Medicare 2011

8/6/2019 Medicare 2011

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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

2011 This is the ocial U.S. government

Medicare handbook with important

inormation about the ollowing:

What's new

Medicare costsWhat Medicare covers

Health and prescription drug plans

Your Medicare rights

Signing up to get future handbooks

electronically

8/6/2019 Medicare 2011


Welcome to Medicare & You 2011I’m onored and excied o announce e 2011 Medicare andbook—e bes and ocialsource o answers o your Medicare quesions. A e Deparmen o Heal and Human

Services, we’re doing more an ever o carry Medicare ino e uure.

Te Aordable Care Ac makes many improvemens o Medicare. Moreover, i guaraneesa you will coninue o ave your basic Medicare benes—weer you ge em rougOriginal Medicare or a Medicare Advanage Plan.

As an example o e ypes o improvemens underway, i you ave Medicare prescripiondrug coverage wi a coverage gap (also known as e “donu ole”), e new law will reducea gap over several years o make prescripion drugs even more aordable. I you reac ecoverage gap in 2010, you may qualiy o ge a one-ime $250 rebae ceck. I you reac ecoverage gap in 2011, you may ge a 50% discoun on brand-name prescripion drugs wen

you buy em. Tere will be addiional savings in e coverage gap eac year roug 2020,wen e donu ole is closed compleely. Te new law also prevens Medicare AdvanagePlans rom carging you more an Original Medicare or cancer reamen and cerain oerservices a you mig need.

I you ave Original Medicare, you will now be able o ge a yearly wellness exam and mosprevenive services or ree. I you’re in a Medicare Advanage Plan, ceck wi your plan osee i ese benes will also be ree or you.

Docors, ospials, and Medicare Advanage Plans will ave new incenives o improvee qualiy o care you receive. Tere will be beer coordinaion o your care aer you’rediscarged rom a ospial o ensure a you ge e services you need aer your ospialsay. I will also be easier o nd ou wic long-erm care ospials, inpaien reabiliaiveospials, and ospice care programs provide beer care in your area.

Tese are jus a ew o e exciing new canges o elp improve your eal care now andin e uure, wile coninuing o keep you ealy, Medicare srong, and your personalinormaion sae.

I you ave quesions, visi Medicare’s new and improved Web sie a www.medicare.gov , orcall 1-800-MEDICARE (1-800-633-4227). You can also call your local Sae Heal InsuranceAssisance Program (SHIP) or area agency on aging, or visi e Adminisraion on Aging awww.aoa.gov .

Sincerely,

/s/

Kaleen Sebelius

Secreary

U.S. Deparmen o Heal and Human Services

/s/

Donald M. Berwick, MD

Adminisraor

Ceners or Medicare & MedicaidServices

http://www.medicare.gov/

http://www.aoa.gov/

http://www.aoa.gov/


8/6/2019 Medicare 2011


3

Tools to Help You Find What You Need

in This Handbook

Please keep this handbook or uture reerence. Inormaionwas correc wen i was prined. Call 1-800-MEDICARE(1-800-633-4227), or visi www.medicare.gov o ge e moscurren inormaion. Y users sould call 1-877-486-2048.

Higligs imporaninormaion

Trougouandbook

Higligs preveniveservices

Pages 29–45

Higligs inormaionrelaed o Medicare Par A

Trougouandbook

Higligs inormaionrelaed o Medicare Par B

Trougouandbook

Higligs inormaionrelaed o Medicare Par D

Trougouandbook

able o Contents

Lis o opics by secion Pages 5–7

Index Alpabeical lis o opics Pages 8–11

Mini ableso Contents

Lis o opics wiin eacsecion

Pages 17, 47, 85, 93, 109, 115

Blue words

in the text

Blue words in e exare explained in e“Deniions” secion

Pages 127–130

“Medicare & You” isn’ a legal documen. Ocial Medicare Program legalguidance is conained in e relevan saues, regulaions, and rulings.



8/6/2019 Medicare 2011


4

Want to Save?

Extra Help is available!

Many people qualiy o ge Exra Help paying eirMedicare prescripion drug coss bu don’ knowi. Mos wo qualiy and join a Medicare drug planwill ge 95% o eir coss covered. Don’ miss ouon a cance o save. Exra Help and oer programs(like Medicare Savings Programs) may elp make

your eal care and prescripion drug coss moreaordable. See Secion 3 or more inormaion abouExra Help and oer programs.

Choose to get uture handbooks electronically.

Save ax dollars and elp e environmen by signingup o access your uure “Medicare & You” andbookselecronically (also called e eHandbook). Visiwww.MyMedicare.gov o reques eHandbooks.

We’ll send you an email nex Ocober wen enew eHandbook is available. You won’ ge a copy o your andbook in e mail i you coose o gei elecronically.

Did your household get more than one copy o

“Medicare & You?”

Tis may appen i ere is a slig dierence inow your or your spouse’s address is enered in

Social Securiy or e Railroad Reiremen Board’s(RRB) mailing sysem. I you would like o ge only one copy in e uure, call 1-800-MEDICARE(1-800-633-4227), and say “Agen.” Y users souldcall 1-877-486-2048. I you ge RRB benes, call yourlocal RRB oce or 1-877-772-5772.

http://www.mymedicare.gov/


8/6/2019 Medicare 2011


ContentsMedicare & You 2011

12 What you need

to know in 20114Get your handbook

electronically 26What Medicare

covers

Continued _

5

2 Welcome to Medicare & You 2011

3 Tools to Help You Find What You Needin This Handbook

4 Want to Save?

8 Index

12 What You Need to Know in 201114 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

17 Medicare Part A and Part B(Signing Up and What’s Covered)

18 Signing Up or Part A and Part B

24 How Much Does Part A Coverage Cost?

25 How Much Does Part B Coverage Cost?

27 Part A-Covered Services

30 Part B-Covered Services

45 Preventive Services Checklist

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

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6

Contents (continued)

47 Your Medicare Choices48 Decide How to Get Your Medicare

48 Need Help Deciding?

50 Things to Consider When Choosing or Changing Your Coverage

51 Original Medicare

52 What You Pay

57 Medigap (Medicare Supplement Insurance) Policies

60 Medicare Advantage Plans (Part C)

63 Who Can Join?65 What You Pay

66 How Do Medicare Advantage Plans Work?

68 Join, Switch, or Drop a Medicare Advantage Plan

70 Other Medicare Health Plans

72 Medicare Prescription Drug Coverage (Part D)

72 Who Can Get Medicare Drug Coverage?

73 Join, Switch, or Drop a Medicare Drug Plan

75 What You Pay78 What is the Part D Late Enrollment Penalty?

80 Important Drug Coverage Rules

84 How Other Insurance Works with Medicare

85 Get Help Paying Your Health and Prescription Drug Costs86 Extra Help Paying or Medicare Prescription Drug Coverage (Part D)

90 Medicare Savings Programs (Help with Medicare Costs)

91 Medicaid

91 State Pharmacy Assistance Programs (SPAPs)

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

92 Supplemental Security Income (SSI) Benets

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

92 Children’s Health Insurance Program

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7

Contents (continued)

93 Protecting Yourself and Medicare94 Your Medicare Rights

95 What is an Appeal?

98 Appealing Your Medicare Drug Plan’s Decisions

102 How Medicare Uses Your Personal Inormation

104 Protect Yoursel rom Identity Thet

105 Protect Yoursel and Medicare rom Fraud

109 Planning Ahead

110 Plan or Long-Term Care110 Paying or Long-Term Care

113 Advance Directives

115 Helpful Resources and Tools116 1-800-MEDICARE (1-800-633-4227)

117 State Health Insurance Assistance Programs (SHIP)

118 Go Online to Get the Inormation You Need

119 Compare the Quality o Plans and Providers

120 Managing Your Health Inormation Online

122 Medicare Publications

122 Caregiver Resources

123 State Health Insurance Assistance Programs (SHIPs)

127 Definitions

131 Medicare Costs

85 Need help

with costs? 115Helpul

Resources 131

Medicare costs

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8

IndexNOTE: Te page number sown in bold provides e mos deailed inormaion.

AAbdominal Aortic Aneurysm 30, 45

Acupuncture 46

Advance Beneciary Notice 101

Advance Directives 113–114

ALS (Amyotrophic Lateral Sclerosis) 18

Ambulance Services 30, 44

Ambulatory Surgical Center 30, 114

Appeal 95–101

Articial Limbs 41

Assignment 53–54

BBalance Exam 36

Barium Enema 32, 45

Benet Period 127, 132

Bills 52, 84, 117–118Blood 27, 30, 132–133

Bone Mass Measurement (Bone Density) 31, 45

Braces (arm/leg/back/neck) 41

Breast Exam 39, 45

CCardiac Rehabilitation 31

Cardiovascular Screenings 31, 45

Caregiving 122

Cataract 35

Catastrophic Coverage 76–77

Children’s Health Insurance Program (CHIP) 92, 122

Chiropractic Services 31

Claims 51, 53, 103, 116

Clinical Laboratory Services 31, 133

Clinical Research Studies 28, 31, 62

COBRA 21–22, 82

C (continued)Colonoscopy 32, 45

Colorectal Cancer Screenings 32, 45

Community-Based Programs 111

Contract (private) 55

Coordination o Benets 16, 84

Cosmetic Surgery 46

Costs (copayments, coinsurance, deductibles, andpremiums) 13, 26–27, 29, 49–55, 62, 65, 75–77,

86, 127–129, 131–134

Coverage Determination (Part D) 98–100

Coverage Gap 12, 76–77, 86

Covered Services (Part A and Part B) 26–45, 132–133

Creditable Prescription Drug Coverage 50, 56, 72–73,

78–79, 82–83, 87, 128

Custodial Care 28, 110, 128

DDenitions 127–130

Demonstrations/Pilot Programs 71

Dental Care and Dentures 46, 60, 92

Department o Deense 16

Department o Health and Human Services (Ofce o

Inspector General) 16, 106–107

Department o Veterans Aairs 16, 78, 83, 111

Depression (see Mental Health Care) 38

Diabetes 33, 36–37, 45

Dialysis (Kidney Dialysis) 14, 19, 37, 62–64, 66–67,

113, 118–119

Discrimination 94, 108

Disenroll 62, 69, 74

Drug Plan 48–49, 56, 59, 62, 67, 72–83, 134

Drugs (outpatient) 40, 81

Durable Medical Equipment (like walkers) 12, 27,

34–35, 37, 40, 54, 116, 132–133

8

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99Index

EEKGs 35, 42

Eldercare Locator 112, 122

Electronic Handbook 4, 119

Electronic Health Record 50, 120

Electronic Prescribing 120

Emergency Department Services 35, 81

Employer Group Health Plan Coverage 21–22, 49–52,

56, 63–64, 70, 72, 78, 82, 84, 110

End-Stage Renal Disease (ESRD) 14, 19, 21, 37, 48,

62–64

Enroll

Part A 18–23

Part B 18–23

Part C 63, 68–69

Part D 72–74

ESRD Network Organization 64

Exception (Part D) 80–81, 98–100

Extra Help (Help Paying Medicare Drug Costs) 4, 65, 68,

73, 75–76, 78, 86–89, 128

Eyeglasses 35

FFecal Occult Blood Test 32, 45

Federal Employee Health Benets Program 16, 22, 83

Federally-Qualied Health Center Services 35, 42

Flexible Sigmoidoscopy 32, 45

Flu Shot 36, 45

Foot Exam 36

Formulary 50, 75, 80, 98, 128

Fraud 12, 104–107

GGap (Coverage) 76–77, 86

General Enrollment Period 21

Glaucoma Test 36, 45

HHealth Care Proxy 113–114

Health Inormation Technology (Health IT) 120–121

Health Maintenance Organization (HMO) 66, 130

Hearing Aids 36, 46

Help with Costs 65, 75–76, 86–89

Hepatitis B Shot 36, 45

HIV Screening 36, 45

Home Health Care 14, 26–27, 37, 54, 91, 101, 110, 119,

132–133

Hospice Care 14, 27, 60, 97, 132

Hospital Care (Inpatient Coverage) 14, 26, 28, 132–133

IIdentity Thet 104, 107

Indian Health Service 78, 83

Inpatient 14, 26–28, 33, 38, 44, 132–133

Institution 67–68, 73, 87, 89, 128

JJoin

Medicare Drug Plan 72–74

Medicare Health Plan 63, 68–69

KKidney Dialysis 14, 19, 37, 62–64, 66–67, 113,

118–119

Kidney Disease Education Services 37

Kidney Transplant 14, 19, 37, 43, 63–64

LLietime Reserve Days 129, 132

Limited Income 24, 56, 65, 86–92 Living Will 113

Long-Term Care 110–112

Low-Income Subsidy (LIS) (Extra Help) 4, 65, 68, 73,

75–76, 78, 86–89, 128

NOTE: Te page number sown in bold provides e mos deailed inormaion.

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10 Index

MMammogram 37, 45, 66–67

Medicaid 67, 71, 84, 86–89, 91–92, 107, 111, 116

Medical Equipment 12, 29, 34–35, 37, 54, 116,132–133

Medical Nutrition Therapy 37, 45

Medical Savings Account (MSA) Plans 61, 68, 72

Medically Necessary 27–30, 33, 129

Medicare

Part A 14, 18–24, 26–28, 131–132

Part B 14, 18–23, 25, 29–45, 131, 133

Part C 14, 60–69, 134

Part D 14, 56, 72–83, 86–89, 134

Medicare Advantage Plans (like an HMO or PPO) 14,

60–69, 134

Medicare Authorization to Disclose Personal Health

Inormation 117

Medicare Beneciary Ombudsman 108

Medicare Card (replacement) 16

Medicare Cost Plan 70, 129

Medicare Drug Integrity Contractor (MEDIC) 104, 106

Medicare Prescription Drug Coverage 14, 56, 72–83,

86–89

Medicare Savings Programs 86, 90

Medicare SELECT 57

Medicare Summary Notice (MSN) 52–53, 96, 106

Medigap (Medicare Supplement Insurance) 15, 22,

57–59, 63, 82

Mental Health Care 28, 38, 132–133

NNon-doctor Services 38

Nurse Practitioner 38

Nursing Home 27, 71, 89, 110–112, 116,119, 122

Nutrition Therapy Services 37, 45

OOccupational Therapy 27, 37–38, 133

Ofce or Civil Rights 16, 103, 108

O (continued)

Ofce o Inspector General 16, 106–107

Ofce o Personnel Management 16, 83

Ombudsman (Medicare Beneciary) 108

Original Medicare 15, 49, 51–56

Orthotic Items 41

Outpatient Hospital Services 39, 133

Oxygen 34, 116

PPap Test 39, 45

Payment Options (premium) 75, 131

Pelvic Exam 39, 45 Penalty (late enrollment)

Part A 21, 24

Part B 25

Part D 78–79, 134

Personal Health Record 121

Physical Exam 30, 35, 39, 45

Physical Therapy 27–28, 37, 40, 133

Physician Assistant 38

Pilot/Demonstration Programs 71, 129

Pneumococcal Shot 40, 45

Power o Attorney 113

Preerred Provider Organization (PPO) Plan 66

Prescription Drugs 14–15, 40, 49–50, 66–67, 72–83,

128, 134

Preventive Services 12, 29–45, 116, 130

Primary Care Doctor 51, 66–67, 130

Privacy Notice 102–103

Private Contract 55

Private Fee-or-Service (PFFS) Plans 67

Programs o All-Inclusive Care or the Elderly (PACE) 71,

92, 111

Prostate Screening (PSA Test) 41, 45

Proxy (Health Care) 113–114

Publications 122

Pulmonary Rehabilitation 41


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11Index

QQuality o Care 16, 50, 71, 119–120

Quality Improvement Organization (QIO) 16, 97, 115,

130

RRailroad Retirement Board (RRB) 16, 18–19, 25, 53,

131

Reerral 30, 39, 41, 50–51, 60, 62, 66–67, 130

Religious Nonmedical Health Care Institution 26, 28

Retiree Health Insurance 21, 23, 83–84

Rights 94–103, 108

Rural Health Clinic 41

SSecond Surgical Opinions 41

Service Area 63, 65–66, 68, 71–73, 130

Shingles Vaccine 80

Shots (vaccinations) 36, 40, 45, 80

Sigmoidoscopy 32, 45

Skilled Nursing Facility (SNF) Care 26, 28, 62, 110, 130

Smoking Cessation 42, 45

Senior Medicare Patrol (SMP) Program 105 Social Security 16, 18–19, 23–25, 53, 75, 88, 92, 131

Special Enrollment Period 21–25, 82

Special Needs Plan (SNP) 64, 67

Speech-language Pathology 27, 37, 42, 133

State Health Insurance Assistance Program (SHIP) 16,

48, 117, 123–126

State Medical Assistance (Medicaid) Ofce 71, 88,

90–91, 107, 111, 116

State Pharmacy Assistance Program (SPAP) 91 Substance Abuse 38

Supplemental Policy (Medigap) 15, 22, 57–59, 63, 82

Supplemental Security Income (SSI) 86, 92

Supplies (medical) 27–28, 33–35, 37, 39, 41–42, 116

Surgical Dressing Services 42

TTelehealth 42

Tests 29, 31–33, 36, 38–39, 42

Tiers (drug ormulary) 80

Transplant Services 43

Travel 44, 50, 57

TRICARE 16, 23, 78, 83–84

TTY 16, 116, 130

UUnion 21–22, 49–52, 56, 63–64, 70, 72, 78, 82, 84,

110

Urgently-Needed Care 44, 55, 60, 66–67

VVaccinations (shots) 36, 40, 45, 80

Veterans’ Benets (VA) 16, 78, 83, 111

Vision 35–36, 60

WWalkers 34–35, 116

Welcome to Medicare Physical Exam 30, 35, 39, 45

Wellness Exam 39, 45 What’s New 12

Wheelchairs 34–35, 116

www.medicare.gov 16, 19, 29, 35, 48, 54, 59, 66, 118

www.MyMedicare.gov 45, 53, 80, 106, 118–119

XX-ray 37, 39, 42


8/6/2019 Medicare 2011


12 What You Need to Know in 2011

Pay Less or Preventive Services See pages 29–45.

You will pay no deducible or coinsurance or mos prevenive services.

Durable Medical Equipment (DME) See pages 34–35.

I you live in cerain areas, you may ave o ge your durable medicalequipmen (suc as walkers) rom specic suppliers. Tis program willelp save you and Medicare money and make sure a you ge qualiy equipmen and supplies.

New Yearly Wellness Exam See page 39.

You can ge a wellness exam eac year o elp you say ealy.

New Dates to Change Plans See pages 13, 68, and 73.

Find ou wen you can make canges o your eal and prescripiondrug coverage.

Help in the Prescription Drug Coverage Gap See page 76.

I you reac e coverage gap in your Medicare prescripion drugcoverage, you may qualiy or savings on brand-name and generic drugs.

Fighting Medicare Fraud See pages 105–107.

Find ou wa Medicare is doing and wa you can do o proec againsraud, wase, and abuse.

Ways to Manage Your Health Inormation Online See pages 120–121.

Tere are ools o elp you manage your eal inormaion wilereducing paperwork and errors, and improving your qualiy o care.

What You Pay or MedicareSee pages

131–134.

Medicare Par A and Par B premiums, deducibles, copaymens, andcoinsurance are on pages 131–133. Inormaion abou Medicare Par Cand Par D coss is on page 134.

Medicare Health and Prescription Drug Plans

Visi www.medicare.gov/nd-a-plan, or call 1-800-MEDICARE(1-800-633-4227) o nd plans in your area. Y users sould call1-877-486-2048.

Blue words

in the textare dened

on pages

127–130.

http://www.medicare.gov/find-a-plan


8/6/2019 Medicare 2011


13

Coverage and Costs Change Yearly.Your Medicare eal or prescripion drug plan can cange ow muc icoss and wa i covers eac year. Even i your plan’s cos and coverage say e same, your eal or nances may ave canged. Review your plan eacyear o make sure i will sill mee your needs. I you’re saised wi yourcurren coverage, you don’ need o cange plans.

Fall Annual Enrollment Period

Mark your calendar with these important dates!

October 2010

Compare your coverage wi oer

available opions o see i ere’s a beercoice or you. See page 15.

November 15, 2010–

December 31, 2010

You can cange your Medicare ealor prescripion drug coverage or 2011.See pages 68 and 73 or oer imes wenyou can swic your coverage.

January 1, 2011New coverage begins i you swiced or joined a plan. New coss and coveragecanges also begin i you kep yourexising coverage.

Is your eal or drug plan leaving Medicare? Heal and prescripiondrug plans can decide no o paricipae in Medicare or e coming year.Your plan will send you a leer i i leaves Medicare or sops providingcoverage in your area. See page 94 or more inormaion abou your rigsand opions.

Coming soon—In e all o 2011, e Annual Enrollmen Period daes willcange o give you more ime i you wan o coose and join a Medicareeal or prescripion drug plan. You will be able o swic your coveragebeween Ocober 15, 2011—December 7, 2011. I you make a cange duringis period, your new coverage will begin January 1, 2012.

What You Need to Know in 2011

AP R I L

7 3 7 2

O c t o b e r

1

8/6/2019 Medicare 2011


14 Medicare Basics

What Is Medicare?Medicare is eal insurance or e ollowing:

People 65 or older■

People under 65 wi cerain disabiliies■People o any age wi End-Sage Renal Disease (ESRD) (permanen kidney ■ailure requiring dialysis or a kidney ransplan)

The Dierent Parts o MedicareTe dieren pars o Medicare elp cover specic services:

Medicare Part A (Hospital Insurance)

Helps cover inpaien care in ospials■

Helps cover■ skilled nursing aciliy , ospice, and ome eal care

See pages 26–28.

Medicare Part B (Medical Insurance)

Helps cover docors’ services, ospial oupaien care, and ome eal care■

Helps cover some■ prevenive services o elp mainain your eal and o keepcerain illnesses rom geing worse

See pages 29–45.

Medicare Part D (Medicare Prescription Drug Coverage)

A prescripion drug opion run by Medicare-approved privae insurance companies■

Helps cover e cos o prescripion drugs■

May elp lower your prescripion drug coss and elp proec agains iger coss in■e uure

See pages 72–83.

Medicare Advanage Plans (like an HMO or PPO) are eal plans run by Medicare-approved privae insurance companies. Medicare Advanage Plans (alsocalled “Par C”) include Par A, Par B, and usually oer coverage like Medicareprescripion drug coverage (Par D), someimes or an exra cos. See pages 60–69.

8/6/2019 Medicare 2011


15Medicare Basics

Your Medicare Coverage Choices at a GlanceTere are wo main ways o ge your Medicare coverage: Original Medicare ora Medicare Advanage Plan. Use ese seps o elp you decide wic way o

ge your coverage.

Part AHospialInsurance

Part BMedicalInsurance

Medigap (MedicareSupplemenInsurance)policy

Part DPrescripionDrug Coverage

Part CCombines Par A, Par B, andusually Par D

ORIGINAL MEDICARE MEDICARE ADVANTAGE PLAN

(like an HMO or PPO)

Step 2: Decide i you need o add drug coverage

Step 3: Decide i you need o addsupplemenal coverage

End

End

Step 1: Decide ow you wan o ge your coverage

Part D PrescripionDrug Coverage(i no already included)

or

Start

I you join a Medicare AdvantagePlan, you don’t need and can’t besold a Medigap policy.

See page 49 or more details.

8/6/2019 Medicare 2011


16

Where to Get Your Medicare Questions Answered

Medicare Basics

1‑800‑MEDICARE

o ge general or claims-specic Medicare

inormaion and imporan eleponenumbers. I you need elp in a languageoer an Englis or Spanis, say “Agen” oalk o a cusomer service represenaive.1-800-633-4227Y 1-877-486-2048www.medicare.gov

State Health Insurance Assistance Program

(SHIP)

o ge ree personalized Medicare counseling

on decisions abou coverage; elp wiclaims, billing, or appeals; and inormaionon programs or people wi limied incomeand resources. See pages 123–126.Call 1-800-MEDICARE o ge e eleponenumbers o SHIPs in oer saes.

Social Security

o ge a replacemen Medicare card; cangeyour address or name; ge inormaion abouPar A and/or Par B eligibiliy, enilemen,

and enrollmen; apply or Exra Help wiMedicare prescripion drug coss; ask quesions abou premiums; and repor adea.1-800-772-1213Y 1-800-325-0778www.socialsecuriy.gov

Coordination o Benets Contractor

o ge inormaion on weer Medicare oryour oer insurance pays rs and o repor

canges in your insurance inormaion.1-800-999-1118Y 1-800-318-8782

Department o Deense

o ge inormaion abou RICARE orLie and e RICARE Parmacy Program.1-866-773-0404 (FL)Y 1-866-773-04051-877-363-1303 (Parmacy)Y 1-877-540-6261

www.ricare.mil/mybene

Department o Health and Human

Services

Oce o Inspector General—I yoususpec Medicare raud.1-800-447-8477Y 1-800-377-4950www.sopmedicareraud.gov Oce or Civil Rights—I you ink you were discriminaed agains or i your eal inormaion privacy rigswere violaed.1-800-368-1019Y 1-800-537-7697

www.s.gov/ocr

Department o Veterans Aairs

I you’re a veeran or ave served in eU.S. miliary.1-800-827-1000Y 1-800-829-4833www.va.gov

Ofce o Personnel Management

o ge inormaion abou e Federal

Employee Heal Benes Program orcurren and reired Federal employees.1-888-767-6738Y 1-800-878-5707www.opm.gov/insure

Railroad Retirement Board (RRB)

I you ave benes rom e RRB, callem o cange your address or name,ceck eligibiliy, enroll in Medicare,replace your Medicare card, and repor

a dea.Local RRB oce or 1-877-772-5772

Quality Improvement Organization

(QIO)

o ask quesions or repor complainsabou e qualiy o care or aMedicare-covered service or i youink your service is ending oo soon.Call 1-800-MEDICARE o ge eelepone number or your QIO.


http://www.socialsecurity.gov/

http://www.tricare.mil/mybenefit

http://www.stopmedicarefraud.gov/

http://www.hhs.gov/ocr

http://www.va.gov/

http://www.opm.gov/insure


http://www.va.gov/






8/6/2019 Medicare 2011


8/6/2019 Medicare 2011


18 Section 1—Medicare Part A and Part B

Signing Up or Part A and Part BTis secion explains ow and wen o sign up and wy you migdecide o wai o ge Par B.

Some People Get Part A and Part B

AutomaticallyIn mos cases, i you’re already geing benes rom Social■Securiy or e Railroad Reiremen Board (RRB), you willauomaically ge Par A and Par B saring e rs day o emon you urn 65. I your birday is on e rs day o emon, Par A and Par B will sar e rs day o e prior mon.

