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U.S. Department of Health and Human Services
Social Security Administration
SSA Publication No. 05-10043
January 1992
ICN 460000

Booklet title: "Medicare"
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Page 1

WHY YOU SHOULD READ THIS BOOKLET

Because, sooner or later, nearly every American will be affected
by Medicare, the Nation's only Federal health insurance program.
In fact, if you pay taxes, you're already affected by Medicare
because a portion of your taxes are used specifically to finance
part of the Medicare program.

But even though you're paying for the program now, and will
likely come to rely on it in the future, chances are you don't
know what Medicare offers--and what it doesn't offer. So take a
few moments to go over the basics given in this booklet. The time
you spend reading this booklet is an important investment in your
future.

Please Note: This booklet refers to premium amounts,
"deductibles," "coinsurance payments," and other figures that
change every year. For the most up-to-date information about
these numbers, ask Social Security for a copy of the fact sheet,
Social Security Update (Publication No. 05-10003).
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Page 2

WHAT'S INSIDE

Page 3    Section 1--What Is Medicare?

Page 4    Section 2--Who Can Get Medicare?

Page 8    Section 3--How Do You Sign Up For Medicare?

Page 14   Section 4--What Does Medicare Cover?

Page 20   Section 5--What Medicare Does Not Cover

Page 21   Section 6--Your Right To Make Health Care Decisions

Page 22   Section 7--What If You Think You Need More Insurance?

Page 25   Section What You Should Know If You Have Other Health
          Insurance

Page 29   Section 9--Want More Information?

Page 30   Other Booklets Available 31 Index

Page 31   Index
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Page 3

SECTION 1 WHAT IS MEDICARE?

Medicare is our country's health insurance program for people 65
or older, certain disabled people under 65, and people of any age
who have permanent kidney failure. It provides basic protection
against the cost of health care, but it doesn't cover all your
medical expenses.

The Health Care Financing Administration is the Agency that is in
charge of running the Medicare program. But we--the Social
Security Administration--are the people who will help you enroll
in the program, and give you general Medicare information like
that found in this booklet.

MEDICARE HAS TWO PARTS

There are two parts of Medicare. They are:

HOSPITAL INSURANCE (also called "Part A" Medicare), which is
financed by part of the payroll (FICA) tax that also pays for
Social Security; and

MEDICAL INSURANCE (also called "Part B" Medicare), which is
financed by monthly premiums paid by people who choose to enroll.

The two parts of Medicare cover different kinds of medical costs,
have different rules about enrolling, and so on. Because of these
differences, the two parts of the Medicare program are described
separately in many sections of this booklet.
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Page 4

A WORD ABOUT MEDICAID

Many people think that Medicaid and Medicare are two different
names for the same program. But actually, Medicaid is a State-run
program designed primarily to help those with low income and
little or no resources. While the Federal government helps pay
for Medicaid, each State has its own rules about who is eligible
and what is covered under Medicaid. Some people can qualify for
both Medicare and Medicaid. If you would like to know more about
the Medicaid program, contact your local social services or
welfare office.

SECTION 2 WHO CAN GET MEDICARE?

HOSPITAL INSURANCE

IF YOU ARE 65 OR OLDER

Most people 65 or older are eligible for Medicare hospital
insurance based on their own--or their spouse's employment. You
are eligible at 65 if:

* You are getting Social Security or railroad retirement
benefits, or

* You are not getting Social Security or railroad retirement
benefits, but you have worked long enough to be eligible for
them, or

* You would be entitled to Social Security benefits based on your
spouse's work record, and your spouse is at least 62 (your spouse
does not have to apply for benefits in order for you to be
eligible based on your spouse's work) or,

* You have worked long enough for Federal State, or local
government to be insured for Medicare.
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Page 5

IF YOU ARE UNDER 65

Before age 65, you are eligible for Medicare hospital insurance
if:

* You have been getting Social Security disability benefits for
24 months, or

* You have worked long enough in Federal State, or local
government, and you meet the requirements of the Social Security
disability program.

If you receive a disability annuity from the Railroad Retirement
Board, you will be eligible for hospital insurance after you
serve a waiting period. (Contact your railroad retirement office
for further details.)

