Medicare Handbook

8/3/2019 Medicare Handbook

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C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

&Medicare

You

2012 This is the ocial U.S. government

Medicare handbook:

Open Enrollment now begins October 15 and

ends December 7 to give you more time to

choose and join a Medicare plan (page 13)

What's new (page 4)

What Medicare covers (page 31)

Your Medicare rights (page 105)

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Welcome to Medicare & You 2012

Tis is an extraordinary time or health care in our Nation’s history. We areworking to make sure you have health care you can depend on—care that’socused on you, and is sae, eective, and timely, at a cost you can aord.

You may have heard about some o the exciting new changes Medicare has beenmaking to help improve your health care—like more ree preventive servicesand lower prescription drug costs.

Tere are some actions you can take right now to help keep yoursel well.Medicare oers a number o preventive services to help keep you healthy and to

nd diseases early when treatments work best. Look at the checklist on the nextpage and take it with you on your next visit to your doctor or other health careprovider. Use it to review and keep track o the preventive services that are rightor you. Our goal is to help you achieve better health, better care, and lowercosts.

One important new Medicare benet—oered ree o charge—is the Yearly “Wellness” visit. Tis is a chance or you and your doctor or other healthcare provider to review your health and talk about what you can do to stay ashealthy as you can. o help you gure out what can help you stay well, your

clinician may ask you to answer a short questionnaire called a Health Risk Assessment, as part o this visit. For more inormation about this and otherimportant preventive services, visit www.medicare.gov/share-the-health.

Tis handbook is the best and ocial source o answers to your Medicarequestions. We also have other helpul resources or you. Visitwww.medicare.gov , or call 1-800-MEDICARE (1-800-633-4227) to get specicanswers to your questions. You can also call your local State Health InsuranceAssistance Program (SHIP). See pages 137–140 or the phone number. Or visitthe Administration on Aging at www.aoa.gov .

Yours in good health,

Kathleen Sebelius

Secretary

U.S. Department o Health and Human Services

Donald M. Berwick, MD

Administrator

Centers or Medicare & MedicaidServices

http://www.medicare.gov/share-the-health

http://www.medicare.gov/

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3

Preventive Services Checklist

alk with your doctor or other health care provider about which o theseservices are right or you. As part o your Yearly “Wellness” visit, you

may be asked to ll out a Health Risk Assessment to help you gure outwhat to work on to stay healthy. o learn more, visit www.medicare.gov .

Medicare-Covered Preventive Service I Need

(Yes/No)

Date Last

Received

Next Date Medicare

Covers This Service

“Welcome to Medicare” Preventive Visit(one-time)

Yearly “Wellness” Visit

Abdominal Aortic Aneurysm Screening

Bone Mass Measurement

Breast Cancer Screening (Mammogram)

Cardiovascular Screenings

Cervical and Vaginal Cancer Screening

Colorectal Cancer Screenings

Fecal Occult Blood est

Flexible Sigmoidoscopy

Colonoscopy Barium Enema

Diabetes Screenings

Diabetes Sel-Management raining

Flu Shots

Glaucoma ests

Hepatitis B Shots

HIV Screening

Medical Nutrition Terapy Services

Pneumococcal Shot

Prostate Cancer Screenings

obacco Use Cessation Counseling (counseling or people with no sign o tobacco-related disease)

For some services, you will need to wait a certain amount o time beore getting the

service again. See pages 37–53 or more inormation.


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4 What’s New and Important in 2012

New Dates to Change Plans See pages 13, 78, and 85.

Starting this year, open enrollment begins and ends earlier—October 15–December 7, 2011.

New Special Enrollment Period See pages 79 and 85.

You can switch to a Medicare Advantage Plan (like an HMO or PPO) orMedicare Prescription Drug Plan that has a 5-star rating at any time duringthe year.

Continued Help in the Prescription Drug Coverage Gap See page 88.

I you reach the coverage gap in your Medicare prescription drug coverage,you will qualiy or savings on brand-name and generic drugs.

Fighting Medicare Fraud See page 117.

Find out what Medicare is doing and what you can do to protect againstraud, waste, and abuse.

Help with Long-term Care Costs See page 123.

I you’re still working, you may be able to enroll in a voluntary insuranceprogram to help you pay or support services i you become disabled.

Better Coordination o Care See pages 132–133.

Learn what Medicare and your health care providers are doing to bettercoordinate your health care and improve medical quality.

Ways to Manage Your Health Inormation Online See page 135.

Learn about the new “Blue Button” on www.MyMedicare.gov that you can useto access your Medicare claims and other personal health inormation.

Medicare Health and Prescription Drug Plans

Visit www.medicare.gov/nd-a-plan or call 1-800-MEDICARE (1-800-633-4227)to nd plans in your area. Y users should call 1-877-486-2048.

Where to Find Out What You Pay or Medicare (Part A and Part B).

See the inside back cover.

Te 2012 Medicare premium and deductible amounts weren’t available at thetime o printing. o get the most up-to-date cost inormation, visitwww.medicare.gov or call 1-800-MEDICARE.

Blue words

in the text

are dened

on pages

141–144.

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5

Tools to Help You Find What You Need

Please keep this handbook or uture reerence. Inormation was correctwhen it was printed. Changes may occur aer printing. Visit

www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get themost current inormation. Y users should call 1-877-486-2048.

Blue words

in the text

Blue words in the textare explained in the“Denitions” section

Pages 141–144

Highlights importantinormation

Troughout handbook

Highlights preventiveservices

Pages 37–53

Highlights inormationrelated to Medicare Part A

Troughout handbook

Highlights inormationrelated to Medicare Part B

Troughout handbook

Highlights inormationrelated to Medicare Part C

Troughout handbook

Highlights inormationrelated to Medicare Part D

Troughout handbook

H

H

able o Contents

List o topics by section Pages 6–8

Index Alphabetical list o topics Pages 9–12

Miniables o Contents

List o topics within each

section

Pages 19, 31, 55, 97, 105,

121, 127

“Medicare & You” isn’t a legal document. Ocial Medicare Program legal

guidance is contained in the relevant statutes, regulations, and rulings.





6

ContentsMedicare & You 2012

2 Welcome to Medicare & You 2012

3 Preventive Services Checklist

4 What’s New and Important in 2012

5 Tools to Help You Find What You Need

9 Index

13 Important Enrollment Information14 Medicare Basics14 What is Medicare?

14 The Dierent Parts o Medicare

15 Your Medicare Coverage Choices at a Glance

16 Where to Get Your Medicare Questions Answered

19 SECTION 1—Signing Up for Medicare Part A and Part B20 Signing Up or Part A and Part B

24 Should You Get Part B?

26 How Other Insurance Works with Medicare

28 How Much Does Part A Coverage Cost?

29 How Much Does Part B Coverage Cost?

31 SECTION 2—What Medicare Part A and Part B Cover33 Part A-Covered Services

37 Part B-Covered Services

54 What’s NOT Covered by Part A and Part B?



7

Continued

Contents

55 SECTION 3—Your Medicare Choices56 Decide How to Get Your Medicare

57 Your Medicare Coverage Choices

58 Things to Consider When Choosing or Changing Your Coverage

59 Original Medicare

60 What You Pay

66 Medicare Supplement Insurance (Medigap) Policies

70 Medicare Advantage Plans (Part C)75 What You Pay

76 How Do Medicare Advantage Plans Work?

78 Join, Switch, or Drop a Medicare Advantage Plan

82 Other Medicare Health Plans

84 Medicare Prescription Drug Coverage (Part D)

85 Join, Switch, or Drop a Medicare Drug Plan

87 What You Pay

90 What is the Part D Late Enrollment Penalty?92 Important Drug Coverage Rules

97 SECTION 4—Get Help Paying Your Healthand Prescription Drug Costs

98 Extra Help Paying or Medicare Prescription Drug Coverage (Part D)

102 Medicare Savings Programs (Help with Medicare Costs)

103 Medicaid

103 State Pharmacy Assistance Programs (SPAPs)

103 Pharmaceutical Assistance Programs (also called Patient Assistance Programs)

104 Programs o All-Inclusive Care or the Elderly (PACE)

104 Supplemental Security Income (SSI) Benets

104 Programs or People Who Live in the U.S. Territories

104 Children’s Health Insurance Program



99

IndexNote: Te page number shown in bold provides the most detailed inormation.

AAbdominal Aortic Aneurysm 3, 37

Accountable Care Organizations (ACOs) 133

Acupuncture 54

Advance Beneciary Notice 113

Advance Directives 125–126

ALS (Amyotrophic Lateral Sclerosis) 20

Ambulance Services 37, 52 Ambulatory Surgical Center 37, 126

Appeal 107–113

Articial Limbs 48

Assignment 36, 62–63, 141

BBalance Exam 44

Barium Enema 3, 40

Benet Period 34–35, 141 Bills 61, 129–130

Blood 33, 38

Bone Mass Measurement (bone density) 3, 38

Braces (arm/leg/back/neck) 48

Breast Exam (clinical) 39

CCardiac Rehabilitation 38

Cardiovascular Screenings 3, 39

Caregiving 136

Cataract 43

Catastrophic Coverage 88–89

Children’s Health Insurance Program (CHIP) 104, 136

Chiropractic Services 39

Claims 59, 61, 118, 128, 135

Clinical Research Studies 34, 40, 72

COBRA 23–25, 95

Colonoscopy 3, 40

Colorectal Cancer Screenings 3, 40

Community-Based Programs 123

Community Living Assistance Services and Supports

(CLASS) Program 123

Contract (private) 64

Coordination o Benets 16, 26–27 Cosmetic Surgery 54

Costs (copayments, coinsurance, deductibles, and

premiums) 13, 28–30, 57–58, 72, 75, 87–89,

90–91, 98, 141–143

Coverage Determination (Part D) 110–112

Coverage Gap 88–89, 98

Covered Services (Part A and Part B) 31–53

Creditable Prescription Drug Coverage 58, 65, 84–85,

90–91, 95–99, 142 Custodial Care 35, 54, 122, 142

DDenitions 141–144

Demonstrations/Pilot Programs 83, 143

Dental Care and Dentures 54, 70

Department o Deense 16

Department o Health and Human Services (Ofce o

Inspector General) 119

Department o Veterans Aairs 17, 90, 96, 123

Depression (see Mental Health Care) 46

Diabetes 3, 41, 43, 46

Dialysis (Kidney Dialysis) 14, 21, 45, 74, 125, 130–131

Discrimination 106, 120

Disenroll 69, 73, 81, 86

Drug Plan 13, 48, 56, 65, 73, 77, 84–94

Drugs (outpatient) 34, 48, 94

Durable Medical Equipment (like walkers) 33, 42, 45,

48, 63, 128

C (continued)

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10 Index

Note: Te page number shown in bold provides the most detailed inormation.

EEKGs 43, 50

Eldercare Locator 124, 136

Electronic Handbook 146 Electronic Health Record 58, 132

Electronic Prescribing 133

Emergency Department Services 43, 94

Employer Group Health Plan Coverage 23–27, 32,

57–59, 65, 68, 73, 84, 95, 99

End-Stage Renal Disease (ESRD) 14, 21, 45, 56, 73–74

Enroll

Part A 20–25

Part B 20–25

Part C 73, 78–80

Part D 85–86

ESRD Network 74

Exception (Part D) 93–94, 110–112

Extra Help (Help Paying Medicare Drug Costs) 16, 65, 79,

98–101, 142, 146

Eyeglasses 43

FFecal Occult Blood Test 3, 40

Federal Employee Health Benets Program 17, 24, 96

Federally-Qualied Health Center Services 43, 50

Flexible Sigmoidoscopy 3, 40

Flu Shot 3, 43

Foot Exam 43

Formulary 58, 87, 93, 110, 142

Fraud 116–120

GGap (Coverage) 88–89, 98

General Enrollment Period 23–24

Glaucoma Test 3, 44

HHealth Care Proxy 125–126

Health Inormation Technology (Health IT) 132–135

Health Maintenance Organization (HMO) 70, 76, 144 Health Risk Assessment 3, 53

Hearing Aids 44, 54

Help with Costs 97–104

Hepatitis B Shot 3, 44

HIV Screening 3, 44

Home Health Care 14, 33, 45, 109, 113, 122, 124,

130–131

Hospice Care 14, 33–34, 70, 109

Hospital Care (Inpatient Coverage) 14, 34–35

IIdentity Thet 116, 119

Indian Health Service 90, 96

Inpatient 14, 34–35, 39, 52, 67, 141

Institution 77, 79, 85, 99, 101, 142

JJoin

Medicare Drug Plan 85–86Medicare Health Plan 73, 78–80

KKidney Dialysis 14, 21, 45, 74, 125, 130–131

Kidney Disease Education Services 45

Kidney Transplant 14, 21, 46, 51, 74

LLab Services 45, 50

Lietime Reserve Days 34, 143 Limited Income 98–104

Living Will 125

Long-Term Care 122–124, 143

Low-Income Subsidy (LIS) (Extra Help) 16, 65, 79,

98–101, 142, 146

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11

MMammogram 3, 38, 76–77

Medicaid 27, 71, 77, 83, 98–103, 120, 123, 128

Medical Equipment 33, 42, 45, 48, 63, 128 Medical Nutrition Therapy 3, 46

Medical Savings Account (MSA) Plans 71, 78, 84

Medically Necessary 33–38, 41, 45, 52, 93–94, 122,

143

Medicare

Part A 5, 14–15, 20–30, 32–35, 57

Part B 5, 14–15, 20–30, 36–53, 57

Part C 5, 14–15, 57, 70–81

Part D 5, 14–15, 48, 56–57, 65, 73, 84–96,98–101, 110–112

Medicare Advantage Plans (like an HMO or PPO) 15,

57, 68–69, 70–81, 143

Medicare Authorization to Disclose Personal Health

Inormation 129

Medicare Beneciary Ombudsman 120

Medicare Card (replacement) 16

Medicare Cost Plan 82, 84, 87, 143

Medicare Drug Integrity Contractor (MEDIC) 92, 116,119

Medicare Prescription Drug Coverage 14–15, 56–57,

65, 76–77, 84–96, 98–101, 110–112

Medicare Savings Programs 98, 102, 146

Medicare SELECT 66

Medicare Summary Notice (MSN) 61, 108, 118

Medicare Supplement Insurance (Medigap) 15, 24, 57,

59, 66–69, 73, 95, 122

Mental Health Care 34, 46

NNon-Doctor Services 41

Nurse Practitioner 33, 41, 46

Nursing Home 33, 71, 79, 83, 85, 103, 122–124, 128,

130–131, 142

Nutrition Therapy Services 3, 46

OOccupational Therapy 33, 45–46

Ofce or Civil Rights 17, 115, 120

Ofce o Inspector General 119Ofce o Personnel Management 17, 96

Ombudsman (Medicare Beneciary) 120

Open Enrollment 4, 13, 78, 85

Original Medicare 15, 32, 56–66, 108–109, 113

Orthotic Items 48

Outpatient Hospital Services 35, 47

Oxygen 42, 128

PPap Test 39, 144

Payment Options (premium) 30, 87

Pelvic Exam 39

Penalty (late enrollment)

Part A 23, 28

Part B 23–24, 30

Part D 90–91, 95, 98–99, 142

Personal Health Record 134

Physical Therapy 33, 35, 45, 47, 144 Physician Assistant 41

Pilot/Demonstration Programs 83, 143

Pneumococcal Shot 3, 47

Power o Attorney 125

Preerred Provider Organization (PPO) Plan 70, 76

Prescription Drugs 14–15, 34, 48, 58–59, 76–77, 84–96,

110–112, 142

Preventive Services 3, 14, 36, 128, 144

Primary Care Doctor 59, 76–77, 144 Privacy Notice 114–115

Private Contract 64

Private Fee-or-Service (PFFS) Plans 71, 77

Programs o All-Inclusive Care or the Elderly (PACE) 83,

104, 123, 143

Prostate Screening (PSA Test) 3, 48

Proxy (Health Care) 125–126

Publications 128, 136

Pulmonary Rehabilitation 49

Index


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12 Index


QQuality o Care 17, 58, 83, 130–131

Quality Improvement Organization (QIO) 17, 109, 127,

144

RRailroad Retirement Board (RRB) 17, 20–21, 129, 146

Reerral 37, 49, 59, 70, 72, 76–77, 144

Religious Nonmedical Health Care Institution 32, 35

Retiree Health Insurance (Coverage) 24–26, 95–96

Rights 105–120

Rural Health Clinic 49–50

SSecond Surgical Opinions 49

Service Area 73, 75, 79, 83, 85, 144

Shingles Vaccine 93

Shots (vaccinations) 3, 43–44, 47

Sigmoidoscopy 3, 40

Skilled Nursing Facility (SNF) Care 35, 67, 72, 144

Smoking Cessation (Tobacco Use Cessation) 3, 50

Senior Medicare Patrol (SMP) Program 117

Social Security 16, 20–21, 28–30, 61, 87, 100, 104, 146 Special Enrollment Period 4, 23, 25, 28, 30, 79, 85, 95

Special Needs Plan (SNP) 71, 74, 77

Speech-Language Pathology 33, 45, 49

State Health Insurance Assistance Program (SHIP) 16,

56, 64, 100, 116, 129, 137–140

State Medical Assistance (Medicaid) Ofce 83, 100,

102–104, 123, 128

State Pharmacy Assistance Program (SPAP) 103

Substance Abuse 46Supplemental Policy (Medigap) 15, 24, 59, 66–69, 73,

95

Supplemental Security Income (SSI) 98, 104

Supplies (medical) 32–35

Surgical Dressing Services 49

TTelehealth 50

Tests 36, 39–41, 44–45, 50

Tiers (drug ormulary) 93Tobacco Use Cessation Counseling 3, 50

Transplant Services 51

Travel 52, 58

TRICARE 16, 20, 25, 27, 90, 96

TTY 128, 144

UUnion 23–24, 26–27, 32, 65, 73, 82, 84, 90, 95

Urgently-Needed Care 52, 64, 70, 76

VVaccinations (shots) 3, 43–44, 47

Veterans’ Benets (VA) 57, 96, 123

Vision 43–44, 70

WWalkers 42, 128

Welcome to Medicare Preventive Visit 3, 37, 43, 53

Wellness Visit 3, 53 What’s New 4

Wheelchairs 42, 128

www.medicare.gov 16, 130–131

www.MyMedicare.gov 4, 61, 130, 135, 146

XX-ray 39, 47, 50

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13Important Enrollment Inormation

AP R I L

7 3 7 2

1

Coverage and Costs Change Yearly.I you join a private Medicare health or prescription drug plan, your plancan change how much it costs and what it covers each year. Even i yourplan’s cost and coverage stay the same, your health or nances may havechanged. Review your plan each year to make sure it will meet your needsor the ollowing year. I you’re satised that your current plan will meetyour needs or next year, you don’t need to do anything.

O c t o b e r Fall Open Enrollment Period

Mark your calendar with these important dates! In most cases, this may be the one chance you have each year to make a change to your health andprescription drug coverage.

Te all Open Enrollment Period dates are earlier this year. Te dateshave changed to give you more time i you want to choose and join aMedicare health or prescription drug plan.

October 1–

October 15, 2011

Compare your coverage with other availableoptions to see i there’s a better choice oryou. See page 15.

October 15–

December 7, 2011

Open Enrollment Period. You can change your Medicare health or prescription drugcoverage or 2012. See pages 78 and 85 or other times when you can switch yourcoverage.

January 1, 2012

New coverage begins i you switchedor joined a plan. New costs and benet

changes also begin i you kept your existingMedicare health or prescription drugcoverage and your plan made changes.

Is your health or drug plan leaving Medicare? Health and prescription drugplans can decide not to participate in Medicare or the coming year.Your plan will send you a letter beore the start o the Open EnrollmentPeriod i it decides to leave Medicare or stop providing coverage in your

area. See pages 106–107 or more inormation about your rights and options.



14 Medicare Basics

What is Medicare?Medicare is health insurance or the ollowing:

■ People 65 or older

■ People under 65 with certain disabilities■ People o any age with End-Stage Renal Disease (ESRD) (permanent

kidney ailure requiring dialysis or a kidney transplant)

The Dierent Parts o MedicareTe dierent parts o Medicare help cover specic services:

Medicare Part A (Hospital Insurance)

■ Helps cover inpatient care in hospitals

■ Helps cover skilled nursing acility, hospice, and home health care

See pages 32–35.

Medicare Part B (Medical Insurance)

■ Helps cover doctors’ and other health care providers’ services, outpatient care,durable medical equipment, and home health care

■ Helps cover some preventive services to help maintain your health and to keep

certain illnesses rom getting worseSee pages 36–53.

Medicare Part C (also known as Medicare Advantage)

Oers health plan options run by Medicare-approved private insurance companies.Medicare Advantage Plans are a way to get the benets and services covered underPart A and Part B. Most Medicare Advantage Plans cover Medicare prescriptiondrug coverage (Part D). Some Medicare Advantage Plans may include extra benetsor an extra cost.

See pages 70–81.

Medicare Part D (Medicare Prescription Drug Coverage)

■ Helps cover the cost o prescription drugs

■ May help lower your prescription drug costs and help protect against higher costs

■ Run by Medicare-approved private insurance companies

See pages 84–94.

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15Medicare Basics

Your Medicare Coverage Choices at a GlanceTere are two main ways to get your Medicare coverage: Original Medicareor a Medicare Advantage Plan. Use these steps to help you decide which way

to get your coverage.

Part AHospitalInsurance

Part BMedicalInsurance

MedicareSupplementInsurance(Medigap) policy

Part DPrescriptionDrug Coverage

Part CCombines Part A,Part B, and usually Part D

ORIGINAL MEDICARE MEDICARE ADVANTAGE PLANPart C (like an HMO or PPO)

Step 2: Decide i you needto add drug coverage.

Step 3: Decide i you need to add supplemental coverage.

End

End

Step 1: Decide how you want to get your coverage.

Part D Prescription DrugCoverage(Most MedicareAdvantage Plans coverprescription drugs. Youmay be able to add drugcoverage in some plantypes i not already included.)

or

Start

I you join a Medicare Advantage Plan, youdon’t need and can’t be sold a MedicareSupplement Insurance (Medigap) policy.

See page 57 or more details.

Step 2: Decide i you need toadd drug coverage.

Step 2: Decide i you need toadd drug coverage.