I you’re under 65 and disabled, you auomaically ge Par A and■ Par B aer you ge disabiliy benes rom Social Securiy orcerain disabiliy benes rom e RRB or 24 mons.

You will ge your red, wie, and blue■Medicare card in e mail 3 monsbeore your 65 birday or your25 mon o disabiliy. I you don’wan Par B, ollow e insrucionsa come wi e card, and send

e card back. I you keep e card,you keep Par B and will pay Par Bpremiums.

I you live in Puero Rico and you ge benes rom Social Securiy ■or e RRB, you will auomaically ge Par A. I you wan Par B,you will need o sign up or i. Conac your local Social Securiy oce or RRB or more inormaion.

I you ave ALS (Amyoropic Laeral Sclerosis, also called Lou■ Gerig’s disease), you auomaically ge Par A and Par B emon your disabiliy benes begin.

I you ave Par A and RICARE (coverage or acive-duy miliary or reirees and eir amilies), you mus ave Par B okeep your RICARE coverage. See page 23.

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19Section 1—Medicare Part A and Part B

Some People Need to Sign Up or Part A and

Part BI you aren’ geing Social Securiy or RRB benes (or■

insance, because you’re sill working) and you wan Par Aor Par B, you will need o sign up (even i you’re eligible oge Par A premium-ree). See page 24. I you’re no eligibleor premium-ree Par A, you can buy Par A and Par B.You sould conac Social Securiy 3 mons beore you urn65. I you worked or a railroad, conac e RRB o sign up.

I you ave End-Sage Renal Disease (ESRD),■you sould visi your local Social Securiy oce, or call Social Securiy a 1-800-772-1213

o sign up or Par A and Par B. Y userssould call 1-800-325-0778. For moreinormaion, visi p://go.usa.gov/lov o

view e bookle, “Medicare Coverage o Kidney Dialysis and Kidney ransplanServices.” You can also call 1-800-MEDICARE(1-800-633-4227) o nd ou i a copy canbe mailed o you. Y users sould call1-877-486-2048.

Call Social Securiy a 1-800-772-1213 or more inormaion■abou your Medicare eligibiliy, and o sign up or Par Aand/or Par B. I you’re 65 or older, you can also apply orpremium-ree Par A and Par B online awww.socialsecuriy.gov/reiremen. Te wole process canake less an 10 minues.

I you ge RRB benes, call e RRB a 1-877-772-5772.■

For general inormaion abou enrolling, visi■www.medicare.gov/MedicareEligibiliy . You can also ge ree,personalized eal insurance counseling rom your SaeHeal Insurance Assisance Program (SHIP). Seepages 123–126 or e elepone number.

Blue words

in the text

are dened

on pages

127–130.

http://go.usa.gov/lov

http://www.socialsecurity.gov/retirement

http://www.medicare.gov/MedicareEligibility

http://www.medicare.gov/MedicareEligibility

http://www.socialsecurity.gov/retirement


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When Can You Sign Up?

Initial Enrollment Period

You can sign up wen you’re rs eligible or Par B. (For example, i

you’re eligible or Par B wen you urn 65, is is a 7-mon perioda begins 3 mons beore e mon you urn 65, includes emon you urn 65, and ends 3 mons aer e mon you urn 65.)

3 months beore

e monyou urn 65

2 months beore

e monyou urn 65

1 month beore

e monyou urn 65

Te monyou urn

65

1 month aer

you urn 65

2 months aer

you urn 65

3 months aer

you urn 65

Sign up early o avoid a delay ingeing coverage or Par B services.o ge Par B coverage e mon youurn 65, you mus sign up during ers ree mons beore e monyou urn 65.

I you wai unil e las our mons o your IniialEnrollmen Period o sign up or Par B, your sardae or coverage will be delayed.

I you enroll in Par B during e rs ree mons o your IniialEnrollmen Period, your coverage sar dae will depend on your birday:

I your birday ■ isn’t on e rs day o e mon, your Par B coveragesars e rs day o your birday mon. For example, Mr. Green’s65 birday is July 20, 2011. I e enrolls in April, May, or June, iscoverage will sar on July 1, 2011.

I your birday ■ is on e rs day o e mon, your coverage will sare rs day o e prior mon. For example, Mr. Kim’s 65 birday isJuly 1, 2011. I e enrolls in Marc, April, or May, is coverage will saron June 1, 2011. o read e car correcly, use e mon beore yourbirday as “e mon you urn 65.”

I you enroll in Par B e mon you urn 65 or during e las 3 monso your Iniial Enrollmen Period, your Par B sar dae will be delayed.For example, Mrs. Simpson urns 65 in July. Wen er coverage sarsdepends on e mon se enrolls:

Month she enrolls Month coverage starts

July Augus 1

Augus Ocober 1

Sepember December 1

Ocober January 1

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When Can You Sign Up? (continued)

Blue words

in the text

are dened

on pages

127–130.

General Enrollment Period

I you didn’ sign up or Par A and/or Par B (or wic you pay

monly premiums) wen you were rs eligible, you can sign upbeween January 1–Marc 31 eac year. Your coverage will beginJuly 1. You may ave o pay a iger premium or lae enrollmen.See pages 24–25.

I you sign up during these months

Your coverage willbegin on

January

July 1February

Marc

Special Enrollment Period

I you didn’ sign up or Par A and/or Par B (or wic you pay monly premiums) wen you were rs eligible because you’recovered under a group eal plan based on curren employmen,you can sign up or Par A and/or Par B as ollows:

Anytime that youor your spouse (oramily member i

you’re disabled) areworking, and you’recovered by a grouphealth plan throughthe employer or unionbased on that work

Or

During the 8-monthperiod that beginsthe month aer theemployment endsor the group healthplan coverage ends,whichever happensrst

Usually, you don’ pay a lae enrollmen penaly i you sign up

during a Special Enrollmen Period. Tis Special Enrollmen Perioddoesn’ apply o people wi End-Sage Renal Disease (ESRD). Seepage 19. You may also qualiy or a Special Enrollmen Period i you’re a voluneer serving in a oreign counry.

Note: I you ave COBRA coverage or a reiree eal plan, youdon’ ave coverage based on curren employmen. You’re noeligible or a special enrollmen period wen a coverage ends.

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When Can You Sign Up? (continued)

Medigap Open Enrollment Period

You ave a 6-mon Medigap (Medicare Supplemen Insurance)

policy open enrollmen period wic sars e rs mon you’rebo 65 and enrolled in Par B. Tis period gives you a guaraneedrig o buy any Medigap policy sold in your sae. Once is periodsars, i can’ be delayed or replaced. See pages 57–59.

o learn more deails abou enrollmen periods, read e ac see“Undersanding Medicare Enrollmen Periods” by visiingp://go.usa.gov/lsi. You can also call 1-800-MEDICARE(1-800-633-4227) o nd ou i a copy can be mailed o you.Y users sould call 1-877-486-2048.

Should You Get Part B?Te ollowing inormaion can elp you decide i you wan o sign upor Par B.

Employer or Union Coverage—I you or your spouse (or amily member i you’re disabled) is still working and you ave coverageroug an employer (including e Federal Employee HealBenes Program) or union, conac your employer or union benes

adminisraor o nd ou ow your insurance works wi Medicare.I may be o your advanage o delay Par B enrollmen. Wen eemploymen ends, ree ings appen:

You may ge o elec COBRA coverage, wic coninues your1.eal coverage roug e employer’s plan (in mos cases oronly 18 mons) and probably a a iger cos o you.

You ave 8 mons o sign up or Par B wiou a penaly.2.See page 21. Tis period will run weer or no you elecCOBRA. I you elec COBRA, don’ wai unil your COBRA endso enroll in Par B. I you enroll in Par B aer e 8 mons, youmay ave o pay a penaly. See page 25.

Wen you sign up or Par B, your Medigap open enrollmen3.period begins. See page 58.

http://go.usa.gov/lsi


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Should You Get Part B? (continued)

RICARE—I you ave Par A and RICARE (coverage oracive-duy miliary or reirees and eir amilies), you must have

Part B to keep your RICARE coverage. However, i you’re anacive-duy service member, or e spouse or dependen cild o anacive-duy service member, e ollowing applies o you:

You don’ ave o enroll in Par B o keep your RICARE■coverage wile e service member is on acive duy.

Beore e acive-duy service member reires, you mus enroll in■Par B o keep RICARE wiou a break in coverage.

You can ge Par B during a special enrollmen period i you ave■Medicare because you’re 65 or older, or you’re disabled.

I you’re in a Medicare Advanage Plan or coose o join a plan, elle plan you ave RICARE, so your bills can be paid correcly.

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How Much Does Part A Coverage Cost?You usually don’ pay a monly premium or Par A coverage i you or your spouse paid Medicare axes wile working.

I you aren’ eligible or premium-ree Par A, you may be able obuy Par A i you mee one o e ollowing condiions:

You’re 65 or older, and you’re eniled o (or enrolling in) Par B■and mee e ciizensip and residency requiremens.

You’re under 65, disabled, and your premium-ree Par A■coverage ended because you reurned o work. (I you’re under 65and disabled, you can coninue o ge premium-ree Par A or upo 8.5 years aer you reurn o work.)

Note: Te 2010 premium amoun or people wo buy Par A is$461.

In mos cases, i you coose o buy Par A, you mus also avePar B and pay monly premiums or bo. I you ave limiedincome and resources, your sae may elp you pay or Par Aand/or Par B. See page 90. Call Social Securiy a 1-800-772-1213or more inormaion abou e Par A premium. Y users souldcall 1-800-325-0778.

Part A Late Enrollment PenaltyI you aren’ eligible or premium-ree Par A, and you don’ buy iwen you’re rs eligible, your monly premium may go up 10%.You will ave o pay e iger premium or wice e number o years you could ave ad Par A, bu didn’ sign-up. For example,i you were eligible or Par A or 2 years bu didn’ sign-up, youwill ave o pay e iger premium or 4 years. Usually, you don’ave o pay a penaly i you mee cerain condiions a allowyou o sign up or Par A during a Special Enrollmen Period. Seepages 21–22.

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How Much Does Part B Coverage Cost?You pay e Par B premium eac mon. Mos people will pay esandard premium amoun. However, i your modied adjusedgross income as repored on your IRS ax reurn rom 2 years ago(e mos recen ax reurn inormaion provided o Social Securiy by e IRS) is above a cerain amoun, you may pay more.

Your modied adjused gross income is your adjused gross incomeplus your ax exemp ineres income. Eac year, Social Securiy will noiy you i you ave o pay more an e sandard premium.Weer you pay e sandard premium or a iger premium cancange eac year depending on your income. I you ave o pay aiger amoun or your Par B premium and you disagree (even

i you ge RRB benes), call Social Securiy a 1-800-772-1213.Y users sould call 1-800-325-0778. You can also view e acsee “Medicare Par B Premiums: Rules For Beneciaries WiHiger Incomes” by visiing www.socialsecuriy.gov/pubs/10161.pd .

Part B Late Enrollment Penalty

I you don’ sign up or Par B wen you’re rs eligible, you may ave o pay a lae enrollmen penaly or as long as you aveMedicare. Your monly premium or Par B may go up 10% or

eac ull 12-mon period a you could ave ad Par B, bu didn’sign up or i. Usually, you don’ pay a lae enrollmen penaly i youmee cerain condiions a allow you o sign up or Par B during aspecial enrollmen period. See pages 21–22.

I you have limited income and resources, see page 90 orinormation about help paying your Medicare premiums.

http://www.socialsecurity.gov/pubs/10161.pdf

http://www.socialsecurity.gov/pubs/10161.pdf

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What Services Does Medicare Cover?Medicare covers cerain medical services and supplies in ospials,docors’ oces, and oer eal care seings. Services are eiercovered under Par A or Par B. I you ave bo Par A and Par B,you can ge all o e Medicare-covered services lised in is secion,weer you ave Original Medicare or a Medicare eal plan.

See■ pages 27–28 or e Par A-covered services lis.

See■ pages 30–44 or e Par B-covered services lis.

What Does Part A (Hospital Insurance) Cover?Par A elps cover e ollowing:

Inpaien care in ospials■

Inpaien care in a skilled nursing aciliy (no cusodial or long erm■care)

Hospice care services■

Home eal care services■

Inpaien care in a Religious Nonmedical Heal Care Insiuion■

See pages 27–28 or more inormaion on Par A-covered services.

You can nd ou i you ave Par A by looking a your Medicare

card. I you ave Original Medicare, you will use is card o ge yourMedicare-covered services. I you join a Medicare plan, you mus usee card rom e plan o ge your Medicare-covered services.

What You Pay or Part A‑Covered ServicesCopaymens, coinsurance, and deducibles may apply or eac servicein e car on e nex wo pages. See page 132 or specic costs andother inormation about these services.

I you join a Medicare Advanage Plan (like an HMO or PPO) or aveoer insurance (like a Medigap policy, or employer or union coverage),your coss may be dieren. Conac e plans you’re ineresed in ond ou abou e coss, or visi www.medicare.gov/nd-a-plan.

http://www.medicare.gov/findaplan

http://www.medicare.gov/findaplan

8/6/2019 Medicare 2011



Part A‑Covered Services

Blood In mos cases, e ospial ges blood rom a blood bank ano carge, and you won’ ave o pay or i or replace i. I e

ospial as o buy blood or you, you mus eier pay eospial coss or e rs 3 unis o blood you ge in a calendaryear or ave e blood donaed by you or someone else.

Home

Health

Services

Limied o medically-necessary par-ime or inermien skillednursing care, or pysical erapy, speec-language paology, ora coninuing need or occupaional erapy. A docor or oereal care provider enrolled in Medicare mus order your care,and a Medicare-ceried ome eal agency mus provide i.Home eal services may also include medical social services,

par-ime or inermien ome eal aide services, and medicalsupplies or use a ome. You mus be omebound, wicmeans a leaving ome is a major eor. For durable medicalequipmen inormaion, see pages 34–35.

Hospice

Care

For people wi a erminal illness. Your docor mus ceriy a you’re expeced o live 6 mons or less. Coverage includesdrugs or pain relie and sympom managemen; medical,nursing, and social services; cerain durable medical equipmen

and oer covered services as well as services Medicareusually doesn’ cover, suc as spiriual and grie counseling.A Medicare-approved ospice usually gives ospice care in yourome or oer aciliy were you live like a nursing ome.

Hospice care doesn’ pay or your say in a aciliy (roomand board) unless e ospice medical eam deermines ayou need sor-erm inpaien says or pain and sympommanagemen a can’ be addressed a ome. Tese says musbe in a Medicare-approved aciliy, suc as a ospice aciliy,

ospial, or skilled nursing aciliy wic conracs wi eospice. Medicare also covers inpaien respie care wic iscare you ge in a Medicare-approved aciliy so a your usualcaregiver can res. You can say up o 5 days eac ime you gerespie care. Medicare will pay or covered services or ealproblems a aren’ relaed o your erminal illness. You canconinue o ge ospice care as long as e ospice medicaldirecor or ospice docor receries a you’re erminally ill.

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Part A‑Covered Services

Hospital

Stays

(Inpatient)

Includes semi-privae room, meals, general nursing, drugs aspar o your inpaien reamen, and oer ospial services and

supplies. Examples include inpaien care you ge in acue careospials, criical access ospials, inpaien reabiliaion aciliies,long-erm care ospials, inpaien care as par o a qualiyingclinical researc sudy, and menal eal care. Tis doesn’t includeprivae-duy nursing, a elevision or elepone in your room (i ere is a separae carge or ese iems), or personal care iemslike razors or slipper socks. I also doesn’ include a privae room,unless medically necessary . I you ave Par B, i covers e docor’sservices you ge wile you’re in a ospial.

Note: Staying overnight in a hospital doesn’t always mean you’re an inpatient. You’re considered an inpaien e day adocor ormally admis you o a ospial wi a docor’s order.Being an inpaien or an oupaien afects your out-o-pocketcosts. Always ask i you’re an inpaien or an oupaien. For moreinormaion, view e publicaion “Are You a Hospial Inpaien orOupaien? I You Have Medicare—Ask!” ap://go.usa.gov/im9. You can also call 1-800-MEDICARE(1-800-633-4227) o nd ou i a copy can be mailed o you.Y users sould call 1-877-486-2048.

ReligiousNonmedical

Health Care

Institution

(Inpatient

care)

Medicare will only cover e non-medical, non-religious ealcare iems and services (like room and board) in is ype o aciliy

or people wo qualiy or ospial or skilled nursing aciliy care, bu or wom medical care isn’ in agreemen wi eir religiousbelies. Non-medical iems and services like wound dressings oruse o a simple walker during your say don’ require a docor’sorder or prescripion. Medicare doesn’ cover e religious aspecso care.

Skilled

NursingFacility Care

Includes semi-privae room, meals, skilled nursing and

reabiliaive services, and oer services and supplies a aremedically necessary aer a 3-day minimum inpatient ospialsay or a relaed illness or injury. An inpaien ospial say beginse day you’re ormally admied wi a docor’s order and doesn’include e day you’re discarged. o qualiy or care in a skillednursing aciliy, your docor mus ceriy a you need daily skilledcare like inravenous injecions or pysical erapy. Medicaredoesn’t cover long-erm care or cusodial care.

http://go.usa.gov/im9

http://go.usa.gov/im9

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What Does Part B (Medical Insurance) Cover?Par B elps cover medically-necessary services like docors’ services andess, oupaien care, ome eal services, durable medical equipmen,and oer medical services. Par B also covers some prevenive services.Look a your Medicare card o nd ou i you ave Par B.

Pages 30–44 include a lis o common Par B-covered services. Medicaremay cover some services and ess more oen an e imerames lisedin e cars i needed o diagnose a condiion. o nd ou i Medicarecovers a service no on is lis, visi www.medicare.gov/coverage,or call 1-800-MEDICARE (1-800-633-4227). Y users sould call1-877-486-2048.

You will see this apple next to the preventive services on the list. Use ececklis on page 45 o ask your docor or oer eal care provider wicprevenive services you need.

What You Pay or Part B‑Covered ServicesTe cars on e ollowing pages give general inormaion abou wa youpay i you ave Original Medicare and see docors or providers wo accepassignmen. You will pay more or docors or providers wo don’ accepassignmen. See page 54. I you’re in a Medicare Advantage Plan (like

an HMO or PPO) or have other insurance, your costs may be diferent.Contact your plan or benets administrator directly to nd out aboutthe costs.

Under Original Medicare, i e Par B deducible applies you mus pay allcoss unil you mee e yearly Par B deducible beore Medicare begins opay is sare. Ten, aer your deducible is me, you ypically pay 20% o e Medicare-approved amoun o e service. Tere is no yearly limi orwa you pay ou-o-pocke. See page 133 or the Part B deductible andcoinsurance amounts.

NEW—Saring January 1, 2011, you will pay noing or mos preveniveservices i you ge e services rom a docor or oer eal care providerwo acceps assignmen. For some prevenive services, you will pay noing or e service, bu you may ave o pay coinsurance or e oce

visi wen you ge ese services.

Blue words

in the text

are dened

on pages

127–130.

http://www.medicare.gov/coverage


8/6/2019 Medicare 2011



Part B‑Covered Services

Abdominal

Aortic

AneurysmScreening

A one-ime screening ulrasound or people a risk. You mus gea reerral or i as par o your one-ime “Welcome o Medicare”

pysical exam. See page 39. Saring January 1, 2011, you pay noing or e screening i e docor acceps assignmen.

Ambulance

Services

Ground ambulance ransporaion wen you need o beranspored o a ospial or skilled nursing aciliy ormedically-necessary services, and ransporaion in any oer veicle could endanger your eal. Medicare may pay or ambulance ransporaion in an airplane or elicopero a ospial i you need immediae and rapid ambulanceransporaion a ground ransporaion can’ provide.

In some cases, Medicare may pay or limied non-emergency ambulance ransporaion i you ave orders rom your docorsaying a ambulance ransporaion is medically necessary.Medicare will only cover services o e neares appropriaemedical aciliy a is able o give you e care you need.You pay 20% o e Medicare-approved amoun, and e Par Bdeducible applies.

Ambulatory

Surgical

Centers

Faciliy ees or approved surgical procedures provided in anambulaory surgical cener (aciliy were surgical procedures

are perormed, and e paien is released wiin 24 ours).Excep or cerain prevenive services (or wic you pay noing), you pay 20% o e Medicare-approved amoun obo e ambulaory surgical cener and e docor wo reasyou, and e Par B deducible applies. You pay all aciliy ees or procedures Medicare doesn’ allow in ambulaory surgical ceners.

Blood In mos cases, e provider ges blood rom a blood bank a no carge, and you won’ ave o pay or i or replace i.

However, you will pay a copaymen or e blood processing andandling services or every uni o blood you ge, and e Par Bdeducible applies. I e provider as o buy blood or you, youmus eier pay e provider coss or e rs 3 unis o bloodyou ge in a calendar year or ave e blood donaed by you orsomeone else.

You pay a copaymen or addiional unis o blood you ge as anoupaien (aer e rs 3), and e Par B deducible applies.

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Bone Mass

Measurement

(Bone Density)

Helps o see i you’re a risk or broken bones. Tis serviceis covered once every 24 mons (more oen i medically

necessary ) or people wo ave cerain medical condiionsor mee cerain crieria. Saring January 1, 2011, you pay noing or is es i e docor acceps assignmen.

Cardiac

Rehabilitation

Medicare covers compreensive programs a includeexercise, educaion, and counseling or paiens wo meecerain condiions. Medicare also covers inensive cardiacreabiliaion programs a are ypically more rigorous ormore inense an regular cardiac reabiliaion programs.You pay e docor 20% o e Medicare-approved amoun

i you ge e services in a docor’s oce. In a ospialoupaien seing, you also pay e ospial a copaymen.

Cardiovascular

Screenings

Blood ess a elp deec condiions a may lead o aear aack or sroke. Tis service is covered every 5 yearso es your coleserol, lipid, and riglyceride levels. You pay noing or e ess, bu you generally ave o pay 20% o eMedicare-approved amoun or e docor’s visi.

Chiropractic

Services

(limited)

Helps correc a subluxaion (wen one or more o e boneso your spine move ou o posiion) using manipulaion o e

spine. You pay 20% o e Medicare-approved amoun, ande Par B deducible applies. Note: You pay all coss or any oer services or ess ordered by a ciropracor.

Clinical

Laboratory

Services

Includes cerain blood ess, urinalysis, some screeningess, and more. You pay noing or ese services, bu yougenerally ave o pay 20% o e Medicare-approved amounor e docor’s visi.

Clinical

Research

Studies

ess ow well dieren ypes o medical care work and i ey are sae. Medicare covers some coss, like docor visis

and ess, in qualiying clinical researc sudies. You pay 20%o e Medicare-approved amoun, and e Par B deducible

applies. Note: I you’re in a Medicare Advanage Plan, seepage 62 or more inormaion.

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Colorectal

Cancer

Screenings

o elp nd precancerous grows or nd cancer early,wen reamen is mos eecive. One or more o e

ollowing ess may be covered. alk o your docor. Fecal Occul Blood es—Once every 12 mons i 50 or■older. You pay noing or e es, bu you generally aveo pay 20% o e Medicare-approved amoun or edocor’s visi.

Flexible Sigmoidoscopy—Generally, once every 48 mons■i 50 or older, or 120 mons aer a previous screeningcolonoscopy or ose no a ig risk. Saring January 1,2011, you pay noing or is es i e docor acceps

assignmen.

Colonoscopy—Generally once every 120 mons (ig■risk every 24 mons) or 48 mons aer a previousfexible sigmoidoscopy. No minimum age. SaringJanuary 1, 2011, you pay noing or is es i e docoracceps assignmen.

Barium Enema—Once every 48 mons i 50 or older■(ig risk every 24 mons) wen used insead o a

sigmoidoscopy or colonoscopy. You pay 20% o eMedicare-approved amoun or e docor’s services. In aospial oupaien seing, you also pay e ospial acopaymen.

Defbrillator

(Implantable

Automatic)

For some people diagnosed wi ear ailure. You pay e docor 20% o e Medicare-approved amoun or edocor’s services. You also pay e ospial a copaymenbu no more an e Par A ospial say deducible (seepage 132) i you ge e device as a ospial oupaien. Te

Par B deducible applies.

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Diabetes

Screenings

Medicare covers ese screenings i you ave any o e ollowing risk acors: ig blood pressure

(yperension), isory o abnormal coleserol andriglyceride levels (dyslipidemia), obesiy, or a isory o ig blood sugar (glucose). ess may also becovered i you mee oer requiremens, like beingoverweig and aving a amily isory o diabees.

Based on e resuls o ese ess, you may be eligibleor up o wo diabees screenings every year. You pay noing or e es, bu you generally ave o pay 20%o e Medicare-approved amoun or e docor’s visi.

Diabetes

Sel‑Management

Training

For people wi diabees wi a wrien order roma docor or oer eal care provider. You pay 20%o e Medicare-approved amoun, and e Par Bdeducible applies.

Diabetes Supplies Includes blood sugar esing moniors, blood sugar essrips, lance devices and lances, blood sugar conrolsoluions, and erapeuic soes (in some cases).Insulin is covered only i used wi an exernal insulinpump. You pay 20% o e Medicare-approved amoun,and e Par B deducible applies.

Note: Insulin and cerain medical supplies used oinjec insulin, suc as syringes, and some oral diabeicdrugs may be covered by Medicare prescripion drugcoverage (Par D).

Doctor Services Services a are medically necessary (includesoupaien and some docor services you ge wenyou’re a ospial inpaien) or covered preveniveservices. Excep or cerain prevenive services, you pay 20% o e Medicare-approved amoun, and e Par Bdeducible applies.

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Durable

Medical

Equipment(like

walkers)

Iems suc as oxygen equipmen and supplies, weelcairs, walkers, andospial beds ordered by a docor or oer eal care provider enrolled

in Medicare or use in e ome. Some iems mus be rened. You pay 20% o e Medicare-approved amoun, and e Par B deducible applies. In all areas o the country, you must get your coveredequipment or supplies and replacement or repair services rom aMedicare-approved supplier or Medicare to pay.

For more inormaion, visi p://go.usa.gov/lo o view a copy o “Medicare Coverage o Durable Medical Equipmen and Oer Devices.”You can also call 1-800-MEDICARE (1-800-633-4227) o nd ou i acopy can be mailed o you. Y users sould call 1-877-486-2048.

New —Medicare is pasing in a new program called “compeiivebidding” o elp save you and Medicare money; ensure a youconinue o ge qualiy equipmen, supplies, and services; and elplimi raud and abuse. In some areas o the country i you needcertain items, you must use specic suppliers, or Medicare won’tpay or the item and you likely will pay ull price. It’s importantto see i you’re afected by this new program to ensure Medicarepayment and avoid any disruption o service.

