Medicare Basics 2014

8/13/2019 Medicare Basics 2014

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CENTERS FOR MEDICARE & MEDICAID SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES



A Guide for Families and Friends of

People with Medicare

BasicsM E D I C A R E


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Introduction

A Guide for Families and Friends of People with Medicare

As your parents, grandparents, relatives, or riends ace health care decisions, they mightneed to rely on you or help. Medicare can be an important actor in many o those deci-sions. I you arent amiliar with Medicare or the other resources that are available or theperson youre caring or, or i you just want to brush up on what you already know, thisbooklet is or you.

Medicare Basics highlights several topics related to the health and care o a person withMedicare. For each o these topics, you will find basic inormation about Medicare andsuggestions on where to go to find more inormation. Words you see that are blue or

highlighted are defined in the Definitions section.

Medicare Basics isnt a legal document. Official Medicare Program legal guidance iscontained in the relevant statutes, regulations, and rulings.

Te inormation in this booklet was correct when it was printed. Changes may occur aferprinting. Call 1-800-MEDICARE (1-800-633-4227), or visit www.medicare.gov to get themost current inormation. Y users should call 1-877-486-2048.

Highlighted words are defined in Section 6.
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Contents

Section 1: Getting OrganizedInformation to Know

Planning for Future Health Care Decisions

Managing Health Care

Section 2: Navigating Medicare

What Is Medicare?

Other Medicare Health Plans

Your Medicare Coverage Choices at a Glance

Checking Current CoverageGetting Medicare

Making Changes to Medicare Coverage

Section 3: Health Care Choices

Medicares Preventive Services

Finding a Doctor, Provider, or Supplier

Help with Hospitalization

Home Health Care

Long-Term Care Options

Considering Hospice Care

Section 4: Help with Billing

How to Use a Medicare Summary Notice

Appeals

Reporting Fraud

Section 5: How to HelpNext Steps

Coping with Illness

Ask Medicare - Information to Help You Care for Others

State Health Insurance Assistance Programs

Medicare.gov and MyMedicare.gov

1-800-MEDICARE

Section 6: Definitions
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4

SECTION 1

Getting Organized

My grandmother is having more and more health problems and she needs my help. Where

do I start?

This section has information to help you get organized. Even though it may

seem difficult to know where to begin, there are several things you can do to

make helping or caring for someone with Medicare easier.


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Section 1Getting Organized

Information to Know

Finding out that a person you may have relied on in the past now needs your help can

be hard. Start by talking with the person about his or her health care and prescriptiondrug needs. Its also important to help the person youre caring or gather the ollowinginormation so its readily available:

Social Security number

Medicare number (you can find this on his or her red, white, and blue Medicarecard)

Medicare plan enrollment [more ino on how to check coverage]

Other insurance plans and policy numbers, including long-term care insurance

Contact inormation or health care proessionals like doctors, specialists, nurses, orpharmacists

List o current prescription drugs and dosages

Current health conditions, treatments, and symptoms

History o past health problems

Allergies or ood restrictions

Emergency contacts, such as close riends, neighbors, clergy, or housing manager

Financial and legal inormation

Next Steps

For help keeping track o this inormation, you can do any o the ollowing:

Visit the National Caregivers Library at www.caregiverslibrary.orgto find ree toolsor caregivers. Te National Caregivers Library contains checklists, orms, and otherresources to help you make decisions and get organized.

Visit www.MyMedicare.govto help the person youre caring or register and view hisor her Medicare eligibility, plan enrollment inormation, claims, and more. [moreino]or more inormation.

Visit www.medicare.gov/phrto learn more about Personal Health Records (PHRs)and get details on special PHR projects Medicare is sponsoring in certain states.[more ino]
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6 Section 1Getting Organized

Planning for Future Health Care Decisions

While its important to be sensitive to privacy, asking the person youre caring or to share

some personal inormation about doctors, medicines, and medical history will betterenable you to help him or her plan or health care and prescription drug needs. Its alsoimportant to encourage the person to decide who should have the legal right to makemedical and treatment decisions i he or she is unable.

alk to the person youre caring or about what he or she wants and doesnt want you todo. He or she may wish to authorize someone to make decisions about his or her medicalcare. Tese decisions are generally called advance directives.

In most cases, advance directivesinclude these types o documents:

A health care proxy, which may also be called a Health Care or Medical Power oAttorneyor a Durable Power o Attorneyor Health Care. Tis document names aspecific person who will make the health care decisions or someone who is unableto make decisions.

A living will. Living wills give directions about the kind o health care a personwants when he or she is unable to make a decision. Living wills state which medicaltreatments a person would accept or reuse i his or her lie were threatened and heor she wasnt able to express these wishes.

Afer-death wishes. Tese documents may include decisions such as organ andtissue donation.

I the person youre caring or has advance directives, make sure you know where thesedocuments are, and give copies to his or her doctors, anyone named in the advancedirectives, and perhaps other concerned amily members or riends.

Note:Beore Medicare will disclose personal health inormation to you, the personyoure caring or has to let Medicare know in writing. I you plan on contactingMedicare, it would be a good idea or the person youre caring or to fill out a MedicareAuthorization to Disclose Personal Health Inormation orm. [more ino]
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Section 1Getting Organized

Next Steps

For more inormation on how to become authorized to make health care decisions on

someones behal, you can do the ollowing: Contact your local office on aging, your state health department, or an attorney to

learn more about advance directives. You can also visit www.eldercare.gov, or call1-800-677-1116 to use the Eldercare Locator. Te Eldercare Locator can help youfind local resources and services that serve the older adults.

Get ree, personalized health insurance counseling rom your State Health InsuranceAssistance Program (SHIP). [more ino]

Managing Health CareTe person youre caring or may have health inormation in lots o placesat home orin doctor or hospital records. You may need to know certain inormation about his orher health care to get the best care possible. For example, you may need to know the lasttime he or she had a certain medical procedure. Or, you may need to know the date o acertain surgery or test. It may seem overwhelming to remember all o these details, andtrying to find the inormation when its in lots o places can be hard.

You may be able to help him or her set up a Personal Health Record (PHR). A PHR is

usually an electronic file or record o health inormation and recent services. With aPHR, a person can keep track o his or her health inormation, like the date o his or herlast physical, major illnesses, operations, allergies, or list o medicines. Tis inormationcan be stored in one place, and then shared with others, as needed. Tese easy-to-usetools can help manage health inormation. I a PHR is web-based, it can be used whereverthere is Internet access. Tere are various companies that offer PHRs.

Te person whose inormation is contained in the PHR controls how the inormation isused and who can access it. I you help the person youre caring or set up a PHR, and he

or she gives you access, it may make your job easier.Note: o view the persons Medicare claims, Medicare eligibility, and plan enrollment,

visit www.MyMedicare.gov. I you create a PHR, you can enter the inormation romMyMedicare.gov into the PHR so its easier to view in different ways. [more ino]
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8 Section 1Getting Organized

Next Steps

For more inormation, you can do one o the ollowing:

Visit www.medicare.gov/phrto learn more about PHRs, and get details on specialPHR projects Medicare is sponsoring in certain states.

