11-29-061 understanding medicare module 1. 11-29-062 lessons 1.medicare basics 2.original medicare...
TRANSCRIPT
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Lessons
1. Medicare Basics
2. Original Medicare Plan
3. Medicare Advantage Plans (Part C) and other Medicare plans
4. Medicare prescription drug coverage (Part D)
5. Programs for people with limited income and resources
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Medicare BasicsLesson 1 Topics
Medicare overviewEnrollmentPart APart BMedicare plan choices
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Medicare Health insurance for people
Age 65 and olderUnder age 65 with certain disabilitiesAny age with End-Stage Renal Disease (ESRD)
Administered byCenters for Medicare & Medicaid Services (CMS)
Enroll throughSocial Security Administration (SSA) orRailroad Retirement Board (RRB)
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Applying for Medicare
Apply 3 months before age 65Need not be retired
Automatically enrolled if receive Social Security or Railroad Retirement benefitsIf don’t already receive benefits, apply
3 months before age 65• Call SSA at 1-800-772-1213
– TTY users call 1-800-325-0778
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Medicare
Medicare hasPart A – Hospital coveragePart B – Medical coveragePart C – Medicare Advantage Plans (like
HMOs and PPOs)Part D – Prescription drug coverage
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Paying for Medicare Part A
Most people receive Part A premium free People with less than 10 years of Medicare-
covered employmentCan pay a premium to get Part A
For information, call SSA1-800-772-1213TTY users call 1-800-325-0778
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Enrolling in Medicare Part B
Initial Enrollment Period (IEP)7 months beginning 3 months before age 65
General Enrollment Period (GEP)January 1 through March 31 each yearCoverage effective July 1Premium increases 10% for each 12-month
period you were eligible but did not enroll• Pay this penalty as long as you have Part B
• Limited exceptions
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Enrolling in Medicare Part B
Special Enrollment PeriodSign up within 8 months of the end of
employer or union health plan coverageNo increased premium
For questions or to enrollCall SSA or RRB
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Paying for Medicare Part B
Monthly Medicare Part B premium2006
• Most people pay $88.50
2007• Most people pay $93.50
• Some with higher incomes pay more
Some programs may help
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Paying the Part B Premium
Taken out of your monthly paymentSocial SecurityRailroad RetirementFederal Government retirement
For information about premiumsCall SSA or RRB
• Office of Personnel Management if a retired Federal employee
May be billed every 3 months Medicare Easy Pay
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Part A Helps Pay for
Hospital inpatient careSkilled nursing facility (SNF) careHome health careHospice careBlood
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Hospital StaysCovered services
Semi-private roomMealsGeneral nursingOther hospital services and supplies
Includes care in critical access hospitals190 days in a lifetime for inpatient mental
health care
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Skilled Nursing Facility Care
Must meet all of the following conditionsRequire daily skilled servicesHospital inpatient at least 3 consecutive
days Admitted to SNF within 30 days after
leaving hospitalCare is for a condition treated in the
hospitalMUST be Medicare participating SNF
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Skilled Nursing Facility Coverage Semi-private room Meals Skilled nursing care Physical, occupational, and speech-
language therapy Medical social services Medications, medical supplies/equipment Ambulance transportation Dietary counseling
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Home Health Care Covered services
Part-time skilled nursing careTherapy
• Occupational
• Physical
• Speech-languageSome home health aide servicesDurable medical equipment
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Home Health Care
For as long as you are eligibleLimited hours per dayLimited days per week
Four conditionsDoctor must make a plan for your care at homeMust need specific skilled servicesMust be homeboundHome health agency must be Medicare-approved
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Hospice Special care for terminally ill
And family
If you likely have less than 6 months to live Certification required for each “period of care”
Two 90-day periodsUnlimited 60-day periods
Hospice provider must be Medicare-approved
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Covered Hospice Services
Medical equipment and supplies Drugs for symptom control and pain relief Respite care in a Medicare-certified facility
Up to 5 days each timeNo limit to number of times
Home health aide and homemaker services Social worker services Dietary counseling Grief counseling
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Part B Helps Pay for
Doctors’ services Outpatient medical and surgical services and
supplies Diagnostic tests Outpatient therapy Outpatient mental health services Some preventive health care services Other medical services
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Covered Preventive Services “Welcome to Medicare”
physical exam Bone mass
measurement Cardiovascular
screenings Colorectal cancer
screenings Diabetes screenings Glaucoma tests
Mammograms (screening) Pap test/pelvic exam/