Tis program starts January 1, 2011, in the ollowing states:CA, FL, IN, KS, KY, MO, NC, OH, PA, SC, X

In certain areas in the states listed above, you need to use specicsuppliers or Medicare to pay or the ollowing items:

Oxygen supplies and equipmen■

Sandard power weelcair, scooer, and relaed accessories■

Cerain complex reabiliaive power weelcairs and relaed■accessories

Mail-order diabees supplies■Eneral nuriens, equipmen, and supplies■

Hospial beds and relaed accessories■

Coninuous Posiive Airway Pressure (CPAP) devices and■Respiraory Assis Devices (RADs) and relaed suppliesand accessories

Walkers and relaed accessories■

Suppor suraces including cerain maresses and overlays■

(Miami, For Lauderdale, and Pompano Beac only)

http://go.usa.gov/loh

http://go.usa.gov/loh

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Durable

Medical

Equipment(like walkers)

(continued)

I you’re currently renting or need durable medicalequipment or supplies and have any questions

about what’s covered or about suppliers, you can getinormation in one o the ollowing ways:

Visi■ www.medicare.gov/supplier. Medicare-approvedsuppliers are lised. Te specic suppliers you need ouse or is new program will ave a symbol beside eirnames.

Call 1-800-MEDICARE (1-800-633-4227).■ Y userssould call 1-877-486-2048.

Call your Sae Heal Insurance Assisance Program(SHIP) or ree eal insurance counseling andpersonalized elp undersanding ese canges. See pages123–126 or e elepone number.

EKG Screening Medicare covers a one-ime screening EKG i orderedby your docor as par o your one-ime “Welcome oMedicare” pysical exam. See page 39. You pay e docor20% o e Medicare-approved amoun, and e Par B

deducible applies. An EKG is also covered as a diagnosices. See page 42. I you ave e es a a ospial ora ospial-owned clinic, you also pay e ospial acopaymen.

Emergency

Department

Services

Wen you ave an injury, a sudden illness, or an illnessa quickly ges muc worse. You pay a speciedcopaymen or e ospial emergency deparmen visi,and you pay 20% o e Medicare-approved amoun ore docor’s services. Te Par B deducible applies.

Eyeglasses

(limited)

One pair o eyeglasses wi sandard rames (or one seo conac lenses) aer caarac surgery a implans aninraocular lens. You pay 20% o e Medicare-approvedamoun, and e Par B deducible applies.

Federally‑

Qualifed

Health Center

Services

Includes many oupaien primary care and preveniveservices you ge roug cerain communiy-based organizaions. Generally, you pay 20% o eMedicare-approved amoun.

http://www.medicare.gov/supplier


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Flu Shots Generally covered once per fu season in e all or winer. Youpay noing or e fu so i e docor or oer eal care

provider acceps assignmen or giving e so. Note: MedicarePar B also covers adminisraion o e H1N1 fu so. You pay noing i your docor acceps assignmen or giving e so.

Foot Exams and

Treatment

I you ave diabees-relaed nerve damage and/or mee ceraincondiions. You pay e docor 20% o e Medicare-approvedamoun, and e Par B deducible applies. In a ospialoupaien seing, you also pay e ospial a copaymen.

Glaucoma Tests Covered once every 12 mons or people a ig risk or eeye disease glaucoma. You’re a ig risk i you ave diabees,

a amily isory o glaucoma, are Arican-American and 50or older, or are Hispanic and 65 or older. An eye docor wois legally allowed by e sae mus do e ess. You pay edocor 20% o e Medicare-approved amoun, and e Par Bdeducible applies or e docor’s visi. In a ospial oupaienseing, you also pay e ospial a copaymen.

Hearing and

Balance Exams

I your docor orders ese ess o see i you need medicalreamen. You pay e docor 20% o e Medicare-approvedamoun, and e Par B deducible applies. In a ospial

oupaien seing, you also pay e ospial a copaymen.Note: Medicare doesn’ cover earing aids and exams or ingearing aids.

Hepatitis B

Shots

Covered or people a ig or medium risk or Hepaiis B.Your risk or Hepaiis B increases i you ave emopilia,End-Sage Renal Disease (ESRD), or cerain condiions aincrease your risk or inecion. Oer acors may increase yourrisk or Hepaiis B, so ceck wi your docor. You pay noingor e so i e docor acceps assignmen.

HIV Screening Medicare covers HIV (Human Immunodeciency Virus)screening or people wi Medicare o any age wo ask ore es, pregnan women, and people a increased risk ore inecion. Medicare covers is es once every 12 monsor up o 3 imes during a pregnancy. You pay noing ore es, bu you generally ave o pay e docor 20% o eMedicare-approved amoun or e docor’s visi.

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Home Health

Services

Covers medically-necessary par-ime or inermien skillednursing care, or pysical erapy, speec-language paology,

or a coninuing need or occupaional erapy. A docor oroer eal care provider enrolled in Medicare mus ordere care, and a Medicare-ceried ome eal agency musprovide i. Home eal services may also include medicalsocial services, par-ime or inermien ome eal aideservices, durable medical equipmen, and medical suppliesor use a ome. You mus be omebound, wic means aleaving ome is a major eor. You pay noing or coveredome eal services. For Medicare-covered durable medical

equipmen inormaion, see pages 34–35.

Kidney Dialysis

Services and

Supplies

For people wi End-Sage Renal Disease (ESRD). Medicarecovers dialysis eier in a aciliy or a ome wen your docororders i. You pay 20% o e Medicare-approved amoun persession, and e Par B deducible applies.

Kidney Disease

Education

Services

Medicare may cover up o six sessions o kidney diseaseeducaion services i you ave Sage IV cronic kidney disease, and your docor reers you or e service. Youpay 20% o e Medicare-approved amoun, and e Par Bdeducible applies.

Mammograms

(screening)

A ype o X-ray o ceck women or breas cancer. Medicarecovers screening mammograms once every 12 monsor women 40 and older. Medicare covers one baselinemammogram or women beween 35–39. Saring January 1,2011, you pay noing or e es i e docor accepsassignmen.

Medical

Nutrition

TherapyServices

Medicare may cover medical nuriion erapy and cerainrelaed services i you ave diabees or kidney disease, oryou ave ad a kidney ransplan in e las 36 mons, andyour docor reers you or e service. Saring January 1,2011, you pay noing or ese services i e docoracceps assignmen.

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Mental Health

Care (outpatient)

o ge elp wi menal eal condiions suc as depressionor anxiey. Includes services generally given ouside a

ospial or in a ospial oupaien seing, including visiswi a psyciaris or oer docor, clinical psycologis,nurse praciioner, pysician’s assisan, clinical nursespecialis, or clinical social worker; subsance abuse services;and lab ess. Cerain limis and condiions apply.

Wa you pay will depend on weer you’re beingdiagnosed and moniored or weer you’re geingreamen.

For visis o a docor or oer eal care provider■

o diagnose your condiion, you pay 20% o eMedicare-approved amoun.

For oupaien■ treatment o your condiion (suc ascounseling or psycoerapy), you pay 45% o eMedicare-approved amoun in 2011. Tis coinsurance amoun will coninue o decrease over e nex 3 years.

Te Par B deducible applies or bo visis o diagnose orrea your condiion.

Note: Inpaien menal eal care is covered under Par Aospial says. See page 132.

alk o your docor i you eel sad, ave lile ineres inings you used o enjoy, eel dependen on drugs or alcool,or ave ougs abou ending your lie.

Non‑doctor

Services

Medicare covers services provided by cerain non-docors,suc as pysician assisans, nurse praciioners, socialworkers, pysical erapiss, and psycologiss. Excep orcerain prevenive services, you pay 20% o e Medicare-

approved amoun, and e Par B deducible applies.

Occupational

Therapy

Evaluaion and reamen o elp you reurn o usualaciviies (suc as dressing or baing) aer an illness oracciden wen your docor ceries you need i. Tere may be limis on ese services and excepions o ese limis.You pay 20% o e Medicare-approved amoun, and ePar B deducible applies.

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Outpatient Medical

and Surgical

Services andSupplies

For approved procedures (like X-rays, a cas, or sices).You pay e docor 20% o e Medicare-approved

amoun or e docor’s services. You also pay e ospiala copaymen or eac service you ge in a ospialoupaien seing. For eac service, e copaymen can’be more an e Par A ospial say deducible. Seepage 132. Te Par B deducible applies, and you pay allcarges or iems or services a Medicare doesn’ cover.

Pap Tests and Pelvic

Exams (includes

clinical breast exam)

Cecks or cervical, vaginal, and breas cancers. Medicarecovers ese screening ess once every 24 mons, oronce every 12 mons or women a ig risk, and or

women wo ave Medicare and are o cild-bearing agewo ave ad an exam a indicaed cancer or oerabnormaliies in e pas 3 years. You pay noing ore Pap lab es. Saring January 1, 2011, you also pay noing or Pap es specimen collecion, and pelvic andbreas exams i e docor acceps assignmen.

Physical Exams

Note: Your rs yearly “Wellness” exam can’ake place wiin12 mons o your“Welcome o Medicare”pysical exam.

Medicare covers two types o physical exams—onewhen you’re new to Medicare and one each yearaer that.

“Welcome to Medicare” physical exam■ —A one-imereview o your eal, educaion and counselingabou prevenive services, and reerrals or oer carei needed. Medicare will cover is exam i you get itwithin the rst 12 months you have Part B. SaringJanuary 1, 2011, you pay noing or e exam i edocor acceps assignmen. Wen you make yourappoinmen, le your docor’s oce know a youwould like o scedule your “Welcome o Medicare”pysical exam. Keep in mind, you don’t need to get the

“Welcome to Medicare” physical exam beore getting a yearly “Wellness” exam.

Yearly “Wellness” exam■ —I you’ve ad Par B orlonger an 12 mons, saring January 1, 2011, youcan ge a yearly wellness visi o develop or updae apersonalized prevenion plan based on your curreneal and risk acors. You pay noing or is exami e docor acceps assignmen. Tis exam is coveredonce every 12 mons.

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Physical

Therapy

Evaluaion and reamen or injuries and diseasesa cange your abiliy o uncion wen your docor

ceries your need or i. Tere may be limis on eseservices and excepions o ese limis. You pay 20%o e Medicare-approved amoun, and e Par Bdeducible applies.

Pneumococcal

Shot

Helps preven pneumococcal inecions (like cerain ypeso pneumonia). Mos people only need is so once ineir lieime. alk wi your docor. You pay noing i edocor or supplier acceps assignmen or giving e so.

PrescriptionDrugs (limited)

Includes a limied number o drugs suc as injecions youge in a docor’s oce, cerain oral cancer drugs, drugsused wi some ypes o durable medical equipmen (likea nebulizer or exernal inusion pump) and under very limied circumsances, cerain drugs you ge in a ospialoupaien seing. You pay 20% o e Medicare-approvedamoun or ese covered drugs.

I e covered drugs you ge in a ospial oupaienseing are par o your oupaien services, you pay ecopaymen or e services. However, i you ge oer ypeso drugs in a ospial oupaien seing (someimes called“sel-adminisered drugs” or drugs you would normally ake on your own), wa you pay depends on weer youave Par D or oer prescripion drug coverage, weeryour drug plan covers e drug, and weer e ospial’sparmacy is in your drug plan’s nework. Conac yourprescripion drug plan o nd ou wa you pay or drugsyou ge in a ospial oupaien seing a aren’ coveredunder Par B. See page 81 or more inormaion.

Oer an e examples above, you pay 100% or mosprescripion drugs, unless you ave Par D or oer drugcoverage.

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Prostate Cancer

Screenings

Medicare covers a digial recal exam and ProsaeSpecic Anigen (PSA) es once every 12 mons

or men over 50 (coverage or is es begins eday aer your 50 birday). You pay noingor e PSA es. You pay e docor 20% o eMedicare-approved amoun, and e Par Bdeducible applies or e docor’s visi. In a ospialoupaien seing, you also pay e ospial acopaymen.

Prosthetic/Orthotic

Items

Includes arm, leg, back, and neck braces; aricialeyes; aricial limbs (and eir replacemen pars);some ypes o breas proseses (aer masecomy);and proseic devices needed o replace an inernalbody par or uncion (including osomy supplies,and pareneral and eneral nuriion erapy) wenyour docor orders i. For Medicare o cover yourproseic or oroic, you mus go o a suppliera is enrolled in Medicare. You pay 20% o e Medicare-approved amoun, and e Par Bdeducible applies.

Pulmonary

Rehabilitation

Medicare covers a compreensive pulmonary reabiliaion program i you ave moderae o

very severe cronic obsrucive pulmonary disease(COPD) and ave a reerral rom e docor reaingyour cronic respiraory disease. You pay e docor20% o e Medicare-approved amoun i you ge eservice in a docor’s oce. You also pay e ospiala copaymen per session i you ge e service in a

ospial oupaien seing.Rural Health Clinic

Services

Includes many oupaien primary care services.You pay 20% o e amoun carged, and e Par Bdeducible applies.

Second Surgical

Opinions

Covered in some cases or surgery a isn’ anemergency. In some cases, Medicare covers irdsurgical opinions. You pay 20% o e Medicare-approved amoun, and e Par B deducible applies.

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Smoking

Cessation

(counseling tostop smoking)

NEW

Includes up o 8 ace-o-ace visis in a 12-mon period i you’re diagnosed wi an illness caused or complicaed by

obacco use, or you ake a medicine a is aeced by obacco.You pay e docor 20% o e Medicare-approved amoun, ande Par B deducible applies. In a ospial oupaien seing,you also pay e ospial a copaymen.

Medicare coverage o smoking cessaion counseling is nowconsidered a covered prevenive service i you aven’ beendiagnosed wi an illness caused or complicaed by obacco use.Saring January 1, 2011 you pay noing or e counselingsessions.

Speech‑Language

Pathology

Services

Evaluaion and reamen given o regain and srengen speecand language skills including cogniive and swallowing skillswen your docor ceries you need i. Tere may be limis onese services and excepions o ese limis. You pay 20% o eMedicare-approved amoun, and e Par B deducible applies.

Surgical

Dressing

Services

For reamen o a surgical or surgically-reaed wound. You pay 20% o e Medicare-approved amoun or e docor’s services.You pay a xed copaymen or ese services wen you ge emin a ospial oupaien seing. You pay noing or e supplies.

Te Par B deducible applies.

Telehealth Includes a limied number o medical or oer eal services,like oce visis and consulaions provided using an ineracivewo-way elecommunicaions sysem (like real-ime audioand video) by an eligible provider wo isn’ a your locaion.Available in some rural areas, under cerain condiions, andonly i you’re locaed a one o e ollowing places: a docor’soce, ospial, rural eal clinic, ederally-qualied ealcener, ospial-based dialysis aciliy, skilled nursing aciliy,

or communiy menal eal cener. You pay 20% o eMedicare-approved amoun, and e Par B deducible applies.

Tests (other

than lab tests)

Includes X-rays, MRIs, C scans, EKGs, and some oerdiagnosic ess. You pay 20% o e Medicare-approvedamoun, and e Par B deducible applies. I you ge e es a aospial as an oupaien, you also pay e ospial a copaymena may be more an 20% o e Medicare-approved amoun,bu i can’ be more an e Par A ospial say deducible.See page 132. See “Clinical Laboraory Services” on page 31 oroer Par B-covered ess.

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Transplants and

Immunosuppressive

Drugs

Includes docor services or ear, lung, kidney,pancreas, inesine, and liver ransplans under cerain

condiions and only in a Medicare-ceried aciliy.Medicare covers bone marrow and cornea ransplansunder cerain condiions.

Immunosuppressive drugs are covered i Medicarepaid or e ransplan, or an employer or uniongroup eal plan was required o pay beoreMedicare paid or e ransplan. You mus avebeen eniled o Par A a e ime o e ransplan,and you mus be eniled o Par B a e ime you

ge immunosuppressive drugs. You pay 20% o e Medicare-approved amoun, and e Par Bdeducible applies.

I you’re inking abou joining a Medicare AdvanagePlan and are on a ransplan waiing lis or believe youneed a ransplan, ceck wi e plan beore you joino make sure your docors and ospials are in eplan’s nework. Also, ceck e plan’s coverage rules orprior auorizaion.

Note: Medicare drug plans (Par D) may coverimmunosuppressive drugs, even i Medicare or anemployer or union group eal plan didn’ pay ore ransplan.

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Travel (health care

needed when

traveling outsidethe United States)

Medicare generally doesn’ cover eal care wile you’reraveling ouside e U.S. (e “U.S.” includes e 50

saes, e Disric o Columbia, Puero Rico, e VirginIslands, Guam, e Norern Mariana Islands, andAmerican Samoa). Tere are some excepions includingsome cases were Medicare may pay or services a youge wile on board a sip wiin e erriorial waersadjoining e land areas o e U.S. Medicare may pay orinpaien ospial, docor, or ambulance services you gein a oreign counry in e ollowing rare cases:

I an emergency arises wiin e U.S. and e oreign1.ospial is closer an e neares U.S. ospial acan rea your medical condiion

I you’re raveling roug Canada wiou2.unreasonable delay by e mos direc roue beweenAlaska and anoer sae wen a medical emergency occurs and e Canadian ospial is closer an eneares U.S. ospial a can rea e emergency

I you live in e U.S. and e oreign ospial is closer3.

o your ome an e neares U.S. ospial a canrea your medical condiion, regardless o weer anemergency exiss

Medicare may cover medically-necessary ambulanceransporaion o a oreign ospial only wi admissionor medically-necessary covered inpaien ospialservices.

You pay 20% o e Medicare-approved amoun, and e

Par B deducible applies.Urgently‑Needed

Care

o rea a sudden illness or injury a isn’ amedical emergency. You pay e docor 20% o eMedicare-approved amoun or e docor’s services, ande Par B deducible applies. In a ospial oupaienseing, you also pay e ospial a copaymen.

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Preventive Services Checklistake is cecklis o your docor or oer eal care provider, and ask wic prevenive services are rig or you. You can also keep rack o your prevenive services by visiing www.MyMedicare.gov . See page 118.

Medicare‑Covered Preventive Service Details

on page

Notes

Abdominal Aoric Aneurysm Screening 30

Bone Mass Measuremen 31

Cardiovascular Screenings 31

Colorecal Cancer Screenings 32

Fecal Occul Blood es 32

Flexible Sigmoidoscopy 32

Colonoscopy 32

Barium Enema 32

Diabees Screenings 33

Diabees Sel-managemen raining 33

Flu Sos 36

Glaucoma ess 36

Hepaiis B Sos 36 HIV Screening 36

Mammogram (screening) 37

Medical Nuriion Terapy Services 37

Pap es and Pelvic Exam(includes breas exam)

39

Physical Exams 39

One-time “Welcome to Medicare”

physical exam

39

Yearly “Wellness” exam 39

Pneumococcal So 40

Prosae Cancer Screenings 41

Smoking Cessaion(counseling o sop smoking or peoplewi no sign o disease)

42

For some services, you will need o wai a cerain amoun o ime beore geing e

service again. See e page numbers lised or more inormaion.



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What’s NOT Covered by Part A and Part B?Medicare doesn’ cover everying. I you need cerain servicesa Medicare doesn’ cover, you will ave o pay or em yoursel unless you ave oer insurance o cover e coss. Even i Medicare covers a service or iem, you generally ave o pay deducibles, coinsurance, and copaymens.

Some o e iems and services a Medicare doesn’ cover includee ollowing:

Long-erm care. See■ pages 110–112.

Rouine denal care.■

Denures.■

Cosmeic surgery.■ Acupuncure.■

Hearing aids.■

Exams or ing earing aids.■

o nd ou i Medicare covers a service you need, visiwww.medicare.gov/coverage. Call 1-800-MEDICARE(1-800-633-4227) or general coverage inormaion. Y userssould call 1-877-486-2048.

Blue words


on pages

127–130.



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47

SECTION 2

Your

Medicare

Choices

Section 2 includes inormation about the ollowing:

Decide How o Ge Your Medicare . . . . . . . . . . . . . . . . 48

Your Medicare Coverage Coices . . . . . . . . . . . . . . . . . 49

Tings o Consider Wen Coosing orCanging Your Coverage . . . . . . . . . . . . . . . . . . . . 50

Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Medigap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Medicare Advanage Plans (Par C) . . . . . . . . . . . . . . . . 60

Oer Medicare Heal Plans . . . . . . . . . . . . . . . . . . . 70

Medicare Prescripion Drug Coverage (Par D) . . . . . . . . . 72

How Oer Insurance Works wi Medicare . . . . . . . . . . . 84

Tis handbook has basic inormation. You will need moredetailed inormation than this handbook provides to make achoice. Beore making any decisions, learn as much as you canabout the types o coverage available to you. See page 48 to gethelp with your Medicare decisions.

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48 Section 2—Your Medicare Choices

Decide How to Get Your MedicareYou can coose dieren ways o ge your Medicare coverage. I youcoose Original Medicare and you wan prescripion drug coverage,you mus also join a Medicare Prescripion Drug Plan (Par D).I you coose o join a Medicare Advanage Plan (like an HMOor PPO), e plan usually includes Medicare prescripion drugcoverage. I you don’ coose a Medicare Advanage Plan or oerMedicare eal plan, you will ave Original Medicare. See e nexpage or more inormaion abou your coverage coices, and edecisions you need o make.

Note: I you ave End-Sage Renal Disease (ESRD), you will usually ge your eal care roug Original Medicare. See page 64 or

more inormaion.

Eac year in e all, you sould review your eal andprescripion needs because your eal, nances, or plan’s coveragemay ave canged. I you decide oer coverage will beer meeyour needs, you can swic plans during cerain imes. See pages 68 and 73. I you’re saised wi your curren plan’s coverage or eollowing year, you don’ need o cange plans.

Need Help Deciding?Visi1. www.medicare.gov/nd-a-plan o nd and compare plansin your area.

Ge ree personalized counseling abou coosing coverage. See2.pages 123–126 or e elepone number o your Sae HealInsurance Assisance Program (SHIP).

Call 1-800-MEDICARE (1-800-633-4227), and say “Agen.”3.Y users sould call 1-877-486-2048. I you need elp in alanguage oer an Englis or Spanis, le e cusomer service

represenaive know.

See pages 102–103 o nd ou ow Original Medicare or a Medicare plan you may join uses and releases your personal inormaion.

Blue words

in the text

are dened

on pages

127–130.



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49Section 2—Your Medicare Choices

Your Medicare Coverage ChoicesTere are wo main coices or ow you ge your Medicare coverage. Use eseseps o elp you decide.

In addiion o Original Medicare or a Medicare Advanage Plan, you may be able o join oerypes o Medicare eal plans. See pages 70–71. You may be able o save money or ave oercoices i you ave limied income and resources. See pages 86–92. You may also ave oer

coverage, like employer or union, miliary, or Veerans’ benes. See pages 82–83.

Note: I you join a Medicare Advanage

Plan, you don’ need a Medigap policy. I youalready ave a Medigap policy, you can’ usei o pay or ou-o-pocke coss you ave ine Medicare Advanage Plan. I you already ave a Medicare Advanage Plan, you can’be sold a Medigap policy.See pages 57–59.

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 is coverage direcly.■You ave your coice o docors, ospials,■and oer providers a accep Medicare.Generally, you or your supplemenal■

coverage pay deducibles and coinsurance.You usually pay a monly ■ premium orPar B.

See pages 51–56.

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)

Privae insurance companies approved by ■Medicare provide is coverage.In mos plans, you need o use plan docors,■ospials, and oer providers, or you may pay more or all o e coss.You usually pay a monly premium (in■addiion o your Par B premium) and acopaymen or coinsurance or covered services.Coss, exra coverage, and rules vary by plan.■

See pages 60–69.

I you wan is coverage, you mus join■a Medicare Prescripion Drug Plan. You

usually pay a monly premium.Tese plans are run by privae companies■approved by Medicare.See pages 72–83.■

I you wan prescripion drug coverage, and■i’s oered by your plan, in mos cases youmus ge i roug your plan.In some ypes o plans a don’ oer■drug coverage, you can join a MedicarePrescripion Drug Plan.

See pages 66–67.

You may wan o ge coverage a lls■gaps in Original Medicare coverage. You

can coose o buy a Medigap (MedicareSupplemen Insurance) policy rom a privaecompany.Coss vary by policy and company.■Employers/unions may oer similar coverage.■

See pages 57–59.

Step 2

Step 3

Step 2

8/6/2019 Medicare 2011



Things to Consider When Choosing or Changing Your Coverage

Coverage Are e services you need covered?

Your other

coverage

Do you ave, or are you eligible or, oer ypes o eal orprescripion drug coverage (like rom a ormer or currenemployer or union)? I so, read e maerials rom your insureror plan, or call em o nd ou ow e coverage works wi, oris aeced by, Medicare. I you ave coverage roug a ormer orcurren employer or union or oer source, alk o your benesadminisraor, insurer, or plan beore making any canges o yourcoverage. I you drop your coverage, you may no be able o gei back.

Cost

How muc are your premiums, deducibles, and oer coss? Howmuc do you pay or services like ospial says or docor visis?Wa’s e yearly limi on wa you pay ou-o-pocke? Your coss

vary and may be dieren i you don’ ollow e coverage rules.

Doctor and

hospital

choice

Do your docors accep e coverage? Are e docors you wan osee acceping new paiens? Do you ave o coose your ospialand eal care providers rom a nework? Do you need reerrals?

Prescription

drugs

Do you need o join a Medicare drug plan? Do you already avecrediable prescripion drug coverage? Will you pay a penaly i you

join a drug plan laer? Wa will your prescripion drugs cos undereac plan? Are your drugs covered under e plan’s ormulary ? Areere any coverage rules a apply o your prescripions?

Quality o

care

Are you saised wi your care? Te qualiy o care and servicesgiven by plans and oer eal care providers can vary. Medicareas inormaion o elp you compare plans and providers. See

page 119.

Convenience

Were are e docors’ oces? Wa are eir ours? Wicparmacies can you use? Can you ge your prescripions by mail? Do e docors use elecronic eal records or prescribeelecronically? See page 120.

Travel Will e plan cover you in anoer sae or ouside e U.S.?

8/6/2019 Medicare 2011


51Section 2—Your Medicare Choices Original Medicare

Original MedicareOriginal Medicare is one o your eal coverage coices as paro e Medicare Program. You will be in Original Medicare unlessyou coose a Medicare eal plan.

How Does It Work?

Original Medicare is ee-or-service coverage managed by eFederal governmen. Generally, ere is a cos or eac service.Here are e general rules or ow i works:

Original Medicare

Can I get my health

care rom any doctor

or hospital?