16 Medicare Basics

Where to Get Your Medicare Questions Answered

1‑800‑MEDICARE (1-800-633-4227)Get general or claims-specic Medicare inormation, help or people

with limited income and resources, and important phone numbers.I you need help in a language other than English or Spanish, say “Agent” to talk to a customer service representative.Y 1-877-486-2048www.medicare.gov

State Health Insurance Assistance Program (SHIP)

Get ree personalized Medicare counseling on decisions aboutcoverage; help with claims, billing, or appeals; and inormation on

programs or people with limited income and resources.See pages 137–140 or the phone number. Visitwww.medicare.gov/contacts or call 1-800-MEDICARE to get thephone numbers o SHIPs in other states.

Social Security

Get a replacement Medicare card; change your address or name; getinormation about Part A and/or Part B eligibility, entitlement, andenrollment; apply or Extra Help with Medicare prescription drug

costs; ask questions about premiums; and report a death.1-800-772-1213Y 1-800-325-0778www.socialsecurity.gov

Coordination o Benets Contractor

Find out i Medicare or your other insurance pays rst and to reportchanges in your insurance inormation.1-800-999-1118Y 1-800-318-8782

Department o Deense

Get inormation about RICARE or Lie and the RICAREPharmacy Program.1-866-773-0404 (FL)Y 1-866-773-04051-877-363-1303 (Pharmacy)Y 1-877-540-6261www.tricare.mil/mybenet


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17Medicare Basics

Department o Health and Human Services

Oce or Civil Rights I you think you were discriminated against or i your health inormationprivacy rights were violated.

1-800-368-1019Y 1-800-537-7697www.hhs.gov/ocr

Department o Veterans Aairs

I you’re a veteran or have served in the U.S. military.1-800-827-1000Y 1-800-829-4833www.va.gov

Ofce o Personnel Management

Get inormation about the Federal Employee Health Benets Program orcurrent and retired Federal employees.1-888-767-6738Y 1-800-878-5707www.opm.gov/insure

Railroad Retirement Board (RRB)

I you have benets rom the RRB, call them to change your address orname, check eligibility, enroll in Medicare, replace your Medicare card, orreport a death.Local RRB oce or 1-877-772-5772www.rrb.gov

Quality Improvement Organization (QIO)

Ask questions or report complaints about the quality o care or aMedicare-covered service or i you think Medicare coverage or yourservice is ending too soon. Visit www.medicare.gov/contacts or call

1-800-MEDICARE to get the phone number or your QIO.

http://www.hhs.gov/ocr

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http://www.rrb.gov/


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18

Notes



19

SECTION 1

Signing Up orMedicare Part A

and Part B

Section 1 includes inormation about the ollowing:

Signing Up or Part A and Part B . . . . . . . . . . . . . . . . . 20

How Other Insurance Works with Medicare . . . . . . . . . . . 26

How Much Does Part A Coverage Cost? . . . . . . . . . . . . . 28

How Much Does Part B Coverage Cost? . . . . . . . . . . . . . 29

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20 Section 1—Signing Up or Medicare Part A and Part B

Signing Up or Part A and Part BTis section explains how and when to sign up and i you shouldwait to get Part B.

Some People Get Part A and Part B Automatically

Are you already getting benets rom Social Security or theRailroad Retirement Board (RRB)? I you are, in most cases, youwill automatically get Part A and Part B starting the rst day o themonth you turn 65. I your birthday is on the rst day o the month,Part A and Part B will start the rst day o the prior month.

Are you under 65 and disabled? I so, you automatically get Part Aand Part B aer you get disability benets rom Social Security or

certain disability benets rom the RRB or 24 months.

I you’re automatically enrolled, you willget your red, white, and blue Medicarecard in the mail 3 months beore your65th birthday or your 25th month o disability. I you don’t want Part B, ollowthe instructions that come with the card,and send the card back. I you keep the

card, you keep Part B and will pay Part Bpremiums. See page 24 or help decidingi you need to sign up or Part B.

Do you have ALS (Amyotrophic Lateral Sclerosis, also calledLou Gehrig’s disease)? I you do, you automatically get Part A andPart B the month your disability benets begin.

Do you live in Puerto Rico and get benets rom Social Security or the RRB? I so, you will automatically get Part A. I you want

Part B, you will need to sign up or it. Contact your local SocialSecurity oce or RRB or more inormation.

Do you have Part A and RICARE (insurance or active duty military or retirees and their amilies)? I you do, you musthave Part B to keep your RICARE coverage. See page 25.

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21Section 1—Signing Up or Medicare Part A and Part B

Some People Need to Sign Up or Part A and Part B

Are you close to 65, but not getting Social Security or

Railroad Retirement Board (RRB) benets? I you aren’tgetting Social Security or RRB benets (or example, becauseyou’re still working) and you want Part A or Part B, youwill need to sign up (even i you’re eligible to get Part Apremium-ree). I you’re not eligible or premium-ree Part A,you can buy Part A and Part B.

Contact Social Security 3 months beore you turn 65. I youworked or a railroad, contact the RRB to sign up.

Do you have End-Stage Renal Disease (ESRD)?I you do, visit your local Social Security oce,or call Social Security at 1-800-772-1213 to signup or Part A and Part B. Y users should call1-800-325-0778. For more inormation, visitwww.medicare.gov/publicationsto view thebooklet “Medicare Coverage o Kidney Dialysisand Kidney ransplant Services.” You can also call1-800-MEDICARE (1-800-633-4227) to nd out i

a copy can be mailed to you. Y users should call1-877-486-2048.

Call Social Security at 1-800-772-1213 or more inormationabout your Medicare eligibility, and to sign up or Part Aand/or Part B. I you’re 65 or older, you can also apply orpremium-ree Part A and Part B (or which you pay a monthly premium) at www.socialsecurity.gov/retirement. Te wholeprocess can take less than 10 minutes. I you get RRB benets,call the RRB at 1-877-772-5772.

For general inormation about enrolling, visitwww.medicare.gov/MedicareEligibility . You can also get ree,personalized health insurance counseling rom your StateHealth Insurance Assistance Program (SHIP). See pages137–140 or the phone number.

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General Enrollment Period

I you didn’t sign up or Part A and/or Part B (or which you pay

monthly premiums) when you were rst eligible, you can sign upbetween January 1–March 31 each year. Your coverage will beginJuly 1. You may have to pay a higher premium or late enrollment.See pages 28 and 30.

I you sign up duringthese months:

Your coverage willbegin on:

January

July 1February

March

Special Enrollment Period

I you didn’t sign up or Part A and/or Part B (or which you pay monthly premiums) when you were rst eligible because you’recovered under a group health plan based on current employment,you can sign up or Part A and/or Part B as ollows:

Anytime that you or your spouse (or amily member i you’re disabled)is working, and you’recovered by a group healthplan through the employeror union based on thatwork

Or

During the 8-monthperiod that beginsthe month aer theemployment ends orthe group health planinsurance based oncurrent employmentends, whicheverhappens rst

Usually, you don’t pay a late enrollment penalty i you sign upduring a Special Enrollment Period. Tis Special Enrollment Perioddoesn’t apply to people with End-Stage Renal Disease (ESRD).See page 21. You may also qualiy or a Special Enrollment Period i you’re a volunteer serving in a oreign country.

Note: COBRA and retiree health plans aren’t considered coveragebased on current employment. You’re not eligible or a SpecialEnrollment Period when that coverage ends. o avoid paying ahigher premium, make sure you sign up or Medicare when you’re

rst eligible.

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Medicare Supplement Insurance (Medigap) Open

Enrollment PeriodMedicare Supplement Insurance (Medigap) policies, sold by private

insurance companies, help pay some o the health care coststhat Medicare doesn’t cover. You have a 6-month Medigap OpenEnrollment Period which starts the rst month you’re 65 and enrolledin Part B. Tis period gives you a guaranteed right to buy any Medigappolicy sold in your state regardless o your health status. Once thisperiod starts, it can’t be delayed or replaced. See pages 66–69.

o learn more details about enrollment periods, visitwww.medicare.gov/publicationsto view the act sheet “UnderstandingMedicare Enrollment Periods.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y usersshould call 1-877-486-2048.

Should You Get Part B?Te ollowing inormation can help you decide i you want to sign upor Part B.

Employer or Union Coverage—I you or your spouse (or amily member i you’re disabled) is still working and you have health

coverage through that employer (including the Federal EmployeeHealth Benets Program) or union, contact your employer or unionbenets administrator to nd out how your coverage works withMedicare. It may be to your advantage to delay Part B enrollment.

You can sign up or Part B any time you have current employer healthcoverage. COBRA and retiree health coverage don’t count as currentemployer coverage.

Once the employment ends, three things happen:

1. You have 8 months to sign up or Part B without a penalty.Tis period will run whether or not you choose COBRA. I youchoose COBRA, don’t wait until your COBRA ends to enroll inPart B. I you don’t enroll in Part B during the 8 months, you may have to pay a penalty. You won’t be able to enroll until the nextGeneral Enrollment Period and you will have to wait beore yourcoverage begins. See page 23.

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How Other Insurance Works with MedicareWhen you have other insurance (like employer group health coverage),there are rules that decide whether Medicare or your other insurancepays rst. Te insurance that pays rst is called the “primary payer.”Te one that pays second is called the “secondary payer.”

Use this chart to see who pays rst.

I you have retiree insurance(insurance rom ormer employment)…

Medicare pays rst.

I you’re 65 or older, have group healthplan coverage based on your or yourspouse’s current employment, and the

employer has 20 or more employees…

Your group health plan paysrst.

I you’re 65 or older, have group healthplan coverage based on your or yourspouse’s current employment, and theemployer has less than 20 employees…

Medicare pays rst.

I you’re under 65 and disabled, havegroup health plan coverage based onyour or a amily member’s current

employment, and the employer has 100or more employees…

Your group health plan paysrst.

I you’re under 65 and disabled, havegroup health plan coverage based onyour or a amily member’s current employment, and the employer has lessthan 100 employees…

Medicare pays rst.

I you have Medicare because o

End-Stage Renal Disease (ESRD)…

Your group health plan

will pay rst or the rst30 months aer you becomeeligible to enroll in Medicare.Medicare will pay rst aerthis 30-month period.

Note: In some cases, your employer may join with other employers orunions to orm a multiple employer plan. I this happens, only one o the employers or unions in the multiple employer plan has to have the

required number o employees or group health plan to pay rst.




Here are some important acts to remember:

■ Te insurance that pays rst (primary payer) pays up to thelimits o its coverage.

■ Te one that pays second (secondary payer) only pays i thereare costs the primary insurer didn’t cover.

■ Te secondary payer (which may be Medicare) may not pay all o the uncovered costs.

■ I your employer insurance is the secondary payer, you may need to enroll in Part B beore your insurance will pay.

Tese types o insurance usually pay rst or services related toeach type:

■ No-ault insurance (including automobile insurance)

■ Liability (including automobile insurance)

■ Black lung benets

■ Workers’ compensation

Medicaid and RICARE never pay rst or services that arecovered by Medicare. Tey only pay aer Medicare, employer group

health plans, and/or Medicare Supplement Insurance have paid.

For more inormation, visit www.medicare.gov/publicationsto view the booklet “Medicare and Other Health Benets: YourGuide to Who Pays First.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y users should call 1-877-486-2048.

I you have other insurance, tell your doctor, hospital, and

pharmacy. I you have questions about who pays rst, oryou need to update your other insurance inormation,call Medicare’s Coordination o Benets Contractor at1-800-999-1118. Y users should call 1-800-318-8782.You can also contact your employer or union benetsadministrator. You may need to give your Medicare number toyour other insurers so your bills are paid correctly and on time.

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How Other Insurance Works with Medicare

(continued)






How Much Does Part A Coverage Cost?You usually don’t pay a monthly premium or Part A coverage i you or your spouse paid Medicare taxes while working.

I you aren’t eligible or premium-ree Part A, you may be able tobuy Part A i you meet one o the ollowing conditions:

■ You’re 65 or older, and you have (or are enrolling in) Part B andmeet the citizenship and residency requirements.

■ You’re under 65, disabled, and your premium-ree Part Acoverage ended because you returned to work. (I you’re under65 and disabled, you can continue to get premium-ree Part Aor up to 8 1/2 years aer you return to work.)

Note: In 2011, people who had to buy Part A paid up to $450each month. Visit www.medicare.gov or call 1-800-MEDICARE(1-800-633-4227) to nd out the amount or 2012. Y usersshould call 1-877-486-2048.

In most cases, i you choose to buy Part A, you must alsohave Part B and pay monthly premiums or both. I you havelimited income and resources, your state may help you pay or Part A and/or Part B. See page 102. Call Social Security at1-800-772-1213 or more inormation about the Part A premium.Y users should call 1-800-325-0778.

Part A Late Enrollment Penalty

I you aren’t eligible or premium-ree Part A, and you don’t buy itwhen you’re rst eligible, your monthly premium may go up 10%.You will have to pay the higher premium or twice the number o years you could have had Part A, but didn’t sign-up. For example,i you were eligible or Part A or 2 years but didn’t sign-up, youwill have to pay the higher premium or 4 years. Usually, youdon’t have to pay a penalty i you meet certain conditions thatallow you to sign up or Part A during a Special EnrollmentPeriod. See page 23.

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Ways to Pay

I you get Social Security, RRB, or Civil Service benets, your Part Bpremium will get deducted rom your benet payment. I you don’tget these benet payments and choose to sign up or Part B, youwill get a bill. I you choose to buy Part A, you will always get a billor your premium. You can mail your premium payments to theMedicare Premium Collection Center, P.O. Box 790355, St. Louis,Missouri 63179-0355. I you get a bill rom the RRB, mail yourpremium payments to RRB, Medicare Premium Payments, P.O. Box9024, St. Louis, Missouri 63197-9024.

Part B Late Enrollment Penalty

I you don’t sign up or Part B when you’re rst eligible, you may have to pay a late enrollment penalty or as long as you haveMedicare. Your monthly premium or Part B may go up 10% oreach ull 12-month period that you could have had Part B, but didn’tsign up or it. Usually, you don’t pay a late enrollment penalty i youmeet certain conditions that allow you to sign up or Part B during aspecial enrollment period. See page 23.

Example: Mr. Smith’s initial enrollment period ended September 30,2008. He waited to sign up or Part B until the General EnrollmentPeriod in March 2011. His Part B premium penalty is 20%. (WhileMr. Smith waited a total o 30 months to sign up, this included only two ull 12-month periods.)

I you have limited income and resources, see page 97 orinormation about help paying your Medicare premiums.

How Much Does Part B Coverage Cost?

(continued)



31

SECTION 2

What Medicare

Part A and

Part B Cover


What Does Part A (Hospital Insurance) Cover? . . . . . . . . . 32

What You Pay or Part A-Covered Services . . . . . . . . . . . . 32

Part A-Covered Services . . . . . . . . . . . . . . . . . . . . . . 33

What Does Part B (Medical Insurance) Cover? . . . . . . . . . 36

What You Pay or Part B-Covered Services . . . . . . . . . . . . 36

Part B-Covered Services . . . . . . . . . . . . . . . . . . . . . . 37

What’s NO Covered by Part A and Part B? . . . . . . . . . . . 54

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32 Section 2—What Medicare Part A and Part B Cover

What Services Does Medicare Cover?Medicare covers certain medical services and supplies in hospitals,doctors’ oces, and other health care settings. Services are eithercovered under Part A or Part B. I you have both Part A and Part B,you can get all o the Medicare-covered services listed in this section,whether you have Original Medicare or a Medicare health plan.

■ See pages 33–35 or the Part A-covered services list.

■ See pages 37–53 or the Part B-covered services list.

What Does Part A (Hospital Insurance) Cover?Part A helps cover the ollowing:

■ Inpatient care in hospitals

■ Inpatient care in a skilled nursing acility (not custodial orlong-term care)

■ Hospice care services

■ Home health care services

■ Inpatient care in a Religious Nonmedical Health Care Institution

You can nd out i you have Part A by looking at your Medicare card.I you have Original Medicare, you will use this card to get yourMedicare-covered services. I you join a Medicare health plan, you

must use the card rom the plan to get your Medicare-covered services.

What You Pay or Part A‑Covered ServicesCopayments, coinsurance, and deductibles may apply or each servicein the list on the next three pages. Visit www.medicare.gov or call1-800-MEDICARE (1-800-633-4227) to get specic cost inormation.Y users should call 1-877-486-2048.

I you’re in a Medicare health plan or have other insurance (like a

Medicare Supplement Insurance (Medigap) policy, or employer orunion coverage), your costs may be diferent. Contact the plans you’reinterested in to nd out about the costs, or visit the Medicare PlanFinder at www.medicare.gov/nd-a-plan.

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33Section 2—What Medicare Part A and Part B Cover

Part A‑Covered Services

Blood

In most cases, the hospital gets blood rom a blood bank at no

charge, and you won’t have to pay or it or replace it. I the hospitalhas to buy blood or you, you must either pay the hospital costsor the rst 3 units o blood you get in a calendar year or have theblood donated by you or someone else.

Home Health Services

Medicare covers medically-necessary part-time or intermittentskilled nursing care, and/or physical therapy, speech-languagepathology services, and/or services or people with a continuing

need or occupational therapy. A doctor enrolled in Medicare,or certain health care providers who work with the doctor, mustsee you ace-to-ace beore the doctor can certiy that you needhome health services. Tat doctor must order your care, and aMedicare-certied home health agency must provide it. Homehealth services may also include medical social services, part-timeor intermittent home health aide services, and medical supplies oruse at home. You must be homebound, which means leaving homeis a major eort.

■ You pay nothing or covered home health care services.■ You pay 20% o the Medicare-approved amount or durable

medical equipment. See page 42.

Hospice Care

o qualiy or hospice care, your doctor must certiy that you’reterminally ill and have 6 months or less to live. I you’re already getting hospice care, a hospice doctor or nurse practitioner willneed to see you about 6 months aer you enter hospice to certiy

that you’re still terminally ill. Coverage includes drugs or painrelie and symptom management; medical, nursing, and socialservices; certain durable medical equipment and other coveredservices as well as services Medicare usually doesn’t cover, suchas spiritual and grie counseling. A Medicare-approved hospiceusually gives hospice care in your home or other acility where youlive such as a nursing home.

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Hospice Care (continued)

Hospice care doesn’t pay or your stay in a acility (room and board)

unless the hospice medical team determines that you need short-terminpatient stays or pain and symptom management that can’t be addressedat home. Tese stays must be in a Medicare-approved acility, such as ahospice acility, hospital, or skilled nursing acility which contracts withthe hospice. Medicare also covers inpatient respite care which is careyou get in a Medicare-approved acility so that your usual caregiver canrest. You can stay up to 5 days each time you get respite care. Medicarewill pay or covered services or health problems that aren’t related toyour terminal illness. You can continue to get hospice care as long as

the hospice medical director or hospice doctor recerties that you’reterminally ill.

■ You pay nothing or hospice care.

■ You pay a copayment o up to $5 per prescription or outpatientprescription drugs or pain and symptom management.

■ You pay 5% o the Medicare-approved amount or inpatient respite care.

Hospital Care (Inpatient)

Medicare covers semi-private rooms, meals, general nursing, and drugs as

part o your inpatient treatment, and other hospital services and supplies.Tis includes care you get in acute care hospitals, critical access hospitals,inpatient rehabilitation acilities, long-term care hospitals, inpatient careas part o a qualiying clinical research study, and mental health care.Tis doesn’t include private-duty nursing, a television or phone in yourroom (i there is a separate charge or these items), or personal care itemslike razors or slipper socks. It also doesn’t include a private room, unlessmedically necessary . I you have Part B, it covers the doctor’s services youget while you’re in a hospital.

■ You pay a deductible and no copayment or days 1–60 each benetperiod.

■ You pay a copayment or days 61–90 each benet period.

■ You pay a copayment per “lietime reserve day” aer day 90 each benetperiod (up to 60 days over your lietime).

■ You pay all costs or each day aer the lietime reserve days.

■ Inpatient mental health care in a psychiatric hospital is limited to 190days in a lietime.

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Hospital Care (Inpatient) (continued)


Note: Staying overnight in a hospital doesn’t always mean you’re

an inpatient. You’re considered an inpatient the day a doctorormally admits you to a hospital with a doctor’s order. Always ask i you’re an inpatient or an outpatient since it afects what you pay andwhether you will qualiy or Part A coverage in a skilled nursingacility . For more inormation, visit www.medicare.gov/publications to view the act sheet “Are You a Hospital Inpatient or Outpatient?I You Have Medicare—Ask!” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you.Y users should call 1-877-486-2048.

Religious Nonmedical Health Care Institution (Inpatient care)

Medicare will only cover the non-medical, non-religious healthcare items and services (like room and board) in this type o acility i you qualiy or hospital or skilled nursing acility care,but your medical care isn’t in agreement with your religious belies.Non-medical items and services, like wound dressings or use o asimple walker during your stay, don’t require a doctor’s order orprescription. Medicare doesn’t cover the religious portion o care.

Skilled Nursing Facility Care

Medicare covers semi-private rooms, meals, skilled nursing andrehabilitative services, and other services and supplies that aremedically necessary aer a 3-day minimum medically-necessary inpatient hospital stay or a related illness or injury. An inpatienthospital stay begins the day you’re ormally admitted with a doctor’sorder and doesn’t include the day you’re discharged. o qualiy orcare in a skilled nursing acility, your doctor must certiy that you

need daily skilled care like intravenous injections or physical therapy.Medicare doesn’t cover long-term care or custodial care.

■ You pay nothing or the rst 20 days each benet period.

■ You pay a coinsurance per day or days 21–100 each benet period.

■ You pay all costs or each day aer day 100 in a benet period.

Note: Visit www.medicare.gov or call 1-800-MEDICARE to nd outwhat you pay or inpatient hospital stays and skilled nursing acility care in 2012.

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What Does Part B (Medical Insurance) Cover?Part B helps cover medically-necessary services like doctors’ services,outpatient care, home health services, durable medical equipment, andother medical services. Part B also covers many preventive services.You can nd out i you have Part B by looking at your Medicare card.

Pages 37–53 include a list o common Part B-covered services and generaldescriptions. Medicare may cover some services and tests more oen thanthe timerames listed i needed to diagnose a condition. o nd out i Medicare covers a service not on this list, visitwww.medicare.gov/coverage or call 1-800-MEDICARE (1-800-633-4227).Y users should call 1-877-486-2048. For more details aboutMedicare-covered services, visit www.medicare.gov/publicationsto view

the booklet “Your Medicare Benets.”You will see this apple next to the preventive services on pages 37–53.Use the preventive services checklist on page 3 to ask your doctor or otherhealth care provider which preventive services you should get.