Visit www.medicare.gov/Publicationsto view the Personal Health Recordsbrochure.
http://www.medicare.gov/phrhttp://www.medicare.gov/Publicationshttp://www.medicare.gov/Publicationshttp://www.medicare.gov/phr


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9

SECTION 2

Navigating Medicare

How are my retired parents paying for their health care? What sort of coverage do they

have?

This section has information that explains what Medicare is and how to get it.

It also explains the different parts of Medicare and what each part covers.


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0 Section 2Navigating Medicare

What Is Medicare?

Medicare is health insurance or the ollowing:

People 65 or older

People under 65 with certain disabilities

People o any age with End-Stage Renal Disease (ESRD) (permanent kidney ailurerequiring dialysis or a kidney transplant)

Medicare Part A (Hospital Insurance)

Helps cover inpatient care in hospitals.

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

Medicare Part B(Medical Insurance)

Helps cover doctors services, hospital outpatient care, and home health care.

Helps cover some preventive services to help maintain your health and to keepcertain illnesses rom getting worse.

Generally pays 80% o the Medicare-approved amountor covered services afer

the Part B deductiblehas been met, with the exception o most preventive serviceswhere Medicare pays 100%.

Medicare Part C (Medicare Advantage Plans)

Medicare Advantage Plans(like an HMO or PPO) are health plans run byMedicare-approved private insurance companies. Medicare Advantage Plans (also calledPart C) include Part A, Part B, and usually other coverage like Medicare prescriptiondrug coverage (Part D), sometimes or an extra cost.

Medicare Part D(Prescription Drug Coverage)

A prescription drug option run by Medicare-approved private insurance companies.

Helps cover the cost o prescription drugs.

May help lower your prescription drug costs and help protect against higher costs inthe uture.
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Other Medicare Health Plans

Some types o Medicare health plans that provide health care coverage arent Medicare

Advantage Plansbut are still part o Medicare. Some o these plans provide Part A and/or Part B coverage, and some also provide Medicare prescription drug coverage. Teseplans have some o the same rules as Medicare Advantage Plans. Some examples includeMedicare Cost Plans, Demonstration or Pilot Programs, and Programs o All-inclusiveCare or the Elderly (PACE).

Note: Medicare demonstrations and pilot programs, sometimes called research studies,are special projects that test improvements in Medicare coverage, payment, and quality ocare. Tey usually operate only or a limited time or a specific group o people and/or areoffered only in specific areas. Check with the demonstration or pilot program or moreinormation about how it works. o find out about current Medicare demonstrationsand pilot programs, call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

Extra Help paying or prescription drugs is available! People with Medicare who havelimited income and resources may qualiy or Extra Help to cover prescription drugs orlittle or no cost. I you think the person youre caring or may qualiy or Extra Help, callSocial Security at 1-800-772-1213 or visit www.socialsecurity.gov. Y users should call1-800-325-0778.

Medicare has been making exciting new changes to help improve health care

things like more free preventive services and lower prescription drug costs. One

change is to offer help in the prescription drug coverage gap.

Most Medicare drug plans have a coverage gap (also called the donut hole). This

means that there is a temporary limit on what the drug plan will cover for drugs.

Once a person enters the coverage gap, he or she gets a 50% discount on covered

brand name drugs and pays 86% of the plans cost for covered generic drugs until

he or she reaches the end of the coverage gap.

In addition to the 50% discount on covered brand-name prescription drugs, there

will be increasing savings for people in the coverage gap each year until the gap

closes in 2020.
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Your Medicare Coverage Choices at a Glance

Tere are two main ways to get your Medicare coverage: Original Medicareor a Medicare

Advantage Plan. Use these steps to help you decide which way to get your coverage.

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

Original Medicare

IncludesPart A: Hospital Insurance and/or

Part B:Medical Insurance

Medicare Advantage Plans

Is also called Part C(like an HMO or PPO) Part C: Combines Part A, Part B, and usually Part D

Step 2:Decide if you need to add drug coverage

Part D:Prescription Drug Coverage. (With a Medicare Advantage Plan, you may beable to add in some plan types i not already included.)

Step 3:Decide if you need to add supplemental coverage

I you choose Original Medicare, you may want to add Medicare SupplementInsurance (Medigap) policy

Note: I you join a Medicare Advantage Plan, you dont need and cant be sold a MedicareSupplement Insurance (Medigap) policy.


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Next Steps

o learn more about the different parts o Medicare, what Medicare covers, and how

much Medicare costs, you do can any o the ollowing: Visit www.medicare.gov.

Visit www.medicare.gov/Publicationsto view the Medicare & You handbook.

Visit www.medicare.gov/Publicationsto view the booklet Your Medicare Benefits.

Visit www.medicare.gov/Publicationsto view the booklet Your Guide to MedicarePrescription Drug Coverage.

Call 1-800-MEDICARE (1-800-633-4227). Y users should call

1-877-486-2048.

Checking Current Coverage

I you dont know what kind o coverage the person youre caring or has, now is the timeto find out. First, check i he or she currently has Medicare. I so, find out i he or shehas Medicare Part A and/or Medicare Part B. Tis inormation is listed on his or her red,white, and blue Medicare card.

You will also want to find out i the person youre caring or is in a Medicare plan like a

Medicare Advantage Plan(like an HMO or PPO) or a Medicare Prescription Drug Plan.I he or she has Original Medicare, check to see i he or she has a Medigap (MedicareSupplement Insurance) policy.

Its essential to find out i the person has other health coverage, such as a health plan witha ormer employer, Veterans benefits, Military benefits (RICARE), Medicaid, or otherinsurance that can help pay or health care needs. I he or she has other health coverage,find out how that coverage will work with Medicare. For example, a person with MedicarePart A who is eligible or RICARE must enroll in Part B or lose the RICARE coverage.

Once you know what Medicare coverage the person has, you will need to make sure thatthe coverage is still meeting his or her needs, and understand when and how to makechanges i its not. [more ino]

I the person doesnt have Medicare, find out i he or she is eligible, what decisions he orshe will need to make, and how to sign up. [more ino]
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Next Steps

o find out what kind o coverage the person youre caring or already has, or to find out

how his or her coverage will work with Medicare, you can do any o the ollowing: Check the persons Medicare card. Also check all other insurance cards that he or

she may have. You can call the phone number on the cards to get more inormationabout the coverage

.

Visit www.MyMedicare.govto help the person youre caring or get direct access to

his or her Medicare eligibility inormation. You can see inormation about his or herMedicare health or prescription drug plan enrollment. [more ino]

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

I the person youre caring or has employer or union coverage, call the employersbenefits administrator.

Call the U.S. Department o Veterans Affairs (VA) at 1-800-827-1000, or visit www.va.govi the person gets Veterans benefits. Y users should call 1-800-829-4833.

Call the company that handles RICARE claims at 1-866-773-0404, or visitwww.tricare.osd.mili the person gets Military benefits. Y users should call1-866-773-0405.