In mos cases, yes. You can go o any docor, supplier, ospial,or oer aciliy a’s enrolled in Medicare and is accepingnew Medicare paiens.

Are prescription drugs

covered?

Wi a ew excepions (see pages 28 and 40), mosprescripions aren’ covered. You can add compreensivedrug coverage by joining a Medicare Prescripion Drug Plan(Par D).

Do I need to choose a

primary care doctor?

No.

Do I have to get

a reerral to see a

specialist?

No, bu e provider mus be enrolled in Medicare.

Should I get a

supplemental policy?

You may already ave employer or union coverage a may pay coss a Original Medicare doesn’. I no, you may wano buy a Medigap (Medicare Supplemen Insurance) policy.See pages 57–59.

What else do I need to

know about Original

Medicare?

You generally pay a se amoun or your eal care■(deducible) beore Medicare pays is sare. Ten, Medicarepays is sare, and you pay your sare (coinsurance/

copaymen) or covered services and supplies. Tere isno yearly limi or wa you pay ou-o-pocke. See pages132–133 o nd ou wa you pay.

You usually pay a monly ■ premium or Par B. Seepage 131. See page 90 or more inormaion abou MedicareSavings Programs or elp paying your Par B premium.

You generally don’ need o le Medicare claims. Te law■requires providers (like docors, ospials, skilled nursingaciliies, and ome eal agencies) and suppliers o leyour claims or e covered services and supplies you ge.

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52 Section 2—Your Medicare Choices Original Medicare

What You PayYour ou-o-pocke coss in Original Medicare depend on e ollowing:

Weer you ave Par A and/or Par B. Mos people ave bo.■

Weer your docor or supplier acceps “assignmen.” See e■nex page.

Te ype o eal care you need and ow oen you need i.■

Weer you coose o ge services or supplies Medicare doesn’ cover.■I you do, you pay all e coss unless you ave oer insurance acovers i.

Weer you ave oer eal insurance (like employer or union■coverage) a works wi Medicare.

Weer you ave Medicaid or ge sae elp paying your■Medicare coss.

Weer you ave a Medigap (Medicare Supplemen Insurance) policy.■

Weer you and your docor sign a privae conrac. See■ page 55.

For more inormaion on ow oer insurance works wi Medicare,see page 84. For more inormaion abou elp o cover e coss aOriginal Medicare doesn’ cover, see pages 57–59 and 90.

Medicare Summary NoticesI you ge a Medicare-covered service, you will ge a Medicare Summary Noice (MSN) in e mail every 3 mons. Te MSN sows all yourservices or supplies a providers and suppliers billed o Medicareduring e 3-mon period, wa Medicare paid, and wa you owe eprovider. Te MSN isn’t a bill. Read i careully and do e ollowing:

I you ave oer insurance, ceck o see i i covers anying a■Medicare didn’.

Keep your receips and bills, and compare em o your MSN■

o be sure you go all e services, supplies, or equipmen lised.See pages 105–107 or inormaion on Medicare raud.

I you paid a bill beore you go your MSN, compare your MSN wi■e bill o make sure you paid e rig amoun or your services.

I an iem or service is denied, call your docor’s oce o make sure■ey submied e correc inormaion. I no, e oce may resubmi.I you wan o le an appeal, see pages 95–96.

8/6/2019 Medicare 2011



I you need o cange your address on your MSN, call SocialSecuriy a 1-800-772-1213. Y users sould call 1-800-325-0778.

I you ge RRB benes, call e RRB a 1-877-772-5772.You don’ ave o wai or your MSN o view your Medicare claims.Visi www.MyMedicare.gov o rack your Medicare claims or viewelecronic MSNs. Your claims will generally be available wiin24 ours aer processing. See page 118.

Keeping Your Costs Down with “Assignment”Assignmen means a your docor, provider, or supplier assigned an agreemen wi Medicare (or is required by law) o

accep e Medicare-approved amoun as ull paymen or coveredservices. Some providers wo are enrolled in Medicare don’ accepassignmen.

Mos docors, providers, and suppliers accep assignmen, buyou sould always ceck o make sure. In some cases docors,providers, and suppliers mus accep assignmen, like weney ave a paricipaion agreemen wi Medicare and give youMedicare-covered services. Find ou ow muc you ave o pay or

eac service or supply beore you ge i.

Here’s wa appens i your docor, provider, or supplier accepts assignmen:

Your ou-o-pocke coss may be less.■

Tey agree o only carge you e Medicare■ deducible andcoinsurance amoun and usually wai or Medicare o pay is sare.

Tey ave o submi your claim o Medicare direcly. Tey can’■

carge you or submiing e claim.

Blue words

in the text

are dened

on pages

127–130.

Medicare Summary Notices (continued)



8/6/2019 Medicare 2011



Keeping Your Costs Down with “Assignment”

(continued)Here’s wa appens i your docor, provider, or supplier doesn’t

accept assignmen:Tey’re supposed o submi a claim o Medicare wen ey give you■Medicare-covered services. Tey can’ carge you or submiinga claim. I ey don’ submi e claim once you ask em o, call1-800-MEDICARE (1-800-633-4227). Y users sould call1-877-486-2048.

Note: You mig ave o pay e enire carge a e ime o service,and en submi your claim o Medicare o ge paid back using ormCMS-1490S. Visi www.medicare.gov/medicareonlineorms or e

orm and insrucions, or call 1-800-MEDICARE.

Tey may carge you more an e■ Medicare-approved amoun, buere is a limi called “e limiing carge.” Tey can only carge youup o 15% over e Medicare-approved amoun. Te limiing cargeapplies only o cerain services and doesn’ apply o some suppliesand durable medical equipmen.

o nd ou i your docors and suppliers accep assignmen orparicipae in Medicare, visi www.medicare.gov/pysician or

www.medicare.gov/supplier. You can also call 1-800-MEDICARE, orask your docor, provider, or supplier i ey accep assignmen.

Note: I you need ome eal care or durable medicalequipmen, your care mus be ordered by a docor or oereal care provider wo is enrolled in Medicare.

http://www.medicare.gov/medicareonlineforms

http://www.medicare.gov/physician



http://www.medicare.gov/physician


8/6/2019 Medicare 2011



What to Know About Private ContractsA “privae conrac” is a wrien agreemen beween you anda docor or oer eal care provider wo as decided no oprovide services o anyone roug Medicare. Te privae conraconly applies o e services provided by e docor or oerprovider wo asked you o sign i. You don’ ave o sign a privaeconrac. You can always go o anoer provider wo gives servicesroug Medicare. I you sign a privae conrac wi your docoror oer provider, e ollowing rules apply:

Medicare won’t pay any amount or the services you get rom■this doctor or provider.

You will ave o pay e ull amoun o waever is provider■

carges you or e services you ge.I you ave a Medigap (Medicare Supplemen Insurance)■policy, i won’ pay anying or e services you ge. Call yourMedigap insurance company beore you ge e service i youave quesions.

Your provider mus ell you i Medicare would pay or e service■i you go i rom anoer provider wo acceps Medicare.

Your provider mus ell you i e or se as been excluded■rom Medicare.

You can’ be asked o sign a privae conrac or emergency orurgen care.

You’re always ree o ge services no covered by Medicare i youcoose o pay or a service yoursel.

You may wan o conac your Sae Heal Insurance AssisanceProgram (SHIP) o ge elp beore signing a privae conrac wiany docor or oer eal care provider. See pages 123–126 or e

elepone number.

See pages 94–107 or inormaion abou your appeal rigs andow o proec yoursel and Medicare rom raud.

Blue words

in the text

are dened

on pages

127–130.

8/6/2019 Medicare 2011



Adding Medicare Drug Coverage (Part D)In Original Medicare, i you don’t already have creditableprescription drug coverage (or example, rom a curren or ormeremployer or union) and you would like Medicare prescripiondrug coverage, you mus join a Medicare Prescripion Drug Plan.Tese plans are available roug privae companies under conracwi Medicare. I you don’ currenly ave crediable prescripiondrug coverage, you sould ink abou joining a MedicarePrescripion Drug Plan as soon as you’re eligible. I you don’ join aMedicare Prescripion Drug Plan wen you’re rs eligible and youdecide o join laer, you may ave o pay a lae enrollmen penaly.See pages 78–79 or more inormaion.

I you have creditable prescription drug coverage rom anemployer or union, call your employer or union’s benesadminisraor beore you make any canges o your coverage.Your employer or union plan will ell you eac year i yourprescripion drug coverage is crediable prescripion drug coverage.I you drop your employer or union coverage, you may no be able oge i back. You also may no be able o drop your employer or uniondrug coverage wiou also dropping your employer or union health (docor and ospial) coverage. I you drop coverage or yoursel, you

may also ave o drop coverage or your spouse and dependans.

Extra Help Paying or CoveragePeople wi limied income and resources may qualiy or ExraHelp paying eir Medicare prescripion drug coverage coss.See pages 86–89 o nd ou i you may qualiy or Exra Help.

Blue wordsin the text

are dened

on pages

127–130.

8/6/2019 Medicare 2011


57Section 2—Your Medicare Choices Medigap

Medigap (Medicare Supplement Insurance) PoliciesOriginal Medicare pays or many, bu no all, eal care services andsupplies. A Medigap policy, sold by privae insurance companies, canelp pay some o e eal care coss (“gaps”) a Original Medicaredoesn’ cover, like copaymens, coinsurance, and deducibles. SomeMedigap policies also oer coverage or services a Original Medicaredoesn’ cover, like medical care wen you ravel ouside e U.S. I youave Original Medicare and you buy a Medigap policy, Medicare will pay is sare o e Medicare-approved amoun or covered eal care coss.Ten your Medigap policy pays is sare. Medicare doesn’ pay any o epremiums or a Medigap policy.

Every Medigap policy mus ollow Federal and sae laws designed o

proec you, and i mus be clearly idenied as “Medicare SupplemenInsurance.” Medigap insurance companies can sell you only a“sandardized” Medigap policy idenied in mos saes by leers.All plans oer e same basic benes bu some oer addiional benes,so you can coose wic one mees your needs.

Note: In Massacuses, Minnesoa, and Wisconsin, Medigap policies aresandardized in a dieren way.

Starting June 1, 2010, the types o Medigap Plans that you canbuy changed:

Tere are wo new Medigap Plans—Plans M and N.■

Plans E, H, I, and J are no longer available o buy. I you boug■Plan E, H, I, or J beore June 1, 2010, you can keep a plan.Conac your plan or more inormaion.

Insurance companies may charge diferent premiums or exactly the

same Medigap coverage. As you sop or a Medigap policy, be sureyou’re comparing e same Medigap policy (or example, compare Plan Arom one company wi Plan A rom anoer company).

In some saes, you may be able o buy anoer ype o Medigap policy called Medicare SELEC (a Medigap policy a requires you o usespecic ospials and, in some cases, specic docors o ge ull coverage).I you buy a Medicare SELEC policy, you also ave rigs o cangeyour mind wiin 12 mons and swic o a sandard Medigap policy.

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58 Section 2—Your Medicare Choices Medigap

More About Medigap PoliciesYou mus ave Par A and Par B.■

You pay a monly ■ premium or your Medigap policy in addiion

o your monly Par B premium.A Medigap policy only covers one person. Spouses mus buy ■separae policies.

I’s imporan o compare Medigap policies since e coss can vary ■and may go up as you ge older. Some saes limi Medigap coss.

Te bes ime o buy a Medigap policy is during e 6-mon■period a begins on e rs day o e mon in wic you’re65 or older and enrolled in Par B. (Some saes ave addiionalopen enrollmen periods.) Aer is enrollmen period, your

opion o buy a Medigap policy may be limied and i may cosmore. For example, i you urn 65 and are enrolled in Par B inJune, e bes ime or you o buy a Medigap policy is rom Juneo November.

I you’re under 65, you won’ ave is open enrollmen period■unil you urn 65, bu sae law mig give you a rig o buy apolicy beore en.

I you ave a Medigap policy and join a Medicare Advanage Plan■(like an HMO or PPO), you may wan o drop your Medigappolicy. Your Medigap policy can’t be used o pay your MedicareAdvanage Plan copaymens, deducibles, and premiums. I youwan o cancel your Medigap policy, conac your insurancecompany. I you drop your policy o join a Medicare AdvanagePlan, in mos cases you won’ be able o ge i back.

I you ave a Medicare Advanage Plan, i’s illegal or anyone o■sell you a Medigap policy unless you’re swicing back o OriginalMedicare. Conac your Sae Insurance Deparmen i is

appens o you.

Blue words

in the text

are dened

on pages

127–130.

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59Section 2—Your Medicare Choices Medigap

More About Medigap Policies (continued)I you join a■ Medicare eal plan or e rs ime, and you aren’appy wi e plan, you will ave special rigs o buy a Medigappolicy i you reurn o Original Medicare wiin 12 mons o

joining.

— I you ad a Medigap policy beore you joined, you may be able o ge e same policy back i e company sillsells i. I i isn’ available, you can buy anoer Medigappolicy.

— Te Medigap policy can no longer ave prescripion drugcoverage even i you ad i beore, bu you may be able o

join a Medicare Prescripion Drug Plan.

— I you joined a Medicare eal plan wen you were rseligible or Medicare, you can coose rom any policy.

You can’ ave prescripion drug coverage in bo your Medigap■policy and a Medicare drug plan. See page 82.

For More Inormation About Medigap PoliciesVisi■ p://go.usa.gov/lo o view e bookle, “Coosing aMedigap Policy: A Guide o Heal Insurance or People wi

Medicare.” You can also call 1-800-MEDICARE (1-800-633-4227)o see i a copy can be mailed o you. Y users sould call1-877-486-2048. You can also visi www.medicare.gov .

Call your Sae Insurance Deparmen. Call 1-800-MEDICARE o■ge e elepone number. You can also visiwww.medicare.gov/conacs.

Call your Sae Heal Insurance Assisance Program (SHIP). See■pages 123–126 or e elepone number.

http://go.usa.gov/lot


http://www.medicare.gov/contacts

http://www.medicare.gov/contacts


http://go.usa.gov/lot

8/6/2019 Medicare 2011


60

Medicare Advantage Plans (Part C)A Medicare Advanage Plan (like an HMO or PPO) is anoerMedicare eal plan coice you may ave as par o Medicare.Medicare Advanage Plans, someimes called “Par C” or “MAPlans,” are oered by privae companies approved by Medicare.I you join a Medicare Advanage Plan, e plan will provide all o your Par A (Hospial Insurance) and Par B (Medical Insurance)coverage. In all ypes o Medicare Advanage Plans, you’re alwayscovered or emergency and urgen care. Medicare Advanage Plansmus cover all o e services a Original Medicare covers excepospice care. Original Medicare covers ospice care even i you’rein a Medicare Advanage Plan. Medicare Advanage Plans aren’

supplemenal coverage.Medicare Advanage Plans may oer exra coverage, suc as vision,earing, denal, and/or eal and wellness programs. Mos includeMedicare prescripion drug coverage (Par D). In addiion o yourPar B premium, you usually pay one monly premium or eservices included.

Medicare pays a xed amoun or your care every mon oe companies oering Medicare Advanage Plans. Tese

companies mus ollow rules se by Medicare. However, eacMedicare Advanage Plan can carge dieren ou-o-pockecoss and ave dieren rules or ow you ge services (likeweer you need a reerral o see a specialis or i you aveo go o only docors, aciliies, or suppliers a belong oe plan or non-emergency or non-urgen care). Tese rulescan cange eac year.

Tere are diferent types o Medicare Advantage Plans:

Heal Mainenance Organizaion (HMO) Plans. See■ page 66.

Preerred Provider Organizaion (PPO) Plans. See■ page 66.

Privae Fee-or-Service (PFFS) Plans. See■ page 67.

Special Needs Plans (SNP). See■ page 67.

Section 2—Your Medicare Choices Medicare Advantage Plans


are dened

on pages

127–130.

8/6/2019 Medicare 2011


61

Medicare Advantage Plans (continued)


Tere are oer less common ypes o Medicare Advanage Plansa may be available:

HMO Poin-o-Service (HMOPOS) Plans—An HMO plan■ a may allow you o ge some services ou-o-nework or aiger cos.

Medical Savings Accoun (MSA) Plans—A plan a combines■a ig deducible eal plan wi a bank accoun. Medicaredeposis money ino e accoun (usually less an ededucible). You can use e money o pay or your eal careservices during e year. For more inormaion abou MSAs,

visi p://go.usa.gov/irD o view e bookle, “Your Guide o

Medicare Medical Savings Accoun Plans.” You can also call1-800-MEDICARE (1-800-633-4227) o see i a copy can bemailed o you. Y users sould call 1-877-486-2048.

Make sure you undersand ow a plan works beore you join. See pages 66–67 or more inormaion abou MedicareAdvanage Plan ypes. I you wan more inormaion aboua Medicare Advanage Plan, you can call any plan andreques a Summary o Benes (SB) documen. Conac

your Sae Heal Insurance Assisance Program (SHIP)or elp comparing plans. See pages 123–126 or eirelepone number.

http://go.usa.gov/irD

http://go.usa.gov/irD

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62

More About Medicare Advantage PlansAs wi Original Medicare, you sill ave Medicare rigs and proecions,■including e rig o appeal. See pages 95–97.

Ceck wi e plan beore you ge a service o nd ou weer ey will■ cover e service and wa your coss may be.

You mus ollow plan rules, like geing a■ reerral o see a specialis oavoid iger coss i your plan requires i. Ceck wi e plan.

You can join a Medicare Advanage Plan even i you ave a pre-exising■condiion, excep or End-Sage Renal Disease. See page 64.

You can only join or leave a plan a cerain imes during e year.■See page 68.

I you go o a docor, aciliy, or supplier a doesn’ belong o e■

plan, your services may no be covered, or your coss could be iger,depending on e ype o Medicare Advanage Plan. In mos cases, isapplies o Medicare Advanage HMOs and PPOs.

I e plan decides o sop paricipaing in Medicare, you will ave■o join anoer Medicare eal plan or reurn o Original Medicare.See pages 94–95.

You usually ge prescripion drug coverage (Par D) roug e plan.■In some ypes o plans a don’ oer drug coverage, you can join aMedicare Prescripion Drug Plan. I you’re in a Medicare Advantage

Plan 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’ aveprescripion drug coverage roug bo a Medicare Advanage Plan anda Medicare Prescripion Drug Plan.

You don’ need o buy (and can’ be sold) a Medigap (Medicare Supplemen■Insurance) policy wile you’re in a Medicare Advanage Plan. I won’ coveryour Medicare Advanage Plan deducibles, copaymen, or coinsurance.

NEW—Saring in 2011I you join a clinical researc sudy, your coss may be lower and some■coss may be covered by your plan. Call your plan or more inormaion.

Medicare Advanage Plans can’ carge you more an Original Medicare■or cerain services like cemoerapy, dialysis, and skilled nursingaciliy care.

Medicare Advanage Plans will ave an annual cap on ow muc you pay ■or Par A and Par B services during e year. Tis annual maximumou-o-pocke amoun can be dieren beween Medicare Advanage

Plans. You sould consider is wen you coose a plan.


Blue words

in the text

are dened

on pages

127–130.

8/6/2019 Medicare 2011


63Section 2—Your Medicare Choices Medicare Advantage Plans

Who Can Join?You can generally join a Medicare Advanage Plan i you meeese condiions:

You ave Par A and Par B.■You live in e■ service area o e plan.

You don’ ave End-Sage Renal Disease (ESRD) (permanen■kidney ailure requiring dialysis or a kidney ransplan) excep asexplained on page 64.

Note: In mos cases, you can join a Medicare Advanage Plan only a cerain imes during e year. See page 68.

I You Have Other Coveragealk o your employer, union, or oer benes adminisraor aboueir rules beore you join a Medicare Advanage Plan. In somecases, joining a Medicare Advanage Plan mig cause you o loseemployer or union coverage. In oer cases, i you join a MedicareAdvanage Plan, you may sill be able o use your employer orunion coverage along wi e plan you join. Remember, i youdrop your employer or union coverage, you may not be able toget it back.

I You Have a Medigap (Medicare Supplement

Insurance) PolicyI you ave a Medigap policy and join a Medicare AdvanagePlan (like an HMO or PPO), you will probably wan o dropyour Medigap policy. You can’ use i o pay or any expenses(copaymens, deducibles, and premiums) you ave under aMedicare Advanage Plan. I you drop your Medigap policy, youmay no be able o ge i back. See pages 58–59.

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64 Section 2—Your Medicare Choices Medicare Advantage Plans

I You Have End‑Stage Renal Disease (ESRD)I you ave End-Sage Renal Disease (ESRD), you usually can’ joina Medicare Advanage Plan. However, you may be able o join aMedicare Advanage Plan in e ollowing siuaions:

I you’re already in a Medicare Advanage Plan wen you develop■ESRD, you can say in your plan or join anoer plan oered by esame company under cerain circumsances.

I you ave an employer or union eal plan or oer eal■coverage roug a company a oers Medicare Advanage Plans,you may be able o join one o eir Medicare Advanage Plans.

I you’ve ad a successul kidney ransplan, you may be able o join■a Medicare Advanage Plan.

You may be able o join a Medicare Special Needs Plan (SNP) or■people wi ESRD i one is available in your area.

I you ave ESRD and are in a Medicare Advanage Plan, and eplan leaves Medicare or no longer provides coverage in your area,you ave a one-ime rig o join anoer Medicare AdvanagePlan. You don’ ave o use your one-ime rig o join a new planimmediaely. I you go direcly o Original Medicare aer your planleaves or sops providing coverage, you will sill ave a one-ime

rig o join a Medicare Advanage Plan laer.For quesions or complains abou kidney dialysis services, call yourlocal ESRD Nework Organizaion. An ESRD Nework Organizaionis a group o kidney care expers paid by e Federal governmeno ceck and improve e care given o Medicare paiens woge dialysis reamens or kidney care. Call 1-800-MEDICARE(1-800-633-4227) o ge e elepone number. Y users souldcall 1-877-486-2048.

For more inormaion abou ESRD, visi p://go.usa.gov/lov o view e bookle, “Medicare Coverage o Kidney Dialysis and Kidney ransplan Services.” You can also call 1-800-MEDICARE o see i acopy can be mailed o you.

Note: I you ave ESRD and Original Medicare, you may join aMedicare Prescripion Drug Plan.



8/6/2019 Medicare 2011


65Section 2—Your Medicare Choices Medicare Advantage Plans

What You PayYour ou-o-pocke coss in a Medicare Advanage Plan depend one ollowing:

Weer e plan carges a monly ■ premium.Weer e plan pays any o your monly Par B premium.■

Weer e plan as a yearly ■ deducible or any addiionaldeducibles.

How muc you pay or eac visi or service (■ copaymens or coinsurance).

Te ype o eal care services you need and ow oen you■ge em.

Weer you ollow e plan’s rules, like using nework providers.■

Weer you need exra benes and i e plan carges or i.■

Te plan’s yearly limi on your ou-o-pocke coss or all■medical services.

o learn more abou your coss in specic Medicare AdvanagePlans, conac e plans you’re ineresed in o ge more deails.Visi www.medicare.gov/nd-a-plan, or call 1-800-MEDICARE(1-800-633-4227) o nd plans in your area. Y users sould call1-877-486-2048.

I you have limited income and resources, you may qualiy orthe ollowing:

Exra Hel■ p paying your premium and oer prescripion drugcoverage coss under Par D. See pages 86–89.

Help rom your sae o pay your Medicare premiums. In some■cases, e sae may also pay your Par A and Par B deduciblesand coinsurance. See page 90.

I you’re in a Medicare plan, review e Evidence o Coverage(EOC) and Annual Noice o Cange (ANOC) your plansends you eac all. Te EOC gives you deails abou wae plan covers, ow muc you pay, and more. Te ANOCincludes any canges in coverage, coss, or service area awill be eecive in January. I you don’ ge an EOC or ANOC,conac your plan.

Blue words

in the text

are dened

on pages

127–130.



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66

How Do Medicare Advantage Plans Work?

Health Maintenance Organization

(HMO) Plan

Preerred Provider

Organization (PPO) Plan

Can I get my

health care

rom any doctor

or hospital?

No. You generally mus ge your care and servicesrom docors or ospials in e plan’s nework (excep emergency care, ou-o-area urgen care,or ou-o-area dialysis). In some plans, you may be able o go ou-o-nework or cerain services,usually or a iger cos. Tis is called an HMOwi a poin-o-service (POS) opion.

In mos cases, yes. PPOs avenework docors and ospials,bu you can also useou-o-nework providersor covered services, usually or a iger cos.

Are prescription

drugs covered?

In mos cases, yes. Ask e plan. I you wan drugcoverage, you mus join an HMO Plan a oers

prescripion drug coverage.

In mos cases, yes. Ask eplan. I you wan drug

coverage, you mus join aPPO Plan a oers i.

Do I need to

choose a primary

care doctor?

In mos cases, yes. No.

Do I have to get

a reerral to see

a specialist?

In mos cases, yes. Cerain services like yearly screening mammograms don’ require a reerral.

No.

What else do Ineed to know

about this type

o plan?

I your docor leaves e plan, your plan will■noiy you. You can coose anoer docor in eplan.

I you ge eal care ouside e plan’s nework,■you may ave o pay e ull cos.

I’s imporan a you ollow e plan’s rules, like■geing prior approval or a cerain service wenneeded.

Tere are wo ypes o PPOs: Regional PPOsand Local PPOs.

Regional PPOs serve one o ■26 regions se by Medicare.

Local PPOs serve e■counies e PPO Plancooses o include in isservice area.


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 makesure you understand the plan’s rules. You may want to contact the plan to nd out i theservice you need is covered and how much it costs. Visit www.medicare.gov/nd-a-plan, orcall 1-800-MEDICARE (1-800-633-4227) to nd plans in your area. Y users should call1-877-486-2048.



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How Do Medicare Advantage Plans Work? (continued)

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

In some cases, yes. You can go to any Medicare-approved doctor or hospital that acceptsthe plan’s payment terms and agrees to treat you.Not all providers will. I you join a PFFS Plan thathas a network, you can also see any o the network providers who have agreed to always treat planmembers.

You generally mus ge your care and servicesrom docors or ospials in e plan’s nework (excep emergency care, ou-o-area urgen care,or ou-o-area dialysis).

Someimes. I your PFFS Plan doesn’ oer drugcoverage, you can join a Medicare Prescripion Drug

Plan (Par D) o ge coverage.

Yes. All SNPs mus provide Medicare prescripiondrug coverage (Par D).

No. Generally, yes.

No. In mos cases, yes. Cerain services like yearly screening mammograms don’ require a reerral.