FAMILY MEMBERS WHO CAN GET MEDICARE

Under certain conditions, your spouse, divorced spouse, widow or
widower, or a dependent parent may be eligible for hospital
insurance when he or she turns 65, based on your work record.

Also, disabled widows and widowers under 65, disabled divorced
widows or widowers under 65, and disabled children may be
eligible for Medicare.

IF YOU HAVE KIDNEY FAILURE

There are special rules for people with permanent kidney failure.
Under these rules, you are eligible for hospital insurance at any
age, if you receive maintenance dialysis or a kidney transplant,
and:

* you are insured or are getting monthly benefits under Social
Security or the railroad retirement system, or

* you have worked long enough in government to be insured for
Medicare.
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Page 6

In addition, your spouse or child may be eligible, based on your
work record, if she or he receives maintenance dialysis or a
kidney transplant, even if no one else in the family is getting
Medicare.

IF YOU DO NOT QUALIFY UNDER THESE RULES

Certain aged or disabled people who do not qualify for Medicare
hospital insurance under these rules may be able to get it by
paying a monthly premium. See page 10 for information about
buying hospital insurance.

MEDICARE MEDICAL INSURANCE

Almost anyone who is 65 or older--or who is under 65 but eligible
for hospital insurance can enroll in Medicare medical insurance
by paying a monthly premium (more on this in the next chapter).
You don't need any Social Security or government work credits to
get this part of Medicare.

Aliens 65 or older who are not eligible for hospital insurance
must be lawfully-admitted permanent residents and must live in
the U.S. for 5 years before they can enroll in medical insurance.

QUESTIONS?

We realize that these rules can be confusing. If you aren't sure
if you qualify for Medicare, or you need more information about
the rules given here, contact Social Security. (But, if you get a
railroad retirement annuity or railroad retirement benefit based
on disability, you should contact a railroad retirement office.)
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Page 7

HELP FOR LOW-INCOME MEDICARE BENEFICIARIES--THE QMB PROGRAM

If you get Medicare, and you have little income or assets, you
should know about a program that can help save you money. It is
called the "Qualified Medicare Beneficiary" or "QMB" program. The
QMB program is run by the Health Care Financing Administration
and the State agency that provides medical assistance under the
Medicaid program.

If you qualify for help from the QMB program, your State will pay
your monthly Medicare premiums. Your State will also pay the
Medicare deductibles and coinsurance, which can save you a lot
more money.

The rules vary from State to State. But, in general, you may
qualify for help from the QMB program if:

* your income is limited; and

* your "resources" do not exceed certain limitations. (Resources
are things you own. But some things don't count. For example, the
home you live in doesn't count, and some other things such as a
car may not count either.)

Only your State can decide if you qualify for help under the QMB
program. If you think you may qualify, contact your State or
local medical assistance (Medicaid) agency, social service
office, or welfare office. For general information, ask Social
Security for a copy of the fact sheet , You Should Know About QMB
(Publication No. 0510079).
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Page 8

SECTION 3--HOW DO YOU SIGN UP FOR MEDICARE?

In Section 2 of this booklet, we talked about who is eligible for
Medicare. The next logical question is, "How do I get Medicare
when I'm eligible for it?"

The answer to this question depends on a number of factors. And
once again, the rules are different for the two different parts
of Medicare. Let's start with the rules for hospital insurance.

GETTING MEDICARE HOSPITAL INSURANCE (PART A)

Some people have to apply for hospital insurance. For others, it
starts automatically.

IF YOU ARE ALREADY GETTING SOCIAL SECURITY OR RAILROAD RETIREMENT
CHECKS

If you are already getting checks when you turn 65, you will be
automatically enrolled in hospital insurance. You will get a
package in the mail 2 or 3 months before you turn 65. The package
will have your Medicare card in it, along with more information
about the Medicare program. (The package will also ask you to
decide if you want to pay a monthly premium to sign up for the
medical insurance part of Medicare.)

IF YOU PLAN TO RETIRE AT 65

If you plan to retire when you turn 65, contact Social Security
about 3 months before your 65th birthday. We'll sign you up for
Medicare at the same time you apply for Social Security benefits.
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Page 9

IF YOU'RE ABOUT TO TURN 65, BUT YOU DON'T PLAN TO RETIRE

You don't have to retire to get Medicare hospital insurance at
65. But you do need to contact Social Security about 3 months
before your 65th birthday so we can help you sign up for
Medicare.

