medicare&you 2009

7/31/2019 Medicare&You 2009

1/128

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

2009&Medicare

You

This is the ocial government handbook with

important inormation about the ollowing:

HWhat's new

H2009 Medicare costs

HWhat Medicare covers

HHealth and prescription drug plans

HYour Medicare rights

HFraud and identity theft


2/128

Welcome to Medicare & You 2009Medicares goal is to make it easy or you to get the highest qualityhealth care at the most aordable price. Medicare is transorming itsel

rom a program which simply pays the bills to a program which activelysupports a high quality health care system.

What do we mean by a high qualityhealth care system? Its a systemthat does the ollowing:

Rewards providers or quality and eciency

Uses objective standards to determine quality and eciency

Communicates using an interconnected, computerized healthinormation network, so providers can get a comprehensive view othe patient securely and without delay

Oers consumers complete, objective, easily accessible inormation,so they can make solid decisions about their own health care based onquality and price

Medicare shares quality inormation about providers in your area atwww.medicare.gov.

In addition, this Medicare & You handbook is another way Medicareis working to make sure you have reliable inormation to help you makegood health care decisions.

Troughout this handbook, we have inormation about how youcan get the most out o your Medicare, including Medicare healthand prescription drug plan choices and coverage, how to protectyoursel and Medicare rom raud, background on advance directives,and resources or detailed inormation and personalized help. Tisinormation is up-to-date between January 1, 2009December 31, 2009.You will get a new handbook every all to help you compare coverageand learn new and important inormation.

Yours in good health,

Michael O. Leavitt

SecretaryDepartment o Healthand Human Services

Kerry N. Weems

Acting AdministratorCenters or Medicare &Medicaid Services
http://www.medicare.gov/http://www.medicare.gov/


3/128

Are You Getting the Most Out o Medicare?Use this checklist to nd out.

oReview how your current coverage will change and compare itto other coverage options or next year to see i theres a betterchoice or you. See page 44.

oRemember that you can only join, switch, or drop Medicareplans at certain times. See pages 11, 59, and 65.

oI you have other health insurance, nd out how it works withMedicare. See pages 7274.

oCall your State Health Insurance Assistance Program (SHIP)

or ree help with your Medicare questions. See pages 111114or the telephone number.

oAsk your doctor or other health care provider which preventiveservices (like screenings, shots, and tests) you should get. akethe checklist on page 39 to your next visit.

oFind out i you qualiy or help paying your Medicare healthand prescription drug costs. See pages 7784.

oProtect yoursel rom identity the and raud. See pages 9497.

oVisit www.MyMedicare.gov to access your personalizedMedicare inormation. Help save tax dollars by choosing toaccess uture Medicare & You handbooks electronically.

oI you are new to Medicare, use the www.MyMedicare.govpassword and instructions Medicare mailed to you. Fill outyour Initial Enrollment Questionnaire (IEQ) online or theIEQ that was mailed to you, so Medicare can process your bills

correctly. See page 109. I you have questions about the IEQor to complete it over the telephone, call the Coordination oBenets Contractor at 1-800-999-1118. Y users should call1-800-318-8782.

oI you are new to Medicare, get a one-time Welcome toMedicare physical exam. See physical exam on page 33 to seewhats covered and what you pay.
http://www.mymedicare.gov/http://www.mymedicare.gov/http://www.mymedicare.gov/http://www.mymedicare.gov/


4/128

Important Inormation aboutThis Handbook

Please keep this handbook or uturereerence. Changes may occur aer printing.Call 1-800-MEDICARE (1-800-633-4227),or visit www.medicare.gov to get the mostcurrent inormation. Y users should call1-877-486-2048.

Did your household get more than one copy oMedicare & You? I you would like to get onlyone copy in the uture, call 1-800-MEDICARE.

Medicare & You isnt a legal document.Ocial Medicare Program legal guidance iscontained in the relevant statutes, regulations,and rulings.

Te term Medicare health plan is usedthroughout this handbook to include allMedicare Advantage Plans, Medicare CostPlans, Demonstration/Pilot Programs, andPrograms o All-Inclusive Care or the Elderly(PACE).

This box letsyou know that

blue wordsin the text

are dened

on pages

115118.

Tis symbol highlights important inormation.


5/128

Contents7 IndexA Quick Way to Find What You Need

11 Medicare Basics11 Whats New and Important in 2009?

12 What Is Medicare?

14 Where to Get Your Medicare Questions Answered

15 Section 1Whats Covered? (Part A and Part B)19 Part A-Covered Services

25 Part B-Covered Services

38 Whats NOT Covered by Part A and Part B?

41 Section 2Decide How to Get Your Medicare42 Your Medicare Choices

44 Things to Consider When Choosing or Changing Your Coverage

45 Original Medicare

50 Medicare Advantage Plans (like an HMO or PPO) (Part C)

59 When Can You Join, Switch, or Drop a Medicare Advantage Plan?61 Other Medicare Health Plans

63 Medicare Prescription Drug Coverage (Part D)

65 When Can You Join, Switch, or Drop a Medicare Drug Plan?

74 How Your Bills Get Paid I You Have Other Health Insurance

75 Medigap (Medicare Supplement Insurance) Policies

Medicare & You 2009

Continued_

15Whats covered?Whats not?11 Whats new? 41 Coverage choices


6/128

6 Medicare & You 2009

Contents (continued)

78Need extra helpwith costs? 94

Fraud andidentity thet 119

2009Medicare costs

77 Section 3Programs or People with LimitedIncome and Resources78 Extra Help Paying or Medicare Prescription Drug Coverage (Part D)

82 Medicaid

83 Medicare Savings Programs (Help rom Medicaid to Pay Medicare

Premiums)

85 Section 4Protecting Yoursel and Medicare86 Your Medicare Rights

86 What Is an Appeal?

92 How Medicare Uses Your Personal Inormation

94 Protect Yoursel rom Fraud and Identity Thet

96 Protect Yoursel and Medicare rom Billing Fraud

99 Section 5Planning Ahead

107 Section 6For More Inormation

(Phone, Websites, Publications)

115 Section 7Defnitions

119 2009 Medicare Costs

124 Tips to Help Prevent Medicare Fraud


7/128

7Medicare & You 2009

IndexAAbdominal Aortic Aneurysm 26

Acupuncture 38

Advance Beneciary Notice 89

Advance Directives 105106

ALS (Amyotrophic Lateral Sclerosis) 17, 22

Ambulance Services 26

Ambulatory Surgical Center 26, 28, 38

Appeal 52, 8691, 108109

Articial Limbs 34

Assignment 25, 4647

BBalance Exam 31

Barium Enema 28

Benet Period 20, 115, 120

Bills 46, 74, 89, 96

Blood 19, 26, 121

Bone Mass Measurement (Bone Density) 27

Braces (arm/leg/back/neck) 34

Breast Exam 33, 39

CCardiovascular Screenings 27, 39

Catastrophic Coverage 67

Chiropractic Services 27, 38Claims 4546, 87, 108109

Clinical Laboratory Services 27, 121

Clinical Research Studies 20, 27

COBRA 24, 72

Coinsurance 2637, 45, 51, 66, 75, 78, 83, 115,

120121

Colonoscopy 28, 39

Colorectal Cancer Screenings 28, 39

C (continued)

Community-Based Programs 103

Consolidated Omnibus Budget Reconciliation Act

(COBRA) 24, 72

Coordination o Benets 14, 74

Copayment 51, 64, 6667, 75, 78, 104, 115, 120121

Cosmetic Surgery 38

Costs 16, 21, 25, 44, 53, 6667, 75, 78, 119122

Coverage Choices 13, 4176

Coverage Determination (Part D) 9091

Coverage Gap 6667, 78

Covered Services (Part A and Part B) 1920, 2637, 39,

120121

Creditable Prescription Drug Coverage 63, 65, 68,

7273, 116

Custodial Care 20, 38, 102, 116DDeductible 2537, 45, 51, 53, 55, 66, 7576, 78, 83,

116, 117, 120121

Denitions 115118

Demonstrations/Pilot Programs 13, 62, 94

Dental Care and Dentures 38

Department o Deense 14

Department o Health and Human Services (Oce o

Inspector General) 14, 9597

Department o Veterans Afairs 14, 68, 73

Diabetes 29, 3032, 39

Dialysis (Kidney Dialysis) 12, 18, 32, 51, 54, 56, 58

Discrimination 86, 97

Disenroll 52, 56, 60

Drug Plan 43, 6371, 9091, 122

Drugs (outpatient) 34, 70

Te page number in bold provides the most detailed inormation.