For inormation about Medicaid eligibility, call the State Medical Assistance(Medicaid) office. Call 1-800-MEDICARE and say Medicaid to get their phonenumber, or visit www.medicare.gov/contacts.
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Getting Medicare

A person will get Medicare Part A and B automatically in the ollowing situations:

When a person turns age 65 and is already getting Social Security or RailroadRetirement Board (RRB) benefits. A Medicare card will be mailed about 3 monthsbeore his or her 65th birthday.

When a person is under age 65 and disabled, he or she will automatically get Part Aand B afer getting disability benefits rom Social Security or certain disability ben-efits rom the RRB or 24 months. A Medicare card will be mailed about 3 monthsbeore the 25th month o disability.

A person whose disability is ALS (Amyotrophic Lateral Sclerosis, also known as Lou

Gehrigs disease) will automatically get Medicare Part A and Part B the month thedisability benefits start.

Note: Part B is optional. Someone who doesnt want Part B must ollow the instructionsthat come with the Medicare card, and send the card back. A person who keeps the cardkeeps Part B and will pay Part B premiums.

A person must sign up or Medicare Part A and/or Part B in the ollowing situations:

Te person is not getting Social Security or RRB benefits (or instance, because he

or she is still working) and wants Part A or Part B. Te person should contact SocialSecurity 3 months beore he or she turns 65. People who worked or a railroadshould contact the RRB to sign up.

Te person has End Stage Renal Disease (ESRD) (permanent kidney ailure thatrequires dialysis or a kidney transplant). Te person should visit the local SocialSecurity office, or call Social Security at 1-800-772-1213 to sign up or Part A andPart B. Y users should call 1-800-325-0778. For more inormation, visitwww.medicare.gov/Publicationsto view the booklet, Medicare Coverage o KidneyDialysis and Kidney ransplant Services.

Te person isnt eligible or premium-ree Part A [more ino]but wants to buy PartA. Te person must also sign up or Part B, and should contact Social Security 3months beore he or she turns 65.
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I someone doesnt automatically get Part B, or isnt eligible or premium-ree Part A (seepage 17), he or she can buy Part A and/or sign up or Part B during one o the ollowingtimes:

Initial Enrollment PeriodA person can sign up when first eligible or Part B.(For example, i the person is eligible or Part B when he or she turns 65, the InitialEnrollment Period is a 7-month period that begins 3 months beore the month heor she turns 65, includes the month he or she turns 65, and ends 3 months afer themonth he or she turns 65.)

General Enrollment PeriodI a person didnt sign up or Part A and/or Part Bwhen first eligible, he or she can sign up between January 1March 31 each year.Te coverage will begin on July 1, but he or she may have to pay a late enrollmentpenalty (a higher premium).

Special Enrollment PeriodA person may decide to wait to sign up or Part Aand/or Part B because he or she is covered by a group health plan based on hisor her own or a spouses current employment, (or i disabled, a amily memberscurrent employment). Someone in this situation can sign up or Part A and/orPart B at any time while he or she has group health plan coverage based on currentemployment or during the 8-month period that begins the month afer the employ-ment ends, or the group health plan coverage ends, whichever happens first. Note:Tis Special Enrollment Period doesnt apply to people with ESRD.

Special Enrollment Period or International VolunteersA person who waited tosign up or Part A and/or Part B because he or she had health insurance while vol-unteering in a oreign country has a special opportunity to sign up.

Medicare Part A and Part B Premiums

Most people dont have to pay a monthly premium or Medicare Part A because they ora spouse paid Medicare taxes while they were working. Tis is called premium-ree PartA. Most people do pay a premium each month or Part B.


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Late Enrollment Penalties

A person who doesnt sign up or Part A when he or she is first eligible may have to pay apenalty equal to 10% o the Part A premium. Te 10% premium penalty applies no matter

how long someone delays Part A enrollment. Te person will have to pay the premiumpenalty or twice the number o years he or she could have had Part A, but didnt sign up.

A person who doesnt sign up or Part B when he or she is first eligible may have to paya late enrollment penalty. Te monthly premium or Part B may go up 10% or each ull12-month period that the person could have had Part B, but didnt sign up or it. Teperson will have to pay the premium penalty or a long as he or she has Medicare.

Usually, there is no late enrollment penalty i someone signs up or Part A and/or Part Bduring a special enrollment period.

When can a person with Medicare join a Medicare Advantage Plan (like an HMO orPPO) or a Medicare Drug Plan?

Tere are specific times when a person can sign up or a Medicare Advantage Planor aMedicare drug plan:

When a person first becomes eligible or Medicare or turns 65, during his or herInitial Enrollment Period.

Between October 15December 7 each year, with coverage beginning on January 1

o the ollowing year. Under certain circumstances that qualiy a person or a Special Enrollment Period

(SEP), such as the ollowing:

Moving out o the plans service area

Having both Medicare and Medicaid

Qualiying or Extra Help to pay or prescription drugs

Living in an institution (like a nursing home)

It may be possible to join, switch, or drop a Medicare Advantage Plan at other times,under certain circumstances. [more ino]
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Next Steps

o find out more about how to get Medicare, you can do any o the ollowing:


Visit www.medicare.gov/Publicationsto view the tip sheet Understanding MedicareEnrollment Periods.

Call Social Security at 1-800-772-1213 or more inormation about Medicare eligi-bility and how to sign up or Part A and/or Part B. Y users should call 1-800-325-0778. For inormation about Railroad Retirement Board (RRB) benefits, call yourlocal RRB office or 1-877-772-5772.

Visit www.medicare.gov, and select Find Out i Youre Eligible.

Visit www.medicare.gov/find-a-planto learn more about Medicare Advantage Plans,Medicare drug plans, Medigap policies, and other Medicare health plans.

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

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Making Changes to Medicare Coverage

I the person youre caring or already has Medicare, its a good idea to make sure the

current coverage is still meeting his or her needs. A Medicare health or prescription drugplan can change how much it costs and what it covers each year. Each all, there is an op-portunity to change Medicare coverage options, so you should help the person review hisor her current health and prescription drug coverage. Health, finances, or coverage needsmay change, and the person youre caring or may decide that other coverage will bettermeet his or her needs.

I he or she is satisfied with the current plans cost and coverage or the coming year,nothing else needs to be done. However, i the person wants to make a change, it can bedone during certain times depending on the type o coverage.

Fall Open Enrollment Period

Between October 15December 7 each year, a person with Medicare can join, switch, ordrop a Medicare Advantage Plan(like an HMO or PPO) or a Medicare drug plan. Tecoverage will begin on January 1 o the ollowing year.

Medicare Advantage Disenrollment Period

Between January 1February 14 each year, i someone is in a Medicare Advantage Plan,he or she can leave that plan and switch to Original Medicare.I the person switches to

Original Medicare during this period, he or she will have until February 14 to also join aMedicare Prescription Drug Planto add drug coverage. Te coverage will begin the firstday o the month afer the plan gets the enrollment orm.