IF YOU'RE A GOVERNMENT EMPLOYEE OR RETIREE

Government employees or retirees who are eligible for Medicare
because of government work should contact Social Security about 3
months before their 65th birthday to apply for hospital
insurance.

IF YOU'RE DISABLED AND UNDER 65

You will automatically get the same Medicare enrollment package
described on page 8, (see paragraph "If You Are Already Getting
Social Security Or Railroad Retirement Checks") about 3 months
before you become eligible for Medicare. You become eligible
after you have been entitled to disability benefits for 24
months.

IF YOU'RE A DISABLED WIDOW OR WIDOWER BETWEEN 50 AND 65

If you're a disabled widow or widower between 50 and 65--but you
haven't applied for disability benefits because you're already
getting another kind of Social Security benefit--you may be able
to get hospital insurance. If you are disabled, contact Social
Security as soon as you can so that you don't lose out on any
Medicare protection.
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Page 10

IF YOU'RE A GOVERNMENT EMPLOYEE AND YOU BECAME DISABLED BEFORE 65

You may be able to get Medicare based on your work in government.
Generally, there is a 29-month waiting period before hospital
insurance benefits can start. But please don't wait to contact
Social Security. Get in touch with us right away so that you
don't lose out on any Medicare protection.

IF YOU'RE 65 BUT DON'T QUALIFY FOR MEDICARE HOSPITAL INSURANCE

If you're 65 or over, but don't meet any of the circumstances
described above, you do have an option. You can choose to buy the
coverage, much like you buy private insurance, for a monthly
premium. But if you want to buy hospital insurance, you also have
to enroll in Medicare medical insurance and pay a monthly premium
for that coverage as well. (If you are an alien, you must be a
lawfully-admitted permanent resident and must live in the U.S.
for 5 years before you can buy Medicare.)

If you choose to buy hospital insurance coverage, the enrollment
periods are the same as described for medical insurance on page
12.

IF YOU'RE UNDER 65 AND USED TO BE ENTITLED TO DISABILITY
INSURANCE BENEFITS AND MEDICARE

If you used to get disability insurance benefits and Medicare but
you lost those benefits solely because you were working, and if
you're still disabled, you can buy Medicare coverage in much the
same way as described for those age 65 or over. But you don't
have to enroll in Medicare medical insurance if you choose not to
do so.
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Page 11

IF YOU, YOUR SPOUSE, OR YOUR DEPENDENT CHILD HAS PERMANENT KIDNEY
FAILURE

Contact Social Security to see if you are eligible for Medicare.

GETTING MEDICARE MEDICAL INSURANCE PART B)

Unlike Medicare hospital insurance, you have to pay a monthly
premium for Medicare medical insurance. Since there's a monthly
premium, you need to decide whether or not you want to enroll.

One Special Note: Many of the services needed by people with
permanent kidney failure are covered only by the medical
insurance part of Medicare.

Here's the way enrollment works.

IF YOU'RE GETTING SOCIAL SECURITY OR RAILROAD RETIREMENT BENEFITS

In the section on signing up for hospital insurance, we explained
that you will get an "enrollment package" 2 or 3 months before
you become eligible for Medicare. That package tells you that
you'll be automatically enrolled in both parts of Medicare. But,
because there's a monthly premium for medical insurance, you have
the option to turn it down. You would still get hospital
insurance. (Complete instructions are given in the packet, and
you can call Social Security or your railroad retirement office
if you have questions.)
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Page 12

IN OTHER SITUATIONS

You need to contact Social Security to apply for medical
insurance if you:

* do not file for hospital insurance at 65 because you plan to
continue working past 65; or

* had medical insurance coverage in the past, but dropped the coverage; or

* turned down medicalinsurance when you became entitled
to hospital insurance; or

* are 65 but you aren't eligible for hospital insurance; or

* are eligible for Medicare based on government work; or

* have permanent kidney failure; or

* are a disabled widow or widowerbetween 50 and 65 and you
aren't getting disability benefits; or

* live in Puerto Rico or outside the U.S.

WHEN YOU CAN SIGN UP FOR MEDICAL INSURANCE

You should know that you have only a specific period of time to
decide if you want medical insurance coverage.