What You Pay or Part B‑Covered ServicesTe alphabetical list on the ollowing pages gives general inormationabout what you pay i you have Original Medicare and see doctors orother health care providers who accept assignment. You will pay more ordoctors or providers who don’t accept assignment. I you’re in a MedicareAdvantage Plan (like an HMO or PPO) or have other insurance, yourcosts may be diferent. Contact your plan or benets administratordirectly to nd out about the costs.

Under Original Medicare, i the Part B deductible applies you must pay all costs until you meet the yearly Part B deductible beore Medicarebegins to pay its share. Ten, aer your deductible is met, you typically pay 20% o the Medicare-approved amount o the service, i the doctor

or other health care provider accepts assignment. Tere is no yearly limit or what you pay out-o-pocket. Visit www.medicare.gov or call1-800-MEDICARE to get specic cost inormation.

You pay nothing or most preventive services i you get the servicesrom a doctor or other health care provider who accepts assignment.However, or some preventive services, you may have to pay a deductible,coinsurance, or both.

Note: See page 62 or more inormation about assignment.

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Part B‑Covered Services

Abdominal Aortic Aneurysm Screening

Medicare covers a one-time screening abdominal aortic aneurysm

ultrasound or people at risk. You must get a reerral or it as part o your one-time “Welcome to Medicare” preventive visit. See page 53.You pay nothing or the screening i the doctor or other health careprovider accepts assignment.

Ambulance Services

Medicare covers ground ambulance transportation when youneed to be transported to a hospital or skilled nursing acility or medically-necessary services, and transportation in any

other vehicle could endanger your health. Medicare may pay oremergency ambulance transportation in an airplane or helicopterto a hospital i you need immediate and rapid ambulancetransportation that ground transportation can’t provide.

In some cases, Medicare may pay or limited non-emergency ambulance transportation i you have orders rom your doctorsaying that ambulance transportation is medically necessary.Medicare will only cover ambulance services to the nearestappropriate medical acility that’s able to give you the care youneed. You pay 20% o the Medicare-approved amount, and thePart B deductible applies.

Ambulatory Surgical Centers

Medicare covers the acility ees or approved surgical proceduresin an ambulatory surgical center (acility where surgical proceduresare perormed, and the patient is released within 24 hours). Exceptor certain preventive services (or which you pay nothing), youpay 20% o the Medicare-approved amount to both the ambulatory surgical center and the doctor who treats you, and the Part Bdeductible applies. You pay all acility ees or procedures Medicaredoesn’t allow in ambulatory surgical centers.

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Blood

In most cases, the provider gets blood rom a blood bank at no

charge, and you won’t have to pay or it or replace it. However, youwill pay a copayment or the blood processing and handling servicesor every unit o blood you get, and the Part B deductible applies.I the provider has to buy blood or you, you must either pay theprovider costs or the rst 3 units o blood you get in a calendar yearor have the blood donated by you or someone else.

Bone Mass Measurement (Bone Density)

Tis test helps to see i you’re at risk or broken bones. It’s covered

once every 24 months (more oen i medically necessary ) or peoplewho have certain medical conditions or meet certain criteria.You pay nothing or this test i the doctor or other health careprovider accepts assignment.

Breast Cancer Screening (Mammograms)

Medicare covers screening mammograms to check or breast canceronce every 12 months or all women with Medicare 40 and older.Medicare covers one baseline mammogram or women between

35–39. You pay nothing or the test i the doctor or other health careprovider accepts assignment.

Cardiac Rehabilitation

Medicare covers comprehensive programs that include exercise,education, and counseling or patients who meet certain conditions.Medicare also covers intensive cardiac rehabilitation programs thatare typically more rigorous or more intense than regular cardiacrehabilitation programs. You pay 20% o the Medicare-approved

amount i you get the services in a doctor’s oce. In a hospitaloutpatient setting, you also pay the hospital a copayment. Te Part Bdeductible applies.




Cardiovascular Screenings

Tese screenings include blood tests that help detect conditions that

may lead to a heart attack or stroke. Medicare covers these screeningtests every 5 years to test your cholesterol, lipid, and triglyceridelevels. You pay nothing or the tests, but you generally have to pay 20% o the Medicare-approved amount or the doctor’s visit.

Cervical and Vaginal Cancer Screening

Medicare covers Pap tests and pelvic exams to check or cervicaland vaginal cancers. As part o the exam, Medicare also covers aclinical breast exam to check or breast cancer. Medicare covers

these screening tests once every 24 months. Medicare covers thesescreening tests once every 12 months i you’re at high risk orcervical or vaginal cancer or i you’re o child-bearing age and hadan abnormal Pap test in the past 36 months. You pay nothing orthe Pap lab test, Pap test specimen collection, and pelvic and breastexams i the doctor or other health care provider accepts assignment.

Chemotherapy

Medicare covers chemotherapy in a doctor’s oce, reestanding

clinic, or hospital outpatient setting or people with cancer. Forchemotherapy given in a doctor’s oce or reestanding clinic, youpay 20% o the Medicare-approved amount. I you get chemotherapy in a hospital outpatient setting, you pay a copayment or thetreatment. For chemotherapy in a hospital inpatient setting coveredunder Part A, see Hospital Care (Inpatient) on page 34.

Chiropractic Services (limited)

Medicare covers these services to help correct a subluxation (when

one or more o the bones o your spine move out o position) usingmanipulation o the spine. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies.

Note: You pay all costs or any other services or tests ordered by achiropractor (including X-rays or massage therapy).






Clinical Research Studies

Clinical research studies test how well dierent types o medical care

work and i they are sae. Medicare covers some costs, like oce visitsand tests, in qualiying clinical research studies. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.Note: I you’re in a Medicare Advantage Plan (like an HMO or PPO),some costs may be covered by your plan.

Colorectal Cancer Screenings

Medicare covers these screenings to help nd precancerous growths ornd cancer early, when treatment is most eective. One or more o the

ollowing tests may be covered. alk to your doctor or other health careprovider.

■ Fecal Occult Blood est—Tis test is covered once every 12 months i you’re 50 or older. You pay nothing or the test.

■ Flexible Sigmoidoscopy—Tis test is generally covered once every 48months i you’re 50 or older, or 120 months aer a previous screeningcolonoscopy or those not at high risk. You pay nothing or this test i the doctor or other health care provider accepts assignment.

■ Colonoscopy—Tis test is generally covered once every 120 months

(high risk every 24 months) or 48 months aer a previous fexiblesigmoidoscopy. No minimum age. You pay nothing or this test i thedoctor or other health care provider accepts assignment.

■ Barium Enema—Tis test is generally covered once every 48months i you’re 50 or older (high risk every 24 months) when usedinstead o a sigmoidoscopy or colonoscopy. You pay 20% o theMedicare-approved amount or the doctor services. In a hospitaloutpatient setting, you also pay the hospital a copayment.

Defbrillator (Implantable Automatic)

Medicare covers these devices or some people diagnosed with heartailure. I the surgery takes place in an outpatient setting, you pay 20% o the Medicare-approved amount or the doctor’s services. I you get the device as a hospital outpatient, you also pay the hospitala copayment, but no more than the Part A hospital stay deductible.Te Part B deductible applies. Surgeries to implant debrillators in ahospital inpatient setting are covered under Part A. See Hospital Care(Inpatient) on page 34.




Diabetes Screenings

Medicare covers these screenings i you have any o the ollowing

risk actors: high blood pressure (hypertension), history o abnormalcholesterol and triglyceride levels (dyslipidemia), obesity, or a history o high blood glucose (blood sugar). ests may also be covered i youmeet other requirements, like being overweight or having a amily history o diabetes.

Based on the results o these tests, you may be eligible or up to twodiabetes screenings every year. You pay nothing or the test i yourdoctor or other health care provider accepts assignment.

Diabetes Sel-Management Training

Medicare covers a program to help people cope with and managediabetes. Te program may include tips or eating healthy, beingactive, monitoring blood sugar, taking medication, and reducingrisks. You must have diabetes and a written order rom your doctoror other health care provider. You pay 20% o the Medicare-approved amount, and the Part B deductible applies.

Diabetes Supplies

Medicare covers blood sugar testing monitors, blood sugar teststrips, lancet devices and lancets, blood sugar control solutions,and therapeutic shoes (in some cases). Medicare only coversinsulin i used with an external insulin pump. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.

Note: Medicare prescription drug coverage (Part D) may coverinsulin and certain medical supplies used to inject insulin, such assyringes, and some oral diabetic drugs.

Doctor and Other Health Care Provider Services

Medicare covers doctor services that are medically necessary (includes outpatient and some doctor services you get when you’rea hospital inpatient) or covered preventive services. Medicare alsocovers services provided by other health care providers, such asphysician assistants, nurse practitioners, social workers, physicaltherapists, and psychologists. Except or certain preventive services(or which you pay nothing), you pay 20% o the Medicare-approved

amount, and the Part B deductible applies.






Durable Medical Equipment (like walkers)

Medicare covers items such as oxygen equipment and supplies,

wheelchairs, walkers, and hospital beds ordered by a doctor or otherhealth care provider enrolled in Medicare or use in the home.Some items must be rented. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies. In all areas o thecountry, you must get your covered equipment or supplies andreplacement or repair services rom a Medicare-approved supplieror Medicare to pay.

For more inormation, visit www.medicare.gov/publicationsto viewthe booklet “Medicare Coverage o Durable Medical Equipment andOther Devices.”

In some areas o the country i you need certain items, you mustuse specic suppliers, or Medicare won’t pay or the item and youlikely will pay ull price. Tis program will help save you andMedicare money; ensure you get quality equipment, supplies, andservices; and help limit raud and abuse. It’s important to see i

you’re afected by this program to ensure Medicare payment andavoid any disruption o service.

Tis program is efective in certain areas in the ollowing states: Caliornia, Florida, Indiana, Kansas, Kentucky, Missouri, NorthCarolina, Ohio, Pennsylvania, South Carolina, and exas. I youcurrently live in or visit one o these areas and are renting or needcertain durable medical equipment or supplies, do any o theollowing to get answers to your questions about what’s covered orabout suppliers:

■ Visit www.medicare.gov/supplier. Medicare-approved suppliers are

listed. Te specic suppliers you need to use or this new programhave an orange star next to their names.

■ Call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

■ Call your State Health Insurance Assistance Program (SHIP). Seepages 137–140 or the phone number.

Te program will expand to 91 additional areas around the country in 2013. Medicare will provide more inormation beore changes

occur in those areas.


http://www.medicare.gov/supplier






EKG (Electrocardiogram) Screening

Medicare covers a one-time screening EKG i ordered by your doctor

or other health care provider as part o your one-time “Welcometo Medicare” preventive visit. See page 53. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.An EKG is also covered as a diagnostic test. See page 50. I you havethe test at a hospital or a hospital owned clinic, you also pay thehospital a copayment.

Emergency Department Services

Tese services are covered when you have an injury, a sudden illness,

or an illness that quickly gets much worse. You pay a speciedcopayment or the hospital emergency department visit, and youpay 20% o the Medicare-approved amount or the doctor’s or otherhealth care provider’s services. Te Part B deductible applies.

Eyeglasses (limited)

Medicare covers one pair o eyeglasses with standard rames (orone set o contact lenses) aer cataract surgery that implants anintraocular lens. You pay 20% o the Medicare-approved amount,

and the Part B deductible applies.

Federally-Qualifed Health Center Services

Medicare covers many outpatient primary care and preventiveservices you get through certain community-based organizations.Generally, you pay 20% o the Medicare-approved amount. You pay nothing or most preventive services.

Flu Shots

Medicare generally covers fu shots once per fu season in the all orwinter. You pay nothing or getting the fu shot i the doctor or otherhealth care provider accepts assignment or giving the shot.

Foot Exams and Treatment

Medicare covers oot exams and treatment i you have diabetes-related nerve damage and/or meet certain conditions. You pay 20% o the Medicare-approved amount, and the Part B deductibleapplies. In a hospital outpatient setting, you also pay the hospital a

copayment.


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http://-/?-




Glaucoma Tests

Tese tests are covered once every 12 months or people at high risk

or the eye disease glaucoma. You’re at high risk i you have diabetes,a amily history o glaucoma, are Arican-American and 50 or older,or are Hispanic and 65 or older. An eye doctor who is legally allowedby the state must do the tests. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies or the doctor’s visit. In ahospital outpatient setting, you also pay the hospital a copayment.

Hearing and Balance Exams

Medicare covers these exams i your doctor or other health care

provider orders them to see i you need medical treatment. You pay 20% o the Medicare-approved amount, and the Part B deductibleapplies. In a hospital outpatient setting, you also pay the hospital acopayment.

Note: Original Medicare doesn’t cover hearing aids or exams ortting hearing aids.

Hepatitis B Shots

Medicare covers these shots or people at high or medium risk or Hepatitis B. Your risk or Hepatitis B increases i you havehemophilia, End-Stage Renal Disease (ESRD), or certain conditionsthat increase your risk or inection. Other actors may increase yourrisk or Hepatitis B, so check with your doctor or other health careprovider. You pay nothing or the shot i the doctor or other healthcare provider accepts assignment.

HIV Screening

Medicare covers HIV (Human Immunodeciency Virus) screening

or people at increased risk or the inection, anyone who asks or thetest, and pregnant women. Medicare covers this test once every 12months or up to 3 times during a pregnancy. You pay nothing or theHIV screening.






Home Health Services

Medicare covers medically-necessary part-time or intermittent

skilled nursing care, and/or physical therapy, speech-languagepathology services, and/or services or people with a continuingneed or occupational therapy. A doctor enrolled in Medicare,or certain health care providers who work with the doctor, mustsee you ace-to-ace beore the doctor can certiy that you needhome health services. Tat doctor must order your care, and aMedicare-certied home health agency must provide it.

Home health services may also include medical social services,part-time or intermittent home health aide services, durablemedical equipment, and medical supplies or use at home.You must be homebound, which means leaving home is a majoreort. You pay nothing or covered home health services.For Medicare-covered durable medical equipment inormation,see page 42.

Kidney Dialysis Services and Supplies

Generally, Medicare covers dialysis treatment three times aweek i you have End-Stage Renal Disease (ESRD). Tis includesdialysis medications, laboratory tests, home dialysis training, andrelated equipment and supplies. Te dialysis acility is responsibleor coordinating your dialysis services (at home or in a acility).You pay 20% o the Medicare-approved amount and the Part Bdeductible applies.

Kidney Disease Education Services

Medicare may cover up to six sessions o kidney diseaseeducation services i you have Stage IV kidney disease, and yourdoctor or other health care provider reers you or the service.You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Laboratory Services

Medicare covers laboratory services including certain blood tests,urinalysis, and some screening tests. You pay nothing or theseservices.




Medical Nutrition Therapy Services

Medicare may cover medical nutrition therapy and certain related services

i you have diabetes or kidney disease, or you have had a kidney transplantin the last 36 months, and your doctor or other health care provider reersyou or the service. You pay nothing or these services i the doctor or otherhealth care provider accepts assignment.

Mental Health Care (outpatient)

Medicare covers mental health care services to help with conditions such asdepression or anxiety. Coverage includes services generally provided in anoutpatient setting (such as a doctor’s or other health care provider’s oce

or hospital outpatient department), including visits with a psychiatrist orother doctor, clinical psychologist, nurse practitioner, physician’s assistant,clinical nurse specialist, or clinical social worker; certain treatment orsubstance abuse; and lab tests. Certain limits and conditions apply.

What you pay will depend on whether you’re being diagnosed andmonitored or whether you’re getting treatment.

■ For visits to a doctor or other health care provider to diagnose yourcondition, you pay 20% o the Medicare-approved amount.

■ Generally, or outpatient treatment o your condition (such as counselingor psychotherapy), you pay 40% o the Medicare-approved amount.Tis coinsurance amount will decrease until it reaches 20% in 2014.

Te Part B deductible applies or both visits to diagnose or treat yourcondition.

Note: Inpatient mental health care is covered under Part A. See HospitalCare (Inpatient) on page 34.

alk to your doctor or other health care provider i you eel sad, have little

interest in things you used to enjoy, eel dependent on drugs or alcohol, orhave thoughts about ending your lie.

Occupational Therapy

Medicare covers evaluation and treatment to help you perorm activities o daily living (such as dressing or bathing) aer an illness or accident whenyour doctor or other health care provider certies you need it. Tere may be a limit on the amount Medicare will pay or these services in a singleyear and there may be certain exceptions to these limits. You pay 20% o

the Medicare-approved amount, and the Part B deductible applies.






Outpatient Hospital Services

Medicare covers many diagnostic and treatment services in

participating hospital outpatient departments. Generally, you pay 20% o the Medicare-approved amount or the doctor’s or otherhealth care provider’s services. You may pay more or servicesyou get in a hospital outpatient setting than you will pay or thesame care in a doctor’s oce. In addition to the amount youpay the doctor, you will usually pay the hospital a copaymentor each service you get in a hospital outpatient setting, exceptor certain preventive services or which there is no copayment.Te copayment can’t be more than the Part A hospital stay

deductible. Te Part B deductible applies.

Outpatient Medical and Surgical Services and Supplies

Medicare covers approved procedures like X-rays, casts, or stitches.You pay 20% o the Medicare-approved amount or the doctor’s orother health care provider’s services. You generally pay the hospitala copayment or each service you get in a hospital outpatientsetting. For each service, the copayment can’t be more than thePart A hospital stay deductible. Te Part B deductible applies, and

you pay all charges or items or services that Medicare doesn’tcover.

Physical Therapy

Medicare covers evaluation and treatment or injuries and diseasesthat change your ability to unction when your doctor or otherhealth care provider certies your need or it. Tere may be a limiton the amount Medicare will pay or these services in a single yearand there may be certain exceptions to these limits. You pay 20% o

the Medicare-approved amount, and the Part B deductible applies.

Pneumococcal Shot

Medicare covers pneumococcal shots to help preventpneumococcal inections (like certain types o pneumonia).Most people only need this shot once in their lietime. alk withyour doctor or other health care provider to see i you shouldget this shot. You pay nothing i the doctor or other health careprovider accepts assignment or giving the shot.





Prescription Drugs (limited)

Medicare covers a limited number o drugs such as injections you get in

a doctor’s oce, certain oral cancer drugs, drugs used with some types o durable medical equipment (like a nebulizer or external inusion pump),and under very limited circumstances, certain drugs you get in a hospitaloutpatient setting. You pay 20% o the Medicare-approved amount orthese covered drugs.

I the covered drugs you get in a hospital outpatient setting are part o your outpatient services, you pay the copayment or the services. However,other types o drugs in a hospital outpatient setting (sometimes called“sel-administered drugs” or drugs you would normally take on yourown), aren’t covered by Part B. What you pay depends on whether youhave Part D or other prescription drug coverage, whether your drug plancovers the drug, and whether the hospital’s pharmacy is in your drug plan’snetwork. Contact your prescription drug plan to nd out what you pay or drugs you get in a hospital outpatient setting that aren’t covered underPart B. See page 94 or more inormation.

Other than the examples above, you pay 100% or most prescription drugs,unless you have Part D or other drug coverage.

Prostate Cancer Screenings

Medicare covers a Prostate Specic Antigen (PSA) test and a digital rectalexam once every 12 months or men over 50 (beginning the day aeryour 50th birthday). You pay nothing or the PSA test. You pay 20% o the Medicare-approved amount, and the Part B deductible applies orthe digital rectal exam. In a hospital outpatient setting, you also pay thehospital a copayment.

Prosthetic/Orthotic ItemsMedicare covers arm, leg, back, and neck braces; articial eyes; articiallimbs (and their replacement parts); some types o breast prostheses (aermastectomy); and prosthetic devices needed to replace an internal body part or unction (including ostomy supplies, and parenteral and enteralnutrition therapy) when ordered by a doctor or other health care providerenrolled in Medicare. For Medicare to cover your prosthetic or orthotic,you must go to a supplier that’s enrolled in Medicare. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.





Pulmonary Rehabilitation

Medicare covers a comprehensive pulmonary rehabilitation

program i you have moderate to very severe chronic obstructivepulmonary disease (COPD) and have a reerral rom the doctortreating this chronic respiratory disease. You pay 20% o theMedicare-approved amount i you get the service in a doctor’soce. You also pay the hospital a copayment per session i you getthe service in a hospital outpatient setting. Te Part B deductible applies.

Rural Health Clinic Services

Medicare covers many outpatient primary care and preventiveservices in rural health clinics. Generally, you pay 20% o theMedicare-approved amount and the Part B deductible applies.However, you pay nothing or most preventive services.

Second Surgical Opinions

Medicare covers second surgical opinions in some cases or surgery that isn’t an emergency. In some cases, Medicare covers thirdsurgical opinions. You pay 20% o the Medicare-approved amount,

and the Part B deductible applies.

Speech-Language Pathology Services

Medicare covers evaluation and treatment given to regain andstrengthen speech and language skills, including cognitive andswallowing skills, when your doctor or other health care providercerties you need it. Tere may be a limit on the amount Medicarewill pay or these services in a single year, and there may be certainexceptions to these limits. You pay 20% o the Medicare-approved

amount, and the Part B deductible applies.

Surgical Dressing Services

Medicare covers these services or treatment o a surgical orsurgically-treated wound. You pay 20% o the Medicare-approvedamount or the doctor’s or other health care provider’s services.You pay a xed copayment or these services when you get themin a hospital outpatient setting. You pay nothing or the supplies.Te Part B deductible applies.





Transplants and Immunosuppressive Drugs

Medicare covers doctor services or heart, lung, kidney, pancreas,

intestine, and liver transplants under certain conditions and only in a Medicare-certied acility. Medicare covers bone marrow andcornea transplants under certain conditions.

Medicare covers immunosuppressive drugs i the transplant waseligible or Medicare payment, or an employer or union grouphealth plan was required to pay beore Medicare paid or thetransplant. You must have Part A at the time o the transplant,and you must have Part B at the time you get immunosuppressivedrugs. You pay 20% o the Medicare-approved amount, and thePart B deductible applies.

I you’re thinking about joining a Medicare Advantage Plan (likean HMO or PPO) and are on a transplant waiting list or believeyou need a transplant, check with the plan beore you join to makesure your doctors, other health care providers, and hospitals are inthe plan’s network. Also, check the plan’s coverage rules or priorauthorization.