During this period, a person cantdo the ollowing:

Switch rom Original Medicare to a Medicare Advantage Plan.

Switch rom one Medicare Advantage Plan to another.

Switch rom one Medicare Prescription Drug Plan to another.

Join, switch, or drop a Medicare Medical SavingsAccount Plan.
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In most cases, a person must stay enrolled in a Medicare Advantageor MedicarePrescription Drug Planor a whole calendar year. However, there are exceptions, such asthe ollowing:

Moving out o the plans service area

Having both Medicare and Medicaid

Qualiying or Extra Help to pay or prescription drugs

Living in an institution (like a nursing home)

Next Steps

Beore recommending any decisions, learn as much as you can about the types o cover-age available to the person youre caring or. Te ollowing resources are available i youneed help deciding what to recommend:


Visit www.medicare.gov/Publicationsto view the tip sheet Understanding MedicareEnrollment Periods.

Call Social Security at 1-800-772-1213 or more inormation about Medicare eli-gibility and how to sign up or Part B. Y users should call 1-800-325-0778. For

inormation about Railroad Retirement Board (RRB) benefits, call your local RRBoffice or 1-877-772-5772.

Visit www.medicare.gov, and select Find Out i Youre Eligible.

Visit www.medicare.gov/find-a-planto learn more about Medicare Advantage Plans,Medicare drug plans, Medigap policies, and other Medicare health plans.


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1

SECTION 3

Health Care Choices

How are my retired parents paying for their health care? What sort of coverage do they

have?

Helping someone make health care choices can be difficult. This section

explains the different types of care available through Medicare and gives you

information to help you make informed recommendations for the person

youre caring for.

Tere have been many recent improvements to Medicare.

One important new benefit is the Yearly Wellness visit. Tis is a chance orsomeone to review his or her health with their provider and talk about whatcan be done to stay as healthy as possible. o help, the person may be askedto answer a short questionnaire called a Health Risk Assessment, as part othis visit. See the next page or more inormation about Medicares preventiveservices.


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2 Section 3Health Care Choices

Medicares Preventive Services

Te best way or you and the person you are caring or to stay healthy is to live a healthy

liestyle. You can live a healthy liestyle and prevent disease by exercising, eating well,keeping a healthy weight, and not smoking. Medicare can help you and the person yourecaring or ocus on preventive care.

Medicare pays or many preventive services to keep people with Medicare healthy.Preventive services can find health problems early, when treatment works best, and canhelp prevent certain diseases or illnesses. Preventive services include exams, lab tests, andscreenings. Tey also include shots, monitoring, and inormation to help people take careo their health.

Medicare helps pay or these ollowing preventive tests and services:

Shots

Pneumococcal

Flu

Hepatitis B (or people at medium to high risk)

Exams

One-ime Welcome to Medicare Preventive Visit (within the first 12 months thatyou have Part B)

Yearly Wellness visit


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Screenings

Colorectal Cancer

Prostate Cancer Breast Cancer (mammograms)

Pelvic Exam

Clinical Breast Exam (as part o the pelvic exam)

Other Preventive Benefits and Benefits to Help Keep You Healthy

Diabetes Supplies and Sel-Management raining

Bone Mass Measurement

Medical Nutrition Terapy

obacco Use Cessation (counseling to quit smoking)

Original Medicarecovers 100% o the Medicare-approved amountor most preventiveservices. Additional conditions will apply.

Next Steps

o learn more about Medicares preventive services, you can do any o the ollowing:

Call 1-800-MEDICARE (1-800-633-4227) to find out what preventive services theperson is able to get and when they are able to get them. Y users should call1-877-486-2048.

Visit www.MyMedicare.govto help the person youre caring or get direct access tohis or her preventive health inormation. You can see a description o covered pre-

ventive services, the date he or she last had the service, and the next date he or shecan get the service. [more ino]

Visit www.medicare.gov/Publicationsto view the booklet Your Guide to MedicaresPreventive Services.
http://-/?-http://-/?-http://www.mymedicare.gov/http://www.medicare.gov/Publicationshttp://www.medicare.gov/Publicationshttp://www.mymedicare.gov/http://-/?-http://-/?-


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Finding a Doctor, Provider, or Supplier

I youre helping someone you care or choose a doctor, provider, or supplier, its impor-

tant to know how he or she gets his or her Medicare coverage.

I the person has Original Medicare, he or she can go to any doctor, provider, or supplierthats enrolled in Medicare and is accepting new Medicare patients. Most doctors, provid-ers, and suppliers accept assignment, but you should always check to make sure.

Note: Assignment can save a person with Medicare money because it is an agreementby a doctor, provider, or supplier to be paid directly by Medicare, to accept the paymentamount Medicare approves or the service, and not to bill or any more than the Medicaredeductibleand coinsurance.

Medicare Advantageand other Medicare health plans usually have different rules or howto get services. For example, a person who belongs to an HMO may have to go to certaindoctors, providers, or suppliers that belong to the plan or the plan to pay. Also, he or shemay need a reerral to see a specialist.

Note: No matter how the person youre caring or gets his or her Medicarecoverage, its a good idea to ask a doctor, provider, or supplier these questions:

Are you accepting new Medicare patients?

Do you accept the persons Medicare plan?

Do you provide and track preventive services, like shots and screenings?

Do you e-prescribe (prescribe medicine electronically)?

What are your office hours?

Which hospitals do you use?

Next StepsI you need help finding a doctor or provider or someone, you can do one o theollowing:

o find doctors and suppliers who accept assignment,visit www.medicare.gov/find-a-doctoror www.medicare.gov/supplier. You can also call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048.

I the person youre caring or is in a Medicare Advantageor other Medicare healthplan, call the plan or check his or her plan materials or more inormation.
http://-/?-http://-/?-http://-/?-http://-/?-http://www.medicare.gov/find-a-doctor/provider-search.aspxhttp://www.medicare.gov/find-a-doctor/provider-search.aspxhttp://www.medicare.gov/supplierhttp://-/?-http://-/?-http://www.medicare.gov/supplierhttp://www.medicare.gov/find-a-doctor/provider-search.aspxhttp://www.medicare.gov/find-a-doctor/provider-search.aspxhttp://-/?-http://-/?-http://-/?-http://-/?-


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Help with Hospitalization

Much like choosing a doctor, provider, or supplier, choosing a hospital generally depends

on how someone gets his or her Medicare coverage.

I the person youre caring or is able to plan ahead and has Original Medicare, he or shecan choose among any hospital or acility that accepts people with Medicare.

I the person youre caring or is in a Medicare health plan, he or she may have to go tocertain hospitals or acilities that belong to the plan or the plan to pay.

In an emergency, he or she should always go to the nearest hospital, even i it isnt on aplans list.

Everyone with Medicare is able to get the ollowing inpatient hospital care:

General nursing

Semi-private room

Diagnostic and therapeutic services such as surgical and medical services providedby the hospital, which may not include the doctors services

Meals and supplies

Original Medicare doesntpay or the ollowing services:

Private-duty nursing

Private room (unless medically necessary)

elevision and phone

Note:Some Medicare Advantageand other Medicare health plans may cover theseservices. Check with your plan or more inormation.