A Quick Way to Find What You Need


8/128

8 Index

D (continued)

Drugs (prescription) 12, 34, 38, 4445, 5456, 6371,

117

Durable Medical Equipment (like walkers) 19, 3031,

34, 47, 120121

EEKGs 35

Eldercare Locator 103

Electronic Handbook 122

Electronic Health Record 101

Emergency Room Services 30, 108

Employer Coverage 24, 4345, 49, 5758, 61, 64, 68,72, 74, 80

End-Stage Renal Disease (ESRD) 12, 18, 22, 32, 51, 58

Enroll 23, 51, 5960, 65, 76

Equipment (like walkers) 19, 3031, 34, 47, 120121

Exception (Part D) 70, 9091

Extra Help (Help Paying Medicare Drug Costs) 63, 67,

69, 7881

Eye Exam 30, 38

Eyeglasses 30, 38

FFecal Occult Blood Test 28, 39

Federal Employee Health Benets Program 14, 73

Federally-Qualied Health Center Services 30

Flexible Sigmoidoscopy 28

Flu Shot 30, 39

Foot Exam 31

Formulary 44, 70, 78

Fraud 9497, 124125

GGap (Coverage) 6667, 78

General Enrollment Period 18, 23

Glaucoma Test 31, 39

Group Health Plan (Employer) 21, 2324, 61, 74

HHealth Care Proxy 105106

Health Maintenance Organization (HMO) 43, 50, 54

Hearing Aids 31, 40

Help with Costs 49, 53, 7784

Hepatitis B Shot 31, 39

Home Health Care 16, 19, 31, 82, 89, 102, 120

Hospice Care 16, 19, 120

Hospital Care (Inpatient Coverage) 16, 20, 30, 120

IIdentity Thet 9495, 97

Immunizations 25, 3031, 33, 3839

Indian Health Service 73

Institution 56, 59, 65, 79, 81, 116

JJoin

Medicare Drug Plan 45, 49, 6365, 68

Medicare Health Plan 51, 5761

KKidney Dialysis 12, 18, 32, 51, 54, 56, 58

Kidney Transplant 12, 18, 36, 51, 58

LLate Enrollment Penalty

Part A 18

Part B 21, 23

Part D 68, 122

Lietime Reserve Days 116, 120

Limited Income 49, 53, 7784, 108, 116

Living Will 105106

Long-Term Care 20, 38, 62, 82, 102104

Low-Income Subsidy (LIS) 63, 67, 69, 7881

MMammogram 32, 39, 54, 56

Medicaid 56, 59, 79, 81, 82, 83

Medical Equipment 19, 3031, 34, 47, 120121



9/128

9Index

M (continued) O (continued)

Medical Nutrition Therapy 32

Medical Savings Account (MSA) Plans 55, 63

Medically Necessary 21, 30, 116

Medicare

Part A 1620, 43, 119120

Part B 2137, 39, 43, 119, 121

Part C 43, 5060, 88, 122

Part D 43, 6371, 9091, 122

Medicare Advantage Plans 43, 5060, 88, 122

Medicare Authorization to Disclose Personal Health

Inormation 108Medicare Beneciary Ombudsman 98

Medicare Card (lost) 17

Medicare Cost Plan 61

Medicare Prescription Drug Coverage 43, 49, 6371,

7273, 7881, 9091

Medicare Prescription Drug Plans (PDP) 43, 6371,

9091, 122

Medicare Savings Programs 79, 83

Medicare SELECT 57, 75Medicare Summary Notice (MSN) 46, 77, 87, 92, 9697

Medigap (Medicare Supplement Insurance) 24, 43, 45,

52, 57, 59, 72, 7576

Mental Health Care 20, 32, 110, 120121

NNursing Home 56, 8182, 100, 102104, 108, 110

Nutrition Therapy Services 32

OOccupational Therapy 19, 3132, 121

Oce or Civil Rights 14, 97

Oce o Inspector General 14, 9596

Oce o Personnel Management 14, 73

Ombudsman (Medicare Beneciary) 98

Online 3, 60, 65, 80, 101, 109

Original Medicare 43, 4549, 7576, 8789, 120121

Orthotic Items 34

Outpatient Hospital Services 28, 33, 121

Oxygen 108

PPap Test 33, 39, 54, 56

Part A 1620, 43, 119120

Part B 2137, 39, 43, 119, 121

Part C 43, 5060, 88, 122

Part D 43, 6371, 9091, 122

Payment Options (premium) 71, 119

Pelvic Exam 33, 39, 54, 56

Penalty

Part A 18

Part B 21, 23

Part D 68, 122

Personal Health Record 101

Physical Exam 26, 30, 33, 3839

Physical Therapy 1920, 3133, 118, 121

Pilot/Demonstration Programs 62, 94

Pneumococcal Shot 33Power o Attorney 105

Practitioner Services 34

Preerred Provider Organization (PPO) Plan 54

Premium 1617, 21, 53, 66, 68, 71, 78, 83, 117, 119

Prescription Drugs 34, 38, 4445, 5456, 6371,

7273, 7879, 82, 103

Preventive Services 2534, 39, 108110

Primary Care Doctor 45, 5456, 117

Privacy Notice 9293

Private Contract 48

Private Fee-or-Service (PFFS) Plans 55, 63, 110

Private Insurance 61, 72, 7576, 102

Programs o All-Inclusive Care or the Elderly (PACE) 62,

82, 103104

Prostate Screening (PSA Test) 34, 39

Proxy (Health Care) 105106

Publications 110



10/128

10 Index

QQuality o Care 14, 44, 88, 100, 109110

Quality Improvement Organization (QIO) 14, 88, 99,

113

RRailroad Retirement Board (RRB) 14, 1718, 2223,

46, 124

Reerral 26, 33, 4445, 5152, 5456, 117

Religious Nonmedical Health Care Institution 16

Replacing a Medicare Card 17

Retiree Health Insurance 24, 4345, 49, 5758, 61, 64,

68, 72, 74Rural Health Clinic 34

SSecond Surgical Opinions 34

Service Area 44, 51, 59, 6465, 117

Shots (vaccinations) 25, 3031, 33, 3839

Sigmoidoscopy 28, 39

Skilled Nursing Facility (SNF) Care 16, 20, 88, 102, 110,

118

Smoking Cessation 34, 39

SMP (Senior Medicare Patrol) Program 95

Social Security 14, 1718, 2123, 71, 8081, 84

Special Enrollment Period 18, 2324, 65, 72

Special Needs Plan (SNP) 56, 58

Speech-language Pathology 19, 31, 35, 121

State Health Insurance Assistance Program (SHIP) 14,

111114

State Medical Assistance (Medicaid) Oce 53, 62, 80,8283, 104

State Pharmacy Assistance Program (SPAP) 82

Substance Abuse 32

Supplemental Policy (see Medigap) 24, 43, 45, 52, 57,

59, 72, 7576

Supplemental Security Income (SSI) 79, 84

Supplies (medical) 1920, 25, 2934, 4647, 96, 108

Surgical Dressing Services 35

TTelemedicine 35

Tests 2629, 3135, 3839, 101

Tiers (drug ormulary) 70

Transplant Services 36

Travel 37

TRICARE 14, 24, 68, 73

TTY 14, 118

UUnion 24, 4345, 49, 5758, 61, 64, 68, 72, 74, 80

Urgently Needed Care 37, 51, 54, 56

VVaccinations (shots) 25, 3031, 33, 3940

Veterans Benets (VA) 14, 68, 73

Vision 51

WWalkers 30, 108

Website 63, 70, 100, 107

Welcome to Medicare Physical Exam 26, 30, 33, 39

Wheelchairs 30, 108

www.medicare.gov 100, 109

www.MyMedicare.gov 39, 46, 87, 109

XX-ray 35



11/128

11Section #Name o Section 11

Whats New and Important in 2009?One-ime Welcome to Medicare physical exam More timeand lower cost. See page 33.

Fraud and Identity Te Protect yoursel and Medicare. Seepages 9497.

Planning Ahead Plan or your current and uture health careneeds. See pages 99106.

New echnology Electronic and Personal Health Records. See

page 101.Medicare health and prescription drug plans Visitwww.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) tond plans in your area. Y users should call 1-877-486-2048.

What You Pay or Medicare (Part A and Part B) Te amountsyou will pay in 2009 are on pages 119121.

Electronic Handbook Choose to get uture Medicare & Youhandbooks electronically. See page 122.

Plan Coverage and Costs Change Yearly.Mark your calendar with these important dates!

October 2008: Prepare and Compare

Your health, nances, or coverage may have changed in the last year.Look at the cost, coverage, quality, and convenience your currentMedicare health or prescription drug coverage will oer in 2009, andcompare it with other available coverage options to see i theres abetter choice or you.

November 15, 2008December 31, 2008: Stay or SwitchYou can switch your Medicare health or prescription drug coverageor 2009 during this period.

January 1, 2009: 2009 Coverage and Costs Begin

New coverage begins i you made a change betweenNovember 15, 2008December 31, 2008. New costs and coveragechanges also begin i you keep your current coverage.

Note: Tere may be other times when you can change your Medicare

health or prescription drug coverage. See pages 59 and 65.

Medicare BasicsMedicare & You 2009

APRIL

7372

October

1


12/128

12 Medicare Basics

What Is Medicare?Medicare is health insurance or people age 65 or older, under age 65 withcertain disabilities, and any age with End-Stage Renal Disease (ESRD)

(permanent kidney ailure requiring dialysis or a kidney transplant).