Note: Medicare drug plans (Part D) may cover immunosuppressivedrugs, even i Medicare or an employer or union group health plandidn’t pay or the transplant.





Travel (health care needed when traveling outside the United

States)

Medicare generally doesn’t cover health care while you’re travelingoutside the U.S. (the “U.S.” includes the 50 states, the District o Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the NorthernMariana Islands, and American Samoa). Tere are some exceptionsincluding some cases where Medicare may pay or services that you getwhile on board a ship within the territorial waters adjoining the landareas o the U.S. Medicare may pay or inpatient hospital, doctor, orambulance services you get in a oreign country in the ollowing rarecases:

1. You’re in the U.S. when an emergency occurs and the oreignhospital is closer than the nearest U.S. hospital that can treat yourmedical condition.

2. You’re traveling through Canada without unreasonable delay by themost direct route between Alaska and another state when a medicalemergency occurs and the Canadian hospital is closer than thenearest U.S. hospital that can treat the emergency.

3. You live in the U.S. and the oreign hospital is closer to your homethan the nearest U.S. hospital that can treat your medical condition,

regardless o whether an emergency exists.Medicare may cover medically-necessary ambulance transportation toa oreign hospital only with admission or medically-necessary coveredinpatient hospital services.

You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Urgently-Needed Care

Medicare covers urgently-needed care to treat a sudden illness or injury that isn’t a medical emergency. You pay 20% o the Medicare-approvedamount or the doctor’s or other health care provider’s services and thePart B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.


are dened

on pages

141–144.





“Welcome to Medicare” Preventive Visit

During the rst 12 months that you have Part B, you can get a

“Welcome to Medicare” preventive visit. Tis visit helps you and yourdoctor or other health care provider develop a personalized plan toprevent disease, improve your health, and help you stay well. Whenyou make your appointment, let your doctor’s oce know that you

would like to schedule your “Welcome to Medicare” preventive visit.

Yearly “Wellness” Visit

I you’ve had Part B or longer than 12 months, you can get a yearly “Wellness” visit to develop or update a personalized plan to prevent

disease based on your current health and risk actors. Tis visit iscovered once every 12 months.

Your provider may suggest that you ll out a short questionnaire,called a Health Risk Assessment, as part o this visit. Answeringthese questions can help you gure out what to work on to stay healthy. Te questions are based on years o medical research andadvice rom the Centers or Disease Control and Prevention (CDC).For more inormation about the Health Risk Assessment, visitwww.medicare.gov .

Note: Your rst yearly “Wellness” visit can’t take place within 12months o you having Medicare or your “Welcome to Medicare”

visit. However, you don’t need to have a “Welcome to Medicare” visit beore your yearly “Wellness” visit.

You pay nothing or the “Welcome to Medicare” preventive visitor the yearly “Wellness” visit i the doctor or other health careprovider accepts assignment. However i your doctor or otherhealth care provider perorms additional tests or services duringthe same visit that aren’t covered under these preventive benets,you may have to pay coinsurance, and the Part B deductible may apply.





55

SECTION 3

Your

Medicare

Choices


Decide How to Get Your Medicare . . . . . . . . . . . . . . . . 56

Your Medicare Coverage Choices . . . . . . . . . . . . . . . . . 57

Tings to Consider When Choosing orChanging Your Coverage . . . . . . . . . . . . . . . . . . . . 58

Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Medicare Supplement Insurance (Medigap) . . . . . . . . . . . 66

Medicare Advantage Plans (Part C) . . . . . . . . . . . . . . . . 70

Other Medicare Health Plans . . . . . . . . . . . . . . . . . . . 82

Medicare Prescription Drug Coverage (Part D) . . . . . . . . . 84

Tis handbook has basic inormation. You will need moredetailed inormation than this handbook provides to make an

inormed choice. Beore making any decisions, learn as much as you can about the types o coverage available to you. See page 56to get help with your Medicare decisions.



56 Section 3—Your Medicare Choices

Decide How to Get Your MedicareYou can choose dierent ways to get your Medicare coverage.

1. You can choose Original Medicare and i you want prescription

drug coverage, you must also join a Medicare Prescription DrugPlan (Part D).2. You can choose to join a Medicare Advantage Plan (like an HMO

or PPO), and the plan may include Medicare prescription drugcoverage. In most cases, you must take the drug coverage thatcomes with the Medicare Advantage Plan.

I you don’t join a Medicare Advantage Plan or other Medicare healthplan, you will have Original Medicare. See the next page or moreinormation about your coverage choices, and the decisions you need

to make.

Note: I you have End-Stage Renal Disease (ESRD), you will usually get your health care through Original Medicare. See page 59.

Each year in the all, you should review your health and prescriptionneeds because your health, nances, or plan’s coverage may havechanged. I you decide other coverage will better meet your needs,

you can switch plans between October 15–December 7. See pages78 and 85. I you’re satised with your current plan’s coverage or the

ollowing year, you don’t need to do anything.

Need Help Deciding?1. Visit the Medicare Plan Finder at www.medicare.gov/nd-a-plan to

nd and compare plans in your area.2. Get ree personalized counseling about choosing coverage.

See pages 137–140 or the phone number o your State HealthInsurance Assistance Program (SHIP).

3. Call 1-800-MEDICARE (1-800-633-4227), and say “Agent.”Y users should call 1-877-486-2048. I you need help in alanguage other than English or Spanish, let the customer servicerepresentative know.

See pages 114–115 to nd out how Original Medicare or a Medicareplan you may join uses and releases your personal inormation.

Blue words

in the textare dened

on pages

141–144.

H





57Section 3—Your Medicare Choices

Your Medicare Coverage ChoicesTere are two main choices or how you get your Medicare coverage. Use thesesteps to help you decide.

Note: I you join a Medicare AdvantagePlan, you can’t use Medicare SupplementInsurance (Medigap) to pay or out-o-pocketcosts you have in the Medicare AdvantagePlan. I you already have a MedicareAdvantage Plan, you can’t be sold a Medigappolicy. See pages 66-69.

Decide I You Want Original Medicare or a Medicare Advantage Plan

Original Medicare IncludesPart A (Hospital Insurance)

and/or Part B (Medical Insurance)

■ Medicare provides this coverage directly.■ You have your choice o doctors, hospitals,

and other providers that accept Medicare.■ Generally, you or your supplemental

coverage pay deductibles and coinsurance.■ You usually pay a monthly premium or

Part B.See pages 59–65.

Decide I You Want Prescription

Drug Coverage (Part D)

Decide I You Want Prescription

Drug Coverage (Part D)

Decide I You Want

Supplemental Coverage

Medicare Advantage Plan

(like an HMO or PPO)

Part C—Includes BOTH Part A (HospitalInsurance) and Part B (Medical Insurance)■ Private insurance companies approved by

Medicare provide this coverage.■ In most plans, you need to use plan doctors,

hospitals, and other providers or you may pay more or all o the costs.

■ You usually pay a monthly premium (inaddition to your Part B premium) and acopayment or coinsurance or covered services.

■ Costs, extra coverage, and rules vary by plan.See pages 70–81.

■ I you want this coverage, you must joina Medicare Prescription Drug Plan. You

usually pay a monthly premium.■ Tese plans are run by private companies

approved by Medicare.See pages 84–94.

■ I you want prescription drug coverage, andit’s oered by your plan, in most cases youmust get it through your plan.

■ In some types o plans that don’t oerdrug coverage, you can join a MedicarePrescription Drug Plan.

See page 73.

■ You may want to get coverage that llsgaps in Original Medicare coverage. You

can choose to buy a Medicare SupplementInsurance (Medigap) policy rom a privatecompany.

■ Costs vary by policy and company.■ Employers/unions may oer similar coverage.See pages 66–69.

Step 2

Step 3

Step 2

In addition to Original Medicare or a Medicare Advantage Plan, you may be able to join othertypes o Medicare health plans. See pages 82–83. You may be able to save money or have otherchoices i you have limited income and resources. See pages 98–104. You may also have other

coverage, like employer or union, military, or Veterans’ benets. See pages 95–96.



59Section 3—Your Medicare Choices Original Medicare

Original MedicareOriginal Medicare is one o your health coverage choices as parto the Medicare Program. You will be in Original Medicareunless you choose a Medicare health plan.

How Does It Work?

Original Medicare is coverage managed by the Federalgovernment. Generally, there is a cost or each service. Here arethe general rules or how it works:

Original Medicare

Can I get my health

care rom any doctor,

other health care

provider, or hospital?

In most cases, yes. You can go to any doctor, other health careprovider, hospital, or other acility that’s enrolled in Medicareand is accepting new Medicare patients.

Are prescription drugs

covered?

With a ew exceptions (see pages 34 and 48), mostprescriptions aren’t covered. You can add drug coverage by joining a Medicare Prescription Drug Plan (Part D).

Do I need to choose a

primary care doctor?

No.

Do I have to get

a reerral to see a

specialist?

In most cases no, but the specialist must be enrolled inMedicare.

Should I get a

supplemental policy?

You may already have employer or union coverage that may pay costs that Original Medicare doesn’t. I not, you may wantto buy a Medicare Supplement Insurance (Medigap) policy.See pages 66–69.

What else do I need to

know about Original

Medicare?

■ You generally pay a set amount or your health care(deductible) beore Medicare pays its share. Ten, Medicarepays its share, and you pay your share (coinsurance/

copayment) or covered services and supplies. Tere is noyearly limit or what you pay out-o-pocket.

■ You usually pay a monthly premium or Part B. Seepage 102 or more inormation about Medicare SavingsPrograms or help paying your Part B premium.

■ You generally don’t need to le Medicare claims. Te lawrequires providers (like doctors, hospitals, skilled nursingacilities, and home health agencies) and suppliers to leyour claims or the covered services and supplies you get.

H



60 Section 3—Your Medicare Choices Original Medicare

What You PayYour out-o-pocket costs in Original Medicare depend on the ollowing:

■ Whether you have Part A and/or Part B. Most people have both.

■ Whether your doctor, other health care provider, or supplier accepts“assignment.”

■ Te type o health care you need and how oen you need it.

■ Whether you choose to get services or supplies Medicare doesn’t cover.I you do, you pay all the costs unless you have other insurance thatcovers it.

■ Whether you have other health insurance that works with Medicare.

■ Whether you have Medicaid or get state help paying yourMedicare costs. See pages 102–103.

■ Whether you have a Medicare Supplement Insurance (Medigap) policy.

■ Whether you and your doctor or other health care provider sign aprivate contract. See page 64.

For more inormation on how other insurance works with Medicare,see pages 26–27. For more inormation about help to cover the costs thatOriginal Medicare doesn’t cover, see page 97.

Blue words

in the text

are dened

on pages

141–144.



61Section 3—Your Medicare Choices Original Medicare

Medicare Summary NoticesI you get a Medicare-covered service, you will get a MedicareSummary Notice (MSN) in the mail every 3 months. Te noticeshows all your services or supplies that providers and suppliersbilled to Medicare during the 3-month period, what Medicare paid,and what you may owe the provider. Tis notice isn’t a bill. Read itcareully and do the ollowing:

■ I you have other insurance, check to see i it covers anything thatMedicare didn’t.

■ Keep your receipts and bills, and compare them to your noticeto be sure you got all the services, supplies, or equipment listed.See pages 117–119 or inormation on Medicare raud.

■ I you paid a bill beore you got your notice, compare your noticewith the bill to make sure you paid the right amount or yourservices.

■ I an item or service is denied, call your doctor’s or other healthcare provider’s oce to make sure they submitted the correctinormation. I not, the oce may resubmit.

I you disagree with any decision made, you can le an appeal, seepages 107–108.

I you need to change your address on your notice, call SocialSecurity at 1-800-772-1213. Y users should call 1-800-325-0778.I you get Railroad Retirement Board (RRB) benets, call the RRBat 1-877-772-5772.

You don’t have to wait or your MSN to view your Medicare claims.Visit www.MyMedicare.gov to look at your Medicare claims or

view electronic MSNs. See page 130. Your claims generally will beavailable or viewing within 24 hours aer processing.






Keeping Your Costs Down with “Assignment”Assignment means that your doctor, provider, or supplier agrees(or is required by law) to accept the Medicare-approved amount as ull payment or covered services. Some health care providerswho are enrolled in Medicare have signed an agreement to acceptassignment or all Medicare-covered services. Tey are called“participating” providers. Other health care providers haven’tsigned an agreement to accept assignment or all Medicare-covered services, but they can still choose to accept assignment orindividual services. Tese providers are called “non-participating.”

Most doctors, providers, and suppliers accept assignment, but youshould always check to make sure. Find out how much you have to

pay or each service or supply beore you get it.

Here’s what happens i your doctor, provider, or supplier accepts assignment:

■ Your out-o-pocket costs may be less.

■ Tey agree to charge you only the Medicare deductible andcoinsurance amount and usually wait or Medicare to pay its share beore asking you to pay your share.

■ Tey have to submit your claim directly to Medicare and can’t

charge you or submitting the claim.

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63

Here’s what happens i your doctor, provider, or supplier doesn’t

accept assignment:■ You might have to pay the entire charge at the time o service.

Your doctor, provider, or supplier is supposed to submit a claim toMedicare or any Medicare-covered services they provide to you.Tey can’t charge you or submitting a claim. I they don’t submitthe Medicare claim once you ask them to, call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048.

Note: In some cases, you might have to submit your own claim toMedicare using orm CMS-1490S to get paid back. Visit

www.medicare.gov/medicareonlineorms or the orm andinstructions or call 1-800-MEDICARE.

■ Tey can charge you more than the Medicare-approved amount,but there is a limit called “the limiting charge.” Te provider canonly charge you up to 15% over the amount that non-participatingproviders are paid. Non-participating providers are paid 95% o theee schedule amount. Te limiting charge applies only to certainMedicare-covered services and doesn’t apply to some supplies anddurable medical equipment.

o nd out i your doctors and other health care providers acceptassignment or participate in Medicare, visitwww.medicare.gov/physicianor www.medicare.gov/supplier. You canalso call 1-800-MEDICARE, or ask your doctor, provider, or supplieri they accept assignment.

Section 3—Your Medicare Choices Original Medicare

Keeping Your Costs Down with “Assignment”

(continued)

http://www.medicare.gov/medicareonlineforms

http://www.medicare.gov/physician



http://www.medicare.gov/physician





What to Know About Private ContractsA “private contract” is a written agreement between you anda doctor or other health care provider who has decided not toprovide services to anyone through Medicare. Te private contractonly applies to the services provided by the doctor or otherprovider who asked you to sign it. You don’t have to sign a privatecontract. You can always go to another provider who gives servicesthrough Medicare. I you sign a private contract with your doctoror other provider, the ollowing rules apply:

■ Medicare won’t pay any amount or the services you get romthis doctor or provider, even i it’s a Medicare-covered service.

■ You will have to pay the ull amount o whatever this provider

charges you or the services you get.■ I you have a Medicare Supplement Insurance (Medigap) policy, it

won’t pay anything or the services you get. Call your insurancecompany beore you get the service i you have questions.

■ Your provider must tell you i Medicare would pay or the servicei you got it rom another provider who accepts Medicare.

■ Your provider must tell you i he or she has been excludedrom Medicare.

You can’t be asked to sign a private contract or emergency orurgent care.

You’re always ree to get services not covered by Medicare i youchoose to pay or a service yoursel.

You may want to contact your State Health Insurance AssistanceProgram (SHIP) to get help beore signing a private contract withany doctor or other health care provider. See pages 137–140 or thephone number.

See pages 107–119 or inormation about your appeal rights andhow to protect yoursel and Medicare rom raud.



65

Adding Medicare Drug Coverage (Part D)In Original Medicare, i you don’t already have creditableprescription drug coverage (or example, rom a current or ormeremployer or union) and you would like Medicare prescriptiondrug coverage, you must join a Medicare Prescription Drug Plan.Tese plans are available through private companies under contractwith Medicare. I you don’t currently have creditable prescriptiondrug coverage, you should think about joining a MedicarePrescription Drug Plan as soon as you’re eligible. I you don’t joina Medicare Prescription Drug Plan when you’re rst eligible and

you decide to join later, you may have to pay a late enrollmentpenalty. See pages 90–91 or more inormation.

I you have creditable prescription drug coverage rom anemployer or union, call your employer or union’s benetsadministrator beore you make any changes to your coverage. Youremployer or union plan will tell you each year i your prescriptiondrug coverage is creditable prescription drug coverage. I you dropyour employer or union coverage, you may not be able to get it back.You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. I you drop coverage or yoursel, you

may also have to drop coverage or your spouse and dependants.

Extra Help Paying or CoveragePeople with limited income and resources may qualiy or ExtraHelp paying their Medicare prescription drug coverage costs.See pages 98–101 to nd out i you may qualiy or Extra Help.

Section 3—Your Medicare Choices Original Medicare


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66 Section 3—Your Medicare Choices Medicare Supplement Insurance (Medigap)

Medicare Supplement Insurance (Medigap)

PoliciesOriginal Medicare pays or many, but not all, health care services and

supplies. A Medicare Supplement Insurance policy, sold by privatecompanies, can help pay some o the health care costs that OriginalMedicare doesn’t cover, like copayments, coinsurance, and deductibles.Medicare Supplement Insurance policies are also called Medigappolicies.

Some Medigap policies also oer coverage or services that OriginalMedicare doesn’t cover, like medical care when you travel outside theU.S. I you have Original Medicare and you buy a Medigap policy,Medicare will pay its share o the Medicare-approved amount orcovered health care costs. Ten your Medigap policy pays its share.You have to pay the premiums or a Medigap policy.

Every Medigap policy must ollow Federal and state laws designed toprotect you, and it must be clearly identied as “Medicare SupplementInsurance.” Insurance companies can sell you only a “standardized”policy identied in most states by letters A–N. All policies oer thesame basic benets but some oer additional benets, so you canchoose which one meets your needs. In Massachusetts, Minnesota,

and Wisconsin, Medigap policies are standardized in a dierent way.

Note: Plans E, H, I, and J are no longer available to buy, but i youalready have one o those policies, you can keep it. Contact yourinsurance company or more inormation.

Diferent insurance companies may charge diferent premiumsor the same exact policy. As you shop or a policy, be sure you’recomparing the same policy (or example, compare Plan A rom onecompany with Plan A rom another company).

In some states, you may be able to buy another type o Medigap policy called Medicare SELEC (a policy that requires you to use specichospitals and, in some cases, specic doctors or other health careproviders to get ull coverage). I you buy a Medigap SELEC policy,you have the right to change your mind within 12 months and switchto a standard Medigap policy.

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67Section 3—Your Medicare Choices Medicare Supplement Insurance (Medigap)

Te chart below shows basic inormation about the dierent benetsthat Medigap policies cover. I a check mark appears, the plan coversthe described benet 100%. I a percentage appears, the plan covers thatpercentage o the benet.

Note: You will need more details than this chart provides to compare andchoose a policy. For more details, visit www.medicare.gov/publications to view the booklet “Choosing a Medigap Policy: A Guide to HealthInsurance or People with Medicare.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y usersshould call 1-877-486-2048.

Medicare Supplement Insurance Plans (Medigap)

Benefts A B C D F* G K L M NMedicare Part A Coinsuranceand Hospital Costs (up toan additional 365 days aerMedicare benets are used)

√ √ √ √ √ √ √ √ √ √

Medicare Part B Coinsuranceor Copayment

√ √ √ √ √ √ 50% 75% √ √**

Blood (rst 3 pints) √ √ √ √ √ √ 50% 75%

Part A Hospice CareCoinsurance or Copayment

√ √ √ √ √ √ 50% 75% √ √

Skilled Nursing Facility CareCoinsurance

√ √ √ √ 50% 75% √ √

Medicare Part A Deductible √ √ √ √ √ 50% 75% 50% √Medicare Part B Deductible √ √Medicare Part B ExcessCharges

√ √

Foreign ravel Emergency (up to plan limits)

√ √ √ √ √ √

Out-o-Pocket

Limit$4,640 $2,320

* Plan F also oers a high-deductible plan. I you choose this option,this means you must pay or Medicare-covered costs (coinsurance,copayments, deductibles) up to the deductible amount o $2,000 in 2011beore your policy pays anything.

** Plan N pays 100% o the Part B coinsurance, except or a copaymento up to $20 or some oce visits and up to a $50 copayment or

emergency room visits that don’t result in an inpatient admission.





70 Section 3—Your Medicare Choices Medicare Advantage Plans

Medicare Advantage Plans (Part C)A Medicare Advantage Plan (like an HMO or PPO) is anotherMedicare health plan choice you may have as part o Medicare.Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,”are oered by private companies approved by Medicare. I you join aMedicare Advantage Plan, you still have Medicare. You will get yourPart A (Hospital Insurance) and Part B (Medical Insurance) coveragerom the Medicare Advantage Plan and not Original Medicare. Inall types o Medicare Advantage Plans, you’re always covered oremergency and urgent care. Medicare Advantage Plans must coverall o the services that Original Medicare covers except hospice care.Original Medicare covers hospice care even i you’re in a Medicare

Advantage Plan. Medicare Advantage Plans aren’t supplementalcoverage.

Medicare Advantage Plans may oer extra coverage, such as vision,hearing, dental, and/or health and wellness programs. Most includeMedicare prescription drug coverage (Part D). In addition to yourPart B premium, you usually pay a monthly premium or the MedicareAdvantage Plan.

Medicare pays a xed amount or your care every month to the

companies oering Medicare Advantage Plans. Tese companies mustollow rules set by Medicare. However, each Medicare AdvantagePlan can charge dierent out-o-pocket costs and have dierent rulesor how you get services (like whether you need a reerral to see aspecialist or i you have to go to only doctors, acilities, or suppliersthat belong to the plan or non-emergency or non-urgent care).Tese rules can change each year.

Tere are diferent types o Medicare Advantage Plans:

■ Health Maintenance Organization (HMO) Plans—In most HMOs,you can only go to doctors, other health care providers, or hospitalson the plan’s list except in an emergency. You may also need to get areerral rom your primary care doctor. See page 76.

■ Preerred Provider Organization (PPO) Plans—In a PPO, you pay less i you use doctors, hospitals, and other health care providersthat belong to the plan’s network. You pay more i you use doctors,hospitals, and providers outside o the network. See page 76.

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71

■ Private Fee-or-Service (PFFS) Plans—PFFS plans are similar toOriginal Medicare in that you can generally go to any doctor,other health care provider, or hospital as long as they agree totreat you. Te plan determines how much it will pay doctors,other health care providers, and hospitals, and how much youmust pay when you get care. See page 77.