While the person youre caring for is in a hospital or skilled nursing facility, the

staff is planning for the day he or she goes home or to another facility. During hisor her stay in a hospital, nursing home, or other health care setting, the staff will

work with you to plan for his or her discharge. Youre an important member of

the planning team. Ask to see the plan of care, talk about treatment options, and

be aware of Medicares discharge appeal rights. Most importantly, make sure the

persons wishes are known. Medicares discharge planning checklist can help. Visit

www.medicare.gov/Publications to view Your Discharge Planning Checklist.
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Next Steps

I you need help finding a hospital or someone, you can do one o the ollowing:

o find and compare hospitals, visit www.medicare.gov/hospital. You can also call1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

I the person youre caring or is in a Medicare health plan, call the plan or check hisor her plan materials or more inormation.

Home Health Care

Te right kind o support can go a long way to help people continue to lead independent,productive lives at home. ogether, you and the person youre caring or should start bychecking with his or her doctor about what services are needed and who provides them.

Home health careunder Original Medicareis short-term skilled care at home or thetreatment o an illness or injury, ofen ollowing a hospitalization. Tis includes skillednursing care, physical therapy, occupational therapy, speech-language pathology, medicalsocial work, and care by home health aides. Home health services may also includemedical social services, or durable medical equipment (such as wheelchairs, hospitalbeds, oxygen, and walkers) and medical supplies or use at home. Medicare doesnt pay

or ull-time personal care, homemaker services (shopping, cleaning, laundry), or homemeal delivery.

Medicare home health care benefits are available to patients i they meet all o the ollow-ing conditions:

1. Te patient must be under the care o a doctor, and must be getting services under aplan o care established and reviewed regularly by a doctor.

2. Te patient must need, and a doctor must certiy that the patient needs, one or more

o the ollowing: Intermittent skilled nursing care

Physical therapy

Speech-language pathology services

Continued occupational therapy
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3. Te home health agency caring or the patient must be approved by Medicare(Medicare-certified).

4. Te patient must be homebound, and a doctor must certiy that he or she ishomebound. o be homebound means the ollowing:

Leaving home isnt recommended because o the patients condition.

Te condition keeps the patient rom leaving home without help (such as using awheelchair or walker, needing special transportation, or getting help rom anotherperson).

Leaving home takes a considerable and taxing effort.

Note: A person may leave home or medical treatment or short, inrequent absences ornon-medical reasons, such as attending religious services. A patient can still get homehealth care i he or she attends adult day care, but he or she would get the home careservices in the home.

Medicare Advantageand other Medicare health plans may have additional rules or homehealth services. All Medicare health plans must cover at least the same home health ser-

vices as Original Medicare.

Next Steps

I you need help finding a home health agency, or would like more inormation onMedicare home health care, you can do any o the ollowing:

Ask the doctor or the hospital discharge planner or their recommendations.

Use a senior community reerral service or agency. Visit the Ask Medicare Web siteat www.medicare.gov/caregivers to find resources in the community. [more ino]

o find and compare home health agencies, visitwww.medicare.gov/HHCompare. You can also call 1-800-MEDICARE (1-800-633-

4227). Y users should call 1-877-486-2048. Visit www.medicare.gov/Publications to view the booklet Medicare and Home

Health Care. Tis booklet contains a Home Health Agency Checklist that can beused when choosing a home health agency.

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Long-Term Care Options

Serious and chronic illness or disability may create a need or long-term care. Its a deci-

sion you and the person youre caring or should discuss with the doctor, as well as otheramily members. Long-term care can be provided at home, in the community, in anassisted living acility, or in a nursing home. Medicare and most health insurance plans,including Medigap (Medicare Supplement Insurance)policiesdont pay or this typeo care.

Medicare only covers certain skilled nursing acility carethats needed daily on a short-term basis (up to 100 days). Skilled nursing acility care is skilled care given when theperson needs skilled nursing or rehabilitation staff to manage, observe, and evaluate hisor her care on an inpatient basis. Examples o skilled care include changing sterile dress-ings and physical therapy. Care that can be given by non-proessional staff isnt consid-ered skilled care. Medicare only covers skilled nursing acility care afer a 3-day qualiyinghospital stay.

Tere are times when a persons needs extend beyond the short-term skilled nursingacility care covered by Medicare. You should explore all o the options that are availablein the community. Ofen, community-based senior citizens services offer companionship

visits, help around the house, meal programs, caregiver respite, adult day care services,transportation, and more. Tese support services may be unded by state and county

programs or offered by aith-based or volunteer groups. Community-based servicesacross the country support independent living and are designed to promote the health,well-being, and independence o older adults. Tese services can also supplement thesupportive activities o caregivers.

I other options available in the community arent enough to provide the level o care thatthe person youre caring or needs, you may need to help him or her choose a nursinghome. I he or she needs to move into a nursing home, ollow these steps to find a nursinghome that best meets his or her needs:

1. Find nursing homes in his or her area. Compare the quality o nursing homes you andthe person are considering. Look at health inspection and fire saety inspection reports,nursing home staffing rates, quality measures, and other important inormation suchas how many stars they received on their quality rating. One way to find and comparenursing homes is to use the Nursing Home Compare Web site by

visiting www.medicare.gov/NHCompare. You can also call 1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.
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2. Visit the nursing homes you and the person are interested in. For a nursing homechecklist that can help you with your search, visit www.medicare.gov/Publicationsto

view Medicares Guide to Choosing a Nursing Home.

Long-term carecan be very expensive. Tere are many ways people can pay or long-termcare. Most people who enter nursing homes begin by paying or their care out o theirown pocket. Others may be able to get help rom their state or use long-term care insur-ance. As they use up their resources over a period o time, they may eventually becomeeligible or Medicaid.

Note: Medicaid is a state and Federal program that will pay most nursinghome costs or certain people with limited income and resources. Eligibility

varies by state. Medicaid pays or care or about 7 out o every 10 nursing homeresidents. Medicaid will pay or nursing home care only when provided in aMedicaid-certified acility. For inormation about Medicaid eligibility, callyour State Medical Assistance (Medicaid) office. Call 1-800-MEDICARE (1800 633-4227) and say Medicaid to get their phone number, or visit www.medicare.gov/contacts. Y users should call 1-877-486-2048.

Next Steps

I you need help finding long-term careor someone, there are many resources available.You can do any o the ollowing:

Visit www.medicare.gov/NHCompare.

Visit www.longtermcare.gov to learn more about planning or long-term care anddownload the Long-erm Care Planning Kit.

Contact the Aging and Disability Resource Center (ADRC). ADRCs assist people oall incomes and ages. Forty-three states have ADRCs. o find out i someones area isserved by an ADRC, visit www.adrc-tae.org.