Here's how it works.

INITIAL ENROLLMENT PERIOD

When you are about to become eligible for medical insurance, you
have 7 months to sign up. This 7-month period begins 3 months
before the month you first become eligible and ends 3 months
after that month. If you enroll during the first 3 months, your
medical insurance will start with the month you actually become
eligible; there is no delay. If you enroll during the last 4
months, your coverage will start 1 to 3 months after you sign up.
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Page 13

GENERAL ENROLLMENT PERIOD

What happens if you don't sign up during the initial enrollment
period, but later change your mind? You are given another chance
to sign up each year. This general enrollment period runs from
January 1 through March 31 of each year. But if you enroll during
the general enrollment period, your insurance coverage won't
start until the following July. Also, your monthly premium will
be 10 percent higher for each 12-month period you could have been
enrolled, but weren't. (This limit on when you can enroll and the
10-percent increase in premiums might not apply if you have
employer group health coverage--pages 26-27.)

A SPECIAL NOTE ABOUT HEALTH MAINTENANCE ORGANIZATIONS

Most Medicare beneficiaries have a choice about how and where to
receive their Medicare-covered services. One way is to choose a
particular doctor or hospital approved under Medicare. In this
case, the bill will be sent in to Medicare after the service is
provided. You are responsible for any amounts that Medicare does
not cover. (If you have "Medigap" insurance, it may help pay
these charges.)

Another way is to sign up for a Health Maintenance Organization
(HMO) or Competitive Medical Plan (CMP). HMOs and CMPs provide
health care in exchange for a monthly, fixed fee. Medicare
beneficiaries then get all Medicare-covered hospital and medical
insurance benefits through the plan. Your costs are known in
advance and are generally limited to the fixed monthly premiums
and minimal "copayments." (A copayment is a set amount that the
beneficiary is required to pay for each service.)
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Page 14

Some HMOs and CMPs provide services beyond what Medicare covers,
such as prescription drugs or hearing aids, at no extra cost to
you. But most also have some limits on your care that you should
know about before you enroll. Your Social Security office can
tell you how to contact an HMO or CMP in your area if you want
more information.

SECTION 4--WHAT DOES MEDICARE COVER?

The two parts of Medicare are designed to help pay for different
kinds of health care costs. And there are some kinds of health
care that aren't covered by Medicare at all. We'll look first at
what is covered under Medicare hospital insurance or Medicare
medical insurance. In the next section, we'll tell you what isn't
covered.

You can get specific information about Medicare costs,
deductibles, and "coinsurance" rates by calling Social Security.

MEDICARE HOSPITAL INSURANCE

Medicare hospital insurance can help pay for inpatient hospital
care, inpatient care in a skilled nursing facility, home health
care, and hospice care. Each of these is described in more detail
below.

BENEFIT PERIODS

Before you read the sections below, you need to understand what
we mean by "benefit period," which is a term we use when we
explain what Medicare hospital insurance covers.
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A benefit period starts the day you enter a hospital. It ends
when you have been out of the hospital (or other facility
primarily providing skilled care) for 60 days in a row. If you
remain in a facility (other than a hospital) that primarily
provides skilled care, 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. But special limits do apply to
hospice care. (See "Hospice Care," page 17.)

INPATIENT HOSPITAL CARE

If you need inpatient care, hospital insurance helps pay for up
to 90 days in any Medicare-participating hospital during each
benefit period. Hospital insurance pays for all covered services
(see the next page) for the first 60 days, except for a
deductible. For days 61 through 90, hospital insurance pays for
all "covered services" except for a daily coinsurance amount.
(Coinsurance is the portion of the bill that the beneficiary is
required to pay even after the deductible is met.)

If you are out of the hospital for at least 60 days in a row, and
then go back in, you will start a new benefit period. This means
that your 90 days of coverage will start all over again, with the
same rules as above.