The Dierent Parts o MedicareTe dierent parts o Medicare help cover specic services i you meetcertain conditions. Medicare has the ollowing parts:

Medicare Part A (Hospital Insurance)

Helps cover inpatient care in hospitals

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

See pages 1620.

Medicare Part B (Medical Insurance)

Helps cover doctors services and outpatient care

Helps cover some preventive services to help maintain your healthand to keep certain illnesses rom getting worse

See pages 2137.

Medicare Part C (Medicare Advantage Plans) (like an HMO or PPO)

A health coverage choice run by private companies approved byMedicare

Includes Part A, Part B, and usually other coverage includingprescription drugs

See the next page.

Medicare Part D (Prescription Drug Coverage)

Helps cover the cost o prescription drugs

May help lower your prescription drug costs and help protect againsthigher costs in the uture

See pages 6371.


13/128

13Medicare Basics

Your Medicare Coverage ChoicesWith Medicare, you can choose how you get your health and prescription drugcoverage. Below are brie descriptions o your coverage choices. Section 2 has

more details about these choices and inormation to help you decide.

Original Medicare (See pages 4549.)

Run by the Federal government.

Provides your Part A and Part B coverage.

You can join a Medicare Prescription Drug Plan to add drug coverage.

You can buy a Medigap (Medicare Supplement Insurance) policy (soldby private insurance companies) to help ll the gaps in Part A and Part B

coverage. See pages 7576.

Medicare Advantage Plans (like an HMO or PPO) (See pages 5060.)

Run by private companies approved by Medicare.

Provides your Part A and Part B coverage but can charge dierent amountsor certain services. May oer extra coverage and prescription drugcoverage or an extra cost. Costs or items and services vary by plan.

I you want drug coverage, you must get it through your plan (in most cases).

You dont need a Medigap policy.

Other Medicare Health Plans (See pages 6162 and 103104.)

Plans that arent Medicare Advantage Plans, but are still part o Medicare.

Include Medicare Cost Plans, Demonstration/Pilot Programs, andPrograms o All-Inclusive Care or the Elderly (PACE).

Some plans provide Part A and Part B coverage, and some also provide

prescription drug coverage (Part D).

Note: You might also have health and/or prescription drug coverage rom aormer or current employer or union. See pages 7273.

See page 43 or a chart that explains your Medicare coverage choicesand the decisions you need to make.


14/128

14 Medicare Basics

Where to Get Your Medicare Questions Answered

1-800-MEDICARE

o get general Medicare inormation. See page 108.

1-800-633-4227

Y 1-877-486-2048

State Health Insurance Assistance Program (SHIP)o get ree personalized health insurance counseling,including help making health care decisions, inormation onprograms or people with limited income and resources, andhelp with claims, billing, and appeals.

See pages 111114.

Social Security

o get a replacement Medicare card, change your address orname, get inormation about Part A and/or Part B eligibility,entitlement, and enrollment, apply or extra help with

Medicare prescription drug costs, and report a death.

1-800-772-1213

Y 1-800-325-0778

Coordination o Benets Contractor

o get inormation on whether Medicare or your otherinsurance pays rst.

1-800-999-1118

Y 1-800-318-8782

Department o Deense

o get inormation about RICARE.

o get inormation about RICARE or Lie.

1-888-363-5433

1-866-773-0404

Y 1-866-773-0405

Department o Health and Human ServicesOce o Inspector General

I you suspect raud, see pages 9497.

Oce or Civil Rights

I you think youve been treated unairly, see page 97.

1-800-447-8477

Y 1-800-377-4950

1-800-368-1019

Y 1-800-537-7697

Department o Veterans Afairs

I you are a veteran or have served in the U.S. military.

1-800-827-1000

Y 1-800-829-4833

Oce o Personnel Management

o get inormation about the Federal Employee HealthBenets Program or current and retired Federal employees.

1-888-767-6738

Y 1-800-878-5707

Railroad Retirement Board (RRB)

I you have benets rom the RRB, call them to change youraddress or name, enroll in Medicare, replace your Medicarecard, and report a death.

Local RRB oce or

1-800-808-0772Aer January 1, 2009,call 1-877-772-5772.

Quality Improvement Organization (QIO)

o ask questions or report complaints about the quality ocare or a Medicare-covered service.

1-800-MEDICARE

to get the telephonenumber or your QIO.


15/128

15

WhatsCovered?

(Part A

and Part B)

Medicare is here to help you stay healthy. Were committedto providing you with inormation that can help you

make inormed health care decisions. Tis section explains whatMedicare covers.

Section 1 includes inormation about the ollowing:

Medicare Part A (Hospital Insurance) and What It Covers . . 1620

Medicare Part B (Medical Insurance) and What It Covers . . 2137

Whats NO Covered by Part A and Part B? . . . . . . . . . . . 38

Preventive Services Checklist . . . . . . . . . . . . . . . . . . . 39

SECTION 1


16/128

16 Section 1Whats Covered? (Part A and Part B)

What Services Does Medicare Cover?Medicare covers certain medical services and supplies in hospitals,doctors oces, and other health care settings. Services are either

covered under Medicare Part A (Hospital Insurance) or MedicarePart B (Medical Insurance). I you have both Part A and Part B,you can get the ull range o Medicare-covered services listed here,no matter what type o Medicare coverage you choose.

A list o the services covered by Part A is on pages 1920.A list o the services covered by Part B is on pages 2637.

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

Inpatient care in hospitals (includes critical access hospitals andinpatient rehabilitation acilities)

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

Hospice care services

Home health care services

Inpatient care in a Religious Nonmedical Health Care Institution(acility that provides non-medical, non-religious health care

items and services to people who need hospital or skillednursing acility care but or whom that care wouldnt be inagreement with their religious belies)

See pages 1718 or the conditions you must meet to getPart A-covered services.

You usually dont pay a monthlypremium or Part A coverage iyou or your spouse paid Medicare taxes while working.

I you arent eligible or premium-ree Part A, you may be able tobuy Part A i you meet the citizenship or residency requirementsand you are age 65 or older or you are under age 65, disabled, andyour premium-ree Part A coverage ended because you returnedto work.

Note: Te 2009 premium amount or people who buy Part A is upto $443 each month.

Blue wordsin the text

are dened

on pages

115118.


17/128

17Section 1Whats Covered? (Part A and Part B)

What Is Part A (Hospital Insurance)? (continued)In most cases, i you choose to buy Part A, you must also have Part Band pay monthlypremiums or both.

I you have limited income and resources, your state may help you payor Part A and/or Part B. See page 83.

You can nd out i you have Part A by looking at your Medicare card.

Note: Keep this card sae. I you haveOriginal Medicare, you will use thiscard to get your Medicare-coveredservices. I you join a Medicare plan,you must use the card rom the plan to

get your Medicare-covered services.

See pages 9497 to nd out aboutprotecting yoursel rom identity theand raud.

Is Your Medicare Card Lost or Damaged?

o order a new card, call Social Security at 1-800-772-1213, or visitwww.socialsecurity.gov. Y users should call 1-800-325-0778. I

you get benets rom the RRB, visit www.rrb.gov and select, BenetOnline Services, or call your local RRB oce. Aer January 1, 2009,call the RRB toll-ree at 1-877-772-5772.

When Can You Sign Up or Part A?

Many People Automatically Get Part A

I you get benets rom Social Security or the RRB, you automaticallyget Part A starting the rst day o the month you turn age 65. I youare under age 65 and disabled, you automatically get Part A aer you

get disability benets rom Social Security or certain disability benetsrom the RRB or 24 months. You will get your Medicare card inthe mail 3 months beore your 65th birthday or your 25th month odisability.

I you have ALS (Amyotrophic Lateral Sclerosis, also calledLou Gehrigs disease), you automatically get Part A the month yourdisability benets begin.
http://www.socialsecurity.gov/http://www.rrb.gov/http://www.rrb.gov/http://www.socialsecurity.gov/


18/128


When Can You Sign Up or Part A? (continued)

Some People Need to Sign up or Part A

I you arent getting Social Security or RRB benets (or instance,

because you are still working), you will need to sign up or Part A.You will need to sign up even i you are eligible or premium-reePart A. You should contact Social Security 3 months beore youturn age 65. I you worked or a railroad, contact the RRB to sign up.

I you have End-Stage Renal Disease (ESRD), you cansign up or Part A by visiting your local Social Securityoce or by calling Social Security at 1-800-772-1213.Y users should call 1-800-325-0778. o get moreinormation on how to enroll in Medicare i you haveESRD, visitwww.medicare.gov/Publications/Pubs/pd/10128.pdto view the booklet, Medicare Coverage o KidneyDialysis and Kidney ransplant Services.

I you arent eligible or premium-ree Part A, you can buy itduring the ollowing times:

Initial Enrollment Period When you rst become eligible orMedicare (3 months beore you turn age 65 to 3 months aer the

month you turn age 65).General Enrollment Period Between January 1March 31 eachyear.

