homes in the United States are not skiled nursing falities and many skilled nrsing fadlities are not certified by Medicare. Part A pays for at covered services for the first 20 days of mredially necessary inpatient skilled nursing facility care during a benefit period. In 1987, for the next 60 days. Part A pays atl except $65 a day. Medicare Part A wil not cover your stay in a skided nursing faciiity it the services you receive are mainly personal care or custodial services. such as help in walking, getting in and out of bed eating. dressing. bathing and taking medicine. HOME HEALTH CARE Part A pays the cost of ail medically necessary home health visits. Part A covers part-time services o0 a visiting nurse or physical or speech therapist from a Medicare certified home health agency. It you receive any t these services, Part A can also cover part-tane home health aide services. occupational therapy, medical social services and medical supplies and equipment. Part A does not cover ful-timne nursing care, drugs, meals delivered to your home or homemaker serices tmat are primarily to assist you in meeting personal care or housekeeping needs. HOSPICE CARE Under oritain conditions, Part A can pay for hospice care for people who have a terminal illness. Part A can pay for a maximum of two 90-day hospice benefit periods and one 30-day period. During a hospice benefit period. Part A pays the full cost of au medicat and support services necessary for the symptom management and pain relief ot a tenrninal tthess. Covered services indude the following, when provided by a Medicare certified hospice: physician services, nursing care, medical appliances and supplies (Indcuding outpatient drugs for symptom management and pain relie-. short-term inpatient care. counseling, therapies, and home health aide and homemaker services. There are no deductibles or co-payrments except for linited cost sharing for outpatient drugs and inpatient respite care.
WHAT MEDICARE PART B PAYS 196 MEDICARE MEDICAL INSURANCE BENEFITS (PART B) Medicare Part B helps pay for doctors' bills and Mrany other medical services. You are autornatically erolled in Part B wten you enro in Medicare Part A... although you may state that you don't want it. In 1987, the Part B premium is $17.90 a month. This amount may change each January 1. YOU DON'T HAVE TO PURCHASE PART B-.. BUT IT IS AN EXCELLENT BUY BECAUSE THE FEDERAL GOVERNMENT PAYS ABOUT THREE QUARTERS OF THE ACTUAL COST. You pay the first S75 ot approved charges In 1987. (This is the 1987 Part B deductible.) After that, Medicare Part B generally pays 80% of the amount Medicare approves for covered services you receive the rest of the year. You pay the remaining 20%. This is the Part B co-payment. Unless your doctor or supplier accepts assignment (see explanation below). you are responsible for charges above the amount Medicare approves. SERVICES COVERED * Physicians' and surgeons'serices no matter where you receive them ... at home, In the doctor's office. in a finic or in a hospital. Routine physical exams are excluded * Hone health visits. Medicare pays the fug cost ot medicalty necessary home health visits. You have no deductibtle or co-payrnent. * Physical therapy and speech pathology services. in a doctor's otftie or as an outpatient and. on a iSmited basis, in your home. * Other medical services and s es... such as outpatient hospital services; X-rays and laboratory tests: certain ambulance services; and puredase or rental of durable medical equipment. such as wheelchairs. Part B will not pay for any services which Medicare does not consider medically necessary... neither will most insurance policies. APPROVED AMOUNT In deciding whether a charge is reasonable, Medicare reviews each year the usual charge by the doctor or Page 5 suppier for each covered service, and the charge ot other doctors and suppliers In the area for the same service. The amount approved Is often lower than the actual rharge mrade by the doctor or supplier. Most insurance poides you can buy to supplement Medicare only pay 20% of Medicare's approved amount. You might not get 1t00% coverage tor your Part B bills even i you have Medicare Part 8 and private insurance. Here's how this could happen. Suppose your doctor charges you $400 tor an operation and Medicare detennines the approved amount to be $300. Assuming you have already met the annual Part B deductible, Medicare would pay 80% of the $300. or $240. Most insurance policies would pay 2%. of the $300. or $60. You would pay $100 - the difference between your doctor's actual charge and Medicare s approved amount. However, you may avoid this extra payment iS your doctor accepts assignment. AStt ABOUT ASSIGNMENHT AND PARTICIPATING DOCTORS OR SUPPLIERS Because you can't teil in advance whether the approved amount and the actual charge wil be the same, always ask your doctors or other medical suppliers, such as laboratories and therapists. it they wit accept assignment of Medicare benefits. Assignment means that the doctor or suppler will accept Medicare's approved amount as full payment and cannot legaly Ml you for anything above that amount. In the exanmle above, if your doctor agreed to assignment, he or she would accept $300 as payment in full and you would not have to pay the $100 difference yourself. Doctors and suppliers do not have to accept assignment, but many do. Also, doctors and suppliers can now become Medcre'paricipating doctors or suppliers who agree to accept assignment on at Medicare daims. These doctors and suppliers are listed in the Medicare Partictpating PhysicianlSupplier Directory which is distributed to senior citizen organizations. al Socia! Security and Railroad Retirement offices, and all State and area offices ot the Adrrinistration on Aging. This directory can be purchased from the insurance care, that processes Medicare Part B claims in your area (see the back of Your Medicare Handbook lor the list ot carrier addresses) or you can call the camer to hnid out which doctors and suppliers are panicipating.
