Health Care Resource Links
Telephone 1(800) MEDICARE or 1(800) 633-4227 twenty-four hours a day with questions about Medicare (in general), Medicare health plans, ordering Medicare booklets, Medigap policies, or assistance programs (including help paying health care costs, and telephone numbers for local organizations who work with Medicare).
www.medicare.gov
Social Security Administration at 1(800) 772-1213 with questions about address/name changes, enrolling in Medicare, Medicare replacement cards, or Social Security benefits.
www.ssa.gov
California Health Insurance Counseling and Advocacy Program at 1(800) 434-0222. Call for help with buying a Medigap policy or long-term care insurance, dealing with payment denials or appeals, Medicare rights and protections, help choosing a Medicare health plan, and Medicare bills. In-state calls only.
www.aging.ca.gov
Coordination of Benefits at 1(800) 999-1118 with questions about which insurance pays first, and the Medicare initial enrollment questionnaire.
Railroad Retirement Board (RRB) at 1 (877) 772-5772 with questions about Railroad Retirement benefits and all other services listed for the Social Security Administration for people who get RRB benefits.
www.secure.rrb.gov
Department of Veterans Affairs at 1(800) 827-1000 with questions regarding Veteran’s benefits.
www.benefits.va.gov/benefits
Department of Health and Human Services, Office of the Inspector General — Fraud Hotline at 1(800) 447-8477.
www.oig.hhs.gov/fraud
Office for Civil Rights at 1(800) 368-1019. You can also use the official websites to obtain information:
www.hhs.gov/ocr
Health Care Definitions
Advance Health Care Directive (aka Durable Power of Attorney for Health Care): A document that you sign giving another person, whom you designate as your “attorney-in-fact,” trustee, or agent, the power to make health care or placement decisions for you if you are incapacitated or cannot make the decisions for yourself. You may provide instructions in these documents regarding your care or placement that will be required to be honored. Otherwise, the “attorney-in-fact” or agent will be expected to exercise his or her judgment in making care and placement decisions in your best interest.
Benefit Period: The way Medicare measures your use of hospital or RNHCI services. A benefit period begins the day you go to a hospital or RNHCI (Christian Science nursing facility). The benefit period ends when you haven’t received hospital or religious nonmedical health care for 60 days in a row. If you go into the hospital or facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.
Coinsurance: The percent of the Medicare-approved amount that you have to pay after you pay the deductible for Part A and/or Part B.
Deductible: The amount you must pay for health care, before Medicare begins to pay, either each benefit period for Part A, or each year for Part B. The amounts can change every year.
Inpatient Care: Health care you receive when you are admitted to a hospital or religious nonmedical health care institution.
Legal Representative: Any individual “who, as determined by applicable State law, has the legal authority” to act on behalf of the beneficiary [42 C.F.R. §405.400]. This is usually accomplished via a power of attorney (including, in California, an advance health care directive) without court intervention, or by a court appointed guardian or conservator.
Lifetime Reserve Days: The sixty days that Medicare will pay for when you are in a hospital or religious nonmedical health care institution (RNHCI) more than 90 days during a benefit period. These 60 days can be used only once during your lifetime.
Medicare-Approved Amount: This is the Medicare payment amount for a covered item or service.
Medigap Policy: A Medicare supplemental insurance policy sold by private insurance companies to fill “gaps” in the original Medicare plan coverage, such as the gap created by your Medicare deductible or coinsurance.
Medicare Summary Notice (MSN): A notice you get after the provider files a claim for Part A services in the Original Medicare Plan. It explains what the provider billed for, the Medicare approved amount, how much Medicare will pay, and what you must pay.
HMO: A Health Maintenance Organization (such as Kaiser) requires you to use only their member providers in order to receive covered care. It can be very challenging to get authorization and payment from Medicare Advantage plans, but it is easy with original Medicare.
PPO: A Preferred Provider Organization is assigned by the insurance provider/carrier (such as Blue Cross/Blue Shield of California); the patient is free to see any physician within the PPO without referral. A PPO is less restrictive than an HMO.