Special Enrollment Period I you or your spouse (or amily member i you are disabled) is working and has group health plancoverage through the employer or union. See page 23.

Special Enrollment Period or International Volunteers I youare serving as a volunteer in a oreign country. See page 23.

I you dont buy Part A when you are rst eligible, the monthlypremium may go up 10% unless you are eligible or a specialenrollment period.

For more inormation on Part A, call Social Security, or visitwww.socialsecurity.gov. I you get benets rom the RRB, call yourlocal RRB oce or 1-800-808-0772. Aer January 1, 2009, call theRRB toll-ree at 1-877-772-5772.


are denedon pages

115118.
http://www.medicare.gov/Publications/Pubs/pdf/10128.pdfhttp://www.socialsecurity.gov/http://www.socialsecurity.gov/http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf


19/128


Part A-Covered Services

Blood I the hospital has to buy blood or you, you must either pay thehospital costs or the rst 3 pints o blood you get in a calendar

year or have the blood donated. In most cases, the hospital getsblood rom a blood bank at no charge, and you wont have to payor it or replace it.

Home

Health

Services

Limited to medically-necessarypart-time or intermittent skillednursing care or physical therapy, speech-language pathology, or acontinuing need or occupational therapy. Care must be orderedby a doctor and provided by a Medicare-certied home healthagency. Home health services may also include medical socialservices, part-time or intermittent home health aide services,

durable medical equipment (see page 30), and medical suppliesor use at home. You must be homebound, which means thatleaving home takes a lot o eort. Part A covers the cost o therst 100 home health visits ollowing a hospital stay.

Hospice

Care

For people with a terminal illness who are expected to live 6months or less (as certied by a doctor). Coverage may includedrugs (or pain relie and symptom management), medical,nursing, social services, and other covered services as well as

services not usually covered by Medicare (like grie counseling).Hospice care is usually given in your home (or other acility likea nursing home) by a Medicare-approved hospice. Medicarecovers some short-term inpatient stays (or pain and symptommanagement that requires an inpatient stay) in a Medicare-approved acility, such as a hospice acility, hospital, or skillednursing acility. Medicare also covers inpatient respite care (caregiven to a hospice patient so that the usual caregiver can rest).You can stay in a Medicare-approved acility up to 5 days each

time you get respite care. Medicare may pay or covered servicesor health problems that arent related to your terminal illness.You can continue to get hospice care as long as the hospicemedical director or hospice doctor recerties that you areterminally ill.

See page 120 or specic costs and other inormation about these services.


20/128


Part A-Covered Services

Hospital

Stays

(Inpatient)

Includes semi-private room, meals, general nursing, drugs aspart o your inpatient treatment, and other hospital services and

supplies. Examples include inpatient care you get in acute carehospitals, critical access hospitals, inpatient rehabilitation acilities,long-term care hospitals, inpatient care as part o a qualiyingclinical research study (see page 27), and mental health care. Tisdoesnt include private-duty nursing, a television or telephone inyour room, or personal care items like razors or slipper socks. Italso doesnt include a private room, unless medically necessary.Te doctor services you get while you are in a hospital are coveredunder Part B. See page 30. For emergency room services, also see

page 30.Skilled

Nursing

Facility

Care

Includes semi-private room, meals, skilled nursing andrehabilitative services, and other services and supplies (only aera 3-day minimum inpatient hospital stay or a related illness orinjury) or up to 100 days in a benet period. o get care in askilled nursing acility, your doctor must certiy that you needdaily skilled care like intravenous injections or physical therapy.Medicare doesnt cover long-term care or custodial care in thissetting. See pages 102104.

See page 120 or specic costs and other inormation about these services.


21/128


What Is Part B (Medical Insurance)?Part B helps cover medically-necessaryservices like doctors services,outpatient care, and other medical services. Part B also covers some

preventive services. You can nd out i you have Part B by looking atyour Medicare card. See the sample card on page 17.

How Much Does Part B Cost?You pay the Part B premium each month. Most people will paythe standard premium amount, which is $96.40 in 2009. However,your monthly premium will be higher i you meet the ollowingconditions:

You are single (le an individual tax return), and your yearly

modied adjusted gross income is more than $85,000 (in 2009).You are married (le a joint tax return), and your yearly modiedadjusted gross income is more than $170,000 (in 2009).

Te 2009 Part B premium amounts are on page 119.

Your modied adjusted gross income is your adjusted gross (taxable)income plus your tax exempt interest income. Social Security willnotiy you i you have to pay more than the standard premium. Iyou have to pay a higher amount or your Part B premium and you

disagree, call Social Security.

I you have limited income and resources, see page 83 orinormation about help paying your Medicare premiums.

You also pay a Part B deductible each year beore Medicare starts topay its share. In 2009, the deductible amount is $135.

What Is the Part B Late Enrollment Penalty?I you dont sign up or Part B when you are rst eligible, yourmonthly premium or Part B may go up 10% or each ull 12-monthperiod that you could have had Part B, but didnt sign up or it. Iyou delay taking Part B because you or your spouse (or a amilymember, i you are disabled) is working and has group health plancoverage based on current employment, you may not have to pay thehigher premium. See page 23 (Special Enrollment Period) or moreinormation.


are dened

on pages

115118.


22/128


When Can You Sign Up or Part B?I you get benets rom Social Security or the RRB, you willautomatically get Part B starting the rst day o the month you turn

age 65. I you are under age 65 and disabled, you will automaticallyget Part B aer you get disability benets rom Social Security orcertain disability benets rom the RRB or 24 months. You will getyour Medicare card in the mail about 3 months beore your 65thbirthday or your 25th month o disability. I you dont want Part B,ollow the instructions that come with the card, and send the cardback. I you keep the card, you keep Part B and will pay Part Bpremiums.

I you have ALS (Amyotrophic Lateral Sclerosis, also called

Lou Gehrigs disease), you automatically get Part B the month yourdisability benets begin.

I you have ESRD, you can sign up or Part B when you sign up orPart A. (See page 18 to nd out how to get more inormation.)

I you arent getting Social Security or RRB benets, and you wantto get Part B, you will need to sign up or Part B during your initialenrollment period (the period that begins 3 months beore themonth o your 65th birthday and ends 3 months aer the month o

your 65th birthday).


23/128


When Can You Sign Up or Part B? (continued)I you didnt sign up or Part B when you rst became eligible, youmay be able to sign up during one o these times:

General Enrollment Period Between January 1March 31 eachyear. Your coverage will begin on July 1. Te cost o your Part B willgo up 10% or each ull 12-month period you could have had Part Bbut didnt sign up or it, unless you qualiy or a special enrollmentperiod (see below). You may have to pay this late enrollmentpenalty as long as you have Part B.

Special Enrollment Period I you wait to sign up or Part Bbecause you or your spouse is working and has group health plancoverage based on that work, or i you are disabled and you or a

amily member is working and has group health plan coverage basedon that work. You can sign up or Part B any time while you havegroup health plan coverage based on current employment or duringthe 8-month period that begins the month the employment ends, orthe group health plan coverage ends, whichever happens rst.

Special Enrollment Period or International Volunteers Iyou waited to enroll in Part B because you had health insurancewhile volunteering in a oreign country. You can sign up duringthe 6-month period that begins the month you are no longer

volunteering outside the United States, or the sponsoringorganization is no longer tax exempt, or you no longer have healthcoverage outside the U.S., whichever comes rst.

Usually, you dont pay a late enrollment penalty i you sign up orPart B during a special enrollment period.

Call Social Security at 1-800-772-1213 or more inormationabout your Medicare eligibility and to enroll in Part B. Y usersshould call 1-800-325-0778. I you get RRB benets, call your local

RRB oce or 1-800-808-0772. Aer January 1, 2009, call the RRBtoll-ree at 1-877-772-5772. For general inormation about enrolling,

visit www.medicare.gov and select, Find Out i You Are Eligibleor Medicare and When You Can Enroll. You can also get reepersonalized health insurance counseling rom your State HealthInsurance Assistance Program (SHIP). See pages 111114 or thetelephone number.


are dened

on pages

115118.


24/128


Part B and TRICARE CoverageI you have Medicare and you also have RICARE coverage (oractive-duty military or retirees and their amilies), you will need

to contact RICARE to nd out what you need to do i you wantto keep RICARE. For example, you may have to buy Part B iyou or your spouse is no longer active duty.

See page 73 or more inormation about RICARE.

Note: I you are in a Medicare Advantage Plan or choose to join aplan, tell the plan you have RICARE.

Part B and Group Health Plan Coverage rom

an Employer or UnionYour Part B enrollment rights can be aected i you have coveragethrough an employer (including FEHBP) or union, and you oryour spouse is still working.