What if you need more than 90 days of inpatient care during any
benefit period? You can decide to use some or all of your
"reserve days." Reserve days are 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. You have only 60 reserve days in
your lifetime, and you can decide when you want to use them. For
each reserve day you use, hospital insurance pays for all covered
services except for a daily coinsurance amount.
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Here are examples of what Medicare hospital insurance pays for
when you're in a hospital:

* semi-private room and all meals

* regular nursing services

* operating and recovery room

* intensive care and coronary care

* drugs, lab tests, and X-rays

* medical supplies and appliances

* rehabilitation services, such as physical therapy

* preparatory services related to kidney transplant surgery

SKILLED NURSING FACILITY CARE

If you need inpatient skilled nursing or rehabilitation services after
a hospital stay, and you meet certain other conditions, hospital
insurance helps pay for up to 100 days in a Medicare-participating
skilled nursing facility in each benefit period.

Hospital insurance pays for all covered services for the first 20
days. For the next 80 days, it pays for all covered services
except for a daily coinsurance amount.

Here are examples of what Medicare pays for when you're in a
skilled nursing facility:

* semi-private room and all meals

* regular nursing services

* rehabilitation services, such as physical therapy

* drugs, medical supplies, and medical appliances

NOTE: It is important to point out here that Medicare does not
pay for "custodial care" when that is the only kind of care that
you need. This is
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P.17

the type of care people often think of when they think of nursing
home care. Custodial care is care that could be given by someone
who is not medically skilled (for example, help with dressing,
walking, or eating).

HOME HEALTH CARE

If you are confined to your home and meet certain other
conditions, Medicare can pay the full approved cost of home
health visits from a Medicare-participating home health agency.
There is no limit to the number of covered visits you can have.

Here are examples of what Medicare hospital insurance pays for
when you need home health care:

* intermittent skilled nursing care

* physical therapy

* speech therapy

If you need one or more of the covered services, then hospital
insurance also covers part-time or intermittent services of home
health aides, occupational therapy, medical social services, and
medical supplies and equipment. A 20 percent copayment applies to
covered durable medical equipment (e.g., wheelchairs and hospital
beds).

HOSPICE CARE

A hospice is a program that provides pain relief and other
support services for terminally-ill people. Medicare hospital
insurance can help pay for hospice care for terminally-ill
beneficiaries if the care is provided by a Medicare-certified
hospice and certain other conditions are met.
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P.18

There are special "benefit periods" that apply to hospice care.
Hospital insurance can pay for hospice care for a maximum of two
90-day periods and one 30 day period and one extension period of
indefinite duration when the patient is terminally ill.

Here are examples of what Medicare hospital insurance covers when
you need hospice care:

* doctors' services and nursing services

* medical appliances and supplies, including outpatient drugs for
relief of pain

* physical and speech therapy

* home health aide and homemaker services

* medical social services

* counseling

* respite care (short-term inpatient care to give temporary
relief to the person who normally assists with home care of the
patient)

Hospital insurance pays almost all of the cost of outpatient
drugs and inpatient respite care. And it pays the full cost for
all other covered services.

MEDICAL INSURANCE BENEFITS

Medicare medical insurance helps pay for your doctor's services
and many other medical services and supplies that are not covered
by the hospital insurance part of Medicare.

DEDUCTABLE

Each year, before Medicare medical insurance begins paying for
covered services, you must meet the annual medical insurance
"deductible." (A deductible is the amount a beneficiary must pay
before Medicare begins paying.)
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Page 19

After you meet that deductible, Medicare will generally pay 80
percent of the approved charges for covered services during the
rest of the year.

DOCTORS' SERVICES

Medical insurance covers services you receive from a doctor.
Here are some examples of doctors' services covered by Medicare:

* medical and surgical services, including anesthesia

* diagnostic tests that are a part of your treatment

* X-rays

* radiology and pathology services by doctors while you are a
hospital inpatient or outpatient

* limited treatment of mental illness

* services of your doctor's office nurse

* drugs that cannot be self-administered, blood transfusions, and
other medical supplies

Here are some examples of other services covered by medical insurance:

* outpatient hospital services you receive for diagnosis and
treatment of an illness, including care in an emergency room or
outpatient clinic of a hospital

* home health visits if you don't have hospital insurance and if
certain conditions are met

* ambulance transportation

* home dialysis equipment and support services

* outpatient physical/occupational therapy and speech pathology
services

* radiation treatments
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SECTION 5--WHAT MEDICARE DOES NOT COVER

Medicare provides basic health care coverage, but it can't pay
all of your medical expenses. Here are examples of what Medicare
does not pay for:

* "custodial care" (This is care that could be given safely and
reasonably by a person who is not medically skilled, and which is
given mainly to help the patient with daily living. Examples
include help with walking, bathing, and dressing. Even if you are
in a participating hospital or skilled nursing facility, or you
are getting care from a participating home health agency,
Medicare does not cover the cost of care if it is mainly
custodial.)