clinical breast exam Prostate cancer screening Flu shots Pneumococcal shots Hepatitis B shots Smoking cessation
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Part B Also Helps Pay for
Clinical laboratory testsHome health servicesDurable medical equipmentOutpatient hospital servicesBlood Ambulance service
If other transportation would endanger your health
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Medicare Plan Choices
Original Medicare PlanMedicare Advantage PlansOther Medicare plansMedicare drug plans
Medicare Prescription Drug PlansMedicare Advantage Plans and other Medicare
plans with prescription drug coverage
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Original Medicare PlanLesson 2 Topics
What it is and how it worksYour costs in Original Medicare PlanAssignmentMedigap (Medicare Supplement
Insurance)
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Original Medicare PlanRed, white, and blue Medicare cardPart A and/or Part BGo to any provider that accepts MedicareYou pay
Part B premium• Part A free for most people
DeductiblesCoinsurance or copayments
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Medicare Claims Contractors
Fiscal Intermediary (FI)Regional Home Health Intermediary (RHHI)Medicare CarrierDurable Medical Equipment Regional
Carrier (DMERC)Medicare Administrative Contractors (MAC)
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Original Medicare Plan—Part A
Charges based on “benefit period”Inpatient hospital care and SNF servicesBegins day admitted to hospitalEnds when no care received in a hospital
or SNF for 60 days in a row You pay deductible for each benefit periodNo limit to number of benefit periods
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Paying for Hospital Stays
Each benefit period in 2006 you payInpatient hospital stay of 1 – 60 days
• $952 totalDays 61 – 90
• $238 per dayDays 91 – 150
• $476 per day • 60 Lifetime Reserve Days
All costs for each day beyond 150 days
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Paying for Hospital Stays
Each benefit period in 2007 you payInpatient hospital stay of 1 – 60 days
• $992 totalDays 61 – 90
• $248 per dayDays 91 – 150
• $496 per day • 60 Lifetime Reserve Days
All costs for each day beyond 150 days
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Skilled Nursing Facility Care
Each benefit period in 2006 you payDays 1 – 20
• $0
Days 21 – 100• $119 per day in 2006• $124 in 2007
All costs after 100 days
Must meet requirements for Medicare-covered stayDoes NOT include custodial care
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Paying for Home Health Care
In the Original Medicare Plan you payNothing for covered home health care
services20% of the Medicare-approved amount for
covered durable medical equipment
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Paying for Hospice Care
In the Original Medicare Plan you payUp to $5 for prescription drugs5% for inpatient respite care
• Amount can change each year
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Paying for Part B In the Original Medicare Plan you pay
Monthly Part B premium• $88.50 in 2006• $93.50 in 2007
Yearly deductible• $124 in 2006• $131 in 2007
20% coinsurance for most servicesSome copayments
Some programs may help
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Assignment Agreement between you, doctor, and Medicare Applies to Original Medicare Part B claims Providers who accept assignment
Can’t try to collect more than Medicare deductible and coinsurance amounts
Providers who don’t accept assignmentMay charge more than Medicare-approved amount
• Limit of 15% more for most services– Doesn’t apply to supplies
May ask you to pay entire charge at time of service
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Assignment
In some cases, providers must accept assignmentSome examples
• Medicare Part B-covered prescription drugs• Ambulance providers
Doctors/providers generally have to file claimMay have to file own claim for Part B-covered
drugs or supplies• If supplier or pharmacy not enrolled in Medicare
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Private Contracts
Agreement between you and doctorOriginal Medicare Plan will not payMedigap will not payOther Medicare plans will not payYou will pay chargesNo claim should be submittedCannot be asked to sign in an emergency
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Therapy Limits $1,740 cap
Effective January 1, 2006Combined physical therapy and speech-language
pathology servicesSeparate cap for occupational therapy
Exceptions allowed If medically necessaryCertain diagnoses get automatic exception Some situations justify automatic exception
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What Is Medigap?
Health insurance policies• Sold by private insurance companies• Follow Federal and state laws that protect you• Must say “Medicare Supplement Insurance”• Cover “gaps” in Original Medicare Plan • 12 standardized policies, plans A – L
• Except in Massachusetts, Minnesota, Wisconsin
• Costs may vary• By plan• By company• Where you live
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How Medigap Works Only works with Original Medicare
Don’t need Medigap policy in • Medicare Advantage Plan • Other Medicare plans
Can go to any doctor, hospital, or provider that accepts MedicareExcept with a Medigap SELECT policy
You pay a monthly premium
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Medicare Advantage PlansLesson 3 Topics
What are Medicare Advantage Plans and other Medicare plans
Who can joinHow plans workJoining and switching plans
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What Are Medicare Advantage Plans?