When the employment ends, three things happen:

You may get a chance to elect COBRA coverage, which1.continues your health coverage through the employers plan(in most cases or only 18 months) and probably at a higher

cost to you.You may get a special enrollment period to sign up or Part B2.without a penalty. Tis period only lasts or 8 months aeryour employment ends. Tis period will run whether or notyou elect COBRA, so i you wait until your COBRA ends, yourspecial enrollment period will probably be over.

I you sign up or Part B, it will also start a 6-month Medigap3.open enrollment period which gives you a guaranteed right tobuy a Medigap (Medicare Supplement Insurance) policy. Once

this period starts, it also cant be delayed or repeated. Seepages 7576.


25/128



are dened

on pages

115118.

Part B-Covered ServicesMedically-necessaryservicesServices or supplies that are neededor the diagnosis or treatment o your medical condition and meet

accepted standards o medical practice.Preventive servicesHealth care to prevent illness or detect illnessat an early stage, when treatment is most likely to work best (orexample, Pap tests, fu shots, and prostate cancer screenings).

Pages 2637 include an alphabetical list o common services coveredby Medicare Part B. o nd out i Medicare covers a service thatsnot included on this list, visit www.medicare.gov and select, FindOut What Medicare Covers. You can also call 1-800-MEDICARE

(1-800-633-4227). Y users should call 1-877-486-2048.You will see this symbol next to preventive services.

Your doctor or other health care provider can help you betterunderstand the preventive services Medicare covers and will tell youwhich services you need.

What You Pay or Medicare Part B-Covered

Services

Costs or Part B services vary depending on whether you haveOriginal Medicare or are in a Medicare health plan. Te charts onpages 2638 give general inormation about what you must payi you have Original Medicare. You generally have to pay or thedoctors visit, even i there is no cost or the service itsel. I thePart B deductible applies, you must pay all costs until you meet theyearly Part B deductible beore Medicare begins to pay its share. Seepage 121 or the Part B deductible amount. Ten, you typically pay20% o the Medicare-approved amount o the service. You can save

money i you choose doctors or providers who accept assignment.See page 47. You also may be able to save money on your Medicarecosts i you have limited income and resources. See pages 8284.

I you join a Medicare Advantage Plan (like an HMO or PPO)or have other insurance (like a Medigap policy, or employer orunion coverage), your costs may be dierent rom those shownon pages 2637. For more inormation about the dierent costs,contact the plans you are interested in.


26/128


Part B-Covered Services

Abdominal

Aortic

AneurysmScreening

A one-time screening ultrasound or people at risk. Medicareonly covers this screening i you get a reerral or it as a

result o your one-time Welcome to Medicare physicalexam. See physical exam on page 33. You pay 20% o theMedicare-approved amount.

Ambulance

Services

Emergency ground transportation when you need to betransported to a hospital or skilled nursing acility ormedically-necessary services, and transportation in anyother vehicle could endanger your health. Medicare will payor transportation in an airplane or helicopter i you requireimmediate and rapid ambulance transportation that ground

transportation cant provide.In some cases, Medicare may pay or limited non-emergencytransportation i you have orders rom your doctor. Medicarewill only cover services to the nearest appropriate medicalacility that is able to give you the care you need. You pay 20%o the Medicare-approved amount, and the Part B deductibleapplies.

Ambulatory

Surgical

Centers

Facility ees or approved surgical procedures provided in anambulatory surgical center (acility where surgical procedures

are perormed, and the patient is released the same day). Youpay 20% o the Medicare-approved amount (except or fexiblesigmoidoscopies and screening colonoscopies, or which youpay 25%), and the Part B deductible applies. You pay all acilitycharges or procedures Medicare doesnt allow in ambulatorysurgical centers.

Blood I the provider has to buy blood or you, you must either pay theprovider costs or the rst 3 pints o blood you get in a calendaryear or have the blood donated. In most cases, the provider gets

blood rom a blood bank at no charge, and you wont have topay or it or replace it. You pay 20% o the Medicare-approvedamount or additional pints o blood you get as an outpatient,and the Part B deductible applies.

Part B deductible and coinsurance amounts are on page 121.


27/128



Bone Mass

Measurement

(Bone Density)

Helps to see i you are at risk or broken bones. Tis serviceis covered once every 24 months (more oen imedically

necessary) or people who have certain medical conditionsor meet certain criteria. You pay 20% o the Medicare-approved amount, and the Part B deductible applies.

Cardiovascular

Screenings

Helps prevent a heart attack or stroke. Tis service iscovered every 5 years to test your cholesterol, lipid, andtriglyceride levels. No cost or the test, but you generallyhave to pay 20% o the Medicare-approved amount or thedoctors visit.

Chiropractic

Services (limited)

Helps correct a subluxation (when one or more o the bones

o your spine move out o position) using manipulation othe spine. You pay 20% o the Medicare-approved amount,and the Part B deductible applies.

Clinical Laboratory

Services

Including certain blood tests, urinalysis, some screeningtests, and more. No cost to you.

Clinical Research

Studies

Clinical research studies test dierent types o medicalcare, like how well a cancer drug works. Medicare coverssome costs, like doctor visits and tests, in qualiying clinicalresearch studies. Clinical research studies help doctors andresearchers see i the new care works and i its sae. Youpay 20% o the Medicare-approved amount, and the Part Bdeductible applies.



28/128



Colorectal

Cancer

Screenings

o help nd precancerous growths and help prevent or ndcancer early, when treatment is most eective. One or more o

the ollowing tests may be covered. alk to your doctor.Fecal Occult Blood estOnce every 12 months i age 50 orolder. No cost or the test, but generally you have to pay 20% othe Medicare-approved amount or the doctors visit.

Flexible SigmoidoscopyGenerally, once every 48 monthsi age 50 or older, or or those not at high risk, 120 monthsaer a previous screening colonoscopy. You pay 20% o theMedicare-approved amount.

ColonoscopyGenerally once every 120 months (high risk

every 24 months) or 48 months aer a previous fexiblesigmoidoscopy. No minimum age. You pay 20% o theMedicare-approved amount.

Barium EnemaOnce every 48 months i age 50 or older (highrisk every 24 months) when used instead o a sigmoidoscopy orcolonoscopy. You pay 20% o the Medicare-approved amount.

Note: I you get a fexible sigmoidoscopy or screeningcolonoscopy in an outpatient hospital setting or an ambulatorysurgical center, you pay 25% o the Medicare-approved amount.

Defbrillator

(Implantable

Automatic)

For some people diagnosed with heart ailure. You pay 20% othe Medicare-approved amount, but no more than the Part Ahospital staydeductible (see page 120) i you get the device as ahospital outpatient. Te Part B deductible applies.



29/128



Diabetes

Screenings

Checks or diabetes. Tese screenings are covered i youhave any o the ollowing risk actors: high blood pressure

(hypertension), history o abnormal cholesterol andtriglyceride levels (dyslipidemia), obesity, or a history o highblood sugar (glucose). ests are also covered i you answeryes to two or more o the ollowing questions:

Are you age 65 or older?

Are you overweight?

Do you have a amily history o diabetes (parents, siblings)?

Do you have a history o gestational diabetes (diabetesduring pregnancy), or did you deliver a baby weighing

more than 9 pounds?Based on the results o these tests, you may be eligible or upto two diabetes screenings every year. No cost or the test,but you generally have to pay 20% o the Medicare-approvedamount or the doctors visit.

Diabetes

SelManagement

Training

For people with diabetes. Your doctor or other health careprovider must provide a written training order. You pay 20%o the Medicare-approved amount, and the Part B deductibleapplies.

Diabetes Supplies Including blood sugar testing monitors, blood sugar teststrips, lancet devices and lancets, blood sugar controlsolutions, and therapeutic shoes (in some cases). Insulin iscovered only i used with an insulin pump. You pay 20% othe Medicare-approved amount, and the Part B deductibleapplies.

Note: Insulin and certain medical supplies used to injectinsulin, such as syringes, may be covered by Medicareprescription drug coverage (Part D).



30/128



Doctor

Services

Services that are medically necessary(includes outpatient andsome doctor services you get when you are a hospital inpatient)

or covered preventive services. Doesnt cover routine physicalsexcept or the one-time Welcome to Medicare physical exam.See page 33. You pay 20% o the Medicare-approved amount, andthe Part B deductible applies.

Durable

Medical

Equipment

(like walkers)

Items such as oxygen equipment and supplies, wheelchairs,walkers, and hospital beds ordered by your doctor or use inthe home. Some items must rst be rented. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.You must get your covered equipment or supplies rom a supplier

enrolled in Medicare.For more inormation, visitwww.medicare.gov/Publications/Pubs/pd/11045.pdto viewMedicare Coverage o Durable Medical Equipment and OtherDevices.

Emergency

Room

Services

When you believe your health is in serious danger. You may havea bad injury, a sudden illness, or an illness that quickly gets muchworse. You pay a specied copayment or the hospital emergencydepartment visit, and you pay 20% o the Medicare-approved

amount or the doctors services. Te Part B deductible applies.

Eye Exams or

People with

Diabetes

For people with diabetes to check or diabetic retinopathyonce every 12 months. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies.