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S. HRG. 100-69 CATASTROPHIC HEALTH
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CONTENTS Opening statement by Senat
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2 Second, I think the private insur
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4 So the question before us is how
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6 the elderly, long-term health car
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8 ments for our retirement. I might
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10 Mrs. YELINECK. Well, it would be
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12 As I understand it, you have not
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14 Mrs. YELINECK. One does not expe
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16 Senator BURDICK. Well, thank you
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18 Mrs. YEL.INECK. No. I started ou
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20 Therefore-I am supposed to take
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22 Chairman MELCHER. Well, I am ple
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24 month. Let us assume it costs $1
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26 STATEMENT BY SENATOR PETE WILSON
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28 Mrs. RIEGER. We have; we have wo
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30 Four years ago this August was w
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32 she has only 50 percent vision i
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34 Senator HEINZ. So it is both a p
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36 rich. Indeed, in the academic co
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38 pointedly in the comment from Mr
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40 finding out is that it is very l
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42 industry's role in providing cat
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44 Senator HEINZ. So things are wor
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46 Chairman MELCHER. In exactly the
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48 plement policy, what should that
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50 - 2 - I am Robert Shapland, Vice
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52 - 4 - CATASTRIPC PROTECTION IiDE
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54 -6- MiCIGAP INSJRANCE: A RPL1C/P
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56 To ensure that all of these cont
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58 - 10 - The HJAA also endorses Me
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60 - 12 - Finally, given that Congr
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62 - 14 - A recent HLAA survey of o
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64 Chairman MELCHER. Senator Heinz.
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66 Mr. SHAPLAND. I think we are in
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68 Those problems are real problems
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70 Mr. SHAPLAND. Oh, no. There are
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72 comprehension, and it is growing
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74 that educational process, and we
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76 So we have supported and activel
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78 Mr. SHIAPLAND. How much would nu
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80 rently being offered by the indu
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82 Recently, Karri Lynn has started
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84 Mr. Chairman and Members of the
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86 standards for voluntary certific
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88 non-group subscribers of reporti
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90 We believe a new federal program
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92 However, public awareness is nee
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94 Item 3 Testi~ony of GAIL SHEARER
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96 to Secretary Bowen's proposals c
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98 -4- most-states do not monitor t
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100 Catastrophic Protection within
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102 - a - participants and in part
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104 - 2-- Consumers Union suV orts
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106 29), but fails to acknowledge t
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108 explore all alternatives to lon
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110 adds to the complexity of Medic
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112 - 10- Consider first the propos
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114 - 12- insurance premiums and me
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Consunmer Unon Pubtishcr of Consume
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FOR RELEASE AT 9:00 P.M. H2ST) TUES
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120 Itema I CENTER FOR MEDICARE ALw
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Page 3 122 aide services, however,
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Page 5 state treasuries." 124 Judge
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126 462 6485 New Developments 10,05
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128 462 6-85 New Developments 10,05
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130 462 6-85 New Developments 10,05
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132 10,930 New Developments tI.PZ ;
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10,932 134 New Davelopments 492 346
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136 10,934 New Developments It! ;6
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10,936 138 New Developmenlt I. Thc
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140 10,938 New Development. 492 S-8
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10,940 142 New Developments i92 586
Page 147 and 148: ATroR EYS -HARLES C. -ULiIN JUDITH
Page 149 and 150: 146 reformed its decision-making pr
Page 151 and 152: 148 : 14 2i57 New Developments 13,1
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Page 155 and 156: 152 All Of these figures are based
Page 157 and 158: 154 The requirements of this Act sh
Page 159 and 160: 156 Drefting Note: Where the word "
Page 161 and 162: 158 (b) The issuance of the group p
Page 163 and 164: 160 (2) Contain a provision establi
Page 165 and 166: 162 and competitive reasons. It is
Page 167 and 168: 164 -13- E. Affordability of Long T
Page 169 and 170: NAIC LTC ADVISORY COMMITEE EXPOSURE
Page 171 and 172: Setinzn IS. Poicyx D~efinitieno aid
Page 173 and 174: 170 3. The term "noncancellable' ma
Page 175 and 176: 172 extension of benefits beyond th
Page 177 and 178: artinM B Requirmnts for Rplnmacwt 1
Page 179 and 180: 176 The above "Notice to Applicant"
Page 181 and 182: (pinnal Rasting &mdsninn 178 Benefi
Page 183 and 184: APPEMI!X B 180 OCWARISCN OF lVLCY i
Page 185 and 186: COMPAIeSON OF LOtG TEIM CoAt PfLtCI
Page 187 and 188: COMPABI:SZN OF LC#C TE" CAiE -OLICI
Page 189 and 190: COWaPAISON Of LOSt TERM CARE POLICI
Page 191 and 192: cowRiiSOi or touTE reM CasE nOuczcS
Page 193 and 194: COGPARISON OF LONG TERM CARE POLICI
Page 195 and 196: SOME BASIC THINGS YOU SHOULD KNOW M
Page 197: Private health insurance is availab
Page 201 and 202: EXPENSES NOT COVERED BY MEDICARE Me
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HEARING - U.S. Senate Special Committee on Aging

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