Health plan options approved by Medicare Run by private companies Part of the Medicare program
Sometimes called “Part C”
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Medicare Advantage Plans
Medicare Health Maintenance Organization (HMO)
Medicare Preferred Provider Organization (PPO)
Medicare Private Fee-for-Service (PFFS)Medicare Special Needs Plans (SNPs)Medicare Medical Savings Account (MSA)
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Other Medicare Plans
Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the
Elderly (PACE)
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Who Can Join?
Eligibility requirementsLive in plan’s service areaHave Medicare Part AHave Medicare Part BNot have ESRD at time of enrollment
• Some exceptions
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How Do Medicare Advantage Plans Work? Generally get all Medicare-covered services
through the plan Can include prescription drug coverage May have to see certain doctors or go to
certain hospitals to get care Benefits and cost-sharing may be different
from those in Original Medicare Plan
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Out-of-Pocket Costs
Generally must still pay Part B premiumSome plans may pay all or part
May pay additional monthly premiumPay other out-of-pocket costs
Different from Original Medicare PlanVary from plan to plan
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In a Medicare Advantage Plan
Still in Medicare program Still have Medicare rights and protections Still get all regular Medicare-covered services May get extra benefits
Such as vision, hearing, or dental care
May be able to get prescription drug coverage
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Medicare HMO Plans
Copayment amounts set by planGenerally must get care and services
from plan’s networkUse doctors and hospitals that join the plan May have to pay in full for care outside
plan’s network• Covered if emergency or urgently needed care• Point-of-Service option allows visits to “out-of-
network” providers
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Medicare HMO Plans (cont’d)
May need to choose primary care doctorUsually need a referral to see a specialistDoctors can join or leave
May get Medicare drug coverage
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Medicare PPO Plans
Can see any doctor or provider that accepts MedicareDon’t need referral to see specialistDon’t need referral to see out-of-network
provider Copayment amounts set by plan
• Will usually pay more for out-of-network care
May get Medicare drug coverage
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Medicare PFFS Plans
Can see any Medicare-approved doctor or hospital that accepts the planCan get services outside service areaDon’t need referral to see a specialistPlan sets copayment amounts
Can get emergency care anywhereWithout prior approval
If offered, can get Medicare prescription drug coverageIf not offered, can join a Medicare Prescription
Drug Plan
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Medicare Special Needs Plans (SNPs)
May limit membership to peopleIn certain institutions (like a nursing home)Eligible for both Medicare and MedicaidWith certain chronic or disabling conditions
Designed to provide Special expertise of providersFocused care management
Available in limited areas Must provide prescription drug coverage
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Medicare MSA Plans
Will be offered beginning in 2007 Similar to Health Savings Account plans Have two parts
1. Medicare Advantage Plan with high deductible• Pays covered costs after you meet annual deductible
– Deductible varies by plan
2. Medical Savings Account • Medicare deposits money the person may use
– To pay health care costs
MSA demonstration available in some areas
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Medicare Cost Plans
Available in limited areas Similar to Medicare HMO Plans
Except out-of-network services covered under Original Medicare Plan
Can join any time plan accepts new members Can leave at any time Prescription drug coverage may be offered
If not offered, can join a Medicare Prescription Drug Plan
Plans may differ for some rules
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Medicare Demonstrations/Pilot Programs Special projects
Test improvements in Medicare coverage, payment, and quality of care
Eligibility usually limitedSpecific group of peopleSpecific area of country
ExamplesMedicare Advantage Plan for ESRD patientsNew Medicare preventive services
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Medicare PACE Plans
Programs of All-inclusive Care for the Elderly Combine medical, social, and long-term care
services for frail elderly peopleInclude prescription drug coverageMight be better choice than nursing home
Only available in states that offer it under Medicaid
Qualifications vary from state to stateContact state Medical Assistance office to see if
you qualify
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When Can You Join?You can join a Medicare Advantage Plan
or other Medicare planWhen first eligible for Medicare
• Initial Enrollment Period
Specific enrollment periods• Annual Coordinated Election Period• Medicare Advantage Open Enrollment Period• Special Enrollment Periods
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When Can You Switch?