Eyeglasses

(limited)

One pair o eyeglasses with standard rames (or one set ocontact lenses) aer cataract surgery that implants an intraocularlens. You pay 20% o the Medicare-approved amount, and thePart B deductible applies.

FederallyQualifed

Health Center

Services

Provides a broad range o outpatient primary care and preventiveservices. You pay 20% o the Medicare-approved amount.

Flu Shots Helps prevent infuenza or fu virus. Tis is covered once a fuseason in the all or winter. You need a fu shot or the currentvirus each year. No cost to you or the fu shot i the doctoraccepts assignment (see page 47) or giving the shot.

http://www.medicare.gov/Publications/Pubs/pdf/11045.pdfhttp://www.medicare.gov/Publications/Pubs/pdf/11045.pdf


31/128



Foot Exams and

Treatment

I you have diabetes-related nerve damage and/or meet certainconditions. You pay 20% o the Medicare-approved amount,

and the Part B deductible applies.Glaucoma Tests Helps nd the eye disease glaucoma. Tis is covered once

every 12 months or people at high risk or glaucoma. You areconsidered high risk or glaucoma i you have diabetes, or aamily history o glaucoma, or are Arican-American and age50 or older, or are Hispanic and age 65 or older. ests must bedone by an eye doctor who is legally authorized by the state.You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Hearing andBalance Exams

I your doctor orders it to see i you need medical treatment.Hearing aids and exams or tting hearing aids arent covered.You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Hepatitis B

Shots

Helps protect people rom getting Hepatitis B. Tis is coveredor people at high or medium risk or Hepatitis B. Your risk orHepatitis B increases i you have hemophilia, End-Stage RenalDisease (ESRD), or a condition that lowers your resistance toinection. Other actors may increase your risk or Hepatitis B,

so check with your doctor about your risk. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.

Home Health

Services

Limited to medically-necessarypart-time or intermittentskilled nursing care or physical therapy, or speech-languagepathology, or a continuing need or occupational therapy. Mustbe ordered by a doctor and provided by a Medicare-certiedhome health agency. Home health services may also includemedical social services, part-time or intermittent home healthaide services, durable medical equipment (see page 30) and

medical supplies or use at home. You must be homebound,which means that leaving home takes a lot o eort. No cost toyou or home health services. For Medicare-covered durablemedical equipment, you pay 20% o the Medicare-approvedamount, and the Part B deductible applies.



32/128



Kidney

Dialysis

Services andSupplies

For people with ESRD. Dialysis is covered either in a acilityor at home when your doctor orders it. You pay 20% o the

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

Mammograms

(screening)

A type o X-ray to check women or breast cancer beore theyor their doctor may be able to nd it. Screening mammogramsare covered once every 12 months or all women with Medicareage 40 and older. Medicare covers one baseline mammogramor women between age 35 and 39. You pay 20% o theMedicare-approved amount.

Medical

NutritionTherapy

Services

Medicare may cover medical nutrition therapy and certain

related services i you have diabetes or kidney disease, andyour doctor reers you or the service. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.

Mental

Health Care

(outpatient)

o get help with mental health conditions such as depression,anxiety, or substance abuse. Includes services generally givenoutside a hospital or in a hospital outpatient department,including visits with a doctor, psychiatrist, clinical psychologist,or clinical social worker, and lab tests. Certain limits andconditions apply. For doctor or other health care provider visits

to diagnose, or to monitor or change your prescription, you pay20% o the Medicare-approved amount. For outpatient treatmento your mental health condition (such as therapy), you pay 50%o the Medicare-approved amount. Te Part B deductible applies.

alk to your doctor i you eel sad, have little interest in thingsyou used to enjoy, eel dependent on drugs or alcohol, orhave thoughts about ending your lie. See page 120 or moreinormation about inpatient mental health care.

Occupational

Therapy

Evaluation and treatment to help you return to usual activities

(such as dressing or bathing) aer an illness or accident whenyour doctor certies you need it. In 2009, there may be limitson physical therapy, occupational therapy, and speech-languagepathology services and exceptions to these limits. You pay 20%o the Medicare-approved amount, and the Part B deductibleapplies.



33/128



Outpatient

Hospital

Services

Services you get as an outpatient as part o a doctors care. You paya specied copayment or each service. Te copayment cant be

more than the Part A hospital stay deductible. See page 120. TePart B deductible applies.

Outpatient

Medical and

Surgical

Services and

Supplies

For approved procedures (like X-rays, a cast, or stitches). Youpay a copayment or each service you get in an outpatienthospital setting. For each service, this amount cant be more thanthe Part A hospital stay deductible. See page 120. Te Part Bdeductible applies, and you pay all charges or items or servicesthat Medicare doesnt cover.

Pap Tests and

Pelvic Exams(includes clinical

breast exam)

Checks or cervical, vaginal, and breast cancers. Medicare covers

these screening tests once every 24 months, or once every 12months or women at high risk, and or women o child-bearingage who have had an exam that indicated cancer or otherabnormalities in the past 3 years. No cost to you or the Pap labtest. You pay 20% o the Medicare-approved amount or Pap testcollection, and pelvic and breast exams.

Physical Exam

(onetime

Welcome

to Medicarephysical exam)

A one-time review o your health, and education and counselingabout preventive services, including certain screenings, shots, andreerrals or other care i needed.

New: Starting January 1, 2009, Medicare will cover this exam iyou get it within the rst 12 months you have Part B. You pay 20%o the Medicare-approved amount, and the Part B deductible nolonger applies.

Important: In 2008, you had to get the physical exam within therst 6 months you had Part B, and the Part B deductible applied.

Physical

Therapy

Evaluation and treatment or injuries and diseases that changeyour ability to unction when your doctor certies your need or

it. In 2009, there may be limits on these services and exceptions tothese limits. You pay 20% o the Medicare-approved amount, andthe Part B deductible applies.

Pneumococcal

Shot

Helps prevent pneumococcal inections (like certain types opneumonia). Most people only need this preventive shot oncein their lietime. alk with your doctor. No cost i the doctor orsupplier accepts assignment (see page 47) or giving the shot.



34/128



Practitioner

Services

(Nondoctor)

Such as services provided by physician assistants and nursepractitioners. You pay 20% o the Medicare-approved amount,and the Part B deductible applies.

Prescription

Drugs (limited)

Includes a limited number o prescription drugs such as thoseyou get in a hospital outpatient department under certaincircumstances, injected drugs you get in a doctors oce, certainoral cancer drugs, and drugs used with some types o durablemedical equipment (like a nebulizer or inusion pump). You pay20% o the Medicare-approved amount, and the Part B deductible

applies. Note: Other than the examples above, under Part B, youpay 100% or most prescription drugs, unless you have Part D orother drug coverage. For more inormation, see pages 6371.

Prostate Cancer

Screenings

Helps detect prostate cancer. Medicare covers a digital rectalexam and Prostate Specic Antigen (PSA) test once every 12months or all men with Medicare over age 50. You pay 20%o the Medicare-approved amount, and the Part B deductibleapplies or the doctors visit. No cost to you or the PSA test.

Prosthetic/

Orthotic Items

Including arm, leg, back, and neck braces; articial eyes; articiallimbs (and their replacement parts); breast prostheses (aermastectomy); and prosthetic devices needed to replace an internalbody part or unction (including ostomy supplies, and parenteraland enteral nutrition therapy) when ordered by a doctor. ForMedicare to cover your prosthetic or orthotic, you must goto a supplier that is enrolled in Medicare. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.

Rural Health

Clinic Services

Provides a broad range o outpatient primary care services.You pay 20% o the amount charged, and the Part B deductibleapplies.

Second Surgical

Opinions

Covered in some cases or surgery that isnt an emergency. In

some cases, Medicare covers third surgical opinions. You pay20% o the Medicare-approved amount, and the Part B deductibleapplies.

Smoking

Cessation

(counseling to

stop smoking)

Includes up to 8 ace-to-ace visits in a 12-month period i youare diagnosed with an illness caused or complicated by tobaccouse, or you take a medicine that is aected by tobacco. You pay20% o the Medicare-approved amount, and the Part B deductibleapplies.



35/128



SpeechLanguage

Pathology

Services

Evaluation and treatment given to regain and strengthenspeech and language skills including cognitive and

swallowing skills when your doctor certies your need or it.In 2009, there may be limits on these services and exceptionsto these limits. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies.

Surgical Dressing

Services

For treatment o a surgical or surgically-treated wound. Youpay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Telemedicine Medical or other health services given to a patient usinga communications system (like a computer, telephone,

or television) by a provider in a location dierent romthe patients. Available in some rural areas, under certainconditions and only in a providers oce, a hospital, ora ederally-qualied health center. You pay 20% o theMedicare-approved amount, and the Part B deductibleapplies.

Tests Including X-rays, MRIs, C scans, EKGs, and some otherdiagnostic tests. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies. See Clinical

Laboratory Services on page 27 or other Part B-coveredtests. I you get the test as a hospital outpatient, you paya specied copayment that may be more than 20% o theMedicare-approved amount but cant be more than thePart A hospital stay deductible. See page 120.