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

Te plan decides ow muc you pay or services.■

Some PFFS Plans conrac wi a nework o ■providers wo agree o always rea you even i you’ve never seen em beore.

I you join a PFFS Plan a as a nework, you may ■pay more i you coose an ou-o-nework docor,ospial, or oer provider.

Out-o-network doctors, hospitals, and other■

providers may decide not to treat you even i you’ve seen them beore.

For eac service, make sure your docors, ospials,■and oer providers agree o rea you under eplan, and accep e plan’s paymen erms.

In an emergency, docors, ospials, and oer■providers mus rea you.

A plan mus limi membersip o e ollowing■ groups: 1) people wo live in cerain insiuions (like a nursing ome) or wo require nursingcare a ome, or 2) people wo are eligible orbo Medicare and Medicaid, or 3) people woave specic cronic or disabling condiions(like diabees, ESRD, or HIV/AIDS). Plans may urer limi membersip.

Plans sould coordinae e services and■providers you need o elp you say ealy andollow your docor’s orders.

I you ave Medicare and Medicaid, your plan■sould make sure a all plan docors or oereal care providers you use accep Medicaid.

I you live in an insiuion, make sure plan■providers serve people were you live.


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Join, Switch, or Drop a Medicare Advantage PlanYou can join, swic, or drop a Medicare Advanage Plan a ese imes:

Wen you rs become eligible or Medicare (e 7-mon period a■

begins 3 mons beore e mon you urn 65, includes e monyou urn 65, and ends 3 mons aer e mon you urn 65).

I you ge Medicare due o a disabiliy, you can join during e 3■mons beore o 3 mons aer your 25 mon o disabiliy.

Beween November 15–December 31 in 2010. Your coverage will■begin on January 1, 2011, as long as e plan ges your enrollmenreques by December 31.

NEW—Making changes to your coverage aer December 31Beween January 1–February 14, 2011, i you’re in a MedicareAdvanage Plan, you can leave your plan and swic o OriginalMedicare. I you swic o Original Medicare during is period, youwill ave unil February 14 o also join a Medicare Prescripion DrugPlan o add drug coverage. Your coverage will begin e rs day o emon aer e plan ges your enrollmen orm.

During is period, you can’t do e ollowing:

Swic rom Original Medicare o a Medicare Advanage Plan.■

Swic rom one Medicare Advanage Plan o anoer.■

Swic rom one Medicare Prescripion Drug Plan o anoer.■

Join, swic, or drop a Medicare Medical Savings Accoun Plan.■

In mos cases, you mus say enrolled or a calendar year saring edae your coverage begins. However, in cerain siuaions, you may beable o join, swic, or drop a Medicare Advanage Plan a oer imes.Some o ese siuaions include e ollowing:

I you move ou o your plan’s■ service area.

I you qualiy or■ Exra Help. See pages 86–89.

I you live in an■ insiuion (like a nursing ome).

You can call your Sae Heal Insurance Assisance Program (SHIP)or more inormaion. See pages 123–126 or e elepone number.



are dened

on pages

127–130.

Coming Soon—In

the all o 2011, the

Annual Enrollment

Period will change

to October 15,2011–December 7,

2011. I you make a

change during this

period, your new

coverage will begin

on January 1, 2012.

8/6/2019 Medicare 2011


69

How Do You Join?I you coose o join a Medicare Advanage Plan, you may beable o join by compleing a paper applicaion, calling e plan, orenrolling on e plan’s Web sie or on www.medicare.gov . You canalso enroll by calling 1-800-MEDICARE (1-800-633-4227).Y users sould call 1-877-486-2048. Wen you join aMedicare Advanage Plan, you will ave o provide your Medicarenumber and e dae your Par A and/or Par B coverage sared.Tis inormaion is on your Medicare card. Note: MedicareAdvantage Plans aren’t allowed to call you to enroll you in aplan. Call 1-800-MEDICARE to report a plan that does this.

How Do You Switch?I you’re already in a Medicare Advanage Plan and wan o swic,is is wa you need o do:

o swic o a new Medicare Advanage Plan, simply join e plan■you coose during one o e enrollmen periods explained onpage 68. You will be disenrolled auomaically rom your old planwen your new plan’s coverage begins.

o swic o Original Medicare, conac your curren plan, or call■1-800-MEDICARE. You will also need o decide abou Medicare

prescripion drug coverage (Par D) and i you wan a Medigap(Medicare Supplemen Insurance) policy. See pages 57–59 ormore inormaion abou buying a Medigap policy.

For more inormaion on joining, dropping, and swicingplans, read e ac see “Undersanding Medicare EnrollmenPeriods” by visiing p://go.usa.gov/lsi. You can also call1-800-MEDICARE o see i a copy can be mailed o you.

No one should call you or come to your home uninvitedto sell Medicare products. See pages 104–107 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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Other Medicare Health Plans

Some ypes o Medicare eal plans a provide eal carecoverage aren’ Medicare Advanage Plans bu are sill par o

Medicare. Some o ese plans provide Par A (Hospial Insurance)and/or Par B (Medical Insurance) coverage, and some also providePar D (Medicare prescripion drug coverage). Tese plans avesome o e same rules as Medicare Advanage Plans. Some o eserules are explained briefy below and on e nex page. However,eac ype o plan as special rules and excepions, so you souldconac any plans you’re ineresed in o ge more deails.

Medicare Cost Plans

Medicare Cos Plans are a ype o Medicare eal plan availablein cerain areas o e counry. Here’s wa you sould know abouMedicare Cos Plans:

You can join even i you only ave Par B.■

I you ave Par A and Par B and go o a non-nework provider,■e services are covered under Original Medicare. You would pay e Par A and Par B coinsurance and deducibles.

You can join anyime e plan is acceping new members.■

You can leave anyime and reurn o Original Medicare.■

You can eier ge your Medicare prescripion drug coverage■rom e plan (i oered), or you can join a Medicare PrescripionDrug Plan. Note: You can add or drop Medicare prescripion drugcoverage only a cerain imes. See page 73.

Tere is anoer ype o Medicare Cos Plan a only providescoverage or Par B services. Tese plans never include Par D. Par Aservices are covered roug Original Medicare. Tese plans areeier sponsored by employer or union group eal plans or oered

by companies a don’ provide Par A services.For more inormaion abou Medicare Cos Plans, conac e plansyou’re ineresed in. You can also visi www.medicare.gov . Your SaeHeal Insurance Assisance Program (SHIP) can also give you moreinormaion. See pages 123–126 or e elepone number.

Section 2—Your Medicare Choices Other Medicare Health Plans

Blue words

in the text

are dened

on pages

127–130.



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71

Other Medicare Health Plans (continued)

Section 2—Your Medicare Choices Other Medicare Health Plans

Demonstrations/Pilot Programs

Demonsraions and pilo programs, someimes called “researc sudies,”

are special projecs a es improvemens in Medicare coverage, paymen,and qualiy o care. Tey usually operae only or a limied ime or a specicgroup o people and/or are oered only in specic areas. Ceck wi edemonsraion or pilo program or more inormaion abou ow i works.

o nd ou abou curren Medicare demonsraions and pilo programs,call 1-800-MEDICARE (1-800-633-4227), and say “Agen.” Y userssould call 1-877-486-2048.

Programs o All‑Inclusive Care or the Elderly (PACE)

PACE is a Medicare and Medicaid program oered in many saes aallows people wo oerwise need a nursing ome-level o care o remainin e communiy.

o qualiy or PACE, you mus mee e ollowing condiions:

You’re 55 or older.■

You live in e■ service area o a PACE organizaion.

You’re ceried by your sae as needing a nursing ome-level o care.■

A e ime you join, you’re able o live saely in e communiy wi e■elp o PACE services.

PACE provides coverage or prescripion drugs, docor visis,ransporaion, ome care, ceck-ups, ospial visis, and even nursingome says wenever necessary. I you ave Medicare, Medicare pays orall Medicare-covered services. I you ave Medicare and Medicaid, you willeier ave a small monly paymen or pay noing or e long-erm careporion o e PACE bene. I you ave Medicare bu no Medicaid, youwill be carged a monly premium o cover e long-erm care porion

o e PACE bene and a premium or Medicare Par D drugs. However,in PACE ere is never a deducible or copaymen or any drug, service, orcare approved by e PACE eam o eal care proessionals.

Call your Sae Medical Assisance (Medicaid) oce o nd ou i you’reeligible and i ere is a PACE sie near you, or visi www.pace4you.org ond a program. You can also visi p://go.usa.gov/loL o view e acsee, “Quick Facs abou Programs o All-inclusive Care or e Elderly (PACE).” You can call 1-800-MEDICARE o see i a copy can be mailed

o you.

http://www.pace4you.org/

http://go.usa.gov/loL

http://go.usa.gov/loL

http://www.pace4you.org/

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Medicare Prescription Drug Coverage (Part D)Medicare oers prescripion drug coverage o everyone wi Medicare.Even i you don’ ake a lo o prescripions now, you sould sill consider

joining a Medicare drug plan. o ge Medicare prescripion drug coverage,you mus join a plan run by an insurance company or oer privaecompany approved by Medicare. Eac plan can vary in cos and drugscovered. I you decide no o join a Medicare drug plan wen you’re rseligible, and you don’ ave oer crediable prescripion drug coverage,you will likely pay a lae enrollmen penaly. See pages 78–79.

Tere are wo ways o ge Medicare prescripion drug coverage:

Medicare Prescription Drug Plans.1. Tese plans (someimes called“PDPs”) add drug coverage o Original Medicare, some Medicare

Cos Plans, some Medicare Privae Fee-or-Service (PFFS) Plans, andMedicare Medical Savings Accoun (MSA) Plans.

Medicare Advantage Plans (like an HMO or PPO) or other2. Medicarehealth plans that ofer Medicare prescription drug coverage. Youge all o your Par A and Par B coverage, and prescripion drugcoverage (Par D), roug ese plans. Medicare Advanage Plans wiprescripion drug coverage are someimes called “MA-PDs.”

Both types o plans are called “Medicare drug plans” in this section.

Who Can Get Medicare Drug Coverage?o join a Medicare Prescripion Drug Plan, you mus ave MedicarePar A or Par B. o join a Medicare Advanage Plan, you mus ave Par Aand Par B. You mus also live in e service area o e Medicare drugplan you wan o join.

I you ave employer or union coverage, call your benesadminisraor beore you make any canges, or beore you sign

up or any oer coverage. I you drop your employer or unioncoverage, you may no be able o ge i back. You also may nobe able o drop your employer or union drug coverage wioualso dropping your employer or union health (docor andospial) coverage. I you drop coverage or yoursel, you may also ave o drop coverage or your spouse and dependans.I you wan o know ow Medicare prescripion drug coverageworks wi oer drug coverage you may ave, see pages 82–83.

Section 2—Your Medicare Choices Medicare Prescription Drug Coverage

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Join, Switch, or Drop a Medicare Drug PlanYou can join, swic, or drop a Medicare drug plan a ese imes:

Wen you’re rs eligible or Medicare (e 7-mon period■

a begins 3 mons beore e mon you urn 65, includese mon you urn 65, and ends 3 mons aer e mon youurn 65).

I you ge Medicare due o a disabiliy, you can join during e■3 mons beore o 3 mons aer your 25th mon o disabiliy.You will ave anoer cance o join 3 mons beore e monyou urn 65 o 3 mons aer e mon you urn 65.

Beween November 15–December 31 in 2010. Your coverage will■begin on January 1, 2011, as long as e plan ges your enrollmen

reques by December 31.Anyime, i you qualiy or■ Exra Help.

In mos cases, you mus say enrolled or a calendar year saringe dae your coverage begins. However, in cerain siuaions, youmay be able o join, swic, or drop Medicare drug plans a oerimes. Some o ese siuaions include e ollowing:

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

I you lose oer■ crediable prescripion drug coverage

I you live in an■ insiuion (like a nursing ome)

I you wan o join a plan or swic plans, do so as soon as possibleso you will ave your membersip card wen your coverage begins,and you can ge your prescripions lled wiou delay.

Call your Sae Heal Insurance Assisance Program (SHIP) ormore inormaion. See pages 123–126 or e elepone number.You can also call 1-800-MEDICARE (1-800-633-4227). Y userssould call 1-877-486-2048.

I you ave limied income and resources, you may qualiy orExra Help o pay or Medicare prescripion drug coverage.You may also be able o ge elp rom your sae. See pages 86–91.


Blue words

in the text

are dened

on pages

127–130.

Coming Soon—In

the all o 2011, the

Annual Enrollment

Period will change

to October 15,2011–December 7,

2011. I you make a

change during this

period, your new

coverage will begin

on January 1, 2012.

8/6/2019 Medicare 2011


74

How Do You Join?Once you coose a Medicare drug plan, you may be able o join by compleing a paper applicaion, calling e plan, or enrolling one plan’s Web sie or on www.medicare.gov . You can also enroll by calling 1-800-MEDICARE (1-800-633-4227). Y users sould call1-877-486-2048. Wen you join a Medicare drug plan, you will aveo provide your Medicare number and e dae your Par A and/orPar B coverage sared. Tis inormaion is on your Medicare card.Note: Medicare drug plans aren’t allowed to call you to enroll youin a plan. Call 1-800-MEDICARE to report a plan that does this.

How Do You Switch?

You can swic o a new Medicare drug plan simply by joininganoer drug plan during one o e imes lised on page 73. Youdon’t need to cancel your old Medicare drug plan or send themanything. Your old Medicare drug plan coverage will end wenyour new drug plan begins. You sould ge a leer rom your newMedicare drug plan elling you wen your coverage begins.

I you wan o drop your Medicare drug plan and don’ wan o joina new plan, you can do so during one o e imes lised on page 73.You can disenroll by calling 1-800-MEDICARE. You can also send a

leer o e plan o ell em you wan o disenroll. I you drop yourplan and wan o join anoer Medicare drug plan laer, you ave owai or an enrollmen period. You may ave o pay a lae enrollmenpenaly. See pages 78–79.

I your Medicare Advantage Plan includes prescription drug coverage and you join a Medicare Prescription Drug Plan,

you will be disenrolled rom your Medicare Advantage Planand returned to Original Medicare.

For more inormaion on joining, dropping, and swicing plans,read e ac see “Undersanding Medicare Enrollmen Periods” by

visiing p://go.usa.gov/lsi. You can also call 1-800-MEDICARE osee i a copy can be mailed o you.






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What You PayBelow and coninued on e nex page are descripions o e paymensyou make rougou e year in a Medicare drug plan. Your actual drug plan costs will vary depending on e prescripions you use, e plan youcoose, weer you go o a parmacy in your plan’s nework, weeryour drugs are on your plan’s ormulary (drug lis), and weer you geExra Help paying your Par D coss.

Monthly premium

Mos drug plans carge a monly ee a varies by plan. You pay is inaddiion o e Par B premium. I you belong o a Medicare AdvanagePlan (like an HMO or PPO) or a Medicare Cos Plan a includesMedicare prescripion drug coverage, e monly premium you pay o

your plan may include an amoun or prescripion drug coverage.

Note: Conac your drug plan (no Social Securiy) i you wan yourpremium deduced rom your monly Social Securiy paymen.Your rs deducion will usually ake 3 mons o sar, and 3 mons o premiums will likely be deduced a once. Aer a, only one premiumwill be deduced eac mon. You may also see a delay in premiumsbeing wield i you swic plans.

NEW—Saring January 1, 2011, your Par D monly premium could

be iger based on your income. Tis includes Par D coverage youge rom a Medicare Prescripion Drug Plan, or a Medicare AdvanagePlan or Medicare Cos Plan a includes Medicare prescripion drugcoverage. I your modied adjused gross income as repored on yourIRS ax reurn rom 2 years ago (e mos recen ax reurn inormaionprovided o Social Securiy by e IRS) is above a cerain amoun, youwill pay a iger monly premium. See page 134 or more inormaion.

Yearly deductible

Te amoun you mus pay beore your drug plan begins o pay is sareo your covered drugs. Some drug plans don’ ave a deducible.

Copayments or coinsurance

Amouns you pay a e parmacy or your covered prescripions aere deducible (i e plan as one). You pay your sare, and your drugplan pays is sare or covered drugs.


Blue words

in the text

are dened

on pages

127–130.

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What You Pay (continued)


Blue words

in the text

are dened

on pages

127–130.

Coverage gap

Mos Medicare drug plans ave a coverage gap (also called e “donu

ole”). Tis means a aer you and your drug plan ave spen a cerainamoun o money or covered drugs, you ave o pay all coss ou-o-pocke or your prescripions up o a yearly limi. No everyone willreac e coverage gap. Your yearly deducible, your coinsurance orcopaymens, and wa you pay in e coverage gap all coun oward isou-o-pocke limi. Te limi doesn’ include e drug plan premium youpay or wa you pay or drugs a aren’ covered.

Tere are plans a oer some coverage during e gap, like or genericdrugs. However, plans wi gap coverage may carge a iger monly premium. Ceck wi e drug plan rs o see i your drugs would becovered during e gap. For more inormaion, visip://go.usa.gov/loF o view e ac see “Bridging e Coverage Gap.”You can also call 1-800-MEDICARE (1-800-633-4227) o see i a copy can be mailed o you. Y users sould call 1-877-486-2048.

NEW—I you reac e coverage gap in 2010, (and you aren’ already geing Exra Help), you will ge a one-ime $250 rebae ceck o elp youwi your drug coss. For more inormaion, visi p://go.usa.gov/3Zq

o view e publicaion, “Closing e Prescripion Drug Coverage Gap.”

I you reac e coverage gap in 2011, you will ge a 50% discoun oncovered brand-name prescripion drugs a e ime you buy em. Terewill be addiional savings or you in e coverage gap eac year roug2020 wen you will ave ull coverage in e gap. alk o your docor oroer eal care provider o make sure a you’re aking e lowes cosdrug available a works or you.

Catastrophic coverage

Once you reac your plan’s ou-o-pocke limi, you auomaically ge“caasropic coverage.” Caasropic coverage assures a once you avespen up o your plan’s ou-o-pocke limi or covered drugs, you only pay a small coinsurance amoun or copaymen or e drug or e res oe year.

Note: I you ge Exra Help paying your drug coss, you won’ ave acoverage gap and will pay only a small or no copaymen once you reaccaasropic coverage. See pages 86–89.

http://go.usa.gov/loF

http://go.usa.gov/3Zq

http://go.usa.gov/3Zq

http://go.usa.gov/loF

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What You Pay (continued)

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. Smi payse rs $310 o er drug cossbeore er plansars o pay is

sare.

Ms. Smi pays acopaymen, and erplan pays is sareor eac covereddrug unil eir

combined amoun(plus e deducible)reaces $2,840.

Once Ms. Smi and erplan ave spen $2,840or covered drugs,se is in e coveragegap. In 2011, se ges

a 50% discoun oncovered brand-nameprescripion drugs acouns as ou-o-pockespending, and elps erge ou o e coveragegap.

Once Ms. Smias spen $4,550ou-o-pockeor e year, ercoverage gap ends.

Now se only pays asmall copaymen oreac drug unil eend o e year.


Call e plans you’re ineresed in o ge more deails.You can visi www.medicare.gov/nd-a-plan, or call1-800-MEDICARE (1-800-633-4227) o compare e cos o plans in your area. Y users sould call 1-877-486-2048.For elp comparing plan coss, conac your Sae HealInsurance Assisance Program (SHIP). See pages 123–126 ore elepone number.

Te example below sows coss or covered drugs in 2011 or a plana as a coverage gap.

Ms. Smith joins the ABC Prescription Drug Plan. Her coveragebegins on January 1, 2011. She doesn’t get Extra Help anduses her Medicare drug plan membership card when shebuys prescriptions.



8/6/2019 Medicare 2011


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What is the Part D Late Enrollment Penalty?Te lae enrollmen penaly is an amoun a is added o yourPar D premium. You may owe a lae enrollmen penaly i one o eollowing is rue:

You didn’ join a Medicare drug plan wen you were rs eligible■or Medicare, and you didn’ ave oer crediable prescripiondrug coverage.

You didn’ ave Medicare prescripion drug coverage or oer■crediable prescripion drug coverage or 63 days or more in a row.

Note: I you ge Exra Help, you don’ pay a lae enrollmen penaly.

Here are a ew ways o avoid paying a penaly:

Join a Medicare drug plan when you’re rst eligible.■ You won’ave o pay a penaly, even i you’ve never ad prescripion drugcoverage beore.

Don’t go 63 days or more in a row without a Medicare drug ■plan or other creditable coverage. Crediable prescripion drugcoverage could include drug coverage rom a curren or ormeremployer or union, RICARE, Indian Heal Service, Deparmeno Veerans Aairs, or eal insurance coverage. Your plan willell you eac year i your drug coverage is crediable coverage.

Tis inormaion may be sen o you in a leer or included in anewsleer rom e plan. Keep is inormaion, because you may need i i you join a Medicare drug plan laer.

ell your plan about any drug coverage you had■i they ask about it. Wen you join a plan, and ey believe you wen a leas 63 days in a row wiou oercrediable prescripion drug coverage, ey will send youa leer. Te leer will include a orm asking abou any drug coverage you ad. Complee e orm. I you don’

ell e plan abou your crediable coverage, you may ave o pay a penaly.


Blue words

in the text

are dened

on pages127–130.

8/6/2019 Medicare 2011


79

How Much More Will You Pay?Te cos o e lae enrollmen penaly depends on ow long youdidn’ ave crediable prescripion drug coverage. Currenly, elae enrollmen penaly is calculaed by muliplying 1% o e“naional base beneciary premium” ($32.34 in 2011) imes enumber o ull, uncovered mons a you were eligible bu didn’

join a Medicare drug plan and wen wiou oer crediableprescripion drug coverage. Te nal amoun is rounded o eneares $.10 and added o your monly premium. Since e“naional base beneciary premium” may increase eac year, epenaly amoun may also increase every year. You may ave o pay is penaly or as long as you ave a Medicare drug plan.

Example: Mrs. Jones didn’ join wen se was rs eligible—by May 15, 2006. Se joined a Medicare drug plan beweenNovember 15—December 31, 2009, or an eecive dae o January 1, 2010. Since Mrs. Jones didn’ join wen se was rseligible and wen wiou oer crediable drug coverage or43 mons (June 2007–December 2010), se will be carged amonly penaly o $13.90 in 2011 ($32.34 x.01 = $.3234 x 43= $13.90) in addiion o er plan’s monly premium.

Wen you join a Medicare drug plan, e plan will ell you i youowe a penaly, and wa your premium will be.

I You Don’t Agree With Your PenaltyI you don’ agree wi your lae enrollmen penaly, you may beable o ask Medicare or a review or reconsideraion. You willneed o ll ou a reconsideraion reques orm (a your Medicaredrug plan will send you), and you will ave e cance o provide

proo a suppors your case suc as inormaion abou previousprescripion drug coverage. I you need elp, call your Medicaredrug plan.


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80

Important Drug Coverage RulesTe ollowing inormaion can elp answer common quesions as youbegin o use your coverage.

To Fill a Prescription Beore You Get Your Membership Card

You sould ge a welcome package wi your membersip card wiin5 weeks or sooner aer e plan ges your compleed applicaion. I youneed o go o e parmacy beore your membersip card arrives, youcan use any o e ollowing as proo o membersip:

A leer rom e plan a includes your complee membersip■inormaion.

An enrollmen conrmaion number a you go rom e plan,■

e plan name, and elepone number.A emporary card a you may be able o prin rom■MyMedicare.gov. Visi www.MyMedicare.gov , or see page 118.

I you don’ ave any o e iems lised above, and your parmaciscan’ ge your drug plan inormaion any oer way, you may ave opay ou-o-pocke or your prescripions. I you do, save the receiptsand contact your plan to get your money back.

I you qualiy or Exra Help, see pages 88–89 or more inormaion

abou wa you can use as proo o Exra Help.What’s Covered?

Inormaion abou a plan’s lis o covered drugs (called a ormulary ) isn’included in is andbook because eac plan as is own ormulary.Many Medicare drug plans place drugs ino dieren “iers” on eirormularies. Drugs in eac ier ave a dieren cos. For example, a drugin a lower ier will generally cos you less an a drug in a iger ier. Insome cases, i your drug is on a iger ier and your prescriber inksyou need a drug insead o a similar drug on a lower ier, you can lean excepion o ask your plan or a lower copaymen.

Conac e plan or is curren ormulary, or visi e plan’s Websie. Visi www.medicare.gov/nd-a-plan, or call 1-800-MEDICARE(1-800-633-4227) o ge elepone numbers or e plans in your area.Y users sould call 1-877-486-2048.

Note: Medicare drug plans mus cover all commercially-available vaccines (like e singles vaccine) wen medically necessary o preven

illness excep or vaccines covered under Par B. See pages 36 and 40.






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81Section 2—Your Medicare Choices Medicare Prescription Drug Coverage

Important Drug Coverage Rules (continued)

Blue words

in the text

are dened

on pages

127–130.

Plans may have the ollowing coverage rules:

Prior authorization■ —You and/or your prescriber (your docor

or oer eal care provider wo is legally allowed o wrieprescripions) mus conac e drug plan beore you can llcerain prescripions. Your prescriber may need o sow a edrug is medically necessary or e plan o cover i.

Quantity limits■ —Limis on ow muc medicaion you can ge aa ime.

Step therapy ■ —You mus ry one or more similar, lower cos drugsbeore e plan will cover e prescribed drug.

I you or your prescriber believes that one o these coverage rulesshould be waived, you can ask or an exception. See pages 98–100.

In mos cases, e prescripion drugs (someimes called “sel adminisered drugs” or drugs you would normally ake onyour own) you ge in an oupaien seing like an emergency deparmen or during observaion services aren’ coveredby Par B. Your Medicare drug plan may cover ese drugsunder certain circumstances. You will likely need o pay ou-o-pocke or ese drugs and submi a claim o your drugplan or a reund. Or, i you ge a bill or sel-adminisereddrugs you go in a docor’s oce, call your Medicare drug plan(Par D) or more inormaion. You can also visip://go.usa.gov/lo6 o view e ac see, “How MedicareCovers Sel-Adminisered Drugs Given in HospialOupaien Seings.” You can also call 1-800-MEDICARE(1-800-633-4227) o see i a copy can be mailed o you.

Y users sould call 1-877-486-2048.

http://go.usa.gov/lo6

http://go.usa.gov/lo6

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82 Section 2—Your Medicare Choices Medicare Prescription Drug Coverage

Other Private InsuranceTe cars on e nex wo pages provide inormaion abou ow oerinsurance you ave works wi, or is aeced by, Medicare prescripiondrug coverage (Par D).