Annual Coordinated Election PeriodMedicare Advantage Open Enrollment
PeriodSpecial circumstances
Move out of the plan’s service area and can’t stay in the plan
Plan leaves Medicare programOther special situations
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Annual Coordinated Election PeriodNovember 15 – December 31
Can choose new planNew plan starts January 1 (in most
cases)Plan must accept new members
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Medicare AdvantageOpen Enrollment Period January 1 – March 31, 2007 Same period each year Change effective first day of following month Cannot be used to start or stop Medicare
drug coverage
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Medicare Advantage PlanOpen Enrollment Period LimitsIf coverage is Can use OEP to
getCannot use OEP to get
Medicare Advantage Plan with prescription drug coverage (MA-PD)
MA-PD or
Original Medicare and PDP
MA-only or
Original Medicare only
(Exception: PFFS and PDP)
Medicare Advantage Plan with no prescription drug coverage (MA-only)
MA-only or
Original Medicare only
MAPD or
Original Medicare and PDP
Original Medicare Plan and a prescription drug plan (PDP)
MA-PD MA-only or
A different PDP to use with Original Medicare
Original Medicare Plan only MA-only MA-PD or
Original Medicare and PDP
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Prescription Drug Coverage
Coverage began January 1, 2006Available for all people with Medicare Provided through
Medicare Prescription Drug PlansMedicare Advantage Plans and other
Medicare plans
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Prescription Drug Costs
Costs vary by planMost people will pay
Monthly premiumDeductibleCopayments or coinsuranceVery little after $3,850 out-of-pocket in 2007
Extra help available for people with limited income and resources
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Eligibility and Enrollment
You mustHave Medicare Part A, Part B, or bothLive in plan’s service areaEnroll in a Medicare prescription drug plan
to get coverage
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Enrollment PeriodsInitial Enrollment Period (IEP)
7 months beginning 3 months before the first month of Medicare eligibility
Can change plansAnnual Coordinated Election Period
• November 15 – December 31 each year
Some special enrollment periods available
Some people are enrolled automatically
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Late Enrollment PenaltyPeople who wait to enroll after their IEP
Pay additional 1% of base beneficiary premium
• For every month eligible and not enrolled• For as long as they have Medicare drug
coverage
Except those with other creditable drug coverage
• Coverage at least as good as Medicare prescription drug coverage
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Special Enrollment Periods For people who
Permanently move out of plan’s service areaLose creditable prescription drug coverage Enter, reside in, or leave a long-term care facility
• Like a nursing home
Have Medicaid or are in a Medicare Savings Program
• Have a continuous special enrollment period
Have other exceptional circumstances
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Extra Help Help with drug plan costs for people with
limited income and resources Eligibility determined by SSA or state Income and resources are counted Some groups are automatically eligible
People with Medicare and• Medicaid• Supplemental Security Income only• Medicare Savings Programs
Everyone else must apply
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Income and Resource Limits
IncomeBelow 150% Federal poverty level
• $1,225 per month for an individual* or• $1,650 per month for a married couple*• Based on family size
ResourcesUp to $11,500 (individual)Up to $23,000 (married couple)
• Includes $1,500/person funeral or burial expenses• Counts savings and stocks• Does not count home you live in
*Higher amounts for Alaska and Hawaii
2006 amounts
2006 amounts
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How to Apply for Extra Help
Multiple ways to applyPaper applicationwww.socialsecurity.govState Medical Assistance officeLocal organization
You or someone on your behalf can apply
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Drug Plan Costs for People with Extra Help
Those below Federal poverty level save over 95% on average
People with lowest income and resourcesPay no premiums or deductiblesHave small or no copayments
Those with slightly higher income and resourcesHave a reduced deductiblePay a little more out of pocket
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Lesson 5 Topics
MedicaidMedicare Savings Programs (MSP)Help for people living in U.S. territories
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Medicaid
Federal-state health insurance programPeople with limited income and resourcesCertain people with disabilities
If eligible, most health care costs covered Eligibility determined by state Application processes and benefits vary Office names vary
Social ServicesPublic AssistanceHuman Services
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Medicare Savings ProgramsHelp from Medicaid paying Medicare
premiumsFor people with limited income and
resourcesMay also pay Medicare deductibles and
coinsurancePrograms include
• Qualified Medicare Beneficiary (QMB)• Specified Low-income Medicare Beneficiary
(SLMB)• Qualifying Individual (QI)
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Programs in U.S. Territories Help people pay their Medicare costs U.S. territories
Puerto RicoVirgin IslandsGuamNorthern Mariana IslandsAmerican Samoa
Programs vary Contact state Medical Assistance office
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If you think you might qualify…
1. Review guidelines
2. Collect your personal documents
3. Get more information Call your state Medical Assistance office Call your SHIP Call your local Area Agency on Aging
4. Complete application with state Medical Assistance office
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Module 1 Lessons
1. Medicare Basics
2. Original Medicare Plan
3. Medicare Advantage Plans (Part C) and other Medicare plans
4. Medicare prescription drug coverage (Part D)
5. Programs for people with limited income and resources
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For More Information
1-800-MEDICARE (1-800-633-4227)TTY users should call 1-877-486-2048
Medicare & You handbookOther Medicare publicationswww.medicare.govwww.cms.hhs.govYour local State Health Insurance
Assistance Program (SHIP)