* most nursing home care

* care you get outside the U.S. (but under certain conditions,
care in Canada or Mexico might be covered)

* dental care and dentures

* routine checkups and the tests directly related to these
checkups (except that some screening, Pap smears and mammograms
are covered)

* most immunization shots

* most prescription drugs

* routine foot care

* tests for, and the cost of, eyeglasses or hearing aids

* personal comfort items, such as a phone or TV in your room
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SECTION 6--YOUR RIGHT TO MAKE HEALTH CARE DECISIONS

All Medicare and Medicaid certified hospitals, nursing homes, and
other health care providers and organizations are required by law
to inform adult patients about their right to make their own
health care decisions, including the right to accept or refuse
medical treatment.

Usually, you will be asked to sign a written statement about how
you want future medical decisions to be made if you become
incapacitated. There are two common forms of statements.

1. A Living Will states the kind of medical care you want or
don't want if you become unable to make your own decisions.

2. A Durable Power of Attorney for Health Care is a signed,
dated, and witnessed paper naming another person--such as your
husband, wife, son, daughter, or close friend--to make medical
decisions for you if you become unable to make them for yourself.

When you enter a Medicare or Medicaid health care facility, be
sure you receive information about these rights.

In general, you may prepare, change, or cancel your decision at
any time, in accordance with your State's law. State laws on
these provisions vary.
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SECTION 7--WHAT IF YOU THINK YOU NEED MORE INSURANCE?

As we've seen, Medicare provides basic health care coverage, but
it can't pay all of your medical expenses, and it doesn't pay for
most long-term care. For this reason, many private insurance
companies sell insurance to fill in the gaps in Medicare
coverage. This kind of insurance is often called "Medigap" for
short.

This section explains the types of insurance that are available
and gives some tips on what to look for--and look out for.

KINDS OF PRIVATE HEALTH INSURANCE

There are a number of different kinds of insurance you can buy to
cover some or all of the medical costs that Medicare doesn't
cover. Here's a brief description of the most common ones:

* Medicare Supplement policies pay part or all of Medicare's
deductibles and "coinsurance" amounts. (Coinsurance is the
portion of the bill that the beneficiary is required to pay even
after the deductible is met.) Some also pay for health services
that are not covered by Medicare. Federal law has standardized
these policies to ten basic plans. To find out what new
standardized policies will be available in your State, check with
your State insurance department.

* Major Medical Expense policies help cover the high cost of
serious illness or injury, including some health services not
covered by Medicare. They usually have a large deductible and may
not cover Medicare's deductibles and coinsurance amounts.
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Page 23

* Employer Group Insurance coverage can sometimes be continued or
converted to a suitable individual Medicare-supplement policy
when you reach age 65. Some also offer benefits to the spouse.
(This kind of insurance is explained more fully in section 8.)

* Association Group Insurance is offered by many organizations to
their members over age 65.

Some insurance policies are designed to offer a particular kind
of coverage. For example:

* Nursing Home Coverage usually pays a certain amount per day for
services provided in a skilled nursing facility.

* Hospital Confinement Indemnity Coverage pays a fixed amount for
each day you're in the hospital, up to a specified maximum number
of days.

* Specified Disease Coverage (not available in some States)
provides benefits only if you become ill because of a particular
disease, such as cancer. Benefits are usually limited to a
certain dollar amount.

SHOPPING FOR PRIVATE HEALTH INSURANCE

Buying insurance can be intimidating. There are many different
kinds of insurance to choose from, and many things to consider.
Here are some important tips.

Shop carefully. Contact several different companies and compare
the coverage and cost of insurance.

Understand what you're buying. Go over each policy carefully to
see if it gives you the kind of coverage you need. Make sure you
know what the policy covers. Policies from different companies
may sound like they offer the same coverage, when in fact they
don't. For example, each may say it pays for "skilled nursing
care," but each policy may define the term differently.
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Page 24

Don't buy more insurance than you need.