■ Special Needs Plans (SNP)—SNPs provide ocused andspecialized health care or specic groups o people, such as thosewho have both Medicare and Medicaid, who live in a nursinghome, or have certain chronic medical conditions. See page 77.

Tere are other less common types o Medicare Advantage Plans

that may be available:■ HMO Point-o-Service (HMOPOS) Plans—Tis is an HMO plan

that may allow you to get some services out-o-network or ahigher copayment or coinsurance.

■ Medical Savings Account (MSA) Plans—Tis is a plan thatcombines a high deductible health plan with a bank account.Medicare deposits money into the account (usually less than thedeductible). You can use the money to pay or your health careservices during the year. For more inormation about MSAs, visitwww.medicare.gov/publicationsto view the booklet “Your Guideto Medicare Medical Savings Account Plans.” You can also call1-800-MEDICARE (1-800-633-4227) to nd out i a copy can bemailed to you. Y users should call 1-877-486-2048.

Make sure you understand how a plan works beore you join. See pages 76–77 or more inormation about MedicareAdvantage Plan types. I you want more inormation about

a Medicare Advantage Plan, you can call any plan andrequest a Summary o Benets (SB) document. Contact yourState Health Insurance Assistance Program (SHIP) or helpcomparing plans. See pages 137–140 or the phone number.

Section 3—Your Medicare Choices Medicare Advantage Plans

H Medicare Advantage Plans (continued)






More About Medicare Advantage Plans

Important Facts

■ As with Original Medicare, you still have Medicare rights and

protections, including the right to appeal. See pages 107–109.■ You can check with the plan beore you get a service to nd out i

it’s covered and what your costs may be.

■ You must ollow plan rules, like getting a reerral to see a specialistto avoid higher costs i your plan requires it. Te specialist you’rereerred to must also be in the plan’s network. Check with the plan.

■ I you go to a doctor, other health care provider, acility, or supplierthat doesn’t belong to the plan, your services may not be covered, oryour costs could be higher. In most cases, this applies to MedicareAdvantage HMOs and PPOs.

■ I you join a clinical research study, some costs may be covered by your plan. Call your plan or more inormation.

■ Medicare Advantage Plans can’t charge more than OriginalMedicare or certain services, like chemotherapy, dialysis, andskilled nursing acility care.

■ Medicare Advantage Plans have a yearly cap on how much youpay or Part A and Part B services during the year. Tis yearly

maximum out-o-pocket amount can be dierent between MedicareAdvantage Plans. You should consider this when you choose a plan.

Joining and Leaving

■ You can join a Medicare Advantage Plan even i you have apre-existing condition, except or End-Stage Renal Disease (ESRD).See page 74.

■ You can only join or leave a plan at certain times during the year.See pages 78–79.

■ Each year, Medicare Advantage Plans can choose to leave Medicareor make changes to the services they cover and what you pay. I theplan decides to stop participating in Medicare, you will have to joinanother Medicare health plan or return to Original Medicare.See pages 106–107.

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73

Prescription Drug Coverage

■ You usually get prescription drug coverage (Part D) through the plan.

In some types o plans that don’t oer drug coverage, you can join aMedicare Prescription Drug Plan. I you’re in a Medicare AdvantagePlan that includes prescription drug coverage and you join a MedicarePrescription Drug Plan, you will be disenrolled rom your MedicareAdvantage Plan and returned to Original Medicare. You can’t haveprescription drug coverage through both a Medicare Advantage Planand a Medicare Prescription Drug Plan.

Who Can Join?

o join a Medicare Advantage Plan you must meet these conditions:■ You have Part A and Part B.

■ You live in the plan’s service area.

■ You don’t have End-Stage Renal Disease (ESRD) except as explainedon page 74.

Note: In most cases, you can join a Medicare Advantage Plan only atcertain times during the year. See pages 78–79.

I You Have Other Coveragealk to your employer, union, or other benets administrator about theirrules beore you join a Medicare Advantage Plan. In some cases, joininga Medicare Advantage Plan might cause you to lose employer or unioncoverage. I you lose coverage or yoursel, you may also lose coverageor your spouse and dependants. In other cases, i you join a MedicareAdvantage Plan, you may still be able to use your employer or unioncoverage along with the plan you join. Remember, i you drop youremployer or union coverage, you may not be able to get it back.

I You Have a Medicare Supplement Insurance PolicyYou don’t need to buy (and can’t be sold) a Medicare Supplement Insurance(Medigap) policy while you’re in a Medicare Advantage Plan. I youalready have a Medigap policy and join a Medicare Advantage Plan, youwill probably want to drop your Medigap policy. You can’t use it to pay orany expenses (copayments, deductibles, and premiums) you have under aMedicare Advantage Plan. I you drop your Medigap policy, you may notbe able to get it back. See pages 66–69.


H More About Medicare Advantage Plans (continued)




I You Have End‑Stage Renal Disease (ESRD)I you have End-Stage Renal Disease (ESRD), you can only join aMedicare Advantage Plan in certain situations:

■ I you’re already in a Medicare Advantage Plan when you developESRD, you may be able to stay in your plan or join another planoered by the same company.

■ I you have an employer or union health plan or other healthcoverage through a company that oers Medicare Advantage Plans,you may be able to join one o their Medicare Advantage Plans.

■ I you’ve had a successul kidney transplant, you may be able to joina Medicare Advantage Plan.

■ You may be able to join a Medicare Special Needs Plan (SNP) or

people with ESRD i one is available in your area.

Your Rights i Your Plan Stops Participating in Medicare

I you have ESRD and are in a Medicare Advantage Plan, and theplan leaves Medicare or no longer provides coverage in your area, youhave a one-time right to join another plan. You don’t have to use yourone-time right to join a new plan immediately. I you go directly toOriginal Medicare aer your plan leaves or stops providing coverage,you will still have a one-time right to join a Medicare Advantage Plan

later.

Have Questions or Complaints about Kidney Dialysis Services?

Call your local ESRD Network. ESRD Networks help people withESRD get the right care at the right time. Te Networks make surethat dialysis services are administered eectively, help improvequality o care or people with ESRD, and provide help to people withESRD including resolving patient grievances. Call 1-800-MEDICARE(1-800-633-4227) to get the phone number or the ESRD Network in

your area. Y users should call 1-877-486-2048.

For More Inormation

Visit www.medicare.gov/publicationsto view the booklet “MedicareCoverage o Kidney Dialysis and Kidney ransplant Services.” Youcan also call 1-800-MEDICARE to see i a copy can be mailed to you.

Note: I you have ESRD and Original Medicare, you may join aMedicare Prescription Drug Plan.

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75

What You PayYour out-o-pocket costs in a Medicare Advantage Plan depend onthe ollowing:

■ Whether the plan charges a monthly premium.■ Whether the plan pays any o your monthly Part B premium.

■ Whether the plan has a yearly deductible or any additionaldeductibles.

■ How much you pay or each visit or service (copayments or coinsurance).

■ Te type o health care services you need and how oen youget them.

■ Whether you go to a doctor or supplier who accepts assignment (i you’re in a Preerred Provider Organization, PrivateFee-or-Service Plan, or Medical Savings Account Plan and yougo out-o-network). See page 62 or more inormation aboutassignment.

■ Whether you ollow the plan’s rules, like using network providers.

■ Whether you need extra benets and i the plan charges or it.

■ Te plan’s yearly limit on your out-o-pocket costs or allmedical services.

■ Whether you have Medicaid or get help rom your state.

o learn more about your costs in specic Medicare AdvantagePlans, visit www.medicare.gov/nd-a-plan. You can also call1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

I you’re in a Medicare plan, review the Evidence o Coverage(EOC) and Annual Notice o Change (ANOC) your plan sends

you each all. Te EOC gives you details about what the plancovers, how much you pay, and more. Te ANOC includes any changes in coverage, costs, or service area that will be eectivein January. I you don’t get these important documents,contact your plan.


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http://-/?-



http://-/?-



76

Health Maintenance Organization

(HMO) Plan

Preerred Provider

Organization (PPO) Plan

Can I get my

health care

rom any doctor,

other health

care provider, or

hospital?

No. You generally must get your care and servicesrom doctors, other health care providers, orhospitals in the plan’s network (except emergency care, out-o-area urgent care, or out-o-areadialysis). In some plans, you may be able to goout-o-network or certain services, usually or ahigher cost. Tis is called an HMO with a point-o-service (POS) option.

In most cases, yes. PPOs havenetwork doctors, other healthcare providers, and hospitals,but you can also useout-o-network providersor covered services, usually or a higher cost.

Are prescription

drugs covered?

In most cases, yes. Ask the plan. I you wantMedicare drug coverage, you must join an HMO

Plan that oers prescription drug coverage.

In most cases, yes. Ask theplan. I you want Medicare

drug coverage, you must join a PPO Plan that oersprescription drug coverage.

Do I need to

choose a primary

care doctor?

In most cases, yes. No.

Do I have to get

a reerral to see

a specialist?

In most cases, yes. Certain services, like yearly screening mammograms, don’t require a reerral.

In most cases, no.

What else do Ineed to know

about this type

o plan?

■ I your doctor or other health care providerleaves the plan, your plan will notiy you. Youcan choose another doctor in the plan.

■ I you get health care outside the plan’s network,you may have to pay the ull cost.

■ It’s important that you ollow the plan’s rules,like getting prior approval or a certain servicewhen needed.

■ Tere are two types o PPOs: Regional PPOsand Local PPOs.

■ I your doctor or otherhealth care provider leavesthe plan, your plan willnotiy you. You can chooseanother doctor in the plan.

■ I you get health careoutside the plan’s network,

you may have to pay theull cost.


HHow Do Medicare Advantage Plans Work?

Tere may be several private companies that ofer diferent types o Medicare AdvantagePlans in your area. Each plan can vary. Read individual plan materials careully to make sureyou understand the plan’s rules. You may want to contact the plan to nd out i the service youneed is covered and how much it costs. Visit the Medicare Plan Finder atwww.medicare.gov/nd-a-plan to nd plans in your area. You can also call 1-800-MEDICARE

(1-800-633-4227). Y users should call 1-877-486-2048.





77

Private Fee-or-Service (PFFS) Plan Special Needs Plan (SNP)

In some cases, yes. You can go to any Medicare-approveddoctor, other health care provider, or hospital that acceptsthe plan’s payment terms and agrees to treat you. Not allproviders will. I you join a PFFS Plan that has a network,you can also see any o the network providers who haveagreed to always treat plan members. You can also choosean out-o-network doctor, hospital, or other provider, whoaccepts the plan’s terms, but you may pay more.

You generally must get your care and servicesrom doctors, other health care providers,or hospitals in the plan’s network (exceptemergency care, out-o-area urgent care, orout-o-area dialysis).

Sometimes. I your PFFS Plan doesn’t oer drug coverage,you can join a Medicare Prescription Drug Plan (Part D) to

get coverage.

Yes. All SNPs must provide Medicareprescription drug coverage (Part D).

No. Generally, yes.

No. In most cases, yes. Certain services, like yearly screening mammograms, don’t require a

■ PFFS Plans aren’t the same as Original Medicare orMedigap.

■ Te plan decides how much you must pay or services.

■ Some PFFS Plans contract with a network o providerswho agree to always treat you even i you’ve never seenthem beore.

■ Out-o-network doctors, hospitals, and other providersmay decide not to treat you even i you’ve seen thembeore.

■ For each service you get, make sure your doctors,hospitals, and other providers agree to treat you underthe plan, and accept the plan’s payment terms.

■ In an emergency, doctors, hospitals, and other providersmust treat you.

■ A plan must limit membership to theollowing groups: 1) people who live incertai (like a nursing home)or who require nursing care at home, or 2)people who are eligible or both Medicareand Medicaid, or 3) people who havespecic chronic or disabling conditions (likediabetes, ESRD, HIV/AIDS, chronic heartailure, or dementia). Plans may urther limitmembership. You can join a SNP at any time.

■ Plans should coordinate the services andproviders you need to help you stay healthy and ollow doctor’s or other health careprovider’s orders.

■ I you have Medicare and Medicaid, yourplan should make sure that all o the plandoctors or other health care providers you useaccept Medicaid.

■ I you live in an institution, make sure thatplan providers serve people where you live.

n institutions

reerral.

HHow Do Medicare Advantage Plans Work? (continued)




78

Join, Switch, or Drop a Medicare Advantage Plan■ When you rst become eligible or Medicare, you can join during

the 7-month period that begins 3 months beore the month youturn 65, includes the month you turn 65, and ends 3 months aerthe month you turn 65.

■ I you get Medicare due to a disability, you can join during the7-month period that begins 3 months beore your 25th month o disability and ends 3 months aer your 25th month o disability.

■ NEW—Between October 15–December 7 anyone can join, switch,or drop a Medicare Advantage Plan. Tis open enrollment periodhas changed to give you more time to choose and join a plan. Yourcoverage will begin on January 1, as long as the plan gets your

request by December 7.Making changes to your coverage aer December 7Between January 1–February 14, i you’re in a Medicare AdvantagePlan, you can leave your plan and switch to Original Medicare. I youswitch to Original Medicare during this period, you will have untilFebruary 14 to also join a Medicare Prescription Drug Plan to adddrug coverage. Your coverage will begin the rst day o the monthaer the plan gets your enrollment orm.

During this period, you can’t do the ollowing:■ Switch rom Original Medicare to a Medicare Advantage Plan.

■ Switch rom one Medicare Advantage Plan to another.

■ Switch rom one Medicare Prescription Drug Plan to another.

■ Join, switch, or drop a Medicare Medical Savings Account Plan.


H



79Section 3—Your Medicare Choices Medicare Advantage Plans

Special Enrollment Periods

In most cases, you must stay enrolled or the calendar year starting thedate your coverage begins. However, in certain situations, you may beable to join, switch, or drop a Medicare Advantage Plan during a specialenrollment period. Contact your plan i any o these situations apply to you:

■ You move out o your plan’s service area.

■ You have Medicaid.

■ You qualiy or Extra Help. See pages 98–101.

■ You live in an institution (like a nursing home).

NEW: 5-Star Special Enrollment PeriodMedicare uses inormation rom member satisaction surveys, plans, andhealth care providers to give overall perormance star ratings to plans.A plan can get a rating between one to ve stars. A 5-star rating isconsidered excellent. Tese ratings help you compare plans based onquality and perormance.

Starting December 8, 2011, you can switch to a 5-star MedicareAdvantage Plan at any time during the year.

■ Te overall plan star ratings are available atwww.medicare.gov/nd-a-plan.

■ You can only join a 5-star Medicare Advantage Plan i one is available inyour area.

■ You can only use this special enrollment period to switch to a 5-star planone time each year.

■ You can’t use this period to join a Medicare Cost Plan. See page 82.

Visit the Medicare Plan Finder at www.medicare.gov/nd-a-plantosearch or plans. For more inormation about overall plan ratings, visitwww.medicare.gov/publicationsto view the act sheet “Use Medicare’sInormation on Quality to Help You Compare Plans.” You can alsocall 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

Note: You may lose your prescription drug coverage i you move rom aMedicare Advantage Plan that has drug coverage to a Medicare AdvantagePlan that doesn’t. You will have to wait until the next open enrollmentperiod to get drug coverage, and you may have to pay a late enrollment

penalty. See page 90.

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H Join, Switch, or Drop a Medicare Advantage Plan

(continued)










How Do You Join?I you choose to join a Medicare Advantage Plan, you may be ableto join by doing the ollowing:

■ Enrolling on the plan’s Web site or on www.medicare.gov .■ Completing a paper application.

■ Calling the plan.

■ Calling 1-800-MEDICARE (1-800-633-4227). Y users shouldcall 1-877-486-2048.

When you join a Medicare Advantage Plan, you will have toprovide your Medicare number and the date your Part A and/orPart B coverage started. Tis inormation is on your Medicare card.

Medicare Advantage Plans aren’t allowed to call you toenroll you in a plan. Also, plans should never ask youor nancial inormation, including credit card or bank account numbers, over the phone. Call 1-800-MEDICAREto report a plan that does this. Don’t give your personalinormation to anyone who calls you to enroll in a plan.

H





81

How Do You Switch?Follow these steps i you’re already in a Medicare Advantage Planand want to switch:

■ o switch to a new Medicare Advantage Plan, simply join the planyou choose during one o the enrollment periods explained onpages 78–79. You will be disenrolled automatically rom your oldplan when your new plan’s coverage begins.

■ o switch to Original Medicare, contact your current plan, orcall 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048. Unless you have other drug coverage, you shouldcareully consider Medicare prescription drug coverage (Part D).You may also want to consider a Medicare Supplement Insurance

(Medigap) policy. See pages 66–69 or more inormation aboutbuying a Medigap policy.

For more inormation on joining, dropping, and switchingplans, visit www.medicare.gov/publicationsto view the act sheet“Understanding Medicare Enrollment Periods.” You can also call1-800-MEDICARE to nd out i a copy can be mailed to you.

No one should call you or come to your home uninvitedto sell Medicare products. See pages 116–119 or moreinormation about how to protect yoursel rom identity the and raud. I you believe a plan has misled you, call1-800-MEDICARE.


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82 Section 3—Your Medicare Choices Other Medicare Health Plans

Other Medicare Health Plans

Some types o Medicare health plans that provide health care coveragearen’t Medicare Advantage Plans but are still part o Medicare. Some

o these plans provide Part A (Hospital Insurance) and Part B (MedicalInsurance) coverage, while most others provide only Part B coverage.In addition, some also provide Part D prescription drug coverage.Tese plans have some o the same rules as Medicare Advantage Plans.Some o these rules are explained briefy below and on the next page.However, each type o plan has special rules and exceptions, so youshould contact any plans you’re interested in to get more details.

Medicare Cost Plans

Medicare Cost Plans are a type o Medicare health plan availablein certain areas o the country. Here’s what you should know aboutMedicare Cost Plans:

■ You can join even i you only have Part B.

■ I you have Part A and Part B and go to a non-network provider, theservices are covered under Original Medicare. You would pay thePart A and Part B coinsurance and deductibles.

■ You can join anytime the plan is accepting new members.

■ You can leave anytime and return to Original Medicare.

■ You can either get your Medicare prescription drug coverage rom theplan (i oered), or you can join a Medicare Prescription Drug Plan.Note: You can add or drop Medicare prescription drug coverage only at certain times. See page 85.

Tere is another type o Medicare Cost Plan that only provides coverageor Part B services. Tese plans never include Part D. Part A services arecovered through Original Medicare. Tese plans are either sponsoredby employer or union group health plans or oered by companies thatdon’t provide Part A services.

For more inormation about Medicare Cost Plans, contact the plansyou’re interested in. You can also visit the Medicare Plan Finder atwww.medicare.gov/nd-a-plan. Your State Health Insurance AssistanceProgram (SHIP) can also give you more inormation. See pages 137–140 or the phone number.

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83Section 3—Your Medicare Choices Other Medicare Health Plans

Demonstrations/Pilot Programs

Demonstrations and pilot programs (also called “research studies”) are

special projects that test and measure the eect o potential changes inMedicare coverage, payment, and quality o care. Usually, they operateonly or a limited time or a specic group o people and/or are oeredonly in specic areas. Check with the demonstration or pilot programor more inormation about how it works.

o nd out about current Medicare demonstrations and pilotprograms, call 1-800-MEDICARE (1-800-633-4227), and say “Agent.”Y users should call 1-877-486-2048.

Programs o All-Inclusive Care or the Elderly (PACE)PACE is a Medicare and Medicaid program oered in many statesthat allows people who otherwise need a nursing home-level o care toremain in the community.

o qualiy or PACE, you must meet the ollowing conditions:

■ You’re 55 or older.

■ You live in the service area o a PACE organization.

■ You’re certied by your state as needing a nursing home-level o care.

■ At the time you join, you’re able to live saely in the community withthe help o PACE services.

PACE provides coverage or prescription drugs, doctor or other healthcare provider visits, transportation, home care, hospital visits, andeven nursing home stays whenever necessary. I you have Medicaid,you won’t have to pay a monthly premium or the long-term care portion o the PACE benet. I you have Medicare but not Medicaid,you will be charged a monthly premium to cover the long-term careportion o the PACE benet and a premium or Medicare Part Ddrugs. However, in PACE there is never a deductible or copayment orany drug, service, or care approved by the PACE team o health careproessionals.

Call your State Medical Assistance (Medicaid) oce to nd out i you’re eligible and i there is a PACE site near you, or visitwww.pace4you.org. You can also visit www.medicare.gov/publications to view the act sheet “Quick Facts about Programs o All-InclusiveCare or the Elderly (PACE).” You can call 1-800-MEDICARE to nd

out i a copy can be mailed to you.

Other Medicare Health Plans (continued)

http://www.pace4you.org/



http://www.pace4you.org/



84 Section 3—Your Medicare Choices Medicare Prescription Drug Coverage

Medicare Prescription Drug Coverage (Part D)Medicare oers prescription drug coverage to everyone with Medicare.Even i you don’t take a lot o prescriptions now, it’s very importantor you to consider joining a Medicare drug plan. I you decide not to

join a Medicare drug plan when you’re rst eligible, and you don’t haveother creditable prescription drug coverage, or you don’t get Extra Help,you will likely pay a late enrollment penalty. See pages 90–91. o getMedicare prescription drug coverage, you must join a plan run by aninsurance company or other private company approved by Medicare.Each plan can vary in cost and specic drugs covered.

Tere are two ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. Tese plans (sometimes called

“PDPs”) add drug coverage to Original Medicare, some MedicareCost Plans, some Medicare Private Fee-or-Service (PFFS) Plans,and Medicare Medical Savings Account (MSA) Plans.

2. Medicare Advantage Plans (like an HMO or PPO) or otherMedicare health plans that ofer Medicare prescription drugcoverage. You get all o your Part A and Part B coverage, andprescription drug coverage (Part D), through these plans. MedicareAdvantage Plans with prescription drug coverage are sometimescalled “MA-PDs.” You must have Part A and Part B to join aMedicare Advantage Plan.

In either case, you must live in the service area o the Medicare drugplan you want to join. Both types o plans are called “Medicare drugplans” in this handbook.

I you have employer or union coverage, call your benetsadministrator beore you make any changes, or beore you

sign up or any other coverage. I you drop your employer orunion coverage, you may not be able to get it back. You alsomay not be able to drop your employer or union drug coveragewithout also dropping your employer or union health (doctorand hospital) coverage. I you drop coverage or yoursel,you may also have to drop coverage or your spouse anddependants. I you want to know how Medicare prescriptiondrug coverage works with other drug coverage you may have,see pages 95–96.