36/128



Transplants and

Immunosuppressive

Drugs

Including doctor services or heart, lung, kidney, pancreas,intestine, and liver transplants under certain conditions

and only in a Medicare-certied acility. Bone marrow andcornea transplants are covered under certain conditions.

Immunosuppressive drugs are covered i Medicare paidor the transplant, or an employer or union group healthplan that was required to pay beore Medicare paid or thetransplant. You must have been entitled to Part A at thetime o the transplant and entitled to Part B at the time youget immunosuppressive drugs, and the transplant musthave been perormed in a Medicare-certied acility. You

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

I you are thinking o joining a Medicare Advantage Planand are on a transplant waiting list or believe you need atransplant, check with the plan beore you join to makesure your doctors and hospitals are in the plans network.Also, check the plans coverage rules.

Note: Medicare drug plans (Part D) may coverimmunosuppressive drugs, even i Medicare or an

employer or union group health plan didnt pay or thetransplant.



37/128



Travel (health

care needed

when travelingoutside the

United States)

Medicare generally doesnt cover health care while you aretraveling outside the U.S. (the U.S. includes the 50 states, the

District o Columbia, Puerto Rico, the Virgin Islands, Guam,the Northern Mariana Islands, and American Samoa). Tereare some exceptions including some cases where Medicaremay pay or services that you get while on board a ship withinthe territorial waters adjoining the land areas o the U.S. Inrare cases, Medicare may pay or inpatient hospital, doctor,or ambulance services you get in a oreign country in theollowing situations:

1) I an emergency arose within the U.S. and the oreign

hospital is closer than the nearest U.S. hospital that can treatyour medical condition

2) I you are traveling through Canada without unreasonabledelay by the most direct route between Alaska and anotherstate when a medical emergency occurs and the Canadianhospital is closer than the nearest U.S. hospital that can treatthe emergency

3) I you live in the U.S. and the oreign hospital is closer toyour home than the nearest U.S. hospital that can treat your

medical condition, regardless o whether an emergency exists

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

Urgently

Needed Care

o treat a sudden illness or injury that isnt a medicalemergency. You pay 20% o the Medicare-approved amount,and the Part B deductible applies.



38/128


Whats NOT Covered by Part A and Part B?Items and services that Medicare doesnt cover include, but arentlimited to, the ollowing:

Acupuncture.Chiropractic services (except as listed on page 27).

Cosmetic surgery.

Custodial care , except when you also get skilled nursing care in askilled nursing acility, at home, or as part o hospice care.

Deductibles , coinsurance, or copayments when you get certain healthcare services. See pages 120121 or these amounts. People withlimited income and resources may get help paying these costs. Seepages 8284.

Dental care and dentures (with a ew exceptions).Eye exams (routine), eye reractions (exam that measures how well yousee at specic distances), and eyeglasses (except as listed on page 30).

Foot care (routine), like cutting corns or calluses (with ewexceptions). See page 31.

Hearing aids and exams or the purpose o tting a hearing aid.

Hearing tests that havent been ordered by your doctor.

Laboratory tests (screening), except those listed on pages 2635.

Long-term care. See pages 102104.Orthopedic shoes (with ew exceptions). See page 29 under DiabetesSupplies.

Physical exams (routine or yearly). Medicare will cover a one-timephysical exam. See page 33.

Prescription drugs (with ew exceptions). See page 34. See pages 6371or inormation about Medicare prescription drug coverage (Part D).

Shots to prevent illness, except as listed on pages 30, 31, and 33. Part Dmust cover all commercially-available vaccines (like the shingles

vaccine) except those covered by Part B.Surgical procedures given in ambulatory surgical centers that arentincluded on Medicares list o ambulatory surgical center coveredprocedures.

Syringes or insulin. Insulin used with an insulin pump is covered byPart B. Syringes or insulin may be covered by Part D.

ravel (health care while youre traveling outside the United States,except as listed on page 37).

Blue words

in the textare dened

on pages

115118.


39/128


Preventive Services Checklistake this checklist to your doctor or other health care provider, andask which preventive services are right or you. Look on pages 2534

or more details about the costs, how oen, and whether you meetthe conditions to get these services. Write down any notes (like thedate you get the service).

Medicarecovered Preventive Service

Details

on Page Notes

Abdominal Aortic AneurysmScreening

26

Bone Mass Measurement 27

Cardiovascular Screenings 27Colorectal Cancer Screenings

Fecal Occult Blood est 28

Flexible Sigmoidoscopy 28

Colonoscopy 28

Barium Enema 28

Diabetes Screenings 29

Diabetes Sel-Management raining 29

Flu Shots 30

Glaucoma ests 31

Hepatitis B Shots 31

Mammogram (screening) 32

Medical Nutrition Terapy Services 32

Pap est and Pelvic Exam (includesbreast exam)

33

Physical Exam (one-time Welcometo Medicare physical exam)

33

Pneumococcal Shot 33

Prostate Cancer Screenings 34

Smoking Cessation (counseling tostop smoking)

34

Visit www.MyMedicare.gov to keep track o your preventive services. See page 109.
http://www.mymedicare.gov/http://www.mymedicare.gov/


40/128


Notes


41/128

41

Decide How

to Get Your

Medicare

You have choices about how you get your Medicare health andprescription drug coverage. Beore making any decisions, learn

as much as you can about the types o coverage available to you.

Section 2 includes inormation about the ollowing:

Your Medicare Choices . . . . . . . . . . . . . . . . . . . . . 4244

Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . 4549

Medicare Advantage Plans (Part C) . . . . . . . . . . . . . . 5060

Other Medicare Health Plans . . . . . . . . . . . . . . . . . 6162

Medicare Prescription Drug Coverage (Part D) . . . . . . . 6373

How Your Bills Get Paid I You Have OtherHealth Insurance . . . . . . . . . . . . . . . . . . . . . . . . . 74

Medigap (Medicare Supplement Insurance) Policies . . . . 7576

Tis handbook has basic inormation. You may need moredetailed inormation than this handbook provides to make achoice. See page 42 to nd out how to get personalized healthinsurance counseling.

SECTION 2


42/128

42 Section 2Decide How to Get Your Medicare

Your Medicare ChoicesYou can choose dierent ways to get your Medicare coverage,Original Medicare or a Medicare Advantage Plan (like an HMO

or PPO). I you choose Original Medicare and you want drugcoverage, you can join a Medicare Prescription Drug Plan.I youchoose to join a Medicare Advantage Plan, the plan may includeMedicare prescription drug coverage. In most cases, i you dontmake a choice, you will have Original Medicare. See page 43 ormore inormation about your coverage choices and the decisionsyou need to make.

Each year you should review your health and prescription needsbecause your health, nances, or coverage may have changed. I you

decide other coverage will better meet your needs, you can switchplans during certain times. See pages 59 and 65.

Need Help Deciding?Visit1. www.medicare.gov and select, Compare Health Plansand Medigap Policies in Your Area or Compare MedicarePrescription Drug Plans.

Get ree counseling about choosing coverage. See pages 1111142.or the telephone number o your State Health InsuranceAssistance Program (SHIP).

Call 1-800-MEDICARE (1-800-633-4227), and say Agent.3.Y users should call 1-877-486-2048.


are dened

on pages

115118.


43/128

43Section 2Decide How to Get Your Medicare

Decide i You Want

Original Medicare OR a Medicare Advantage Plan(like an HMO or PPO)

Part A (Hospital Insurance) andPart B (Medical Insurance)

Medicare provides this coverage.You have your choice o doctors, hospitals,and other providers.Generally, you pay deductibles andcoinsurance.

You usually pay a monthly premium orPart B.

See pages 4549.

Part CIncludes BOTH Part A (HospitalInsurance) and Part B (Medical Insurance)

Private insurance companies approved byMedicare provide this coverage.In most plans, you need to use plan doctors,hospitals, and other providers or you pay more.You usually pay a monthly premium (in

addition to your Part B premium) and acopayment or covered services.Costs, extra coverage, and rules vary by plan.

See pages 5060.

Decide I You Want Prescription Drug Coverage (Part D)

I you want this coverage, you must chooseand join a Medicare Prescription DrugPlan.Tese plans are run by private companiesapproved by Medicare.

See pages 6371.

I you want this coverage, in most cases youmust get it through your Medicare AdvantagePlan.Most Medicare Advantage Plans includeprescription drug coverage (Part D), usuallyor an extra cost.

See pages 5456.

Decide I You Want Supplemental Coverage

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

You can choose to buy private

supplemental coverage, like a Medigap(Medicare Supplement Insurance) policy.Costs vary by policy and company.Employers/unions may oer similarcoverage.

See pages 7576.

Note: I you join a Medicare AdvantagePlan, you dont need a Medigap policy. I you

already have a Medigap policy, you cant useit to pay or any expenses you have underthe Medicare Advantage Plan. I you alreadyhave a Medicare Advantage Plan, you cantbe sold a Medigap policy. See page 57.