Does the policy pay a set dollar amount, or a percentage of the
cost of care? With inflation, policies that pay a fixed dollar
amount lose relative value over time.

How long will the coverage last? Some policies provide benefits
for a certain length of time most commonly, up to 1 year. Others
pay for the rest of the policyholder's life.

What isn't covered? Always check for waiting periods and
"pre-existing condition" exclusions. These exclusions mean that a
policy will not pay for treatment of a medical condition you
already have. And often, insurers won't pay benefits for
treatment of mental illness, alcoholism or drug addiction, etc.

How much does nursing home care cost in your area? Before buying
a policy, get an idea of the cost of nursing home care and home
health care in your area. Otherwise, you won't be able to tell if
your coverage would be adequate.

Check your right to renew the policy. Policies that renew
automatically offer the best protection.

Beware of scams. Don't believe anyone who tells you that he or
she is from the Government, and tries to sell you insurance.
Policies to supplement Medicare are not sold or serviced by the
Medicare program or any other State or Federal Government agency.
Also, it is illegal for any insurance company or agent to
knowingly sell you a policy that duplicates Medicare coverage or
your private health insurance coverage. Companies or agents that
break this law are subject to Federal penalties. (If you think
you have been the victim of an illegal insurance sales practice,
contact your State insurance department or call the U.S.
Department of Health and Human Services, toll-free, at 1-800-638-
6833.)
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Take your time. Don't let a salesperson pressure you, and never
pay the agent in cash. Allow yourself enough time to make an
informed decision. And when your policy arrives, read it to make
sure it gives the coverage you ordered.

SECTION 8 WHAT YOU SHOULD KNOW IF YOU HAVE OTHER HEALTH INSURANCE

As we've explained, Medicare hospital insurance is free, but you
pay a monthly premium for medical insurance. If you already have
other health insurance when you become eligible for Medicare, is
it worth the monthly premium cost to sign up for Medicare medical
insurance?

The answer varies with the individual and the kind of other
health insurance. Although we can't give you "yes" or "no"
answers, we can offer a few tips that may be helpful when you
make your decision.

IF YOU HAVE A PRIVATE INSURANCE PLAN

Get in touch with your insurance agent to see how your private
plan fits or "integrates"--with Medicare medical insurance. This
is especially important if you have family members who are
covered under the same policy. And remember, just as Medicare
doesn't cover all health services, most private plans don't
either. In planning your health insurance coverage, be mindful
that most nursing home care is not covered by Medicare or private
health insurance policies. One important word of caution: For
your own protection, don't cancel any health insurance you now
have until your Medicare coverage actually begins.
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IF YOU HAVE HEALTH INSURANCE FROM AN EMPLOYER GROUP HEALTH PLAN

In this case, there are some special rules you should know about.

If you work past 65--or are 65 or older and the spouse of a
worker of any age and are covered under an employer group health
plan, you can wait to enroll in Medicare medical insurance during
a 7-month "special enrollment period." This period begins with
the month the group health coverage ends, or the month employment
ends--whichever comes first. If you meet certain requirements,
you won't have to wait for a general enrollment period, and you
won't have to pay the 10-percent premium surcharge for late
enrollment in Medicare.

Group health plans of employers with 20 or more employees are
required by law to offer workers who are 65 (or older) the same
health benefits that are provided to younger employees. They must
also offer the spouses who are 65 (or older) , of workers of any
age the same health benefits given younger spouses. If you are 65
or older and continue working--or you are 65 or older and you are
the spouse of the worker--and you accept the employer's health
insurance plan, Medicare will be the "secondary payer." This
means that the employer plan pays first on your hospital and
medical bills. If the employer plan does not pay all of your
expenses, Medicare may pay secondary benefits. On the other hand,
if you reject the employer's health plan, Medicare will be the
primary health insurance payer. The employer is not allowed to
offer you Medicare supplemental coverage if you reject his or her
health plan.
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If you are under 65 and disabled, you are an employee or the
family member of an employee, and you have health coverage under
a "large group health plan," Medicare will be the secondary
payer. A large group health plan is one that covers employees of
at least one employer who has 100 or more workers. If that's the
case, you will also have special enrollment period and premium
rights that are similar to those for workers 65 or older.