85Section 3—Your Medicare Choices Medicare Prescription Drug Coverage

Join, Switch, or Drop a Medicare Drug Plan■ When you’re rst eligible or Medicare, you can join during the 7-month

period that begins 3 months beore the month you turn 65, includes themonth you turn 65, and ends 3 months aer the month you turn 65.

■ I you get Medicare due to a disability, you can join during the 7-monthperiod that begins 3 months beore your 25th month o disability and ends3 months aer your 25th month o disability. You will have another chanceto join during the 7-month period that begins 3 months beore the monthyou turn 65 and ends 3 months aer the month you turn 65.

■ NEW—Between October 15–December 7, anyone can join, switch, ordrop a Medicare drug plan. Te change will take eect on January 1 aslong as the plan gets your request by December 7.

■ Anytime, i you qualiy or Extra Help.

You generally must stay enrolled or the calendar year. However, in certainsituations like the ollowing, you may be able to join, switch, or dropMedicare drug plans at other times:

■ I you move out o your plan’s service area

■ I you lose other creditable prescription drug coverage

■ I you live in an institution (like a nursing home)

Call your State Health Insurance Assistance Program (SHIP) or more

inormation. See pages 137–140 or the phone number. You can also call1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

Note: I you have limited income and resources, you may qualiy or ExtraHelp to pay or Medicare prescription drug coverage. You may also be able toget help rom your state. See pages 98–104.

NEW—5-Star Special Enrollment PeriodStarting December 8, 2011, you can switch to a 5-star Medicare PrescriptionDrug Plan at any time during the year. Te overall plan star ratings areavailable at www.medicare.gov/nd-a-plan. See page 79 or more inormation.

■ You can only switch to a 5-star Medicare Prescription Drug Plan i one isavailable in your area.

■ You can only use this period to switch to a 5-star plan one time each year.

Visit the Medicare Plan Finder at www.medicare.gov/nd-a-plan to search orplans. For more inormation about overall plan ratings, visitwww.medicare.gov/publications to view the act sheet “Use Medicare’sInormation on Quality to Help You Compare Plans.” You can also call1-800-MEDICARE.

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http://www.medicare.gov/findaplan





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How Do You Join?Once you choose a Medicare drug plan, you may be able to join by doing the ollowing:

■ Enrolling on the plan’s Web site or on www.medicare.gov .■ Completing a paper application.

■ Calling the plan.

■ Calling 1-800-MEDICARE (1-800-633-4227). Y users shouldcall 1-877-486-2048.

When you join a Medicare drug plan, you will have to provide yourMedicare number and the date your Part A and/or Part B coveragestarted. Tis inormation is on your Medicare card.

Note: Medicare drug plans aren’t allowed to call you to enroll you in aplan. Call 1-800-MEDICARE to report a plan that does this. Don’t give your personal inormation to anyone who calls you to enroll in a plan.

How Do You Switch?You can switch to a new Medicare drug plan simply by joininganother drug plan during one o the times listed on page 85. Youdon’t need to cancel your old Medicare drug plan or send themanything. Your old Medicare drug plan coverage will end when

your new drug plan begins. You should get a letter rom your newMedicare drug plan telling you when your coverage begins.

How Do You Drop a Medicare Drug Plan?I you want to drop your Medicare drug plan and you don’t want to join anew plan, you can do so during one o the times listed on page 85. You candisenroll by calling 1-800-MEDICARE. You can also send a letter to theplan to tell them you want to disenroll. I you drop your plan and want to join another Medicare drug plan later, you have to wait or an enrollment

period. You may have to pay a late enrollment penalty. See pages 90–91.

I your Medicare Advantage Plan includes prescription drugcoverage and you join a Medicare Prescription Drug Plan, you willbe disenrolled rom your Medicare Advantage Plan and returnedto Original Medicare.

For more inormation, visit www.medicare.gov/publications to view theact sheet “Understanding Medicare Enrollment Periods.” You can also

call 1-800-MEDICARE to nd out i a copy can be mailed to you.








What You PayBelow and continued on the next page are descriptions o the payments youmake throughout the year in a Medicare drug plan. Your actual drug plan costswill vary depending on the ollowing:

■ Te prescriptions you use and whether your plan covers them

■ Te plan you choose

■ Whether you go to a pharmacy in your plan’s network

■ Whether your drugs are on your plan’s ormulary (drug list)

■ Whether you get Extra Help paying your Part D costs

Monthly Premium

Most drug plans charge a monthly ee that varies by plan. You pay this inaddition to the Part B premium. I you belong to a Medicare Advantage

Plan (like an HMO or PPO) or a Medicare Cost Plan that includes Medicareprescription drug coverage, the monthly premium you pay to your plan may include an amount or prescription drug coverage.

Note: Contact your drug plan (not Social Security) i you want your premiumdeducted rom your monthly Social Security payment. Your rst deduction willusually take 3 months to start, and 3 months o premiums will likely be deductedat once. Aer that, only one premium will be deducted each month. You may also see a delay in premiums being withheld i you switch plans. I you want tostop premium deductions and get billed directly, contact your drug plan.

What you pay or Part D coverage could be higher based on your income.Tis includes Part D coverage you get rom a Medicare Prescription Drug Plan,a Medicare Advantage Plan, a Medicare Cost Plan, or employer group MedicareAdvantage Plan that includes Medicare prescription drug coverage.I your modied adjusted gross income as reported on your IRS tax return rom2 years ago (the most recent tax return inormation provided to Social Security by the IRS) is above a certain limit, you will pay an extra amount in additionto your plan premium. Usually, the extra amount will be deducted rom yourSocial Security check. I you have to pay an extra amount and you disagree (orexample, you have a lie event that lowers your income), call Social Security at1-800-772-1213. Y users should call 1-800-325-0778. For more inormation, visit www.socialsecurity.gov .

Yearly Deductible

Te amount you must pay beore your drug plan begins to pay its share o yourcovered drugs. Some drug plans don’t have a deductible.

Copayments or Coinsurance

Amounts you pay or your covered prescriptions aer the deductible (i the planhas one). You pay your share and your drug plan pays its share or covered drugs.

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Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut

hole”). Tis means that there is a temporary limit on what the drug planwill cover or drugs. Te coverage gap begins aer you and your drugplan have spent a certain amount or covered drugs. Once you enter thecoverage gap, you get a 50% discount on covered brand name drugs andpay 86% o the plan’s cost or covered generic drugs until you reach theend o the coverage gap. Not everyone will enter the coverage gap. Teollowing items all count toward you getting out o the coverage gap:

■ Your yearly deductible, coinsurance, and copayments

■ Te discount you get on brand-name drugs in the coverage gap ■ What you pay in the coverage gap

Te drug plan premium and what you pay or drugs that aren’t covereddon’t count toward getting you out o the coverage gap.

Tere are plans that oer additional coverage during the gap, like orgeneric drugs. However, plans with additional gap coverage may chargea higher monthly premium. Check with the drug plan rst to see i yourdrugs would be covered during the gap.

In addition to the 50% discount on covered brand-name prescriptiondrugs, there will be increasing savings or you in the coverage gap eachyear until the gap closes in 2020. alk to your doctor or other healthcare provider to make sure that you’re taking the lowest cost drugavailable that works or you. For more inormation, visitwww.medicare.gov/publicationsto view the act sheet “Closing theCoverage Gap—Medicare Prescription Drugs Are Becoming MoreAordable.” You can also call 1-800-MEDICARE (1-800-633-4227)to nd out i a copy can be mailed to you. Y users should call1-877-486-2048.

Catastrophic Coverage

Once you get out o the coverage gap, you automatically get “catastrophiccoverage.” Catastrophic coverage assures that you only pay a smallcoinsurance amount or copayment or covered drugs or the rest o the year.

Note: I you get Extra Help, some o these costs won’t apply to you.See page 98.

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What You Pay (continued)






Te example below shows costs or covered drugs in 2012 or a planthat has a coverage gap.

Ms. Smith joins the ABC Prescription Drug Plan. Her coveragebegins on January 1, 2012. She doesn’t get Extra Help anduses her Medicare drug plan membership card when she buysprescriptions.

Monthly Premium—Ms. Smith pays a monthly premium throughout the year.

1. Yearly

Deductible

2. Copayment or

Coinsurance

(What you payat the pharmacy)

3. Coverage Gap 4. Catastrophic

Coverage

Ms. Smith paysthe rst $320 o her drug costsbeore her planstarts to pay itsshare.

Ms. Smith pays acopayment, and herplan pays its share oreach covered druguntil their combined amount (plus thedeductible) reaches$2,930.

Once Ms. Smith and herplan have spent $2,930 orcovered drugs, she is inthe coverage gap. In 2012,she gets a 50% discounton covered brand-nameprescription drugs and shepays 86% o the plan’s costor covered generic drugs.What she pays (and the50% discount paid by thedrug company) counts asout-o-pocket spending,and helps her get out o the coverage gap.

Once Ms. Smith hasspent $4,700 out-o-pocket or theyear, her coveragegap ends. Now sheonly pays a smallcoinsurance orcopayment or eachdrug until the end o the year.

o get specic Medicare drug plan costs, call the plans you’re interested in.You can also visit the Medicare Plan Finder at www.medicare.gov/nd-a-plan,or call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048. For help comparing plan costs, contact your State HealthInsurance Assistance Program (SHIP). See pages 137–140 or the phonenumber.

What You Pay (continued)






What is the Part D Late Enrollment Penalty?Te late enrollment penalty is an amount that’s added to your Part Dpremium. You may owe a late enrollment penalty i at any timeaer your initial enrollment period is over, there is a period o 63 ormore days in a row when you don’t have Part D or other creditableprescription drug coverage.

Note: I you get Extra Help, you don’t pay a late enrollment penalty.

Here are a ew ways to avoid paying a penalty:

■ Join a Medicare drug plan when you’re rst eligible. You won’thave to pay a penalty, even i you’ve never had prescription drugcoverage beore.

■ Don’t go 63 days or more in a row without a Medicare drugplan or other creditable coverage. Creditable prescription drugcoverage could include drug coverage rom a current or ormeremployer or union, RICARE, Indian Health Service, theDepartment o Veterans Aairs, or health insurance coverage.Your plan must tell you each year i your drug coverage iscreditable coverage. Tis inormation may be sent to you in a letteror included in a newsletter rom the plan. Keep this inormation,because you may need it i you join a Medicare drug plan later.

■ ell your plan about any drug coverage you had i they ask aboutit. When you join a Medicare drug plan, and the plan believes youwent at least 63 days in a row without other creditable prescription

drug coverage, the plan will send you a letter. Te letterwill include a orm asking about any drug coverageyou had. Complete the orm and return it to your drugplan. I you don’t tell the plan about your creditableprescription drug coverage, you may have to pay apenalty.

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How Much More Will You Pay?Te cost o the late enrollment penalty depends on how long youdidn’t have creditable prescription drug coverage. Currently, the

late enrollment penalty is calculated by multiplying 1% o the“national base beneciary premium” ($32.34 in 2011) times thenumber o ull, uncovered months that you were eligible but didn’t

join a Medicare drug plan and went without other creditableprescription drug coverage. Te nal amount is rounded to thenearest $.10 and added to your monthly premium. Since the“national base beneciary premium” may increase each year, thepenalty amount may also increase every year. You may have to pay this penalty or as long as you have a Medicare drug plan.

Example: Mrs. Jones didn’t join when she was rst eligible—by May 15, 2007. She joined a Medicare drug plan with aneective date o January 1, 2011. Since Mrs. Jones didn’t joinwhen she was rst eligible and went without other creditabledrug coverage or 43 months (June 2007–December 2010),she will be charged a monthly penalty o $13.90 in 2011($32.34 X .01 = $.3234 X 43 = $13.90) in addition to her plan’smonthly premium.

Aer you join a Medicare drug plan, the plan will tell you i youowe a penalty, and what your premium will be.

I You Don’t Agree With Your PenaltyI you don’t agree with your late enrollment penalty, you can ask Medicare or a review or reconsideration. You will need to ll outa reconsideration request orm (that your Medicare drug planwill send you), and you will have the chance to provide proo that

supports your case, such as inormation about previous creditableprescription drug coverage. I you need help, call your Medicareplan. You can also contact your State Health Insurance AssistanceProgram (SHIP). See pages 137–140 or the phone number.




Important Drug Coverage RulesTe ollowing inormation can help answer common questions as youbegin to use your coverage.

To Fill a Prescription Beore You Get Your Membership Card

You should get a welcome package with your membership card within 5weeks aer the plan gets your completed application. I you need to goto the pharmacy beore your membership card arrives, you can use any o the ollowing as proo o membership:

■ A letter rom the plan that includes your membership inormation.You should get this letter within 2 weeks aer the plan gets yourcompleted application.

■ An enrollment conrmation number that you got rom the plan, theplan name, and phone number.

■ A temporary card that you may be able to print rom MyMedicare.gov.Visit www.MyMedicare.gov or more inormation, or see page 130.

I you don’t have any o the items listed above, your pharmacist may beable to get your drug plan inormation i you provide your Medicarenumber or the last 4 digits o your Social Security number. I yourpharmacist can’t get your drug plan inormation, you may have to pay

out-o-pocket or your prescriptions. I you do, save the receipts andcontact your plan to get your money back .

I you qualiy or Extra Help, see pages 98–101 or more inormationabout what you can use as proo o Extra Help.

Note: Every month that you ll a prescription, your drug planmails you an Explanation o Benets (EOB) notice. Tis noticegives you a summary o your prescription drug claims and your

costs. Review your notice and check it or mistakes. Contactyour plan i you have questions or nd mistakes. I you suspectraud, call the Medicare Drug Integrity Contractor (MEDIC)at 1-877-7SAFERX (1-877-772-3379). See page 116 or moreinormation about the MEDIC.






What’s Covered?

Inormation about a plan’s list o covered drugs (called a ormulary )

isn’t included in this handbook because each plan has its ownormulary. Many Medicare drug plans place drugs into dierent“tiers” on their ormularies. Drugs in each tier have a dierentcost. For example, a drug in a lower tier will generally cost youless than a drug in a higher tier. In some cases, i your drug is ona higher tier and your prescriber (your doctor or other health careprovider who is legally allowed to write prescriptions) thinks youneed that drug instead o a similar drug on a lower tier, you oryour prescriber can ask your plan or an exception to get a lower

copayment.

Contact the plan or its current ormulary, or visit the plan’s Website. Visit the Medicare Plan Finder atwww.medicare.gov/nd-a-planto get phone numbers orthe plans in your area. You can also call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048. Your planwill notiy you o any ormulary changes.

Note: Medicare drug plans must cover all commercially-available

vaccines (like the shingles vaccine) when medically necessary toprevent illness, except or vaccines covered under Part B.

I you’re in a Medicare drug plan and you have complex healthneeds, you may be eligible to participate in a Medication Terapy Management (MM) program. Tese programs help you andyour doctor make sure that your medications are working.MM programs include a ree discussion and review o all o yourmedications by a pharmacist or other health proessional to help

you use them saely. You will get a summary o this discussionto help you get the most benet rom your medications. You canhave this summary available when you talk with your doctors orother health care providers. I you take many medications or morethan one chronic health condition, contact your drug plan to see i you’re eligible.

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Plans may have the ollowing coverage rules:

■ Prior authorization—You and/or your prescriber must contact the

drug plan beore you can ll certain prescriptions. Your prescribermay need to show that the drug is medically necessary or the planto cover it.

■ Quantity limits—Limits on how much medication you can get at atime.

■ Step therapy —You must try one or more similar, lower cost drugsbeore the plan will cover the prescribed drug.

I you or your prescriber believe that one o these coverage rules

should be waived, you can ask or an exception. See pages 110–111.

In most cases, the prescription drugs (sometimes called“sel-administered drugs” or drugs you would usually take onyour own) you get in an outpatient setting, like an emergency department, or during observation services aren’t covered by Part B. Your Medicare drug plan may cover these drugs undercertain circumstances. You will likely need to pay out-o-pocketor these drugs and submit a claim to your drug plan or a

reund. Or, i you get a bill or sel-administered drugs you gotin a doctor’s oce, call your Medicare drug plan (Part D) ormore inormation. Visit www.medicare.gov/publicationsto

view the act sheet, “How Medicare Covers Sel-AdministeredDrugs Given in Hospital Outpatient Settings.” You can also call1-800-MEDICARE (1-800-633-4227) to nd out i a copy canbe mailed to you. Y users should call 1-877-486-2048.

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Important Drug Coverage Rules (continued)






Other Government InsuranceTe types o insurance listed on this page are all considered creditableprescription drug coverage. I you have one o these types o insurance, inmost cases, it will be to your advantage to keep your current coverage.

Federal Employee Health Benets (FEHB) Program—Health coverage orcurrent and retired Federal employees and covered amily members. FEHBplans usually include prescription drug coverage, so you don’t need to joina Medicare drug plan. However, i you decide to join a Medicare drug plan,you can keep your FEHB plan, and your plan will let you know who paysrst. For more inormation, contact the Oce o Personnel Managementat 1-888-767-6738, or visit www.opm.gov/insure. Y users should call1-800-878-5707. You can also call your plan i you have questions.

Veterans’ Benets—Health coverage or veterans and people who have servedin the U.S. military. You may be able to get prescription drug coverage throughthe U.S. Department o Veterans Aairs (VA) program. You may join aMedicare drug plan, but i you do, you can’t use both types o coverage or thesame prescription at the same time. For more inormation, call the VA at1-800-827-1000, or visit www.va.gov . Y users should call 1-800-829-4833.

RICARE (Military Health Benets)—Health care plan or active-duty service members, retirees, and their amilies. Most people with RICARE

who are entitled to Part A must have Part B to keep RICARE prescriptiondrug benets. I you have RICARE, you don’t need to join a MedicarePrescription Drug Plan. However, i you do, your Medicare drug plan paysrst, and RICARE pays second. I you join a Medicare Advantage Plan (likean HMO or PPO) with prescription drug coverage, your Medicare AdvantagePlan and RICARE may coordinate their benets i your Medicare AdvantagePlan network pharmacy is also a RICARE network pharmacy. For moreinormation, call the RICARE Pharmacy Program at 1-877-363-1303, or visitwww.tricare.mil/mybenet. Y users should call 1-877-540-6261.

Indian Health Services—Health care services or American Indians andAlaska Natives. Many Indian health acilities participate in the Medicareprescription drug program. I you get prescription drugs through an Indianhealth acility, you will continue to get drugs at no cost to you and yourcoverage won’t be interrupted. Joining a Medicare drug plan may help yourIndian health acility because the drug plan pays the Indian health acility or the cost o your prescriptions. alk to your local Indian health benetscoordinator who can help you choose a plan that meets your needs and tell youhow Medicare works with the Indian health care system.

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http://www.va.gov/



http://www.va.gov/




98 Section 4—Get Help Paying Your Health and Prescription Drug Costs

Programs or People with Limited Income and

ResourcesI you have limited income and resources, you might qualiy or help to

pay or some health care and prescription drug costs.

Extra Help Paying or Medicare Prescription Drug

Coverage (Part D)Extra Help is a Medicare program to help people with limitedincome and resources pay Medicare prescription drug costs. You may qualiy or Extra Help, also called the low-income subsidy (LIS) i youryearly income and resources are below the ollowing limits in 2011:

■ Single person—Income less than $16,335 and resources less than$12,640

■ Married person living with a spouse and no other dependants—Income less than $22,065 and resources less than $25,260

Tese amounts may change in 2012. You may qualiy even i you havea higher income (like i you still work, live in Alaska or Hawaii, or havedependants living with you). Resources include money in a checkingor savings account, stocks, bonds, mutual unds, and IndividualRetirement Accounts (IRAs). Resources don’t include your home,

car, household items, burial plot, up to $1,500 or burial expenses (perperson), or lie insurance policies.

I you qualiy or Extra Help and join a Medicare drug plan, you will getthe ollowing:

■ Help paying your Medicare drug plan’s monthly premium, yearly deductible, coinsurance, and copayments

■ No coverage gap

■ No late enrollment penalty

You automatically qualiy or Extra Help i you have Medicare andmeet one o these conditions:

■ You have ull Medicaid coverage

■ You get help rom your state Medicaid program paying your Part Bpremiums (in a Medicare Savings Program)

■ You get Supplemental Security Income (SSI) benets

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99Section 4—Get Help Paying Your Health and Prescription Drug Costs

o let you know you automatically qualiy or Extra Help, Medicare

will mail you a purple letter that you should keep or your records.You don’t need to apply or Extra Help i you get this letter.

■ I you aren’t already in a Medicare drug plan, you must join one touse this Extra Help.

■ I you don’t join a Medicare drug plan, Medicare may enroll youin one. I Medicare enrolls you in a plan, you will get a yellow orgreen letter letting you know when your coverage begins.

■ Dierent plans cover dierent drugs. Check to see i the planyou’re enrolled in covers the drugs you use and i you can go to the

pharmacies you want. Compare with other plans in your area.

■ I you’re getting Extra Help, you can switch to another Medicaredrug plan anytime. Your new coverage will be eective the rstday o the next month.

■ I you have Medicaid and live in certain institutions (like a nursinghome) or get home and community-based services (see page 123),you pay nothing or your covered prescription drugs.

I you don’t want to join a Medicare drug plan (or example, because

you want only your employer or union coverage), call the planlisted in your letter, or call 1-800-MEDICARE (1-800-633-4227).Y users should call 1-877-486-2048. ell them you don’t want tobe in a Medicare drug plan (you want to “opt out”). I you continueto qualiy or Extra Help or i your employer or union coverageis creditable prescription drug coverage, you won’t have to pay apenalty i you join later.

I you have employer or union coverage and you join a

Medicare drug plan, you may lose your employer or unioncoverage even i you qualiy or Extra Help. Call youremployer’s benets administrator or more inormation beoreyou join.

Extra Help Paying or Medicare Prescription

Drug Coverage (Part D) (continued)




I you didn’t automatically qualiy or Extra Help, you can apply:

■ Visit www.socialsecurity.gov/i1020to apply online.■ Call Social Security at 1-800-772-1213 to apply or Extra Help by phone

or to get a paper application. Y users should call 1-800-325-0778.