Employer or Union Health Coverage—Heal coverage rom your,your spouse’s, or oer amily member’s curren or ormer employer orunion. I you ave prescripion drug coverage based on your curren orprevious employmen, your employer or union will noiy you eac yearo le you know i your prescripion drug coverage is crediable. Keepthe inormation you get. Call your benes adminisraor or moreinormaion beore making any canges o your coverage. Note: I you join a Medicare drug plan, you, your spouse, or your dependans may lose your employer or union eal coverage.

COBRA—A Federal law a may allow you o emporarily keepemployer or union eal coverage aer e employmen ends or aeryou lose coverage as a dependan o e covered employee. As explainedon page 22, ere may be reasons wy you sould ake Par B insead o,or in addiion o, COBRA. However, i you ake COBRA and i includescrediable prescripion drug coverage, you will ave a special enrollmenperiod o join a Medicare drug plan wiou paying a penaly wen e

COBRA coverage ends. alk wi your Sae Heal Insurance AssisanceProgram (SHIP) o see i COBRA is a good coice or you. See pages123–126 or e elepone number.

Medigap (Medicare Supplement Insurance) Policy with PrescriptionDrug Coverage—Medigap policies can no longer be sold wiprescripion drug coverage, bu i you ave drug coverage under a currenMedigap policy, you can keep i. However, i may be o your advanageo join a Medicare drug plan because mos Medigap drug coverage isn’

crediable. I you join a Medicare drug plan, your Medigap insurancecompany mus remove e prescripion drug coverage under yourMedigap policy and adjus your premiums. Call your Medigap insurancecompany or more inormaion.

Note: Keep any crediable prescripion drug coverage inormaion you gerom your plan. You may need i i you decide o join a Medicare drug planlaer. Don’ send crediable coverage leers/cericaes o Medicare.

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83

Other Government InsuranceTe ypes o insurance lised on is page are all considered crediableprescripion drug coverage. I you ave one o ese ypes o insurance, inmos cases, i will be o your advanage o keep your curren coverage.

Federal Employee Health Benets (FEHB) Program—Heal coverage orcurren and reired Federal employees and covered amily members. FEHBplans usually include prescripion drug coverage, so you don’ need o join aMedicare drug plan. However, i you do decide o join a Medicare drug plan,you can keep your FEHB plan, and your plan will le you know wo paysrs. For more inormaion, conac e Oce o Personnel Managemena 1-888-767-6738, or visi www.opm.gov/insure. Y users sould call1-800-878-5707. You can also call your plan i you ave quesions.

Veterans’ Benets—Heal coverage or veerans and people wo aveserved in e U.S. miliary. You may be able o ge prescripion drug coverageroug e U.S. Deparmen o Veerans Aairs (VA) program. You may joina Medicare drug plan, bu i you do, you can’ use bo ypes o coverage ore same prescripion a e same ime. For more inormaion, call e VA a1-800-827-1000, or visi www.va.gov . Y users sould call 1-800-829-4833.

RICARE (Military Health Benets)—Heal care plan or acive-duy service members, reirees, and eir amilies. Most people with RICAREwho are entitled to Part A must have Part B to keep RICARE prescriptiondrug benets. I you ave RICARE, you don’ need o join a MedicarePrescripion Drug Plan. However, i you do, your Medicare drug plan paysrs, and RICARE pays second. I you join a Medicare Advanage Plan wiprescripion drug coverage, your Medicare Advanage Plan and RICARE may coordinae eir benes i your Medicare Advanage Plan nework parmacy isalso a RICARE nework parmacy. For more inormaion, call e RICAREParmacy Program a 1-877-363-1303, or visi www.ricare.mil/mybene.Y users sould call 1-877-540-6261.

Indian Health Services—Heal care services or American Indians and AlaskaNaives. Many Indian eal aciliies paricipae in e Medicare prescripiondrug program. I you ge prescripion drugs roug an Indian eal aciliy,you will coninue o ge drugs a no cos o you and your coverage won’ beinerruped. Joining a Medicare drug plan may elp your Indian eal aciliy because e drug plan pays e Indian eal aciliy or e cos o yourprescripions. alk o your local Indian eal benes coordinaor wo canelp you coose a plan a mees your needs and ell you ow Medicare workswi e Indian eal care sysem.


Blue words

in the text

are dened

on pages

127–130.


http://www.va.gov/



http://www.va.gov/


8/6/2019 Medicare 2011



How Other Insurance Works with MedicareWen you ave oer insurance (like employer group eal coverage), ereare rules a decide weer Medicare or your oer insurance pays rs. Teinsurance a pays rs is called e “primary payer” and pays up o e limis o

is coverage. Te one a pays second, called e “secondary payer,” only pays i ere are coss le uncovered by e primary coverage. Te secondary payer may no pay all o e uncovered coss.

Tese rules apply or employer or union group eal plan coverage:

I you ave■ retiree coverage, Medicare pays rs.

I your group eal plan coverage is based on your or a amily member’s■current employment, wo pays rs depends on your age, e size o eemployer, and weer you ave Medicare based on age, disabiliy, or End-SageRenal Disease (ESRD):

— I you’re under 65 and disabled and you or your amily member is sillworking, your plan pays rs i e employer as 100 or more employeesor a leas one employer in a muliple employer plan as more an 100employees.

— I you’re over 65 and you or your spouse is sill working, e plan paysrs i e employer as 20 or more employees or a leas one employerin a muliple employer plan as more an 20 employees.

I you ave Medicare because o ESRD, your group eal plan will pay rs or■

e rs 30 mons aer you become eligible or Medicare.Tese ypes o coverage usually pay rs or services relaed o eac ype:

No-aul insurance (including auomobile insurance)■

Liabiliy (including auomobile insurance)■

Black lung benes■

Workers’ compensaion■

Medicaid and RICARE never pay rst or Medicare-covered services. Tey only pay aer Medicare, employer group eal plans, and/or Medigap ave paid.

For more inormaion, view e bookle “Medicare and Oer Heal Benes:Your Guide o Wo Pays Firs” by visiing p://go.usa.gov/loH. You can also call1-800-MEDICARE (1-800-633-4227). Y users sould call 1-877-486-2048.

I you ave oer insurance, ell your docor, ospial, and parmacy. I youave quesions abou wo pays rs, or you need o updae your oerinsurance inormaion, call Medicare’s Coordinaion o Benes Conracor a1-800-999-1118. Y users sould call 1-800-318-8782. You may need o giveyour Medicare number o your oer insurers (once you ave conrmed eirideniy) so your bills are paid correcly and on ime.

http://go.usa.gov/loH

http://go.usa.gov/loH

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85

SECTION 3

Get Help PayingYour Health and

Prescription

Drug Costs


Exra Help Paying or Medicare PrescripionDrug Coverage (Par D) . . . . . . . . . . . . . . . . . . . . . 86

Medicare Savings Programs . . . . . . . . . . . . . . . . . . . . 90

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Sae Parmacy Assisance Programs (SPAPs) . . . . . . . . . . 91

Programs o All-inclusive Care or e Elderly (PACE) . . . . . 92

Supplemenal Securiy Income (SSI) Benes . . . . . . . . . . 92

Programs or People Wo Live in e U.S. erriories . . . . . . 92

Cildren’s Heal Insurance Program . . . . . . . . . . . . . . . 92

Keep all inormaion you ge rom Medicare, Social Securiy,

your Medicare eal or prescripion drug plan, Medigapinsurer, or employer or union. Tis may include noiceso award or denial, Annual Noices o Cange, noices o crediable prescripion drug coverage, or Medicare Summary Noices. You may need ese documens o apply or eprograms explained in is secion. Also keep copies o any applicaions you submi.

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86 Section 3—Get Help Paying Your Health and Prescription Drug Costs

Programs or People with Limited Income and

ResourcesI you ave limied income and resources, you mig qualiy or elp o

pay or some eal care and prescripion drug coss.Te U.S. Virgin Islands, Guam, American Samoa, e Commonwealo Puero Rico, and e Commonweal o Norern Mariana Islandsprovide eir residens elp wi Medicare drug coss. Tis elp isn’ esame as e Exra Help described below. See page 92 or more inormaion.

Extra Help Paying or Medicare Prescription Drug

Coverage (Part D)

You may qualiy or Exra Help, also called e low-income subsidy (LIS),rom Medicare o pay prescripion drug coss i your yearly income andresources are below e ollowing limis in 2010:

Single person—Income less an $16,245 and resources less an $12,510■

Married person living wi a spouse and no oer dependans—Income■less an $21,855 and resources less an $25,010

Tese amouns may cange in 2011. You may qualiy even i you ave aiger income (like i you sill work, or i you live in Alaska or Hawaii, or

ave dependans living wi you). Resources include money in a ceckingor savings accoun, socks, and bonds. Resources don’t include your ome,car, ouseold iems, burial plo, up o $1,500 or burial expenses (perperson), or lie insurance policies.

I you qualiy or Exra Help and join a Medicare drug plan, you will gee ollowing:

Help paying your Medicare drug plan’s monly ■ premium, any yearly deducible, coinsurance, and copaymens

No coverage gap■

No lae enrollmen penaly ■

You automatically qualiy or Exra Help i you ave Medicare and meeone o ese condiions:

You ave ull Medicaid coverage.■

You ge elp rom your sae Medicaid program paying your Par B■premiums (in a Medicare Savings Program).

You ge Supplemenal Securiy Income (SSI) benes.■

Blue words

in the text

are dened

on pages

127–130.

8/6/2019 Medicare 2011


87Section 3—Get Help Paying Your Health and Prescription Drug Costs

Extra Help Paying or Medicare Prescription

Drug Coverage (Part D) (continued)o le you know you auomaically qualiy or Exra Help, Medicare

will mail you a purple leer a you sould keep or your records.You don’ need o apply or Exra Help i you ge is leer.

I you aren’ already in a Medicare drug plan, you mus join one o■ge is Exra Help.

I you don’ join a Medicare drug plan, Medicare may enroll■you in one. I Medicare enrolls you in a plan, Medicare willsend you a yellow or green leer leing you know wen yourcoverage begins.

Dieren plans cover dieren drugs. Ceck o see i e plan you■

are enrolled in covers e drugs you use and i you can go o eparmacies you wan. Compare wi oer plans in your area.

I you’re geing Exra Help, you can swic o anoer Medicare■drug plan anyime. Your coverage will be eecive e rs day o e nex mon.

I you ave Medicaid and live in cerain■ insiuions (like a nursing ome), you pay noing or your coveredprescripion drugs.

I you don’ wan o join a Medicare drug plan (or example,because you wan only your employer or union coverage),call e plan lised in your leer, or call 1-800-MEDICARE(1-800-633-4227). Y users sould call 1-877-486-2048.ell em you don’ wan o be in a Medicare drug plan (youwan o “op ou”). I you coninue o qualiy or Exra Help or i your employer or union coverage is crediable prescripion drugcoverage, you won’ pay a penaly i you join laer.

I you ave employer or union coverage and you join aMedicare drug plan, you may lose your employer or uniondrug, and possibly eal coverage even i you qualiy orExra Help. Your dependans may also lose eir coverage. Callyour employer’s benes adminisraor or more inormaionbeore you join.

8/6/2019 Medicare 2011




Drug Coverage (Part D) (continued)

Blue words

in the text

are dened

on pages

127–130.

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

Visi■ www.socialsecuriy.gov o apply online.Call Social Securiy a 1-800-772-1213 o apply by pone or o ge■a paper applicaion. Y users sould call 1-800-325-0778.

Visi your Sae Medical Assisance (Medicaid) oce. Call■1-800-MEDICARE (1-800-633-4227), and say “Medicaid” o gee elepone number, or visi www.medicare.gov . Y userssould call 1-877-486-2048.

Note: You can apply or Exra Help a anyime. Wi your consen,

Social Securiy will orward inormaion o your sae o sar anapplicaion or a Medicare Savings Program. See page 90.

Drug coss in 2011 or mos people wo qualiy will be nomore an $2.50 or eac generic drug and $6.30 or eacbrand-name drug. Look on e Exra Help leers you ge, orconac your plan o nd ou your exac coss.

o ge answers o your quesions abou Exra Help and elp

coosing a plan, call your Sae Heal Insurance AssisanceProgram (SHIP). See pages 123–126 or e elepone number. Youcan also call 1-800-MEDICARE.

Paying the Right Amount

Medicare ges inormaion rom your sae or Social Securiy aells weer you qualiy or Exra Help. I Medicare doesn’ avee rig inormaion, you may be paying e wrong amoun oryour prescripion drug coverage.

I you auomaically qualiy or Exra Help, you can sow yourdrug plan e purple, yellow, or green leer you go rom Medicareas proo a you qualiy. I you applied or Exra Help, you cansow your “Noice o Award” rom Social Securiy as proo ayou qualiy.





8/6/2019 Medicare 2011




Drug Coverage (Part D) (continued)

Paying the Right Amount (continued)

You can also give your plan any o e ollowing documens (alsocalled “Bes Available Evidence”) as proo a you qualiy or ExraHelp. Your plan mus accep ese documens. Eac iem lisedbelow mus sow a you were eligible or Medicaid during amon aer June 2010.

Proo You Have Medicaid and

Live in an Institution

Other Proo You Have Medicaid

A bill rom e■ insiuion (likea nursing ome) or a copy o asae documen sowing Medicaidpaymen o e insiuion or aleas a mon

A prin-ou rom your sae’s■Medicaid sysems sowing a youlived in e insiuion or a leasa mon

A copy o your Medicaid card (i ■you ave one)

A copy o a sae documen a■sows you ave Medicaid

A prin-ou rom a sae elecronic■enrollmen le or rom your sae’sMedicaid sysems a sows youave Medicaid

Any oer documen rom your■ sae a sows you ave Medicaid

I you aren’ already enrolled in a Medicare drug plan and paidor prescripions since you qualied or Exra Help, you may beable o ge back par o wa you paid. Keep your receipts, andcall Medicare’s Limied Income Newly Eligible ransiion (NE)Program a 1-800-783-1307 or more inormaion. Y userssould call 1-877-801-0369.

For more inormaion, visi p://go.usa.gov/loo o view e acsee “Are You Paying e Rig Amoun or Your Prescripions?”You can also call 1-800-MEDICARE (1-800-633-4227) o see i acopy can be mailed o you. Y users sould call 1-877-486-2048.

http://go.usa.gov/loo

http://go.usa.gov/loo

8/6/2019 Medicare 2011



Medicare Savings Programs (Help with

Medicare Costs)Saes ave programs a pay Medicare premiums and, in some

cases, may also pay Par A and Par B deducibles, coinsurance, andcopaymens. Tese programs elp people wi Medicare save money eac year.

o qualiy or a Medicare Savings Program, you mus mee all o ese condiions:

Have Par A■

Have monly income less an $1,239 and resources less an■$6,600—single person

Have monly income less an $1,660 and resources less an■$9,910—married and living ogeer

Note: Tese amouns may cange eac year. Many saes gureyour income and resources dierenly, so you may qualiy inyour sae even i your income or resources are iger. Resourcesinclude money in a cecking or savings accoun, socks, and bonds.Resources don’ include your ome, car, burial plo, burial expensesup o your sae’s limi, urniure, or oer ouseold iems.

For More InormationCall or visi your Sae Medical Assisance (Medicaid) oce, and■ask or inormaion on Medicare Savings Programs. Te names o ese programs and ow ey work may vary by sae. Call i youink you qualiy or any o ese programs, even i you aren’ sure.

Call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid”■o ge e elepone number or your sae. Y users sould call1-877-486-2048.

Visi■ p://go.usa.gov/loA o view e brocure, “Ge HelpWi Your Medicare Coss: Geing Sared.” You can also call1-800-MEDICARE o see i a copy can be mailed o you.

Conac your Sae Heal Insurance Assisance Program (SHIP)■or ree eal insurance counseling. See pages 123–126 or eelepone number.


are dened

on pages

127–130.

http://go.usa.gov/loA

http://go.usa.gov/loA

8/6/2019 Medicare 2011



MedicaidMedicaid is a join Federal and sae program a elps pay medicalcoss i you ave limied income and resources and mee oereligibiliy requiremens. Some people qualiy or bo Medicare andMedicaid. Tese people are also called “dual eligibles.”

I you ave Medicare and ull Medicaid coverage, mos o your■eal care coss are covered. You ave e opion o OriginalMedicare or a Medicare Advanage Plan (like an HMO or PPO) oryour Medicare coverage.

I you ave Medicare and Medicaid, Medicare provides you wi■prescripion drug coverage insead o Medicaid. Medicaid may sillcover some drugs and oer care Medicare doesn’ cover.

People wi Medicaid may ge coverage or services a Medicare■doesn’ ully cover, suc as nursing ome and ome eal care.

Medicaid programs vary rom sae o sae. Tey may also ave■dieren names, suc as “Medical Assisance” or “Medi-Cal.”

Eac sae as dieren Medicaid eligibiliy income and resource■limis and oer eligibiliy requiremens.

In some saes, you may need Medicare o be eligible or Medicaid.■

Call your Sae Medical Assisance (Medicaid) oce or more■inormaion and o see i you qualiy. Call 1-800-MEDICARE(1-800-633-4227) and say “Medicaid” o ge e elepone numberor your Sae Medical Assisance (Medicaid) oce. Y userssould call 1-877-486-2048. You can also visi www.medicare.gov .

State Pharmacy Assistance Programs (SPAPs)Many saes ave Sae Parmacy Assisance Programs (SPAPs)a elp cerain people pay or prescripion drugs based onnancial need, age, or medical condiion. Eac SPAP makes is

own rules abou ow o provide drug coverage o is members.Depending on your sae, e SPAP will elp you in dieren ways.o nd ou abou e SPAP in your sae, call your Sae HealInsurance Assisance Program (SHIP). See pages 123–126 or eelepone number.



8/6/2019 Medicare 2011



Programs o All‑Inclusive Care or the Elderly (PACE)PACE is a Medicare and Medicaid program oered in many saes aallows people wo need a nursing ome-level o care o remain in ecommuniy. See page 71 or more inormaion.

Supplemental Security Income (SSI) BenetsSSI is a cas bene paid by Social Securiy o people wi limied incomeand resources wo are disabled, blind, or 65 or older. SSI benes elppeople mee basic needs or ood, cloing, and seler. SSI benes aren’e same as Social Securiy benes.

You can visi www.socialsecuriy.gov , and use e “Bene Eligibiliy Screening ool” o nd ou i you may be eligible or SSI or oer

benes. Call Social Securiy a 1-800-772-1213, or conac your localSocial Securiy oce or more inormaion. Y users sould call1-800-325-0778.

Note: People wo live in Puero Rico, e Virgin Islands, Guam, orAmerican Samoa can’ ge SSI.

Programs or People Who Live in the U.S. TerritoriesTere are programs in Puero Rico, e Virgin Islands, Guam, eNorern Mariana Islands, and American Samoa o elp people wilimied income and resources pay eir Medicare coss. Programs vary inese areas. Call your local Medical Assisance (Medicaid) oce o ndou more abou eir rules, or call 1-800-MEDICARE (1-800-633-4227)and say “Medicaid” or more inormaion. Y users sould call1-877-486-2048. You can also visi www.medicare.gov .

Children’s Health Insurance ProgramDo you ave cildren or grandcildren wo need eal insurance? Te

Cildren’s Heal Insurance Program provides low cos eal insurancecoverage o cildren in amilies wo earn oo muc income o qualiy orMedicaid bu can’ aord privae eal insurance.

In many saes, uninsured cildren 18 and younger, wose amilies earnup o $44,100 a year (or a amily o our) are eligible or ree or low-coseal insurance a pays or docor visis, denal care, prescripiondrugs, ospializaions, and muc more. Pregnan women and oeraduls may also be eligible or coverage. Eac sae as is own program,wi is own eligibiliy rules. Call 1-877-KIDS-NOW (1-877-543-7669),

or visi www.insurekidsnow.gov o learn more.

Blue words


on pages

127–130.



http://www.insurekidsnow.gov/

http://www.insurekidsnow.gov/



8/6/2019 Medicare 2011


93

SECTION 4

Protecting

Yoursel

and Medicare


Your Medicare Rigs . . . . . . . . . . . . . . . . . . . . . . . . 94

Your Rigs i Your Plan Sops Paricipaing in Medicare . . . . 94

Wa is an Appeal? . . . . . . . . . . . . . . . . . . . . . . . . . 95

Advance Beneciary Noice (ABN) . . . . . . . . . . . . . . . 101

How Medicare Uses Your Personal Inormaion . . . . . . . . 102

Proec Yoursel rom Ideniy Te . . . . . . . . . . . . . . . 104

Te Senior Medicare Parol (SMP) Program Can Help You . . 105

Proec Yoursel and Medicare rom Fraud . . . . . . . . . . . 105

How Medicare Proecs You . . . . . . . . . . . . . . . . . . . 107

Te Medicare Beneciary Ombudsman . . . . . . . . . . . . . 108

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94 Section 4—Protecting Yoursel and Medicare

Your Medicare RightsNo maer wa ype o Medicare coverage you ave, you avecerain guaraneed rigs. As a person wi Medicare, you ave erig o all o e ollowing:

Be reaed wi digniy and respec a all imes■

Be proeced rom discriminaion■

Have access o docors, specialiss, and ospials■

Have your quesions abou Medicare answered■

Learn abou all o your reamen coices and paricipae in■reamen decisions

Ge inormaion in a way you undersand rom Medicare, eal■care providers, and, under cerain circumsances, conracors

Ge emergency care wen and were you need i■

Ge a decision abou eal care paymen or services, or■prescripion drug coverage

Ge a review (appeal) o cerain decisions abou eal care■paymen, coverage o services, or prescripion drug coverage

File complains (someimes called grievances), including■complains abou e qualiy o your care

Have your personal and eal inormaion kep privae■

Your Rights i Your Plan Stops Participating in

MedicareMedicare eal and prescripion drug plans can decide no oparicipae in Medicare or e coming year. Plans a coose oleave e Medicare Program enirely or in cerain areas are said obe “non-renewing.” In ese cases, e plan will send you a leerabou your opions, and you will ave e rig o join anoer

Medicare plan.I you wan o coninue o ave Medicare prescripion drugcoverage (Par D) or a Medicare Advanage Plan (like an HMO orPPO), you need o join a new plan or e coming year. You sould

join a new Medicare plan by December 31s o make sure you avecoverage as o January 1. I you don’ join a plan by December 31s,you will coninue o ave Medicare coverage (roug OriginalMedicare only) as o January 1.

Blue words

in the text

are dened

on pages

127–130.

8/6/2019 Medicare 2011


95Section 4—Protecting Yoursel and Medicare

Your Rights i Your Plan Stops Participating in

Medicare (continued)Your Medicare plan will send you a leer abou your opions.

You will ave rom Ocober 1, 2010, unil January 31, 2011, ocoose and join a new Medicare plan.

Generally, i you’re in a Medicare Advanage Plan, you will■auomaically reurn o Original Medicare i you don’ cooseo join anoer Medicare Advanage Plan. You will also ave erig o buy cerain Medigap policies. I you reurn o OriginalMedicare, you can also join a Medicare Prescripion Drug Plan.

I you’re in a Medicare Prescripion Drug Plan, you will ave■e rig o join anoer Medicare Prescripion Drug Plan or a

Medicare Advanage Plan wi drug coverage. I you don’ join anew plan, you won’ ave Medicare prescripion drug coverage(Par D).

What is an Appeal?An appeal is e acion you can ake i you disagree wi acoverage or paymen decision made by Medicare or your Medicareplan. You can appeal i Medicare or your plan denies one o eollowing:

A reques or a eal care service, supply, or prescripion a■you ink you sould be able o ge

A reques or paymen or eal care services or supplies or a■prescripion drug you already go a was denied

A reques o cange e amoun you mus pay or a■prescripion drug

You can also appeal i Medicare or your plan sops providing orpaying or all or part o an iem or service you ink you sill need.

I you decide o le an appeal, ask your docor or oer eal careprovider or supplier or any inormaion a may elp your case.

8/6/2019 Medicare 2011



How to File an AppealHow you le an appeal depends on e ype o Medicare coverageyou ave:

I you ave Original Medicare, do e ollowing o le an appeal:■Ge e Medicare Summary Noice (MSN) a sows e iem1.or service you’re appealing. Your MSN is e saemen you geevery 3 mons a liss all e services billed o Medicare andells you i Medicare paid or e services. See pages 52–53.

Circle e iem(s) you disagree wi on e MSN, and wrie an2.explanaion on e MSN o wy you disagree.

Sign, wrie your elepone number, and provide your Medicare3.number on e MSN. Keep a copy or your records.

Send e MSN, or a copy, o e Medicare conracor’s4.address lised on e MSN. You can also send any addiionalinormaion you may ave abou your appeal.

You mus le e appeal wiin 120 days o e dae you ge e5.MSN. I you wan o le an appeal, read your MSN careully,and ollow e insrucions on e back. Or, use CMS Form20027, and le i wi e Medicare conracor a e addresslised on e MSN. o view or prin is orm, visiwww.medicare.gov/medicareonlineorms, or call1-800-MEDICARE (1-800-633-4227) or a copy. Y userssould call 1-877-486-2048.

You will generally ge a decision rom e Medicare conracor(eier in a leer or a Medicare Summary Noice) wiin60 days aer ey ge your reques.

I you ave a■ Medicare eal plan, learn ow o le an appealby looking a e maerials your plan sends you eac year, callingyour plan, or visiing p://go.usa.gov/low o view e bookle,“Your Medicare Rigs and Proecions.” You can also call1-800-MEDICARE o see i a copy can be mailed o you.

I you ave a Medicare Prescripion Drug Plan, look a your plan■maerials, call your plan, or look on pages 98–100 o learn ow o lean appeal.

You can also le a as appeal in some cases. See page 97.

Conac your Sae Heal Insurance Assisance Program (SHIP) i you

need elp ling an appeal. See pages 123–126 or e elepone number.

Blue words

in the text

are dened

on pages

127–130.


http://go.usa.gov/low



8/6/2019 Medicare 2011



Your Right to a Fast AppealI you’re geing Medicare services rom a ospial, skillednursing aciliy, ome eal agency, compreensive oupaienreabiliaion aciliy, or ospice, and you ink yourMedicare-covered services are ending oo soon, you ave erig o a as appeal. Your provider will give you a noice beoreyour services end a will ell you ow o ask or a as appeal.You sould read is noice careully. I you don’ ge is noice,ask your provider or i. Wi a as appeal, an independenreviewer, called a Qualiy Improvemen Organizaion (QIO), willdecide i your services sould coninue.

You may ask your docor or any inormaion a may elp your■

case i you decide o le a as appeal.You mus call your local QIO o reques a as appeal no laer an■e ime sown on e noice you ge rom your provider. Use eelepone number or your local QIO lised on your noice.