Contact the Centers or Independent Living (CILs). CILs assist people with dis-abilities o all incomes and ages. A state-by-state directory o CILs can be ound by

visiting www.ncil.org/directory.html.
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Contact your local Area Agency on Aging (AAA). o find the AAA in your area,call the Eldercare Locator at 1-800-677-1116 weekdays rom 9:00 a.m. to 8:00 p.m.(ES), or visit www.eldercare.gov.

For more inormation about help paying or nursing care and other health carecosts, call your State Health Insurance Assistance Program [more ino]or yourLong-term Care Ombudsman. o find their phone numbers, visit www.medicare.gov/contacts.

For more inormation on Medicare coverage o skilled nursing acility care, visitwww.medicare.gov/Publications to view the booklet Medicare Coverage o SkilledNursing Facility Care.


Considering Hospice Care

Hospicecare is a special way o caring or people who are terminally ill that also helpstheir amilies cope. Te goal o hospice is to provide end-o-lie care, not to cure theillness. Tis care includes treatment to relieve symptoms and keep the individual com-ortable. It includes medical care, nursing care, social services, drugs or the terminal andrelated conditions, durable medical equipment, counseling, and other types o items and

services.

Medicares hospice benefit provides or support and comort to terminally ill patientsincluding some services not usually paid or by Medicare. o be eligible or hospice care,all o the ollowing must be true:

Te patient must have Medicare Part A.

Te doctor and hospice medical director must certiy that the patient is terminallyill and has 6 months or less to live.

Te patient must sign a statement choosing hospice care instead o routineMedicare-covered benefits or the terminal illness.

Te patient must get care rom a Medicare-approved hospice program.
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Below is inormation providing a snapshot o Original Medicarecoverage or hospicecare.

Medicare helps pay or the ollowing services:

Medical caredoctors services, skilled nursing

Support caresocial services, hospice aide services, homemaker services

Short-term inpatient care, including respite care

Terapyphysical therapy, occupational therapy, speech-language pathology

Counselingdietary counseling, spiritual counseling, other counseling or patientand amily

Drugsor symptom control and pain relie (except coinsuranceup to $5 perprescription)

Medical supplies and equipmenthospital beds, walkers, wound dressings

Certain conditions will apply.

Although Medicare hospicebenefits dont include treatment to cure terminal illness, ahospice patient will continue to have Medicare benefits to help pay or treatment o con-ditions unrelated to the terminal illness. I the patients health improves or the illness goes

into remission, he or she always has the right to stop getting hospice care.Most hospice patients get hospice care in the comort o their home and with their ami-lies. Depending on the patients condition, then may also get hospice care in a Medicare-approved hospice acility, hospital, or nursing home. Hospice volunteers are available todo household chores, provide companionship, and offer support to the patient and amily.Medicare pays or inpatient respite careso that the usual caregiver can rest.

Medicare Advantageand other Medicare health plans must provide inormation on theMedicare-certified hospices available in your area. A person is ree to elect hospice care

rom any available Medicare hospice even i he or she is enrolled in a Medicare Advantageor other Medicare health plan.


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Consider these questions when selecting hospice care providers:

Is the hospice program certified and licensed by the state or Federal government?

Does the hospice provider train caregivers to care or the patient at home?

How will the patients doctor work with the doctor in the hospice program?

How many other patients are assigned to each member o the hospice care staff?

Does the hospice staff meet regularly with the patient and amily to discuss care?

How does the hospice staff respond to afer-hour emergencies?

What measures are in place to ensure hospice care quality?

What services do hospice volunteers offer? Are they trained?

Next Steps

I you need help finding a hospiceprogram or someone, or i you would like more inor-mation on Medicares hospice benefits, you can do any o the ollowing:

Contact your State Hospice Organization. You can find their phone number in the bluepages o your phone book or by visiting www.medicare.gov/contacts.

Visit www.medicare.gov/Publicationsto view the booklet Medicare Hospice Benefits.


I the person youre caring or is in a Medicare Advantageor other Medicare health plan,you can call the plan or check his or her plan materials or more inormation. You canalso use the resources listed above. In any event, the person is ree to elect hospice carerom any available Medicare hospice even though he or she is enrolled in a MedicareAdvantage or other Medicare health plan.
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3

SECTION 4

Help with Billing

Alice asked for my help. Shes in the hospital, and Im trying to sort out her bills.

You can protect the person youre caring for and Medicare by knowing his or

her rights (including the right to appeal) and how to identify and report fraud.

This section tells you how to read a Medicare Summary Notice (MSN) and

what to do if you disagree with something on the MSN.


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4 Section 4Help With Billing

How to Use a Medicare Summary Notice

I a person with Original Medicaregets a Medicare-covered service, he or she will get

a Medicare Summary Notice (MSN) in the mail. MSNs are mailed every 3 months. IMedicare owes someone a reund, the MSN will be mailed as soon as the claim is pro-cessed. Te MSN isnt a bill. Te notice lists the services the person got and the amounthe or she may be billed by a hospital, doctor, or other provider. Tese notices are sent bycompanies that handle bills or Medicare.

When the person youre caring or gets an MSN, you should do the ollowing:

I he or she has other insurance, check to see i it covers anything that Medicaredidnt.

Keep receipts and bills, and compare them to the MSN to be sure he or she got allthe services, supplies, or equipment listed. [more ino]

I he or she paid a bill beore getting the MSN, compare the MSN with the bill tomake sure he or she paid the right amount or the services.

I a person with Medicare disagrees with the inormation on an MSN, he or she can filean appeal. Inormation on how to appeal is included on the notice.

Next Steps

For more inormation about the MSN, you have the ollowing options:

o view a sample MSN and get inormation on how to read it, visit www.medicare.gov, and select Medicare Basics and then Understanding Claims.

o order a copy o an MSN, call 1-800-MEDICARE (1-800-633-4227). Y usersshould call 1-877-486-2048.

o help someone view his or her Medicare claims and order copies o his orher MSNs, visit www.MyMedicare.gov. See page 46 or more inormation about

MyMedicare.gov. I the person youre caring or needs to change his or her address on MSNs, call

Social Security at 1-800-772-1213. Y users should call 1-800-325-0778. I heor she gets Railroad Retirement Board (RRB) benefits, call the local RRB office at1-877-772-5772.

For questions about a statement rom a Medicare Advantage Plan, MedicarePrescription Drug Plan, or Medigap policy, call the benefits coordinator at thecompany or health plan that offers the plan. o locate phone numbers, look at thenotice or bill rom the plan.
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5 Section 4Help With Billing

Appeals

All people with Medicare have certain guaranteed rights. One o these is the right to get

a review (appeal) o certain decisions about health care payment, coverage o services, orprescription drug coverage.

Inormation on how to file an appeal is on the Medicare Summary Notice MSN) or in thehealth or drug plan materials.

Note: I the person youre caring or wants you to file an appeal on his or her behal, heor she will need to complete an Appointment o Representative orm. You can findthis orm by visiting www.cms.gov/cmsorms/downloads/cms1696.pd or by calling1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

Next Steps

I the person youre caring or decides to file an appeal, you can help by doing theollowing:

Ask the doctor or provider or any inormation that may help the case.