■ Visit your State Medical Assistance (Medicaid) oce. Visitwww.medicare.gov/contacts or call 1-800-MEDICARE(1-800-633-4227) to get the phone number. Y users should call1-877-486-2048.

Note: You can apply or Extra Help at anytime. With your consent,

Social Security will orward inormation to the Medicaid oce inyour state to start an application or a Medicare Savings Program.See page 102.

Drug costs in 2012 or most people who qualiy will be no more than$2.60 or each generic drug and $6.50 or each brand name drug.Look on the Extra Help letters you get, or contact your plan to nd outyour exact costs.

o get answers to your questions about Extra Help and help choosing

a plan, call your State Health Insurance Assistance Program(SHIP). See pages 137–140 or the phone number. You can also call1-800-MEDICARE.

Paying the Right Amount

Medicare gets inormation rom your state or Social Security that tellswhether you qualiy or Extra Help. I Medicare doesn’t have the rightinormation, you may be paying the wrong amount or your prescriptiondrug coverage.

I you automatically qualiy or Extra Help, you can show your drug planthe colored letter you got rom Medicare as proo that you qualiy. I youapplied or Extra Help, you can show your “Notice o Award” rom SocialSecurity as proo that you qualiy.

You can also give your plan any o the documents listed on the next page(also called “Best Available Evidence”) as proo that you qualiy or ExtraHelp. Your plan must accept these documents. Each item must show thatyou were eligible or Medicaid during a month aer June o 2011.

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Extra Help Paying or Medicare Prescription Drug

Coverage (Part D) (continued)

http://www.socialsecurity.gov/i1020



http://www.socialsecurity.gov/i1020




Medicare Savings Programs (Help with Medicare

Costs)States have programs that pay Medicare premiums and, in some

cases, may also pay Part A and Part B deductibles, coinsurance, andcopayments. Tese programs help people with Medicare who havelimited income and resources. Te names o these programs and howthey work may vary by state.

In most cases, to qualiy or a Medicare Savings Program, you mustmeet all o these conditions:

■ Have Part A.

■ Have monthly income less than $1,246 and resources less than$6,680—single person.

■ Have monthly income less than $1,675 and resources less than$10,020—married and living together.

Note: Tese amounts may change each year. Many states gure yourincome and resources dierently, so you may qualiy in your stateeven i your income or resources are higher than the amounts listedabove. I you have a disability and are working, you may qualiy eveni your income is higher. Resources include money in a checkingor savings account, stocks, bonds, mutual unds, and Individual

Retirement Accounts (IRAs). Resources don’t include your home, car,burial plot, burial expenses up to your state’s limit, urniture, or otherhousehold items. Some states don’t have any limits on resources.

For More Inormation

■ Call or visit your State Medical Assistance (Medicaid) oce, and ask or inormation on Medicare Savings Programs. Call i you think you qualiy or any o these programs, even i you aren’t sure. o getthe phone number or your state visit www.medicare.gov/contacts.

You can also call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid.” Y users should call 1-877-486-2048.

■ Visit www.medicare.gov/publicationsto view the brochure “GetHelp With Your Medicare Costs: Getting Started.” You can also call1-800-MEDICARE to nd out i a copy can be mailed to you.

■ Contact your State Health Insurance Assistance Program (SHIP).See pages 137–140 or the phone number.

H

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103Section 4—Get Help Paying Your Health and Prescription Drug Costs

MedicaidMedicaid is a joint Federal and state program that helps pay medical costsi you have limited income and resources and meet other requirements.Some people qualiy or both Medicare and Medicaid and are called “dualeligibles.”

■ I you have Medicare and ull Medicaid coverage, most o your healthcare costs are covered. You can get your Medicare coverage throughOriginal Medicare or a Medicare Advantage Plan (like an HMO or PPO).

■ I you have Medicare and ull Medicaid, Medicare covers yourprescription drugs. Medicaid may still cover some drugs and other carethat Medicare doesn’t cover.

■ People with Medicaid may get coverage or services that Medicare doesn’t

ully cover, such as nursing home care.■ Medicaid programs vary rom state to state. Tey may also have dierent

names, such as “Medical Assistance” or “Medi-Cal.”

■ Each state has dierent income and resource requirements.

■ In some states, you may need Medicare to be eligible or Medicaid.

■ Call your State Medical Assistance (Medicaid) oce or more inormationand to see i you qualiy. Visit www.medicare.gov/contacts. You can alsocall 1-800-MEDICARE (1-800-633-4227), and say “Medicaid” to get thephone number or your State Medical Assistance (Medicaid) oce.Y users should call 1-877-486-2048.

State Pharmacy Assistance Programs (SPAPs)Many states have State Pharmacy Assistance Programs (SPAPs) that helpcertain people pay or prescription drugs based on nancial need, age, ormedical condition. Each SPAP makes its own rules on how to provide drugcoverage to its members. o nd out about the SPAP in your state, call yourState Health Insurance Assistance Program (SHIP). See pages 137–140 or

the phone number.

Pharmaceutical Assistance Programs (also called

Patient Assistance Programs)Many major drug manuacturers oer assistance programs or people withMedicare drug coverage who meet certain requirements.

Note: Visit www.medicare.gov/pap/index.aspto learn more aboutPharmaceutical Assistance Programs.


http://www.medicare.gov/pap/index.asp

http://www.medicare.gov/pap/index.asp





Programs o All‑Inclusive Care or the Elderly (PACE)PACE is a Medicare and Medicaid program oered in many states thatallows people who need a nursing home-level o care to remain in thecommunity. See page 83 or more inormation.

Supplemental Security Income (SSI) BenetsSSI is a cash benet paid by Social Security to people with limited incomeand resources who are disabled, blind, or 65 or older. SSI benets helppeople meet basic needs or ood, clothing, and shelter. SSI benets aren’tthe same as Social Security benets.

You can visit www.socialsecurity.gov , and use the “Benet Eligibility Screening ool” to nd out i you’re eligible or SSI or other benets.

Call Social Security at 1-800-772-1213 or contact your local Social Security oce or more inormation. Y users should call 1-800-325-0778.

Note: People who live in Puerto Rico, the U.S. Virgin Islands, Guam, orAmerican Samoa can’t get SSI.

Programs or People Who Live in the U.S. TerritoriesTere are programs in Puerto Rico, the U.S. Virgin Islands, Guam, theNorthern Mariana Islands, and American Samoa to help people with

limited income and resources pay their Medicare costs. Tis help isn’t thesame as the Extra Help described on pages 98–101. Programs vary in theseareas. Call your local Medical Assistance (Medicaid) oce to learn more,or call 1-800-MEDICARE (1-800-633-4227) and say “Medicaid” or moreinormation. Y users should call 1-877-486-2048.

Children’s Health Insurance ProgramDo you have children or grandchildren who need health insurance?

Te Children’s Health Insurance Program provides low cost healthinsurance coverage to children in amilies who earn too muchincome to qualiy or Medicaid, but not enough to buy private healthinsurance.

Each state has its own program, with its own eligibility rules.Call 1-877-KIDS-NOW (1-877-543-7669), or visitwww.insurekidsnow.gov or more inormation about the Children’sHealth Insurance Program.

Blue words


on pages

141–144.


http://www.insurekidsnow.gov/

http://www.insurekidsnow.gov/




105

SECTION 5

Protecting

Yoursel and

Medicare


Your Medicare Rights . . . . . . . . . . . . . . . . . . . . . . . 106

Your Rights i Your Plan Stops Participating in Medicare . . . 106

What is an Appeal? . . . . . . . . . . . . . . . . . . . . . . . . 107

How to File an Appeal . . . . . . . . . . . . . . . . . . . . . . 108

Your Rights i You Tink Your Services are Ending oo Soon 109

Appealing Your Medicare Drug Plan’s Decisions . . . . . . . . 110

Advance Beneciary Notice (ABN) . . . . . . . . . . . . . . . 113

How Medicare Uses Your Personal Inormation . . . . . . . . 114

Protect Yoursel rom Identity Te . . . . . . . . . . . . . . . 116

Te Senior Medicare Patrol (SMP) Program Can Help You . . 117

Protect Yoursel and Medicare rom Fraud . . . . . . . . . . . 117

How Medicare Protects You . . . . . . . . . . . . . . . . . . . 119

Te Medicare Beneciary Ombudsman . . . . . . . . . . . . . 120



106 Section 5—Protecting Yoursel and Medicare

Your Medicare RightsNo matter what type o Medicare coverage you have, you have certainguaranteed rights. As a person with Medicare, you have the right to all o the ollowing:

■ Be treated with dignity and respect at all times

■ Be protected rom discrimination

■ Have access to doctors, other health care providers, specialists, andhospitals

■ Have your questions about Medicare answered

■ Learn about your treatment choices and participate in treatmentdecisions

■ Get inormation in a way you understand rom Medicare, health careproviders, and under certain circumstances, contractors

■ Get emergency care when and where you need it

■ Get a decision about health care payment or coverage o services, orprescription drug coverage

■ Get a review (appeal) o certain decisions about health care payment,coverage o services, or prescription drug coverage

■ File complaints (sometimes called grievances), including complaints

about the quality o your care

■ Have your personal and health inormation kept private

Your Rights i Your Plan Stops Participating in

MedicareMedicare health and prescription drug plans can decide not to participatein Medicare or the coming year. Plans that choose to leave Medicareentirely or in certain areas are said to be “non-renewing.” In these cases,

the plan will send you a letter about your options and your right to joinanother Medicare plan.

I you want to continue to have Medicare prescription drug coverage(Part D) or a Medicare Advantage Plan (like an HMO or PPO), you needto join a new plan or the coming year. I you join a new Medicare planby December 31, you will have coverage as o January 1. I you don’t join anew Medicare Advantage Plan by December 31, you will continue to haveMedicare coverage through Original Medicare. I you don’t join a Part Dplan by that date, you will no longer have Medicare drug coverage.

H



107Section 5—Protecting Yoursel and Medicare

I you didn’t join a new plan by December 31, you will have until

February 29, 2012, to choose and join a new Medicare plan.■ Generally, i you’re in a Medicare health plan, you will

automatically return to Original Medicare i you don’t choose to join another Medicare health plan. You will also have the right tobuy certain Medigap policies. I you return to Original Medicare,you can also join a Medicare Prescription Drug Plan.

■ I you’re in a Medicare Prescription Drug Plan, you will havethe right to join another Medicare Prescription Drug Plan or aMedicare health plan with drug coverage. I you don’t join a new

plan, you won’t have Medicare prescription drug coverage (Part D).

What is an Appeal?An appeal is the action you can take i you disagree with a coverageor payment decision made by Medicare or your Medicare plan.You can appeal i Medicare or your plan denies one o the ollowing:

■ A request or a health care service, supply, item, or prescriptiondrug that you think you should be able to get

■ A request or payment or health care services, supplies, items, orprescription drugs you already got

■ A request to change the amount you must pay or a prescriptiondrug

You can also appeal i Medicare or your plan stops providing orpaying or all or part o an item or service you think you still need.

I you decide to le an appeal, you can ask your doctor or otherhealth care provider or supplier or any inormation that may help

your case.

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H Your Rights i Your Plan Stops Participating in

Medicare (continued)




HYour Rights i You Think Your Services are

Ending Too SoonI you’re getting Medicare services rom a hospital, skilled

nursing acility, home health agency, comprehensive outpatientrehabilitation acility, or hospice, and you think your Medicare-covered services are ending too soon, you can ask or a ast appeal.Your provider will give you a notice beore your services end thatwill tell you how to ask or a ast appeal. You should read this noticecareully. I you don’t get this notice, ask your provider or it. With aast appeal, an independent reviewer, called a Quality ImprovementOrganization (QIO), will decide i your services should continue.

■ You may ask your doctor or other health care provider or any

inormation that may help your case i you decide to le a astappeal.

■ You must call your QIO to request a ast appeal no later than thetime shown on the notice you get rom your provider. Use thephone number or your QIO listed on your notice to request yourappeal.

■ I you miss the deadline, you still have appeal rights:

— I you have Original Medicare, call your QIO.

— I you’re in a Medicare health plan, read your noticecareully and ollow the instructions or ling an appealwith your plan. You can also call your plan.

Visit www.medicare.gov/contacts or call 1-800-MEDICARE(1-800-633-4227) to get the phone number or the QIO in yourstate. Y users should call 1-877-486-2048.






Appealing Your Medicare Drug Plan’s DecisionsI you have Medicare prescription drug coverage (Part D), youhave the right to do all o the ollowing (even beore you buy yourprescription):

■ Get a written explanation (called a “coverage determination”) romyour Medicare drug plan. A coverage determination is the rstdecision made by your Medicare drug plan (not the pharmacy)about your prescription drug benets. Tis includes whether acertain drug is covered, whether you have met all the requirementsor getting a requested drug, and how much you’re required to pay or a drug.

■ Ask or an exception i you or your prescriber (your doctor or other

health care provider who is legally allowed to write prescriptions)believes you need a drug that isn’t on your plan’s ormulary .

■ Ask or an exception i you or your prescriber believes that acoverage rule (such as prior authorization) should be waived.

■ Ask or an exception i you think you should pay less or a highertier (more expensive) drug because you or your prescriber believesyou can’t take any o the lower tier (less expensive) drugs or thesame condition.

You or your prescriber must contact your plan to ask or a coveragedetermination, including an exception. I your network pharmacy can’t ll a prescription as written, the pharmacist will give you anotice that explains how to contact your Medicare drug plan so youcan make your request. I the pharmacist doesn’t give you this notice,ask or it.




You or your prescriber may make a standard appeal request by

phone or in writing, i you’re asking or prescription drug benetsyou haven’t received yet. I you’re asking to get paid back orprescription drugs you already bought, your plan can require youor your prescriber to make the standard request in writing.

You or your prescriber can call or write your plan or an expedited(ast) request. Your request will be expedited i you haven’t receivedthe prescription and your plan determines, or your prescriber tellsyour plan, that your lie or health may be at risk by waiting.

Once your plan has received your request, it has 72 hours (or astandard request or coverage) or 24 hours (or an expedited requestor coverage) to notiy you o its decision.

I you’re requesting an exception, your prescriber mustprovide a statement explaining the medical reason why theexception should be approved.

Appealing Your Medicare Drug Plan’s Decisions

(continued)




I you disagree with your Medicare drug plan’s coverage

determination, including an exception decision, you can appeal.Te rst level is appealing to your plan. Once your Medicare drugplan gets your appeal, it has 7 days (or a standard appeal) or 72hours (or an expedited appeal) to notiy you o its decision. I youdisagree with the plan’s decision, you can ask or an independentreview o your case. Te notice you get with the plan’s decision willexplain what you can do next.

You can get help ling an appeal rom your State Health InsuranceAssistance Program (SHIP). See pages 137–140 or the phonenumber.

I your plan doesn’t respond to your request or a coveragedetermination including an exception, or an appeal, you can lea complaint (also called a grievance). Call your plan. You can alsocall 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

For more inormation about the dierent levels o appeals ina Medicare drug plan, visit www.medicare.gov/publications to view the booklet “Medicare Appeals.” You can also call1-800-MEDICARE to nd out i a copy can be mailed to you.

Appealing Your Medicare Drug Plan’s Decisions

(continued)






Advance Beneciary Notice (ABN)I you have Original Medicare, your health care provider orsupplier may give you a notice called an “Advance Beneciary Notice” (ABN).

■ Tis notice says Medicare probably (or certainly) won’t pay orsome services in certain situations.

■ You will be asked to choose whether to get the items or serviceslisted on the ABN.

■ I you choose to get the items or services listed on the ABN, youwill have to pay i Medicare doesn’t.

■ You will be asked to sign the ABN to say that you have read andunderstood it.

■ Doctors, other health care providers, and suppliers don’t have to(but still may) give you an ABN or services that Medicare nevercovers. See page 54.

■ An ABN isn’t an ocial denial o coverage by Medicare. Youcould choose to get the items listed on the ABN and still ask yourhealth care provider or supplier to submit the bill to Medicare oranother insurer. I Medicare denies payment, you can still le anappeal. However, you will have to pay or the items or services

i Medicare determines that the items or services aren’t covered(and no other insurer is responsible or payment).

■ You may get a Home Health ABN or other reasons, such as whenyour doctor or other health care provider makes changes to orreduces your home health care.

■ You may get a Skilled Nursing Facility ABN when the acility believes Medicare will no longer cover your stay.

■ I you should have received an ABN but didn’t, in most cases your

provider must pay you back what you paid or the item or service.

I you’re in a Medicare plan, call your plan to nd out i a service oritem will be covered.

For more inormation about ABNs, visitwww.medicare.gov/publicationsto view the booklet “MedicareAppeals.” You can also call 1-800-MEDICARE (1-800-633-4227)to nd out i a copy can be mailed to you. Y users should call1-877-486-2048.

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141–144.

H

http://-/?-



http://-/?-




By law, Medicare must have your written permission (an “authorization”) to use or give outyour personal medical inormation or any purpose that isn’t set out in this notice. You may take back (“revoke”) your written permission anytime, except to the extent that Medicarehas already acted based on your permission.

By law, you have the right to take these actions:

■ See and get a copy o your personal medical inormation held by Medicare.

■ Have your personal medical inormation amended i you believe that it is wrong or i inormation is missing, and Medicare agrees. I Medicare disagrees, you may have astatement o your disagreement added to your personal medical inormation.

■ Get a listing o those getting your personal medical inormation rom Medicare.Te listing won’t cover your personal medical inormation that was given to you or yourpersonal representative, that was given out to pay or your health care or or Medicareoperations, or that was given out or law enorcement purposes i it would likely get in the

way o these purposes.■ Ask Medicare to communicate with you in a dierent manner or at a dierent place (or

example, by sending materials to a P.O. Box instead o your home address).

■ Ask Medicare to limit how your personal medical inormation is used and given out topay your claims and run the Medicare Program. Please note that Medicare may not beable to agree to your request.

■ Get a separate paper copy o this notice.

Visit www.medicare.gov or more inormation on the ollowing:

■ Exercising your rights set out in this notice.

■ Filing a complaint, i you believe Original Medicare has violated these privacy rights.Filing a complaint won’t aect your coverage under Medicare.

You can also call 1-800-MEDICARE (1-800-633-4227) to get this inormation. Ask tospeak to a customer service representative about Medicare’s privacy notice. Y usersshould call 1-877-486-2048.

You may le a complaint with the Secretary o the Department o Health and HumanServices. Call the Oce or Civil Rights at 1-800-368-1019. Y users should call1-800-537-7697. You can also visit www.hhs.gov/ocr/privacy .

By law, Medicare is required to ollow the terms in this privacy notice. Medicare has the

right to change the way your personal medical inormation is used and given out.I Medicare makes any changes to the way your personal medical inormation is used andgiven out, you will get a new notice by mail within 60 days o the change.

Te Notice o Privacy Practices or Original Medicare became efective April 14, 2003.

Note: I you join a Medicare plan, the plan will let you know how it will use andrelease your personal inormation as permitted or required by law including ortreatment, payment, health care operations, and or research and other purposes.


http://www.hhs.gov/ocr/privacy

http://www.hhs.gov/ocr/privacy





Protect Yoursel rom Identity ThetIdentity the is a serious crime. Identity the happens when someone usesyour personal inormation without your consent to commit raud or othercrimes. Personal inormation includes things like your name and yourSocial Security, Medicare, or credit card numbers. Guard against identity the by keeping your personal inormation sae.

I you think someone is using your personal inormation withoutyour consent, call your local police department and the Federal radeCommission’s ID Te Hotline at 1-877-438-4338 to make a report.Y users should call 1-866-653-4261.

What You Can Do

Generally, no one should call you or come to your home uninvited toget you to join a Medicare plan. Don’t give your personal inormationto someone who does this. Only give personal inormation like yourMedicare number to doctors, other health care providers, and plansapproved by Medicare; any insurer who pays benets on your behal;and to trusted people in the community who work with Medicare,like your State Health Insurance Assistance Program (SHIP) or SocialSecurity . Call 1-800-MEDICARE (1-800-633-4227) i you aren’t sure i aprovider is approved by Medicare. Y users should call 1-877-486-2048.

Plans Must Follow Rules

Medicare plans must ollow certain rules when marketing their plans andgetting your enrollment inormation. Tey can’t ask you or credit card orbanking inormation over the phone or via email, unless you’re already amember o that plan. Medicare plans can’t enroll you into a plan over thephone unless you call them and ask to enroll. Call 1-800-MEDICARE toreport any plans that ask or your personal inormation over the phoneor that call to enroll you in a plan. You can also call the Medicare Drug

Integrity Contractor (MEDIC) at 1-877-7SAFERX (1-877-772-3379). TeMEDIC helps prevent inappropriate activity and ghts raud, waste, andabuse in Medicare Advantage Plans (Part C) and Medicare PrescriptionDrug (Part D) Programs. For more inormation on the rules thatMedicare plans must ollow, visit www.medicare.gov/publicationsto viewthe booklet “Protecting Medicare and You rom Fraud.” You can also call1-800-MEDICARE to nd out i a copy can be mailed to you.

For more inormation about identity the or to le a complaint online, visit www.c.gov/idthe. You can also visit www.stopmedicareraud.gov .

H


http://www.ftc.gov/idtheft

http://www.stopmedicarefraud.gov/

http://www.stopmedicarefraud.gov/

http://www.ftc.gov/idtheft





The Senior Medicare Patrol (SMP) Program Can

Help YouTe SMP Program educates and empowers people with Medicare

to take an active role in detecting and preventing health careraud and abuse. Te SMP Program not only protects peoplewith Medicare, it also helps preserve Medicare. Tere is an SMPProgram in every state, the District o Columbia, Guam, the U.S.Virgin Islands, and Puerto Rico. Contact your local SMP Programto get personalized counseling and to nd out about community events in your area. For more inormation or to nd your localSMP Program, visit www.smpresource.org or call 1-877-808-2468.You can also call 1-800-MEDICARE (1-800-633-4227). Y users

should call 1-877-486-2048.

Protect Yoursel and Medicare rom FraudMost doctors, pharmacists, plans, and other health care providerswho work with Medicare are honest. Unortunately, there may besome who are dishonest. Medicare raud happens when Medicareis billed or services or supplies you never got. Medicare raudcosts Medicare a lot o money each year. You pay or it with higherpremiums.

Remember these tips to help prevent billing raud:

■ Ask questions! You have the right to know everything about yourhealth care, including the costs o the items and services billed toMedicare.

■ Educate yoursel about Medicare. Know your rights and what aprovider can and can’t bill to Medicare.