I you miss e deadline, you sill ave appeal rigs:■

— I you ave Original Medicare, call your local QIO.

— I you’re in a Medicare eal plan, call your plan. Look inyour plan maerials o ge e elepone number.

Call 1-800-MEDICARE (1-800-633-4227) o ge e eleponenumber or e QIO in your sae, or visi www.medicare.gov .Y users sould call 1-877-486-2048.



8/6/2019 Medicare 2011



Appealing Your Medicare Drug Plan’s DecisionsI you ave Medicare prescripion drug coverage (Par D), you avee rig o do all o e ollowing (even beore you buy a ceraindrug):

Ge a wrien explanaion (called a “coverage deerminaion”) rom■your Medicare drug plan. A coverage deerminaion is e rsdecision made by your Medicare drug plan (no e parmacy)abou your benes, including weer a cerain drug is covered,weer you’ve me e requiremens o ge a requesed drug, owmuc you pay or a drug, and weer o make an excepion o aplan rule wen you reques i.

Ask or an excepion i you or your prescriber (your docor or oer■

eal care provider wo is legally allowed o wrie prescripions)believes you need a drug a isn’ on your plan’s ormulary.

Ask or an excepion i you or your prescriber believes a a■coverage rule (suc as prior auorizaion) sould be waived.

Ask or an excepion i you ink you sould pay less or a iger■ier (more expensive) drug because you or your prescriber believesyou can’ ake any o e lower ier (less expensive) drugs or esame condiion.

You or your prescriber mus conac your plan o ask or a coveragedeerminaion or an excepion. I your nework parmacy can’ ll aprescripion, e parmacis will sow you a noice a explains owo conac your Medicare drug plan so you can make your reques.I e parmacis doesn’ sow you is noice, ask o see i.

8/6/2019 Medicare 2011



Appealing Your Medicare Drug Plan’s Decisions

(continued)You or your prescriber may make a sandard reques by pone or in

wriing, i you’re asking or prescripion drug benes you aven’received ye. I you’re asking o ge paid back or prescripion drugsyou already boug, you or your prescriber mus make e sandardreques in wriing.

You or your prescriber can call or wrie your plan or an expedied(as) reques. Your reques will be expedied i you aven’ receivede prescripion and your plan deermines, or your prescriber ellsyour plan, a your lie or eal may be a risk by waiing.

I you’re requesting an exception, your prescriber mustprovide a statement explaining the medical reason why theexception should be approved.

I you disagree wi your Medicare drug plan’s coveragedeerminaion or excepion decision, you can appeal. Tere are velevels o appeal. Te rs level is appealing o your plan. Once yourMedicare drug plan ges your appeal, i as 7 days (or a sandard

appeal) or 72 ours (or an expedied appeal) o noiy you o isdecision. I you disagree wi e plan’s decision, you can ask or anindependen review o your case. Te noice you ge wi e plan’sdecision will explain e nex level o appeal.

8/6/2019 Medicare 2011



Appealing Your Medicare Drug Plan’s Decisions

(continued)You can ge elp ling an appeal rom your Sae Heal

Insurance Assisance Program (SHIP). See pages 123–126 or eelepone number.

I your plan doesn’ respond o your reques or a coveragedeerminaion, an excepion, or an appeal, you can le acomplain (also called a grievance). You can also call your planor 1-800-MEDICARE (1-800-633-4227). Y users sould call1-877-486-2048.

For more inormaion abou your rigs and e dieren levels o

appeal, visi p://go.usa.gov/igx o view e bookle “Your Guide oMedicare Prescripion Drug Coverage,” or call 1-800-MEDICARE osee i a copy can be mailed o you.

http://go.usa.gov/igx

http://go.usa.gov/igx

8/6/2019 Medicare 2011



Advance Beneciary Notice (ABN)I you ave Original Medicare, your eal care provider orsupplier may give you a noice called an “Advance Beneciary Noice o Noncoverage” (ABN).

Tis noice says Medicare probably (or cerainly) won’ pay or■some services in cerain siuaions.

You will be asked o coose weer o ge e iems or services■lised on e ABN.

I you coose o ge e iems or services lised on e ABN, you■will ave o pay i Medicare doesn’.

You will be asked o sign e ABN o say a you ave read and■undersood i.

An ABN isn’ an ocial denial o coverage by Medicare.■You could coose o ge e iems lised on e ABN and sillask your eal care provider or supplier o submi e bill oMedicare or anoer insurer. I Medicare denies paymen, you cansill le an appeal. However, you will ave o pay or e iems orservices i Medicare deermines a e iems or services aren’covered (and no oer insurer is responsible or paymen).

You may also ge a Home Heal ABN or oer reasons, suc■as wen your docor or eal care provider reduces your omeeal care.

I you sould ave received an ABN bu didn’, in mos cases■Medicare will require your provider o reund you or wa youpaid or e iem or service.

I you’re in a Medicare plan, call your plan o nd ou i a service oriem will be covered.

For more inormaion abou ABNs, visi p://go.usa.gov/low

o view e bookle, “Your Medicare Rigs and Proecions,” orcall 1-800-MEDICARE (1-800-633-4227). Y users sould call1-877-486-2048.

Blue words

in the text

are dened

on pages

127–130.



8/6/2019 Medicare 2011



How Medicare Uses Your Personal InormationYou ave e rig o ave your personal and eal inormaion kepprivae. Te nex wo pages describe ow your inormaion may beused and given ou and explain ow you can ge is inormaion.

Notice o Privacy Practices or Original MedicareHIS NOICE DESCRIBES HOW MEDICAL INFORMAION ABOU YOU

MAY BE USED AND DISCLOSED AND HOW YOU CAN GE ACCESS O HISINFORMAION. PLEASE REVIEW I CAREFULLY.

By law, Medicare is required o proec e privacy o your personal medical inormaion.Medicare is also required o give you is noice o ell you ow Medicare may use and giveou (“disclose”) your personal medical inormaion eld by Medicare.

Medicare mus use and give ou your personal medical inormaion o provide inormaion

o e ollowing:o you or someone wo as e legal rig o ac or you (your personal represenaive)■

o e Secreary o e Deparmen o Heal and Human Services, i necessary, o make■sure your privacy is proeced

Were required by law■

Medicare as e rig o use and give ou your personal medical inormaion o pay oryour eal care and o operae e Medicare Program. Examples include e ollowing:

Companies a pay bills or Medicare use your personal medical inormaion o pay or■deny your claims, o collec your premiums, o sare your bene paymen wi your

oer insurer(s), or o prepare your Medicare Summary Noice.Medicare may use your personal medical inormaion o make sure you and oer people■wi Medicare ge qualiy eal care, o provide cusomer service o you, o resolve any complains you ave, or o conac you abou researc sudies.

Medicare may use or give ou your personal medical inormaion or e ollowingpurposes under limied circumsances:

o sae and oer Federal agencies a ave e legal rig o receive Medicare daa■(suc as o make sure Medicare is making proper paymens and o assis Federal/SaeMedicaid programs)

For public eal aciviies (suc as reporing disease oubreaks)■

For governmen eal care oversig aciviies (suc as raud and abuse invesigaions)■

For judicial and adminisraive proceedings (suc as in response o a cour order)■

For law enorcemen purposes (suc as providing limied inormaion o locae a missing■person)

For researc sudies, including surveys, a mee all privacy law requiremens (suc as■researc relaed o e prevenion o disease or disabiliy)

o avoid a serious and imminen rea o eal or saey ■

o conac you abou new or canged coverage under Medicare■

o creae a collecion o inormaion a can no longer be raced back o you■

8/6/2019 Medicare 2011



By law, Medicare mus ave your wrien permission (an “auorizaion”) o use or give ouyour personal medical inormaion or any purpose a isn’ se ou in is noice. You may ake back (“revoke”) your wrien permission anyime, excep o e exen a Medicareas already aced based on your permission.

By law, you ave e rig o ake ese acions:

See and ge a copy o your personal medical inormaion eld by Medicare.■

Have your personal medical inormaion amended i you believe a i is wrong or i ■inormaion is missing, and Medicare agrees. I Medicare disagrees, you may ave asaemen o your disagreemen added o your personal medical inormaion.

Ge a lising o ose geing your personal medical inormaion rom Medicare.■Te lising won’ cover your personal medical inormaion a was given o you or yourpersonal represenaive, a was given ou o pay or your eal care or or Medicareoperaions, or a was given ou or law enorcemen purposes i i would likely ge in e

way o ese purposes.Ask Medicare o communicae wi you in a dieren manner or a a dieren place (or■example, by sending maerials o a P.O. Box insead o your ome address).

Ask Medicare o limi ow your personal medical inormaion is used and given ou o■pay your claims and run e Medicare Program. Please noe a Medicare may no beable o agree o your reques.

Ge a separae paper copy o is noice.■

Visi www.medicare.gov or more inormaion on e ollowing:

Exercising your rigs se ou in is noice.■

Filing a complain, i you believe Original Medicare as violaed ese privacy rigs.■ Filing a complain won’ aec your coverage under Medicare.

You can also call 1-800-MEDICARE (1-800-633-4227) o ge is inormaion. Ask o speak o a cusomer service represenaive abou Medicare’s privacy noice. Y users sould call1-877-486-2048.

You may le a complain wi e Secreary o e Deparmen o Heal and HumanServices. Call e Oce or Civil Rigs a 1-800-368-1019. Y users sould call1-800-537-7697. You can also visi www.s.gov/ocr/privacy .

By law, Medicare is required o ollow e erms in is privacy noice. Medicare as e

rig o cange e way your personal medical inormaion is used and given ou.I Medicare makes any canges o e way your personal medical inormaion is used andgiven ou, you will ge a new noice by mail wiin 60 days o e cange.

Te Notice o Privacy Practices or Original Medicare became efective April 14, 2003.

Note: I you join a Medicare plan, e plan will le you know ow i will use andrelease your personal inormaion as permied or required by law including orreamen, paymen, eal care operaions, and or researc and oer purposes.


http://www.hhs.gov/ocr/privacy

http://www.hhs.gov/ocr/privacy


8/6/2019 Medicare 2011



Protect Yoursel rom Identity ThetIdeniy e is a serious crime. Ideniy e appens wensomeone uses your personal inormaion wiou your consen ocommi raud or oer crimes. Personal inormaion includes ingslike your name and your Social Securiy, Medicare, or credi cardnumbers. Guard agains ideniy e by keeping your personalinormaion sae.

I you ink someone is using your personal inormaion wiouyour consen, call your local police deparmen and e Federalrade Commission’s ID Te Holine a 1-877-438-4338 o make arepor. Y users sould call 1-866-653-4261.

Generally, no one sould call you or come o your ome uninvied oge you o join a Medicare plan. Don’ give your personal inormaiono someone wo does is. Only give personal inormation like

your Medicare number to doctors, other health care providers,and plans approved by Medicare; any insurer who pays benetson your behal; and to trusted people in the community whowork with Medicare, like your State Health Insurance AssistanceProgram (SHIP) or Social Security. Call 1-800-MEDICARE(1-800-633-4227) i you aren’ sure i a provider is approved by

Medicare. Y users sould call 1-877-486-2048.Medicare plans can’ ask you or credi card or banking inormaionover e elepone or email, unless you’re already a member o aplan. Medicare plans can’ enroll you ino a plan over e eleponeunless you call em and ask o enroll. Call 1-800-MEDICARE toreport any plans that ask or your personal inormation over thetelephone or that call to enroll you in a plan. You can also call eMedicare Drug Inegriy Conracor (MEDIC) a 1-877-7SAFERX(1-877-772-3379). Te MEDIC gs raud, wase, and abuse in

Medicare Advanage (Par C) and Medicare Prescripion Drug(Par D) Programs. Te MEDIC is commied o parnering wi youo preven inappropriae aciviy in Medicare.

For more inormaion abou ideniy e or o le a complainonline, visi www.c.gov/ide. You can also visiwww.sopmedicareraud.gov/gback_brocure_rev.pd o view ebrocure, “Medical Ideniy Te & Medicare Fraud.”


are dened

on pages

127–130.

http://www.ftc.gov/idtheft

http://www.stopmedicarefraud.gov/fightback_brochure_rev.pdf

http://www.stopmedicarefraud.gov/fightback_brochure_rev.pdf

http://www.ftc.gov/idtheft

8/6/2019 Medicare 2011



The Senior Medicare Patrol (SMP) Program Can

Help YouTe SMP Program educaes and empowers people wi Medicare

o ake an acive role in deecing and prevening eal careraud and abuse. Te SMP Program no only proecs peoplewi Medicare, ey also elp preserve e Medicare Program.Tere is an SMP Program in every sae, e Disric o Columbia,Guam, e U.S. Virgin Islands, and Puero Rico. Conac yourlocal SMP Program o ge one-on-one counseling and o ndou abou communiy evens in your area. For more inormaionor o nd your local SMP Program, visi www.smpresource.org,or call 1-877-808-2468. You can also call 1-800-MEDICARE

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

Protect Yoursel and Medicare rom FraudMos docors, parmaciss, plans, and oer eal care providerswo work wi Medicare are ones. Unorunaely, ere may besome wo are disones. Medicare raud appens wen Medicareis billed or services or supplies you never go. Medicare raudcoss Medicare a lo o money eac year. You pay or i wi igerpremiums.

Remember ese ips o elp preven billing raud:

Ask quesions! You ave e rig o know everying abou your■eal care including e coss billed o Medicare.

Educae yoursel abou Medicare. Know your rigs and wa a■provider can and can’ bill o Medicare.

Be wary o providers wo ell you a e iem or service■isn’ usually covered, bu ey “know ow o bill Medicare” soMedicare will pay.

I you believe a Medicare plan or provider as used alseinormaion o mislead you, call 1-800-MEDICARE.

http://www.smpresource.org/

http://www.smpresource.org/

8/6/2019 Medicare 2011



Protect Yoursel and Medicare rom Fraud

(continued)

Blue words

in the text

are dened

on pages

127–130.

Wen you ge eal care services, record e daes on a calendar

and save e receips and saemens you ge rom providers o ceck or misakes. Tese include e Medicare Summary Noice i youave Original Medicare, or similar saemens a lis e servicesyou go or prescripions you lled.

I you ink you see an error, do e ollowing o nd ou wa wasbilled:

Ask your eal care provider or supplier or an iemized saemen.■Tey sould give is o you wiin 30 days.

Ceck your MSN i you ave Original Medicare o see i e service■ was billed o Medicare. I you’re in a Medicare plan, ceck wiyour plan.

Visi■ www.MyMedicare.gov o view your Medicare claims.Your claims are generally available online wiin 24 ours aerprocessing. Te sooner you see and repor errors, e sooner we cansop raud. You can also call 1-800-MEDICARE (1-800-633-4227).Y users sould call 1-877-486-2048.

I you suspec Medicare raud, ere’s wa you can do:

Conac your eal care provider o be sure e bill is correc.1.

Call 1-800-MEDICARE.2.

Call e raud oline o e Deparmen o Heal and Human3.Services Oce o Inspecor General a 1-800-HHS-IPS(1-800-447-8477). Y users sould call 1-800-377-4950. Youcan also email [email protected]. Note: I you live in Floridaor were carged or a service rom a docor, oer provider, orsupplier in Florida and suspec raud, call Medicare’s Florida

raud oline a 1-866-417-2078. You can also [email protected].

Call e Medicare Drug Inegriy Conracor a 1-877-7SAFERX4.(1-877-772-3379) i you’re in a Medicare Advanage Plan or aMedicare Prescripion Drug Plan.

For more inormaion on proecing yoursel rom Medicare raudand ips or spoing and reporing raud, visiwww.sopmedicareraud.gov , or conac your local SMP Program.See page 105.





8/6/2019 Medicare 2011



Fighting Fraud Can PayYou may ge a reward o up o $1,000 i you mee all ese condiions:

You repor suspeced Medicare raud.■

Te suspeced Medicare raud you repor mus be proven as poenial raud by ■ e Program Saeguard Conracor or e Zone Program Inegriy Conracor

(e Medicare conracors responsible or invesigaing poenial raud and

abuse) and ormally reerred as par o a case by one o e conracors o e

Oce o Inspecor General or urer invesigaion.

You aren’ an “excluded individual.” For example, you didn’ paricipae in e■

raud oense being repored. Or, ere isn’ anoer reward a you qualiy or

under anoer governmen program.

Te person or organizaion you’re reporing isn’ already under invesigaion by ■

law enorcemen.

Your repor leads direcly o e recovery o a leas $100 o Medicare money.■

For more inormaion, call 1-800-MEDICARE (1-800-633-4227). Y users

sould call 1-877-486-2048.

Reporting Suspected Medicaid FraudYou can repor Medicaid raud o your Sae Medical Assisance (Medicaid)

Oce. Visi www.cms.gov/raudabuseorconsumers . Medicaid raud can

also be repored o e OIG Naional Fraud oline a 1-800-HHS-IPS

(1-800-447-8477).

How Medicare Protects YouWi elp rom ones eal care providers, suppliers, law enorcemen, and

ciizens like you, Medicare is improving is abiliy o preven raud and ideniy

e. Medicare is also working wi oer governmen agencies o proec

Medicare rom raud and o proec you rom ideniy e. Te Deparmen o

Jusice and e Deparmen o Heal and Human Services’ Medicare Fraud Srike

Force is a muli-agency eam o Federal, sae, and local invesigaors designed o

comba Medicare raud roug Medicare daa analysis and communiy policing.

Tese agencies are also working ogeer o bo preven raud and enorce

curren ani-raud laws around e counry on a Heal Care Fraud Prevenion

and Enorcemen Acion eam (HEA). In 2009, as a resul o ese eors,

approximaely $2.5 billion was deposied o e Medicare rus Fund, a $569

million increase over e previous year.

Because o all o ese eors, some disones eal care providers ave been

removed rom Medicare, and some ave gone o jail. Tese acions are saving

money or axpayers and proecing Medicare or e uure.

http://www.cms.gov/fraudabuseforconsumers

http://www.cms.gov/fraudabuseforconsumers

8/6/2019 Medicare 2011



You Are Protected rom DiscriminationEvery company or agency a works wi Medicare mus obey e law. You can’ be reaed dierenly because o your race, color,naional origin, disabiliy, age, religion, or sex. I you ink ayou aven’ been reaed airly or any o ese reasons, call eDeparmen o Heal and Human Services, Oce or Civil Rigsoll-ree a 1-800-368-1019. Y users sould call 1-800-537-7697.You can also visi www.s.gov/ocr or more inormaion.

The Medicare Beneciary OmbudsmanAn “ombudsman” is a person wo reviews issues and elpsresolve em. Te Medicare Beneciary Ombudsman makes

sure inormaion abou e ollowing is available o all peoplewi Medicare:

Your Medicare coverage■

Inormaion o elp you make good eal care decisions■

Your Medicare rigs and proecions■

How you can ge issues resolved■

Te Ombudsman reviews e concerns raised by people wiMedicare roug 1-800-MEDICARE and roug your Sae

Heal Insurance Assisance Program (SHIP).Visi www.medicare.gov/Ombudsman/resources.asporinormaion on inquiries and complains, aciviies o eOmbudsman, and wa people wi Medicare need o know.

Blue words

in the text

are dened

on pages

127–130.


http://www.medicare.gov/Ombudsman/resources.asp

http://www.medicare.gov/Ombudsman/resources.asp


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109

SECTION 5

Planning

Ahead


Plan or Long-erm Care . . . . . . . . . . . . . . . . . . . . . 110

Paying or Long-erm Care . . . . . . . . . . . . . . . . . . . . 110

Advance Direcives . . . . . . . . . . . . . . . . . . . . . . . . 113

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110 Section 5—Planning Ahead

Plan or Long‑Term CareLong-erm care includes medical and non-medical care or people woave a cronic illness or disabiliy. Non-medical care includes non-skilledpersonal care assisance, suc as elp wi everyday aciviies like dressing,baing, and using e baroom. A leas 70% o people over 65 will needlong-erm care services a some poin. Medicare and most health insuranceplans, including Medigap (Medicare Supplement Insurance) policiesdon’t pay or this type o care, also called “custodial care.” Medicare only pays or medically-necessary skilled nursing aciliy care or ome eal carei you mee cerain condiions. Long-erm care can be provided a ome,in e communiy, in assised living, or in a nursing ome. I’s imporan osar planning or long-erm care now o mainain your independence and

o make sure you ge e care you may need in e uure.

Paying or Long‑Term CareLong-term Care Insurance—Tis ype o privae insurance policy canelp pay or many ypes o long-erm care, including bo skilled andnon-skilled (cusodial) care. Long-erm care insurance can vary widely.Some policies may cover only nursing ome care. Oers may includecoverage or a range o services like adul day care, assised living, medicalequipmen, and inormal ome care.

Note: Long-erm care insurance doesn’ replace your Medicare coverage.

Your curren or ormer employer or union may oer long-erm careinsurance. Curren and reired Federal employees, acive and reiredmembers o e uniormed services, and eir qualied relaives canapply or coverage under e Federal Long-erm Care Insurance Program.I you ave quesions, visi www.opm.gov/insure/lc, or call e FederalLong-erm Care Insurance Program a 1-800-582-3337. Y users souldcall 1-800-843-3557.

Personal Resources—You can use your savings o pay or long-erm care.Some insurance companies le you use your lie insurance policy o pay orlong-erm care. Ask your insurance agen ow is works.

Other Private Options—Besides long-erm care insurance and personalresources, you may coose o pay or long-erm care roug a rus orannuiy. Wa opion is bes or you depends on your age, your ealsaus, your risk o needing long-erm care, and your personal nancialsiuaion. Visi www.longermcare.gov or more inormaion abou

your opions.

Blue words

in the text

are dened

on pages

127–130.

http://www.opm.gov/insure/ltc

http://www.longtermcare.gov/


http://www.opm.gov/insure/ltc

8/6/2019 Medicare 2011


111Section 5—Planning Ahead

Paying or Long‑Term Care (continued)Medicaid—Medicaid is a join Federal and sae program a pays orcerain eal services or people wi limied income and resources.I you qualiy, you may be able o ge elp o pay or nursing ome care oroer eal care coss. See page 91 or more inormaion abou Medicaid.

Home and Community-based Services Programs—I you’re already eligible or Medicaid (or, in some saes, would be eligible or Medicaidcoverage in a nursing ome), you or your amily members may be ableo ge elp wi e coss o services a elp you say in your omeinsead o moving o a nursing ome. Examples include omemakerservices, personal care, and respie care. For more inormaion, conacyour Sae Medical Assisance (Medicaid) oce. Call 1-800-MEDICARE

(1-800-633-4227), and say “Medicaid” o ge e elepone number, or visi www.medicare.gov . Y users sould call 1-877-486-2048.

Veterans’ Benets—Te Deparmen o Veerans Aairs (VA) may provide long-erm care or service-relaed disabiliies or or ceraineligible veerans. Te VA also as a Housebound and an Aid andAendance Allowance Program a provides cas grans o eligibledisabled veerans and surviving spouses insead o ormally-providedomemaker, personal care, and oer services needed or elp a ome.

For more inormaion, call e VA a 1-800-827-1000, or visiwww.va.gov .

Programs o All-inclusive Care or the Elderly (PACE)—PACE isa Medicare and Medicaid program oered in many saes a allowspeople wo oerwise need a nursing ome-level o care o remain in ecommuniy. See page 71 or more inormaion.

Coming Soon—Te Community Living Assistance Services andSupports (CLASS) Program is a naional, volunary insurance

program o elp you pay or services and suppors so you can mainainindependence in your communiy i you become disabled. People over18 wo are working will ave e opporuniy o enroll in e CLASSprogram saring in lae 2012, eier roug payroll deducions orindividual enrollmen. Enrollees wo become disabled (a any poin aera ve year vesing period) and need elp wi basic daily living aciviiessuc as eaing, using e baroom, and geing in and ou o bed willbe able o ge a bene a will average no less an $50 a day o elppay or suppors o say independen. alk o your employer or benes

adminisraor or more inormaion.


http://www.va.gov/

http://www.va.gov/


8/6/2019 Medicare 2011



Paying or Long‑Term Care (continued)


are dened

on pages

127–130.

Long‑Term Care Contacts

Use e ollowing resources o ge more inormaion abou

long-erm care:Visi■ www.medicare.gov/LCPlanning. You can also visiwww.medicare.gov/NHCompare orwww.medicare.gov/HHCompare o compare nursing omes orome eal agencies in your area.

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

Visi■ www.longermcare.gov o learn more abou planning orlong-erm care.

Call your Sae Insurance Deparmen o ge inormaion■abou long-erm care insurance. Call 1-800-MEDICARE oge e elepone number. You can also call your Sae HealInsurance Assisance Program. See pages 123–126 or eirelepone number.

Call e Naional Associaion o Insurance Commissioners■a 1-866-470-6242 o ge a copy o “A Sopper’s Guide o

Long-erm Care Insurance.”

Visi e Eldercare Locaor a■www.eldercare.gov o ndyour local Aging and Disabiliy Resource Cener (ADRC). Youcan also call 1-800-677-1116.ADRCs oer a ull range o long-erm care services andsuppor in a single, coordinaedprogram.

http://www.medicare.gov/LTCPlanning

http://www.medicare.gov/NHCompare

http://www.medicare.gov/HHCompare


http://www.eldercare.gov/



http://www.medicare.gov/HHCompare

http://www.medicare.gov/NHCompare

http://www.medicare.gov/LTCPlanning

8/6/2019 Medicare 2011


113Section 5—Planning Ahead

Advance Directives

Advance direcives are legal documens a allow you o pu inwriing wa kind o eal care you would wan or name someonewo can speak or you i you were oo ill o speak or yoursel.Advance direcives mos oen include e ollowing:

A eal care proxy (durable power o aorney)■

A living will■

Aer-dea wises■

alking wi your amily, riends, and eal care providers abouyour wises is imporan, bu ese legal documens ensure yourwises are ollowed. I’s beer o ink abou ese imporandecisions beore you’re ill or a crisis srikes.

A eal care proxy (someimes called a “durable powero aorney or eal care”) is used o name e personyou wis o make eal care decisions or you i youaren’ able o make em yoursel. Having a eal careproxy is imporan because i you suddenly aren’ ableo make your own eal care decisions, someone yourus will be able o make ese decisions or you.

A living will is anoer way o make sure your voice is eard.I saes wic medical reamen you would accep or reuse i your lie is reaened. Dialysis or kidney ailure, a breaingmacine i you can’ breae on your own, CPR (cardiopulmonary resusciaion) i your ear and breaing sop, or ube eeding i you can no longer ea are examples o medical reamen you cancoose o accep or reuse.