Call the State Health Insurance Assistance Program (SHIP) or help filing an appeal.[more ino]

Visit www.medicare.gov/Publications to view the booklet Medicare Appeals. Call 1-800-MEDICARE. Call the plan or check his or her plan materials i he or she

is in a Medicare Advantageor other Medicare health plan.

Visit www.medicare.gov/appeals or more inormation.


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7

SECTION 5

How to HelpNext Steps

Henry is doing better after his illness, but he may need some ongoing help. How do I find him

the services he needs?

You can support the person youre caring for by becoming familiar with

Medicare and other services. The resources in this booklet provide a starting

point. Once you gather the information, the next step is to contact the people

and organizations that can help. This section explains some of Medicares

resources, and tells you where to find more help.


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8 Section 5How to Help - Next Steps

Coping with Illness

Facing a chronic health condition or surgery will raise questions and increase concerns

or the person youre caring or. Having your support is important. alk with this personabout his or her condition and treatment and about what the doctor said during visits.Going over the acts may relieve some concerns and give a more realistic picture o thesituation. Having you to talk to will be comorting and helpul as he or she makes healthcare decisions.

Helping someone cope with a serious health condition, especially over a long period otime, can be physically and emotionally draining.

I you are a caregiver, there are a ew things you can do:

Find someone you can talk to about your eelings. All o them are legitimate, eventhose that upset you.

Set realistic goals. Balancing work, amily, and time or yoursel is difficult.Determine your priorities and turn to other people or help with some tasks.

Carve out time or yoursel, even i its just an hour or two.

Note: I available, take advantage o respite care. Respite care is a service that providestemporary care. Respite care may mean help with a specific task or having health care

providers care or the individual at home or in an extended care acility while you taketime off. Medicare doesnt usually pay or respite care, except or when it is related tohospice care. However, other help may be available.


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Next Steps

Sharing experiences with others can help you manage stress, locate resources, and reduce

eelings o isolation. Tere may be resources in your community that can help. o locate acaregiver support group in your area, you can do any o the ollowing:

Check the newspaper or local library to find help that is available in yourcommunity.

Contact your local Area Agency on Aging. Visit the Eldercare Locator at www.eldercare.gov, or call 1-800-677-1116 or your local Area Agency on Aging phonenumber.

Visit the Ask Medicare Web site at www.medicare.gov/caregiversto find resources

or caregivers in your community and online. [more ino] Check to see i help is available through your employee assistance program at work.

You may be able to talk to a proessional who is trained to provide counseling oncaregiving issues.
http://www.eldercare.gov/http://www.eldercare.gov/http://www.medicare.gov/caregivershttp://www.medicare.gov/caregivershttp://www.eldercare.gov/http://www.eldercare.gov/


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Ask Medicare - Information to Help You Care for Others

Medicare is working to meet the needs o people with Medicare and those who care or

them. Medicare has two tools to help you get the inormation you need.

Ask Medicare is Medicares premier Web site or caregivers. Visitwww.medicare.gov/caregivers to help the person youre caring or choose a drug plan,compare nursing homes, get help with billing, find local care resources, and more.

From the Ask Medicare Web site, you can sign up or Medicares reebi monthly e-Newsletter to get the latest inormation, including important dates, changesto Medicare, resources in your community, and tips to help you take care o yoursel andthe person youre caring or.


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State Health Insurance Assistance Programs

Te State Health Insurance Assistance Program (SHIP) provides ree, personalized coun-

seling and assistance about Medicare and insurance-related issues. Te SHIP can helppeople with Medicare, or amily and riends who have authorization to help someonewith Medicare.

You can meet with a SHIP counselor ace-to-ace or over the phone or personal assis-tance. Te counselors at your SHIP office can answer general questions about enrollmentin Medicare plans,long-term care insurance, claims and billing problems, inormationand reerrals on public benefit programs or those with limited income and resources,and other health insurance benefit inormation. When you have a Medicare concern,your SHIP is a good place to start or solutions.

o get the most up-to-date SHIP phone numbers, call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov/contacts. Y users should call 1-877-486-2048.

Medicare.gov and MyMedicare.gov

Visit www.medicare.gov to view the official U.S. Government Web site or people withMedicare. Its an easy-to-use, comprehensive resource. Here are some o the things you orthe person youre caring or can do on the Web site:

Find out i he or she is eligible or Medicare and when he or she can enroll.

See what Medicare covers, including preventive services.

Get detailed inormation about the Medicare health and prescription drug plans inhis or her area, including what they cost and what services they provide.

Find doctors and suppliers who provide Medicare services or products.

Get inormation about the quality o care provided by nursing homes, hospitals,home health agencies, Medicare plans, and dialysis acilities.

Get Medicare appeals inormation and orms. Look up helpul phone numbers.

View Medicare publications.
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Medicares secure online service or accessing your personal Medicare inormation, www.MyMedicare.gov, is available 24 hours a day, every day. You can help the person yourecaring or register on the site. On www.MyMedicare.gov, you or the person can do theollowing:

Complete an Initial Enrollment Questionnaire so Medicare can process his or herbills correctly.

Create and print an On the Go report that lists inormation you can share withproviders.

rack health care claims.

Order a duplicate Medicare Summary Notice (MSN) or replacement Medicare card.

Check Part B deductiblestatus.

View eligibility inormation.

rack the preventive services he or she can get.

Find inormation about his or her Medicare health or prescription drug plan, orsearch or a new one.

Keep his or her Medicare inormation in one convenient place.

Sign up to get the Medicare & You handbook electronically.
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1-800-MEDICARE

Medicare is here or you 24 hours a day, every day. Call 1-800-MEDICARE (1-800-633-

4227) to talk with a Medicare customer service representative. Y users should call1-877-486-2048.

You or the person youre caring or can call 1-800-MEDICARE or any o the ollowingreasons:

Get answers to questions about what Medicare Part A and Part B cover.

Get inormation about his or her claims.

Ask or inormation about his or her Medicare health coverage choices including

cost, benefits, quality, and more. Get inormation and ask questions about Medicare health and prescription drug

plans in his or her area, including what they cost and what services they provide.

Join a Medicare Prescription Drug Planor Medicare Advantage Plan(like an HMOor PPO) when eligible.

Get inormation about nursing homes, hospitals, home health agencies, and dialysisacilities in his or her area.

Get inormation about Medicare appeal and patient rights.

Ask or Medicare publications, including the Medicare & You handbook.

Get helpul phone numbers.

Beore you call, have the persons Medicare number rom his or her red, white, and blueMedicare card available.


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Medicare cant give personal health inormation unless the person youre caring or givesverbal permission while youre on the phone or has submitted written authorization. Itsa good idea to have the person youre caring or fill out an authorization orm in advance.He or she can do this in the ollowing ways:

Fill out and submit an e-Authorization Form online by visitingwww.medicare.gov/MedicareOnlineForms. I the person youre caring or is havingdifficulty completing the orm online, he or she can call 1-800-MEDICARE and askthe customer service representative to help submit the orm electronically while onthe phone. Filling out the orm online lets you immediately call and speak on behalo the person youre caring or.