If you are under 65, entitled to Medicare because of permanent
kidney failure, and have employer group health coverage, Medicare
will be the secondary payer for the first 18 months of your
Medicare Part A eligibility or entitlement. At the end of the
18-month period, Medicare becomes your primary payer.

IF YOU HAVE HEALTH CARE PROTECTION FROM THE DEPARTMENT OF
VETERAN'S AFFAIRS (DVA) OR CHAMPUS OR CHAMPVA PROGRAM

In this case, your health benefits may change or end when you
become eligible for Medicare. You should contact the DVA,
Department of Defense, or a military health benefits advisor for
information before you decide whether or not to enroll in
Medicare medical insurance.
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IF YOU HAVE HEALTH CARE PROTECTION FROM THE INDIAN HEALTH
SERVICE, A FEDERAL EMPLOYEE HEALTH PLAN, OR A STATE MEDICAL
ASSISTANCE PROGRAM

If this is your situation, you should contact the people in those
offices. They can help you decide whether it is to your advantage
to have Medicare medical insurance.

QUESTIONS?

We've covered a number of difficult rules in this chapter. If you
are not sure if any apply to you, contact Social Security for
help. (But if you aren't sure about the size of the employer
group health plan, check with the personnel office or the
employer.)
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SECTION 9--WANT MORE INFORMATION?

It's difficult to summarize a program as complex as Medicare in a
single booklet. If you have other questions about Medicare,
please contact Social Security. You can do this by visiting one
of our offices, writing to us, or calling our toll-free number,
1-800 772-1213. You can call from 7:00 a.m. to 7:00 p.m. any
business day.

The Social Security Administration treats all calls
confidentially--whether they're made to our toll-free number or
to one of our local offices. We also want to ensure that you
receive accurate and courteous service. That is why we have a
second Social Security representative listen to some incoming and
outgoing telephone calls.
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OTHER BOOKLETS AVAILABLE

The Social Security Administration produces many other
publications and fact sheets to give you information about other
parts of the Social Security program. You can get a free copy of
these publications from any Social Security office. Here's a list
of some of the publications we have available.

* Understanding Social Security (Publication No. 05-10024--A brief
overview of each of the Social Security programs

* Retirement (Publication No. 05-10035--A guide to Social Security
retirement benefits

* Disability (Publication No. 05-10029--A guide to Social Security
disability benefits

* Survivors (Publication No. 05-10084--A guide to Social Security
survivors benefits

* SSI (Publication No. 05-11000-A guide to the SSI program

All of these publications, including this one, are available in
Spanish.
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Index                                                       Page

Subject benefit period.......................................14-15
CHAMPUS/CHAMPVA health insurance ............................27
coinsurance..................................................15
competitive medical plans....................................13
copayment....................................................13
covered services.............................................14-19
--doctors' services..........................................19
--home health care...........................................17
--hospice care ..............................................17-18
--hospital inpatient.........................................15
--hospital outpatient .......................................19
--skilled nursing facility ..................................16
custodial care...............................................16,20
deductible...................................................18
doctors'services.............................................19
eligibility..................................................4-6
--hospital insurance.........................................4-6
--medical insurance..........................................6
employer group health plans..................................26-27
enrollment...................................................8-14
--general enrollment period..................................13
--hospital insurance.........................................8-11
--initial enrollment period..................................12
--medical insurance..........................................11-12
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SUBJECT                                                    Page

health maintenance organizations ............................13-14
home health care.............................................17
hospice care ................................................17-18
hospital care ...............................................14-16
--inpatient..................................................15-16
--outpatient.................................................19
--kidney failure, benefits for victims of....................5-6,11
living will..................................................21
Medicaid ....................................................4
Medicare hospital insurance..................................14
Medicare medical insurance ..................................18
Medigap policies ............................................22-23
non-covered services.........................................20
Part A Medicare..............................................3
Part B Medicare..............................................3
power of attorney ...........................................21
private health insurance.....................................22-25
--types of...................................................22-23,25-28
--tips when shopping for.....................................23-25
QMB Program..................................................7
reserve days.................................................15
respite care.................................................18
secondary payer, Medicare as ................................26
Veteran's Affairs, Department of ............................27

U.S. department of Health and Human Services
Social Security Administration
SSA Publication No. 05-10043
January 1992
ICN 460000

U.S. Government Printing Office 1992 -- 312-168/60011