In some saes, advance direcives can also include aer-deawises. Tese may include coices suc as organ and issue

donaion.

8/6/2019 Medicare 2011



Advance Directives (continued)I you already ave advance direcives, ake ime now o reviewem o be sure you’re sill saised wi your decisions, and your

eal care proxy is sill willing and able o carry ou your plans.Find ou ow o cancel or updae em in your sae i ey nolonger refec your wises. Eac sae as is own laws or creaingadvance direcives. Mos saes may allow you o combine youradvance direcives in one documen. For more inormaion, conacyour eal care provider, an aorney, your local Area Agency onAging, or your Sae Heal Deparmen.

Tips

Keep e original copies o your advance direcives were ey 1.are easily ound.

Give e person you’ve named as your eal care proxy, and2.oer concerned amily members or riends, a copy o youradvance direcives.

Give your docor a copy o your advance direcives or your3.medical record. Provide a copy o any ospial or nursing omeyou say in or any ambulaory surgical cener were you ave

procedures done.Carry a card in your walle a saes you ave advance4.direcives.

8/6/2019 Medicare 2011


115

SECTION 6

HelpulResources

and Tools


1-800-MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . 116

Sae Heal Insurance Assisance Programs (SHIP) . . . . . 117

www.medicare.gov . . . . . . . . . . . . . . . . . . . . . . . . 118

www.MyMedicare.gov . . . . . . . . . . . . . . . . . . . . . . 118

Compare e Qualiy o Plans and Providers . . . . . . . . . . 119

Managing Your Heal Inormaion Online . . . . . . . . . . 120

Medicare Publicaions . . . . . . . . . . . . . . . . . . . . . . 122

Caregiver Resources . . . . . . . . . . . . . . . . . . . . . . . . 122

SHIP elepone Numbers . . . . . . . . . . . . . . . . . . . . 123

I you ave a quesion or complain abou e qualiy o aMedicare-covered service, call your local Qualiy ImprovemenOrganizaion (QIO). Call 1-800-MEDICARE (1-800-633-4227)o ge your QIO’s elepone number. Y users sould call1-877-486-2048. You can also visi www.medicare.gov .



8/6/2019 Medicare 2011


116 Section 6—Helpul Resources and Tools

1‑800‑MEDICARE (1‑800‑633‑4227)

TTY Users 1‑877‑486‑2048.

Get Inormation 24 Hours a Day, Including Weekends.

Speak clearly, ave your Medicare card in ron o you, and be ready o■provide your Medicare number. Tis elps reduce e amoun o ime youmay wai o speak o a cusomer service represenaive. I also allows us oplay messages a may specically impac your coverage and may elp usge you o a represenaive more quickly.

o ener your Medicare number, speak clearly e numbers and leers■one a a ime. Or, you can ener your Medicare number on e eleponekeypad. Use e sar key o indicae any place ere may be a leer.

For example, i your Medicare number is 000-00-0000A, you would ener0-0-0-0-0-0-0-0-0-*. Te voice sysem will en ask you or a leer.

Say “AGEN” at anytime to talk to a customer service representative,■or use this chart. I you need elp in a language oer an Englis orSpanis, le e cusomer service represenaive know e language.

I you’re calling about… Say …

Medicare prescripion drug coverage “Drug Coverage”

Claim or billing issues, or appeals“Claims” or “Billing”

Prevenive services “Prevenive Services”

Help paying eal or prescripion drugcoss

“Limied Income”

Forms or publicaions “Publicaions”

elepone numbers or your Sae MedicalAssisance (Medicaid) oce

“Medicaid”

Oupaien docor’s care“Docor Service”

Hospial visi or emergency care “Hospial Say”

Equipmen or supplies like oxygen,weelcairs, walkers, or diabeic supplies

“Medical Supplies”

Inormaion abou your Par B deducible “Deducible”

Nursing ome services “Nursing Home”

8/6/2019 Medicare 2011


117Section 6—Helpul Resources and Tools

1‑800‑MEDICARE (1‑800‑633‑4227) (continued)

People wo ge benes rom e Railroad Reiremen Boardsould call 1-800-833-4455 wi quesions abou Par B services

and bills.

I you wan someone o be able o call 1-800-MEDICARE onyour beal, you need o le Medicare know in wriing. You canll ou a “Medicare Auorizaion o Disclose Personal HealInormaion” orm so Medicare can give your personal ealinormaion o someone oer an you. You can do is onlineby visiing www.medicare.gov/medicareonlineorms or by calling 1-800-MEDICARE (1-800-633-4227) o ge a copy o e

orm. Y users sould call 1-877-486-2048. You may wan odo is now in case you become unable o do i laer.

State Health Insurance Assistance Programs

(SHIP)Sae Heal Insurance Assisance Programs are sae programsa ge money rom e Federal governmen o give ree localeal insurance counseling o people wi Medicare. SHIPsare independen and no conneced o any insurance company or eal plan. SHIP voluneers work ard o elp you wi eollowing Medicare quesions or concerns:

Your Medicare rigs■

Complains abou your medical care or reamen■

Billing problems■

Plan coices■

I you’re interested in becoming a volunteer SHIP counselor,contact the SHIP in your state to learn more. See pages 123–126 or the telephone number.



8/6/2019 Medicare 2011



Go Online to Get the Inormation You Need

Need General Inormation about Medicare?

Visi www.medicare.gov :

Ge deailed inormaion abou e Medicare eal and prescripion■drug plans in your area, including wa ey cos and wa servicesey provide.

Find docors or oer eal care providers and suppliers wo paricipae■in Medicare.

See wa Medicare covers, including■ prevenive services.

Ge Medicare appeals inormaion and orms.■

Ge inormaion abou e qualiy o care provided by plans, nursing■

omes, ospials, ome eal agencies, and dialysis aciliies.Look up elpul Web sies and elepone numbers.■

View Medicare publicaions.■

I you don’ ave a compuer, your local library or senior cener may beable o elp you look up is inormaion. You can also call your SaeHeal Insurance Assisance Program (SHIP). See pages 123–126 or eelepone number.

Need Personalized Medicare Inormation?

Regiser a www.MyMedicare.gov , Medicare’s secure online service oraccessing your personal Medicare inormaion:

Creae and prin an “On e Go” repor a liss inormaion you can■sare wi your providers.

Add or modiy sel-repored eal managemen inormaion suc as■medical condiions and allergies.

View or modiy your personal drug lis and parmacy inormaion, and■see your prescripion drug coss.

Searc or and creae a lis o your avorie providers, and access qualiy ■inormaion abou em.

Complee your Iniial Enrollmen Quesionnaire so your bills can ge■paid correcly.

rack your Original Medicare claims, and order a Medicare■Summary Noice.

Ceck your Par B■ deducible saus.

View your eligibiliy inormaion.■

Ge noices abou wa services you will be eligible or in e coming year.■





8/6/2019 Medicare 2011



Go Online to Get the Inormation You Need

(continued)

Need Personalized Medicare Inormation? (continued)

Blue words

in the text

are dened

on pages

127–130.

Find a Medicare eal or prescripion drug plan.■

Access online orms, publicaions, and messages sen by Medicare.■

Sign up o ge is andbook elecronically.■

Compare the Quality o Plans and ProvidersYou can’ always plan aead wen you need eal care, bu wenyou can, ake ime o compare. Medicare collecs inormaion aboue qualiy o care and services given by mos Medicare plans and

oer eal care providers. Medicare also as inormaion abou eexperiences o people wi e care and services ey ge.

Compare e qualiy o care and services given by eal andprescripion drug plans or eal care providers naionwideby visiing www.medicare.gov or by calling your Sae HealInsurance Assisance Program (SHIP). See pages 123–126 or eelepone number.

Wen you, a amily member, riend, or SHIP counselor visi Medicare’s

Web sie, under “Resource Locaor,” selec one o e ollowing:“Drug and Heal Plans”■

“Dialysis Faciliies”■

“Home Heal Agencies”■

“Hospials”■

“Nursing Homes”■

Tese searc ools on www.medicare.gov give you a “snapso” o equaliy o care and services some plans and providers give. Find ou

more abou e qualiy o care and services by doing e ollowing:Ask wa your plan or provider does o ensure and improve e■qualiy o care and services. Every plan and eal care providersould ave someone you can alk o abou qualiy.

Ask your docor wa e or se inks abou e qualiy o care or■services e plan or oer eal care provider gives. alk o yourdocor abou Medicare’s inormaion on e qualiy o care andservices a plans and providers give.





8/6/2019 Medicare 2011



Managing Your Health Inormation OnlineEven i you don’ use a compuer, ere are new ways o elp manageyour eal inormaion and improve ow you communicae wi youreal care providers. Tis ecnology (also called Heal Inormaionecnology or Heal I) reduces paperwork, medical errors, andeal care coss. I can also elp improve e qualiy and coordinaiono your eal care.

Here are examples o Heal I a your health care providers can use:

Electronic Prescribing—An elecronic way or your prescribers (yourdocor or oer eal care provider wo is legally allowed o wrieprescripions) o send your prescripions direcly o your parmacy.Elecronic prescribing can save you money, ime, and elp keepyou sae.

You don’ ave o drop o your prescripion and wai or■your parmacis o ll i. Your prescripion may be ready wenyou arrive.

Prescribers can ceck wic drugs your insurance covers and■prescribe a drug a coss you less.

Elecronic prescripions are easier or e parmacis o read■an andwrien prescripions. Tis means ere’s less cance

a you will ge e wrong drug or dose.Prescribers will ave secure access o your prescripion isory,■so ey can be alered o poenial drug ineracions, allergies,and oer warnings.

Electronic Health Records (EHRs)—A sae and condenial record ayour docor, your docor’s sa, or a ospial keeps on a compuer abouyour eal care or reamens. I your providers use elecronic ealrecords, ey can join a nework o securely sare your records wi

eac oer.EHRs can elp lower e cances o medical errors and can elp■improve your overall qualiy o care.

EHRs can elp all o your providers ave e same up-o-dae■inormaion abou your condiions, reamens, ess, andprescripions.

8/6/2019 Medicare 2011



Managing Your Health Inormation Online

(continued)Te ollowing is an example o Heal I a you can use:

Personal Health Records (PHRs)—A record wi inormaionabou your eal a you or someone elping you keeps or easy reerence using a compuer.

Tese easy-o-use ools can elp you manage your eal■inormaion rom anywere you ave inerne access.

Wi a PHR, you can keep rack o eal inormaion, like■e dae o your las pysical, major illnesses, operaions,allergies, or a lis o your prescripions.

PHRs are oen oered by providers, eal plans, and■ privae companies. Some are ree, wile oers carge ees.

Wen you use a PHR, make sure a i’s on a secure Web■sie. Wi a secure Web sie, you usually ave o creae aunique user ID and password, and e inormaion youype is encryped (pu in code) so oer people can’ read i.

Tere are Federal and sae laws a proec e privacy andsecuriy o your inormaion. PHRs a aren’ sponsored ormainained by eal plans or eal care providers may noave privacy rules.

Visit www.medicare.gov/phr to learn more about PersonalHealth Records.

http://www.medicare.gov/phr

http://www.medicare.gov/phr

8/6/2019 Medicare 2011



Medicare Publicationso read, prin, or download copies o bookles, brocures, or acsees on dieren Medicare opics, visiwww.medicare.gov/publicaions. You can searc by keyword(suc as “rigs” or “menal eal”), or selec “View All MedicarePublicaions.”

I e publicaion you wan as a ceck box aer “Order Publicaion,”you can ave a prined copy mailed o you. You can also call1-800-MEDICARE (1-800-633-4227), and say “Publicaions” o ndou i a prined copy can be mailed o you. Y users sould call1-877-486-2048.

Caregiver ResourcesDo You Help Someone With Medicare?

Medicare as resources o elp you ge e inormaion you need.

Visi “Ask Medicare” a■ www.medicare.gov/caregivers o elp

someone you care or coose a drug plan, compare nursing omes,ge elp wi billing, and more!

Sign up or e ree bi-monly “Ask Medicare” elecronic■newsleer (e-Newsleer) wen you go o e sie menioned above.Te e-Newsleer as e laes inormaion including imporandaes, Medicare canges, and resources in your communiy.

Visi e Eldercare Locaor a■ www.eldercare.gov , or call1-800-677-1116 o nd caregiver suppor services in your area.

Follow ocial Medicare inormaion on wier a■

www.wier.com/CMSGov and e Cildren’s Heal InsuranceProgram a www.wier.com/IKNGov .

Visi■ www.Youube.com/cmssgov o see videos covering an array o eal care opics on Medicare’s Youube cannel.

Blue words

in the text

are dened

on pages

127–130.

http://www.medicare.gov/publications

http://www.medicare.gov/caregivers


http://www.twitter.com/CMSGov

http://www.twitter.com/IKNGov

http://www.youtube.com/cmshhsgov

http://www.youtube.com/cmshhsgov

http://www.twitter.com/IKNGov

http://www.twitter.com/CMSGov


http://www.medicare.gov/caregivers

http://www.medicare.gov/publications

8/6/2019 Medicare 2011



State Health Insurance Assistance Programs (SHIPs)For elp wi quesions abou appeals, buying oer insurance, coosing aeal plan, buying a Medigap policy, and Medicare rigs and proecions.

Tis page as been inenionally le blank. Te prined version conainspone number inormaion. For e mos recen pone number inormaion,please visi www.medicare.gov/conacs/ome.asp. Tank you.

http://www.medicare.gov/contacts/home.asp


8/6/2019 Medicare 2011






8/6/2019 Medicare 2011


127

SECTION 7

Deinitions

Benet Period—Te way a Original Medicare measures youruse o ospial and skilled nursing aciliy (SNF) services. A beneperiod begins e day you go ino a ospial or skilled nursingaciliy. Te bene period ends wen you aven’ received any inpaien ospial care (or skilled care in a SNF) or 60 days in arow. I you go ino a ospial or a skilled nursing aciliy aer onebene period as ended, a new bene period begins. You muspay e inpaien ospial deducible or eac bene period.Tere is no limi o e number o bene periods.

Coinsurance—An amoun you may be required o pay as yoursare o e cos or services aer you pay any deducibles.Coinsurance is usually a percenage (or example, 20%).

Copayment—An amoun you may be required o pay as yoursare o e cos or a medical service or supply, like a docor’s visi,ospial oupaien visi, or a prescripion. A copaymen is usually a se amoun, raer an a percenage. For example, you mig pay $10 or $20 or a docor’s visi or prescripion.

8/6/2019 Medicare 2011


128 Section 7—Defnitions

Creditable Prescription Drug Coverage—Prescripion drugcoverage (or example, rom an employer or union) a is expeced opay, on average, a leas as muc as Medicare’s sandard prescripiondrug coverage. People wo ave is kind o coverage wen ey

become eligible or Medicare can generally keep a coverage wioupaying a penaly, i ey decide o enroll in Medicare prescripiondrug coverage laer.

Critical Access Hospital—A small aciliy a provides oupaienservices, as well as inpaien services on a limied basis, o people inrural areas.

Custodial Care—Nonskilled personal care, suc as elp wiaciviies o daily living like baing, dressing, eaing, geing in or

ou o a bed or cair, moving around, and using e baroom. I may also include e kind o eal-relaed care a mos people doemselves, like using eye drops. In mos cases, Medicare doesn’ pay or cusodial care.

Deductible—Te amoun you mus pay or eal care orprescripions, beore Original Medicare, your prescripion drug plan,or your oer insurance begins o pay.

Extra Help—A Medicare program o elp people wi limiedincome and resources pay Medicare prescripion drug program coss,suc as premiums, deducibles, and coinsurance.

Formulary—A lis o prescripion drugs covered by a prescripiondrug plan or anoer insurance plan oering prescripiondrug benes.

Inpatient Rehabilitation Facility—A ospial, or par o a ospial,a provides an inensive reabiliaion program o inpaiens.

Institution—A aciliy a provides sor-erm or long-ermcare, suc as a nursing ome, skilled nursing aciliy (SNF), orreabiliaion ospial. Privae residences, suc as an assised livingaciliy, or group ome aren’ considered insiuions or is purpose.

8/6/2019 Medicare 2011


129Section 7—Defnitions

Lietime Reserve Days—In Original Medicare, ese are addiionaldays a Medicare will pay or wen you’re in a ospial or morean 90 days. You ave a oal o 60 reserve days a can be usedduring your lieime. For eac lieime reserve day, Medicare pays all

covered coss excep or a daily coinsurance.

Long‑Term Care Hospital—Generally, acue care ospials aprovide reamen or paiens wo say, on average, more an 25days. Mos paiens are ranserred rom an inensive or criicalcare uni. Services provided include compreensive reabiliaion,respiraory erapy, ead rauma reamen, and pain managemen.

Medically Necessary—Services or supplies a are needed or ediagnosis or reamen o your medical condiion and mee acceped

sandards o medical pracice.

Medicare‑Approved Amount—In Original Medicare, is is eamoun a docor or supplier a acceps assignmen can be paid.I includes wa Medicare pays and any deducible, coinsurance,or copaymen a you pay. I may be less an e acual amoun adocor or supplier carges.

Medicare Health Plan—A Medicare eal plan is oered by aprivae company a conracs wi Medicare o provide Par Aand Par B benes o people wi Medicare wo enroll in e plan.Tis erm is used rougou is andbook o include all MedicareAdvanage Plans, Medicare Cos Plans, Demonsraion/PiloPrograms, and Programs o All-inclusive Care or e Elderly (PACE).

Medicare Plan—Reers o any way oer an Original Medicarea you can ge your Medicare eal or prescripion drugcoverage. Tis erm includes all Medicare eal plans and MedicarePrescripion Drug Plans.

Premium—Te periodic paymen o Medicare, an insurancecompany, or a eal care plan or eal or prescripiondrug coverage.

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130 Section 7—Defnitions

Preventive Services—Heal care o preven illness or deecillness a an early sage, wen reamen is likely o work bes(or example, prevenive services include Pap ess, fu sos, andscreening mammograms).

Primary Care Doctor—Your primary care docor is e docor you seers or mos eal problems. He or se makes sure you ge e care youneed o keep you ealy. He or se also may alk wi oer docors andeal care providers abou your care and reer you o em. In many Medicare Advanage Plans, you mus see your primary care docorbeore you see any oer eal care provider.

Quality Improvement Organization (QIO)—A group o pracicingdocors and oer eal care expers paid by e Federal governmen o

ceck and improve e care given o people wi Medicare.

Reerral—A wrien order rom your primary care docor or youo see a specialis or o ge cerain medical services. In many HealMainenance Organizaions (HMOs), you need o ge a reerral beoreyou can ge medical care rom anyone excep your primary care docor.I you don’ ge a reerral rs, e plan may no pay or e services.

Service Area—A geograpic area were a eal insurance plan accepsmembers i i limis membersip based on were people live. For plansa limi wic docors and ospials you may use, i’s also generally earea were you can ge rouine (non-emergency) services. Te plan may disenroll you i you move ou o e plan’s service area.

Skilled Nursing Facility (SNF) Care—Skilled nursing care andreabiliaion services provided on a coninuous, daily basis, in a skillednursing aciliy. Examples o skilled nursing aciliy care include pysicalerapy or inravenous injecions a can only be given by a regiserednurse or docor.

TTY—A eleypewrier (Y) is a communicaion device used by peoplewo are dea, ard-o-earing, or ave a severe speec impairmen.People wo don’ ave a Y can communicae wi a Y userroug a message relay cener (MRC). An MRC as Y operaorsavailable o send and inerpre Y messages.

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131Medicare Costs

Medicare CostsYour Monthly Premiums or MedicarePart A (Hospital Insurance) Monthly Premium

Mos people don’ pay a Par A premium because ey paid Medicareaxes wile working.

In 2011, you pay up o $450 eac mon i you don’ ge premium-reePar A. I you pay a lae enrollmen penaly, is amoun is iger.

Part B (Medical Insurance) Monthly Premium (See page 25.)

Most people will continue to pay the same Part B premiumthey paid last year.

I Your Yearly Income in 2009 was You Pay

File Individual Tax Return File Joint Tax Return

$85,000 or below $170,000 or below $115.40

$85,001–$107,000 $170,001–$214,000 $161.50

$107,001–$160,000 $214,001–$320,000 $230.70

$160,001–$214,000 $320,001–$428,000 $299.90above $214,000 above $428,000 $369.10

I you ave quesions abou your Par B premium, call SocialSecuriy a 1-800-772-1213. Y users sould call 1-800-325-0778.

Note: I you don’ ge Social Securiy, RRB, or Civil Service benepaymens and coose o sign up or Par B, you will ge a bill. I youcoose o buy Par A, you will always ge a bill or your premium.You can mail your premium paymens o e Medicare Premium

Collecion Cener, P.O. Box 790355, S. Louis, MO 63179-0355.I you ge a bill rom e RRB, mail your premium paymens oRRB, Medicare Premium Paymens, P.O. Box 9024, S. Louis, MO63197-9024.

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132 Medicare Costs

What You Pay i You Have Original Medicare

Part A Costs or Covered Services and Items

Blood In mos cases, e ospial ges blood rom a blood bank a no carge,

and you won’ ave o pay or i or replace i. I e ospial as o buy blood or you, you mus eier pay e ospial coss or e rs 3unis o blood you ge in a calendar year or ave e blood donaed.

Home

Health Care

You pay:

$0 or ome eal care services■

20% o e■ Medicare-approved amoun or durable medicalequipmen

Hospice

Care

You pay:

$0 or ospice care■A■ copaymen o up o $5 per prescripion or oupaienprescripion drugs or pain and sympom managemen

5% o e Medicare-approved amoun or inpaien respie care■(sor-erm care given by anoer caregiver, so e usual caregivercan res)

Medicare doesn’ cover room and board wen you ge ospice care inyour ome or anoer aciliy were you live (like a nursing ome).

HospitalInpatient

Stay

You pay:$1,132■ deducible and no coinsurance or days 1–60 eac beneperiod

$283 per day or days 61–90 eac bene period■

$566 per “■ lieime reserve day ” aer day 90 eac bene period(up o 60 days over your lieime)

All coss or eac day aer e lieime reserve days■

Inpaien menal eal care in a psyciaric ospial limied o■

190 days in a lieimeSee “Medical and Oer Services” on page 133 or wa you pay ordocor services wile you’re a ospial inpaien.

Skilled

Nursing

Facility Stay

You pay:

$0 or e rs 20 days eac bene period■

$141.50 per day or days 21–100 eac bene period■

All coss or eac day aer day 100 in a bene period■

Note: I you’re in a Medicare Advanage Plan, coss vary by plan and may be eier iger

or lower an ose noed above. Review e Evidence o Coverage rom your plan.

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133Medicare Costs

What You Pay i You Have Original Medicare (continued)

Part B Costs or Covered Services and Items

Part B

Deductible

You pay e rs $162 yearly or Par B-covered services or iems.

Blood In mos cases, e provider ges blood rom a blood bank a no carge, and you won’ ave o pay or i or replace i.However, you will pay a copaymen or e blood processing andandling services or every uni o blood you ge, and e Par Bdeducible applies. I e provider as o buy blood or you, youmus eier pay e provider coss or e rs 3 unis o bloodyou ge in a calendar year or ave e blood donaed by you orsomeone else.

You pay a copaymen or addiional unis o blood you ge as anoupaien (aer e rs 3), and e Par B deducible applies.

Clinical

Laboratory

Services

You pay $0 or Medicare-approved services.

Home Health

Services

You pay $0 or Medicare-approved services. You pay 20% o eMedicare-approved amoun or durable medical equipmen.

Medical andOther Services

You pay 20% o e Medicare-approved amoun or mos docorservices (including mos docor services wile you’re a ospialinpaien), oupaien erapy*, and durable medical equipmen.

Mental Health

Services

You pay 45% o e Medicare-approved amoun or mosoupaien menal eal care.

Other Covered

Services

You pay copaymen or coinsurance amouns.

Outpatient

Hospital

Services

You pay a coinsurance (or docor services) or a copaymenamoun or mos oupaien ospial services. Te copaymen ora single service can’ be more an e amoun o e inpaienospial deducible.

*In 2011, ere may be limis on pysical erapy, occupaional erapy, andspeec-language paology services. I so, ere may be excepions o ese limis.

Note: All Medicare Advanage Plans mus cover ese services. Coss vary by planand may be eier iger or lower an ose noed above. Review e Evidence o Coverage rom your plan.

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134 Medicare Costs

Medicare Advantage Plans (Part C) and Medicare Prescription Drug

Plans (Part D) Premiums

Visi www.medicare.gov/nd-a-plan o ge plan premiums. You canalso call 1-800-MEDICARE (1-800-633-4227). Y users sould call

1-877-486-2048.

Te car below sows your esimaed prescripion drug plan monly premium amoun based on your income. I your income is above a cerainlimi, you will pay an income-relaed monly adjusmen amoun inaddiion o your premium. Te amouns sown are esimaes. Wa youpay may be iger or lower.

Part D Monthly Premium (See page 75.)

I Your Yearly Income in 2009 was You Pay

File Individual Tax Return File Joint Tax Return

$85,000 or below $170,000 or below Your PlanPremium

$85,001–$107,000 $170,001–$214,000 $12.00 + YourPlan Premium

$107,001–$160,000 $214,001–$320,000 $31.10 + YourPlan Premium

$160,001–$214,000 $320,001–$428,000 $50.10 + Your

Plan Premiumabove $214,000 above $428,000 $69.10 + Your

Plan Premium

Te income-relaed monly adjusmen amoun will be deduced romyour monly Social Securiy ceck, no maer ow you usually pay yourplan premium. I a amoun is more an e amoun o your ceck, youwill ge a bill rom Medicare.

Part C and Part D Costs or Covered Services and Supplies

Cos inormaion or e Medicare plans in your area is available by visiing www.medicare.gov . You can also conac e plan, or call1-800-MEDICARE. You can also call your Sae Heal InsuranceAssisance Program (SHIP). See pages 123–126 or e elepone number.

Te gure below is used to estimate the Part D late enrollment penalty. Te naional base beneciary premium amoun can cange eac year.For more inormaion abou esimaing your penaly amoun, see page 79.

2011 Part D National Base Beneciary Premium $32.34





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Medicare cares abou wa you ink. I you avegeneral commens abou is andbook, email us [email protected]. We can’ respond oevery commen, bu we will consider your eedback wen wriing uure versions.

8/6/2019 Medicare 2011


National Medicare Handbook

U.S. DEPARMEN OFHEALH AND HUMAN SERVICES

Ceners or Medicare & Medicaid Services7500 Securiy BoulevardBalimore, Maryland 21244-1850

Ocial BusinessPenaly or Privae Use, $300

CMS Produc No. 10050Sepember 2010

Medicare 2011

Documents

Transcript of Medicare 2011