■ Review your Medicare Summary Notice and other statements,and, i necessary, ask your health care provider about what items

and services they have billed.■ Be wary o providers who tell you that the item or service

isn’t usually covered, but they “know how to bill Medicare” soMedicare will pay.

I you believe a Medicare plan or provider has used alseinormation to mislead you, call 1-800-MEDICARE.

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141–144.

http://www.smpresource.org/

http://www.smpresource.org/




Fighting Fraud Can PayYou may get a reward o up to $1,000 i you meet all these conditions:

■ You report suspected Medicare raud (or example, by calling

1-800-MEDICARE).■ Te suspected Medicare raud you report must be proven as potentialraud by the Program Saeguard Contractor, the Zone Program Integrity Contractor, or the Medicare Drug Integrity Contractor (the Medicarecontractors that investigate potential raud and abuse) and ormally reerred as part o a case by one o the contractors to the Oce o Inspector General or urther investigation.

■ You aren’t an “excluded individual.” For example, you didn’t participatein the raud oense being reported. Or, there isn’t another reward thatyou qualiy or under another government program.

■ Te person or organization you’re reporting isn’t already underinvestigation by law enorcement.

■ Your report leads to the recovery o at least $100 o Medicare money.

For more inormation, call 1-800-MEDICARE (1-800-633-4227).Y users should call 1-877-486-2048.

Investigating Fraud Takes TimeWe take all reports o suspected raud seriously. When you report raud,

you may not hear o an outcome right away. It takes time to investigateyour report and build a case.

How Medicare Protects YouWith help rom honest health care providers, suppliers, law enorcement,other government agencies, and citizens like you, Medicare is improvingits ability to prevent raud and protect you rom identity the.

Te Department o Justice and the Department o Health and HumanServices’ Medicare Fraud Strike Force is a multi-agency team o Federal,

state, and local investigators designed to combat Medicare raud throughMedicare data analysis and community policing. Tese agencies are alsoworking together to both prevent raud and enorce current anti-raudlaws around the country on a Health Care Fraud Prevention andEnorcement Action eam (HEA). Over a 5-year period, it’s estimatedthat the anti-raud eorts and oversight will save $2.7 billion.

Because o all o these eorts, some dishonest health care providers havebeen removed rom Medicare and some have gone to jail. Tese actionsare saving money or taxpayers and protecting Medicare or the uture.



121

SECTION 6

Planning

Ahead


Plan or Long-erm Care . . . . . . . . . . . . . . . . . . . . . 122

Paying or Long-erm Care . . . . . . . . . . . . . . . . . . . 122

Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . 125



123Section 6—Planning Ahead

Paying or Long‑Term Care (continued)Medicaid—Medicaid is a joint Federal and state program thatpays or certain health services or people with limited incomeand resources. I you qualiy, you may be able to get help to pay ornursing home care or other health care costs. See page 103 or moreinormation about Medicaid.

Home and Community-based Services Programs—I you’realready eligible or Medicaid (or, in some states, would be eligible orMedicaid coverage in a nursing home), you or your amily membersmay be able to get help with the costs o services that help youstay in your home instead o moving to a nursing home. Examplesinclude homemaker services, personal care, and respite care. For

more inormation, contact your State Medical Assistance (Medicaid)oce. Visit www.medicare.gov/contactsor call 1-800-MEDICARE(1-800-633-4227), and say “Medicaid” to get the phone number.Y users should call 1-877-486-2048.

Veterans’ Benets—Te Department o Veterans Aairs (VA)may provide long-term care or service-related disabilities or orcertain eligible veterans. Te VA also has a Housebound and an Aidand Attendance Allowance Program that provides cash grants to

eligible disabled veterans and surviving spouses instead o ormally-provided homemaker, personal care, and other services needed orhelp at home. For more inormation, call the VA at 1-800-827-1000,or visit www.va.gov .

Programs o All-inclusive Care or the Elderly (PACE)—PACE is aMedicare and Medicaid program oered in many states that allowspeople who otherwise need a nursing home-level o care to remainin the community. See page 83 or more inormation.

New —Te Community Living Assistance Services and Supports(CLASS) Program will be a national, voluntary insurance programto help pay or services and supports needed to live as independently as possible. CLASS isn’t available yet. Eligible working adults willbe able to enroll in the CLASS program when it begins. Enrolleeswho meet certain eligibility requirements (including at least a 5-year

vesting period and the need or assistance with activities o daily living) will have access to the benet. Visit www.healthcare.gov tolearn more.


http://www.va.gov/

http://www.healthcare.gov/


http://www.va.gov/




124 Section 6—Planning Ahead

Long-Term Care Contacts

Use the ollowing resources to get more inormation about long-term

care:■ Visit www.medicare.gov/ltcplanning. You can visit

www.medicare.gov/nhcompare to compare nursing homes orwww.medicare.gov/hhcompare to compare home health agencies inyour area.

■ Call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

■ Visit www.longtermcare.gov to learn more about planning orlong-term care.

■ Call your State Insurance Department to get inormation aboutlong-term care insurance. Call 1-800-MEDICARE to get the phonenumber. You can also call your State Health Insurance AssistanceProgram. See pages 137–140 or their phone number.

■ Call the National Association o Insurance Commissioners at1-866-470-6242 to get a copy o “A Shopper’s Guide to Long-termCare Insurance.”

■ Visit the Eldercare Locator, a public service o the U.S. Administration

on Aging, at www.eldercare.gov to nd your local Aging andDisability Resource Center (ADRC). You can also call 1-800-677-1116.ADRCs oer a ull range o long-term care services and support in asingle, coordinated program.

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Paying or Long‑Term Care (continued)

http://www.medicare.gov/ltcplanning

http://www.medicare.gov/nhcompare

http://www.medicare.gov/hhcompare

http://www.longtermcare.gov/

http://www.eldercare.gov/


http://www.longtermcare.gov/

http://www.medicare.gov/hhcompare

http://www.medicare.gov/nhcompare

http://www.medicare.gov/ltcplanning



125Section 6—Planning Ahead

Advance Directives

Advance directives are legal documents that allow you to put inwriting what kind o health care you would want or name someonewho can speak or you i you were too ill to speak or yoursel.Advance directives most oen include the ollowing:

■ A health care proxy (durable power o attorney)

■ A living will

■ Aer-death wishes

alking with your amily, riends, and health care providers aboutyour wishes is important, but these legal documents help ensureyour wishes are ollowed. It’s better to think about these importantdecisions beore you’re ill or a crisis strikes.

A health care proxy (sometimes called a “durablepower o attorney or health care”) is used to namethe person you want to make health care decisions oryou i you aren’t able to make them yoursel. Having ahealth care proxy is important because i you suddenly aren’t able to make your own health care decisions,someone you trust will be able to make these decisionsor you.

A living will is another way to make sure your voice is heard.It states which medical treatment you would accept or reuse i your lie is threatened. Dialysis or kidney ailure, a breathingmachine i you can’t breathe on your own, CPR (cardiopulmonary resuscitation) i your heart and breathing stop, or tube eeding i you can no longer eat are examples o such medical treatments.

In some states, advance directives can also include aer-deathwishes. Tese may include choices such as organ and tissue

donation.



126 Section 6—Planning Ahead

I you already have advance directives, take time now to reviewthem to be sure you’re still satised with your decisions and yourhealth care proxy is still willing and able to carry out your plans.Find out how to cancel or update them in your state i they nolonger refect your wishes. Each state has its own laws or creatingadvance directives. Some states may allow you to combine youradvance directives in one document. For more inormation, contactyour health care provider, an attorney, your local Area Agency onAging, or your state health department.

Tips I You Choose to Have Advanced Directives

1. Keep the original copies o your advance directives where they are easily ound.

2. Give the person you’ve named as your health care proxy, andothers close to you, a copy o your advance directives.

3. Give your doctor or other health care provider a copy o youradvance directives or your medical record. Provide a copy to ahospital or nursing home you stay in or any ambulatory surgicalcenter where you have procedures done.

4. Carry a card in your wallet that states you have advancedirectives.

Advance Directives (continued)



127

SECTION 7

Helpul

Resources

and Tools


1-800-MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . 128

State Health Insurance Assistance Programs (SHIP) . . . . . 129

www.medicare.gov . . . . . . . . . . . . . . . . . . . . . . . . 130

www.MyMedicare.gov . . . . . . . . . . . . . . . . . . . . . . 130

Compare the Quality o Plans and Providers . . . . . . . . . . 131

Medicare is Working to Better Coordinate Your Care . . . . . 132

You Can Manage Your Health Inormation Online . . . . . . 134

Medicare Publications . . . . . . . . . . . . . . . . . . . . . . 136

Caregiver Resources . . . . . . . . . . . . . . . . . . . . . . . . 136

SHIP Phone Numbers . . . . . . . . . . . . . . . . . . . . . . . 137

I you have a question or complaint about the quality o a Medicare-covered service, call your local Quality Improvement Organization (QIO). Visitwww.medicare.gov/contacts to get your QIO’s phone number.You can also call 1-800-MEDICARE (1-800-633-4227).Y users should call 1-877-486-2048.





129Section 7—Helpul Resources and Tools

People who get benets rom the Railroad Retirement Board shouldcall 1-800-833-4455 with questions about Part B services and bills.

I you want someone to be able to call 1-800-MEDICARE onyour behal, you need to let Medicare know in writing. You canll out a “Medicare Authorization to Disclose Personal HealthInormation” orm so Medicare can give your personal healthinormation to someone other than you. You can do this by

visiting www.medicare.gov/medicareonlineorms or by calling1-800-MEDICARE (1-800-633-4227) to get a copy o the orm.Y users should call 1-877-486-2048. You may want to do this

now in case you become unable to do it later.

State Health Insurance Assistance Programs

(SHIPs)SHIPs are state programs that get money rom the Federalgovernment to give ree local health insurance counseling to peoplewith Medicare. SHIPs are independent and not connected to any insurance company or health plan. SHIP volunteers work hard tohelp you with the ollowing Medicare questions or concerns:

■ Your Medicare rights

■ Complaints about your medical care or treatment

■ Billing problems

■ Plan choices

See pages 137–140 or the phone number o your localSHIP. I you would like to become a volunteer SHIP

counselor, contact the SHIP in your state to learn more.

1‑800‑MEDICARE (1‑800‑633‑4227) (continued)





130 Section 7—Helpul Resources and Tools

Go Online to Get the Inormation You Need

Need General Inormation about Medicare?

Visit www.medicare.gov :

■ Get detailed inormation about the Medicare health andprescription drug plans in your area, including what they cost andwhat services they provide.

■ Find doctors or other health care providers and suppliers whoparticipate in Medicare.

■ See what Medicare covers, including preventive services.

■ Get Medicare appeals inormation and orms.

■ Get inormation about the quality o care provided by plans, nursing

homes, hospitals, home health agencies, and dialysis acilities.■ Look up helpul Web sites and phone numbers.

Need Personalized Medicare Inormation?

Register at www.MyMedicare.gov , Medicare’s secure online serviceor accessing your personal Medicare inormation: ■ Create and print an “On the Go” report that lists inormation you

can share with your providers.

■ Add or change inormation such as health conditions and allergies.

■ View or change your personal drug list and pharmacy inormation,and see your prescription drug costs.

■ Search or and create a list o your avorite providers, and accessquality inormation about them.

■ Complete your Initial Enrollment Questionnaire so your bills canget paid correctly.

■ rack Original Medicare claims, and order a Medicare Summary Notice.

■ Check your Part B deductible status.

Need Help Finding Other Health Insurance Options?

Visit www.healthcare.gov : ■ ake control o your health care with new inormation and

resources that will help you access quality and aordable healthcoverage.

■ Find public and private health coverage options tailored or yourneeds in a single easy to use tool.










Compare the Quality o Plans and ProvidersYou can’t always plan ahead when you need health care, but whenyou can, take time to compare. Medicare collects inormationabout the quality and saety o medical care and services given by most Medicare plans and other health care providers. Medicarealso has inormation about the experiences o people with the careand services they get.

Compare the quality o care (how well plans and providers work to give you the best care possible) and services given by healthand prescription drug plans or health care providers nationwideby visiting www.medicare.gov or by calling your State HealthInsurance Assistance Program (SHIP). See pages 137–140 or the

phone number.

When you, a amily member, riend, or SHIP counselor visitMedicare’s Web site, under “Resource Locator,” select one o theollowing:

■ “Drug and Health Plans”

■ “Dialysis Facilities”

■ “Home Health Agencies”

■ “Hospitals”

■ “Nursing Homes”

Tese search tools on www.medicare.gov give you a “snapshot”o the quality o care and services some plans and providers give.Find out more about the quality o care and services by doing theollowing:

■ Ask what your plan or provider does to ensure and improve thequality o care and services. Every plan and health care providershould have someone you can talk to about quality.

■ Ask your doctor or other health care provider what he or shethinks about the quality o care or services the plan or otherproviders give. You can also talk to your doctor or other healthcare provider about Medicare’s inormation on quality o careand services.

Blue words

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You Can Manage Your Health Inormation

OnlineHere’s what you can do to help manage your health inormation:

Personal Health Records (PHRs)—A record with inormationabout your health that you or someone helping you keeps or easy reerence using a computer.

■ Tese easy to use tools can help you manage your healthinormation rom anywhere you have Internet access.

■ With a PHR, you can keep track o health inormation, like thedate o your last physical, major illnesses, operations, allergies, ora list o your prescriptions.

■ PHRs are oen oered by providers, health plans, and privatecompanies. Some are ree, while others charge ees.

■ When you use a PHR, make sure that it’s on a secure Web site.With a secure Web site, you usually have to create a unique userID and password, and the inormation you type is encrypted (putin code) so other people can’t read it.

Tere are Federal and state laws that protect the privacy and

security o your inormation. PHRs that aren’t sponsored ormaintained by health plans or health care providers may nothave privacy rules.

Visit www.medicare.gov/phr to learn more about PersonalHealth Records.

http://www.medicare.gov/phr

http://www.medicare.gov/phr




You Can Manage Your Health Inormation

Online (continued)

NEW: Medicare’s “Blue Button”—MyMedicare.gov has a new

“Blue Button” eature that lets you download your OriginalMedicare claims. Te Blue Button also allows you to enterinormation such as emergency contacts, names o pharmaciesand providers, sel-reported allergies, medical conditions, andprescription drugs.

Aer logging on to the secure www.MyMedicare.gov site, you canclick the Blue Button and download a computer le o your claimsdata and add personal health inormation that you can share with

health care providers, caregivers, and amily members.■ Having access to inormation rom Medicare claims and

sel-entered personal health inormation can help you betterunderstand your medical history and partner more eectively with providers.

■ Te Blue Button data le can also be imported into other healthmanagement tools, such as one o the PHR tools described onpage 134. o nd a PHR that can upload the blue button le, visitwww.myphr.com.

■ Te Blue Button is sae, secure, reliable, and easy to use.

Visit www.MyMedicare.gov to sign up or your account and usethe Blue Button today!


http://www.myphr.com/



http://www.myphr.com/





Medicare Publicationso read, print, or download copies o booklets, brochures, or act sheetson dierent Medicare topics, visit www.medicare.gov/publications. Youcan search by keyword (such as “rights” or “mental health”), or select“View All Publications.”

I the publication you want has a check box aer “Order Publication,”you can have a printed copy mailed to you. You can also call1-800-MEDICARE (1-800-633-4227) and say “Publications” to nd outi a printed copy can be mailed to you. Y users should call1-877-486-2048.

Some publications are also available as podcasts that you can downloadand listen to.

Caregiver Resources

Do You Help Someone With Medicare?

Medicare has resources to help you get the inormation you need.

Medicareask

■ Visit “Ask Medicare” at www.medicare.gov/caregivers to helpsomeone you care or choose a drug plan, compare nursing homes,get help with billing, and more.

■ Sign up or the ree bi-monthly “Ask Medicare” electronic newsletter(e-Newsletter) when you go to www.medicare.gov/caregivers. Tee-Newsletter has the latest inormation including important dates,Medicare changes, and resources in your community.

■ Visit the Eldercare Locator, a public service o the U.S.Administration on Aging, at www.eldercare.gov , or call

1-800-677-1116 to nd caregiver support services in your area.

■ Te Centers or Medicare & Medicaid Services (CMS) is now onwitter! Follow ocial Medicare inormation at @CMSGov and theChildren’s Health Insurance Program at @IKNGov.

■ Visit www.Youube.com/cmshhsgov to see videos covering dierenthealth care topics on Medicare’s Youube channel.

Blue words

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141–144.


http://www.medicare.gov/caregivers



http://www.youtube.com/cmshhsgov

http://www.youtube.com/cmshhsgov








State Health Insurance Assistance Programs (SHIPs)For help with questions about appeals, buying other insurance, choosing ahealth plan, buying a Medigap policy, and Medicare rights and protections.

Tis page has been intentionally le blank. Te printed version containsphone number inormation. For the most recent phone number inormation,please visit www.medicare.gov/contacts/home.asp. Tank you.

http://www.medicare.gov/contacts/home.asp




141

SECTION 8

Deinitions

Assignment—An agreement by your doctor, other health careprovider, or supplier to be paid directly by Medicare, to accept thepayment amount Medicare approves or the service, and not to billyou or any more than the Medicare deductible and coinsurance.

Benet Period—Te way that Original Medicare measures youruse o hospital and skilled nursing acility (SNF) services. A benetperiod begins the day you are admitted as an inpatient in a hospitalor skilled nursing acility. Te benet period ends when you haven’treceived any inpatient hospital care (or skilled care in a SNF) or 60days in a row. I you go into a hospital or a skilled nursing acility aer one benet period has ended, a new benet period begins. Youmust pay the inpatient hospital deductible or each benet period.Tere is no limit to the number o benet periods.

Coinsurance—An amount you may be required to pay as yourshare o the cost or services aer you pay any deductibles.

Coinsurance is usually a percentage (or example, 20%).

Copayment—An amount you may be required to pay as yourshare o the cost or a medical service or supply, like a doctor’s visit,hospital outpatient visit, or prescription. A copayment is usually aset amount, rather than a percentage. For example, you might pay $10 or $20 or a doctor’s visit or prescription.



142 Section 8—Defnitions

Creditable Prescription Drug Coverage—Prescription drugcoverage (or example, rom an employer or union) that’s expected topay, on average, at least as much as Medicare’s standard prescriptiondrug coverage. People who have this kind o coverage when they

become eligible or Medicare can generally keep that coveragewithout paying a penalty, i they decide to enroll in Medicareprescription drug coverage later.

Critical Access Hospital—A small acility that provides outpatientservices, as well as inpatient services on a limited basis, to people inrural areas.

Custodial Care—Nonskilled personal care, such as help withactivities o daily living like bathing, dressing, eating, getting in or

out o a bed or chair, moving around, and using the bathroom. Itmay also include the kind o health-related care that most people dothemselves, like using eye drops. In most cases, Medicare doesn’t pay or custodial care.

Deductible—Te amount you must pay or health care orprescriptions beore Original Medicare, your prescription drug plan,or your other insurance begins to pay.

Extra Help—A Medicare program to help people with limitedincome and resources pay Medicare prescription drug program costs,such as premiums, deductibles, and coinsurance.

Formulary—A list o prescription drugs covered by a prescriptiondrug plan or another insurance plan oering prescription drugbenets.

Inpatient Rehabilitation Facility—A hospital, or part o a hospital,that provides an intensive rehabilitation program to inpatients.

Institution—For the purposes o this publication, an institution is aacility that provides short term or long term care, such as a nursinghome, skilled nursing acility (SNF), or rehabilitation hospital. Privateresidences, such as an assisted living acility or group home, aren’tconsidered institutions or this purpose.



143Section 8—Defnitions

Lietime Reserve Days—In Original Medicare, these are additionaldays that Medicare will pay or when you’re in a hospital or morethan 90 days. You have a total o 60 reserve days that can be usedduring your lietime. For each lietime reserve day, Medicare pays all

covered costs except or a daily coinsurance.

Long‑Term Care—A variety o services that help people with theirmedical and non-medical needs over a period o time. Long-termcare can be provided at home, in the community, or in variousother types o acilities, including nursing homes and assisted livingacilities. Most long-term care is custodial care. Medicare doesn’t pay or this type o care i this is the only kind o care you need.

Long‑Term Care Hospital—Acute care hospitals that provide

treatment or patients who stay, on average, more than 25 days.Most patients are transerred rom an intensive or critical care unit.Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

Medically Necessary—Services or supplies that are needed or thediagnosis or treatment o your medical condition and meet acceptedstandards o medical practice.

Medicare‑Approved Amount—In Original Medicare, this is theamount a doctor or supplier that accepts assignment can be paid.It may be less than the actual amount a doctor or supplier charges.Medicare pays part o this amount and you’re responsible or thedierence.

Medicare Health Plan—A plan oered by a private company thatcontracts with Medicare to provide Part A and Part B benets topeople with Medicare who enroll in the plan. Medicare HealthPlans include all Medicare Advantage Plans, Medicare Cost Plans,

Demonstration/Pilot Programs, and Programs o All-inclusive Careor the Elderly (PACE).

Medicare Plan—Reers to any way other than Original Medicarethat you can get your Medicare health or prescription drugcoverage. Tis term includes all Medicare health plans and MedicarePrescription Drug Plans.



145

Notes



Part A and Part B CostsTe law requires Medicare to send the inormation in this handbook to all people with Medicare 15 days beore the start o the all OpenEnrollment Period. Te 2012 premium and deductible amounts orPart A and Part B weren’t available to include at the time o printing.o get the most up-to-date inormation on these costs, visitwww.medicare.gov or call 1-800-MEDICARE (1-800-633-4227).Y users should call 1-877-486-2048.

Part C and Part D (Medicare Health and Prescription

Drug Plans) Costs or Covered Services and SuppliesCost inormation or the Medicare plans in your area is available atwww.medicare.gov . You can also contact the plan, or call1-800-MEDICARE. You can also call your State Health InsuranceAssistance Program (SHIP). See pages 137–140 or the phone number.Medicare Advantage Plans (like an HMO or PPO) must cover all Part Aand Part B-covered services and supplies. Check your plan’s materials oractual amounts.

Medicare cares about what you think. I you have general commentsabout this handbook, email us at [email protected] can’t respond to every comment, but we will consider youreedback when writing uture versions.







U.S. DEPARMEN OFHEALH AND HUMAN SERVICES

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CMS Product No. 10050August 2011

National Medicare Handbook

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