Download and complete a PDF version o the Standard Authorization orm by

visiting www.medicare.gov/MedicareOnlineForms. Te person youre caring or canmail the completed, signed orm to:

Medicare BCC, Written Authorization DepartmentPO Box 1270Lawrence, Kansas 66044

You can also have the person call 1-800-MEDICARE and ask the customer servicerepresentative to help fill out the Standard Authorization orm over the phone. Tecustomer service representative will mail the completed orm to the person youre

caring or to sign and return. Filling out the paper authorization orm takes moretime and you will generally need to wait a ew weeks beore youre able to call andspeak on his or her behal.

I you need help resolving an issue on a Medicare claim or someone who haspassed away, you must have the Medicare Summary Notice (MSN) beoreasking 1-800-MEDICARE questions about the claim. I you dont have an MSN,please call 1-800-MEDICARE and ask or one. It will be sent to the address

listed in Medicares records. Medicare cant change the address on the personsrecord, but Social Security may be able to help you with changing the address.Call Social Security at 1-800-772-1213 or more inormation.
http://www.medicare.gov/MedicareOnlineFormshttp://www.medicare.gov/MedicareOnlineFormshttp://www.medicare.gov/MedicareOnlineFormshttp://www.medicare.gov/MedicareOnlineForms


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SECTION 6

Definitions

Advance Directive

A written document stating how you want medical decisions to be made i you lose theability to make them or yoursel. It may include a Living Will and a Durable Power oAttorney or health care.

Coinsurance

An amount you may be required to pay as your share o the cost or services afer you payany deductibles. Coinsurance is usually a percentage (or example, 20%).

Deductible

Te amount you must pay or health care or prescriptions, beore Original Medicare, yourprescription drug plan, or your other insurance begins to pay.


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46 Section 6Definitions

Durable Power of Attorney

A legal document that enables you to designate another person to act on your behal in

the event you become disabled or incapacitated.Home Health Care

Health care services and supplies a doctor decides you may receive in your home undera plan o care established by your doctor. Medicare only covers home health care on alimited basis as ordered by your doctor.

Hospice

A special way o caring or people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritualneeds o the patient. Hospice also provides support to the patients amily or caregiver aswell.

Living Will

A legal document also known as a medical directive or advance directive. It states yourwishes regarding lie-support or other medical treatment in certain circumstances,usually when death is imminent.

Long-term Care

A variety o services that help people with their medical and non-medical needs over aperiod o time. Long-term care can be provided at home, in the community, or in varioustypes o acilities, including nursing homes and assisted living acilities. Most long-termcare is custodial care. Medicare doesnt pay or this type o care i this is the only kind ocare you need.

Long-term Care Ombudsman

An independent advocate (supporter) or nursing home and assisted living acility resi-dents who works to solve problems between residents and nursing homes or assisted

living acilities. Tey may be able to provide inormation about home health agencies intheir area.


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Medicare Advantage Plan (Part C)

A type o Medicare health plan offered by a private company that contracts with Medicare

to provide you with all your Medicare Part A and Part B benefits. Medicare AdvantagePlans include Health Maintenance Organizations, Preerred Provider Organizations,Private Fee-or-Service Plans, Special Needs Plans, and Medicare Medical SavingsAccount Plans. I youre enrolled in a Medicare Advantage Plan, Medicare services arecovered through the plan and arent paid or under Original Medicare. Most MedicareAdvantage Plans offer prescription drug coverage.

Medicare-approved Amount

In Original Medicare, this is the amount a doctor or supplier that accepts assignment canbe paid. It may be less than the actual amount a doctor or supplier charges. Medicare payspart o this amount and youre responsible or the difference.

Medicare Cost Plan

A type o Medicare health plan available in some areas. In a Medicare Cost Plan, i youget services outside o the plans network without a reerral, your Medicare-coveredservices will be paid or under Original Medicare (your Cost Plan pays or emergencyservices or urgently needed services).

Medicare Medical Savings Account (MSA) Plan

MSA Plans combine a high-deductible Medicare Advantage Plan and a bank account.Te plan deposits money rom Medicare into the account. You can use the money in thisaccount to pay or your health care costs, but only Medicare-covered expenses counttoward your deductible. Te amount deposited is usually less than your deductibleamount so you generally will have to pay out-o-pocket beore your coverage begins.MSA Plans cant offer Part D prescription drug coverage, but you can enroll in a Medicareprescription drug plan while youre enrolled in a MSA Plan.

Medicare Prescription Drug Plan

A stand-alone drug plan that adds prescription drug coverage to Original Medicare,some Medicare Cost Plans, some Medicare Private-Fee-or-Service Plans, and MedicareMedical Savings Account Plans. Tese plans are offered by insurance companies andother private companies approved by Medicare. Medicare Advantage Plans may also offerprescription drug coverage that ollows the same rules as Medicare Prescription DrugPlans.


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Medigap Policy

Medicare supplement insurance sold by private insurance companies to fill gaps in

Original Medicare coverage.Original Medicare

Original Medicare is ee-or-service coverage under which the government pays yourhealth care providers directly or your Part A and/or Part B benefits.

Power of Attorney

A document that lets you appoint someone you trust to make decisions about yourmedical care. Tis type o advance directive also may be called a health care proxy, ap-pointment o health care agent, or a durable power o attorney or health care.

Programs of All-Inclusive Care for the Elderly (PACE)

A special type o health plan that provides all the care and services covered by Medicareand Medicaid as well as additional medically-necessary care and services based on yourneeds as determined by an interdisciplinary team. PACE serves rail older adults whoneed nursing home services but are capable o living in the community. PACE combinesmedical, social, and long-term care services and prescription drug coverage.

Respite Care

emporary or periodic care provided in a nursing home, assisted living acility, or othertype o long-term care program so that a amily member or riend who is the patientscaregiver can rest or take some time off.

Skilled Nursing Facility (SNF) Care

Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in askilled nursing acility.


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You cant always plan ahead when you need health care, but when you can,take time to compare. Medicare collects information about the quality of care

and services given by most Medicare plans and other health care providers. Visit

www.medicare.gov to compare the quality of care and services given by health

and prescription drug plans, health care providers, and facilities nationwide.

If you have a question or complaint about the quality of care that the person youre

caring for has received, call your local Quality Improvement Organization (QIO).

Call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov/contracts to

get your QIOs phone number. TTY users should call 1-877-486-2048.


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0

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers or Medicare & Medicaid Services

7500 Security BoulevardBaltimore, Maryland 21244-1850

Official Business

Penalty or Private Use, $300

CMS Product No. 11034Revised May 2011

Medicare

ask

Necesita una copia en espaol? Visite www.medicare.gov en el sitio Web. Parasaber si esta publicacin esta impresa y disponible (en espaol), llame GRAISal 1-800-MEDICARE (1-800-633-4227). Los usuarios de Y deben llamar al1-877-486-2048.

Medicare Basics 2014

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