Step 1

Step 2 Step 2

Use These Steps to Help You Decide

Step 3

In addition to Original Medicare or a Medicare Advantage Plan, you may be able to join othertypes o Medicare health plans (see pages 6162). You may be able to save money or have otherchoices i you have limited income and resources (see pages 7784). You may also have other

coverage, like employer or union, military, or Veterans benets (see pages 7273).


44/128


Things to Consider When Choosing or Changing

Your CoverageCoverage When choosing between Original Medicare and a

Medicare health plan, does the plan provide extra coverage you wantthat Original Medicare doesnt cover?

Your other coverage Do you have, or are you eligible or, othertypes o health or prescription drug coverage? I so, read thematerials you get rom your insurer or plan, or call them to nd outhow the coverage works with, or is aected by, Medicare. I you havecoverage through a ormer or current employer or union, talk to yourbenets administrator, insurer, or plan beore making any changes toyour coverage.

Cost How much are your premiums and deductibles? How muchdo you pay or services like hospital stays or doctor visits? Your costs

vary and may be dierent i you dont ollow the coverage rules.

Doctor and hospital choice Do your doctors accept the coverage?Are they accepting new patients? I you are considering a Medicarehealth plan, do you have to choose your hospital and health careproviders rom a network? Do you need a reerral to see a specialist?

Prescription drugs What are your drug needs? Do you need tojoin a Medicare drug plan? What will your prescription drugs costunder each plan? Are your drugs covered under the plans ormulary(drug list)? Formularies can change.

Quality o care Te quality o care and services given by plans andother health care providers can vary. Medicare has inormation tohelp you compare plans and providers. See page 100.

Convenience Where are the doctors oces? What are their hours?Which pharmacies can you use? Can you get your prescriptions bymail?

ravel Do you spend part o each year in another state? Will theplan cover you there?

Your Medicare plan will send you an Evidence o Coverage(EOC) and Annual Notice o Change (ANOC) each year. TeEOC gives you details about what the plan covers, how muchyou pay, and more. Te ANOC includes any changes in coverage,costs, or service area that will be eective in January.


are dened

on pages

115118.


45/128


Original MedicareOriginal Medicare is one o your health coverage choices as part oMedicare. You will have Original Medicare unless you choose to

join a Medicare health plan.How Does Original Medicare Work?

Under Original Medicare, you have your choice o doctors andhospitals. You dont need a reerral. You pay a separate amount oreach service. Here are the general rules or how it works:

Original Medicare

Are prescription drugs

covered?

Only in limited situations like when you are a hospital inpatient.

See pages 20 and 34. You can add comprehensive drug coverage byjoining a Medicare Prescription Drug Plan. See pages 6371.

Do I need to choose a

primary care doctor?

No.

Can I get my health

care rom any doctor

or hospital?

Yes. You can go to any doctor, supplier, hospital, or other acility thatis enrolled in Medicare and is accepting new Medicare patients.

Do I have to get

a reerral to see a

specialist?

No.

Do I need a

supplemental policy?

You may already have employer or union coverage that may paycosts that Original Medicare doesnt. I not, you may want to buy aMedigap (Medicare Supplement Insurance) policy. See pages 7576.

What else do I need to

know about Original

Medicare?

Each year, you generally must pay a set amount or your health care(deductible) beore Medicare pays its share. Ten, Medicare paysits share, and you pay your share (coinsurance) or covered servicesand supplies. See pages 120121 to nd out what you pay.

I you have Part A, you can generally get the Part A-covered

services listed on pages 1920.I you have Part B, you can generally get the services listed onpages 2637. You usually pay a monthlypremium or Part B.See page 119.

You generally dont need to le Medicare claims. Providers (likedoctors, hospitals, skilled nursing acilities, and home healthagencies) and suppliers are required by law to le Medicare claimsor the covered services and supplies you get.


46/128


Original Medicare Payment InormationI you get a Medicare-covered service, you will get a MedicareSummary Notice (MSN) in the mail. Te MSN shows all the services

or supplies that were billed to Medicare during each 3-month period,what Medicare paid, and what you may owe the provider. Te MSNisnt a bill. When you get your MSN, you should do the ollowing:

I you have other insurance, check to see i it covers anything thatMedicare didnt.

Keep your receipts and bills, and compare them to your MSN to besure you got all the services, supplies, or equipment listed.

I you paid a bill beore you got your MSN, compare your MSN withthe bill to make sure you paid the right amount or your services.

MSNs are mailed every 3 months. I you are due a reund check romMedicare, the MSN will be mailed as soon as the claim is processed.I you need to change your address on your MSN, call Social Securityat 1-800-772-1213. Y users should call 1-800-325-0778. I youget RRB benets, call your local RRB oce or 1-800-808-0772. AerJanuary 1, 2009, call 1-877-772-5772.

Visit www.MyMedicare.gov to track your Medicare claims.See page 109.

Your Out-o-Pocket Costs in Original Medicare

Depend on the Following:Whether you have Part A and/or Part B (most people have both).

Whether your doctor or supplier accepts assignment. See page 47.

How oen you need health care.

What type o health care you need.

Whether you choose to get services or supplies Medicare doesnt

cover. I you do, you pay all the costs or these services.Whether you have other health insurance that works with Medicare.

Whether you have Medicaid or get state help paying your Medicarecosts. See pages 8283.

See pages 7584 or more inormation about help to cover thecosts that Original Medicare doesnt cover.
http://www.mymedicare.gov/http://www.mymedicare.gov/


47/128


Assignment in Original MedicareAssignment is an agreement between you, Medicare, and doctors,other health care providers, or suppliers. When you assign a

claim, Medicare will pay the doctor, provider, or supplier directlyor the services you get.

Remember the ollowing i your doctor, provider, or supplieraccepts assignment:

Your out-o-pocket costs may be less.

Most doctors, providers, and suppliers accept assignment, butyou should always check to make sure. In some cases they mustaccept assignment, like when they have a participation agreementwith Medicare and give you Medicare-covered services.

I a doctor, provider, or supplier accepts assignment, they agreeto only charge you the Medicare deductible or coinsuranceamount and wait or Medicare to pay its share.

All doctors, providers, and suppliers that give youMedicare-covered services have to submit your claim toMedicare directly. Tey cant charge you or submitting the claim.

Remember the ollowing i your doctor, provider, or supplierdoesnt accept assignment:

Tey still must submit a claim to Medicare when they give youMedicare-covered services. I they dont submit the claim orthese services, you should contact the company that handlesbills or Medicare or your state to le a complaint. You cancall 1-800-MEDICARE (1-800-633-4227) or their telephonenumber. Y users should call 1-877-486-2048. In themeantime, you might have to pay the entire charge at the time oservice, and then submit your claim to Medicare to get paid back.

Tey may charge you more than the Medicare-approved amount,but there is a limit called the limiting charge. Tey can onlycharge you up to 15% over the Medicare-approved amount. Telimiting charge applies only to certain services and doesnt applyto some supplies and durable medical equipment.

o nd doctors and suppliers who accept assignment, visitwww.medicare.gov and select, Find a Doctor or Other HealthcareProessional or Find Suppliers o Medical Equipment in YourArea. You can also call 1-800-MEDICARE.


are dened

on pages

115118.


48/128


What Is a Private Contract?A private contract is a written agreement between you and adoctor or other health care provider who has decided not to provide

services through Medicare. Te private contract only applies to theservices provided by the doctor who asked you to sign it. You cant beasked to sign a private contract in an emergency situation or whenyou need urgent care. You dont have to sign a private contract witha doctor. You can go to another doctor who will provide servicesthrough Medicare. I you sign a private contract with your doctor,remember these rules:

Medicare wont pay anyamount or the services you get rom thisdoctor.

You will have to pay whatever this doctor or provider charges youor the services you get.

I you have a Medigap (Medicare Supplement Insurance) policy, itwont pay anything or this service. Call your Medigap insurancecompany beore you get the service i you have questions.

Your doctor must tell you i Medicare would pay or the service iyou got it rom another doctor who accepts Medicare.

Your doctor must tell you i he or she has been excluded romMedicare.

You are always ree to get non-covered services on your own iyou choose to pay or the service yoursel. See page 38 or a list oservices and items that Medicare doesnt cover.

You may want to contact your State Health Insurance AssistanceProgram (SHIP) to get help beore signing a private contract withany doctor or other health care provider. See pages 111114 or thetelephone number.

See pages 8598 or inormation about your appeal rights andhow to protect yoursel and Medicare rom raud.


49/128


Adding Medicare Prescription Drug Coverage

(Part D)I you have Original Medicare and you want Medicare drug

coverage, you must join a Medicare Prescription Drug Plan. Teseplans are available through private companies that work withMedicare to provide prescription drug coverage. See pages 6371or more details about Medicare prescription drug coverage.

Call your employer or unions benets administrator beoreyou make any changes to your coverage. I you drop youremployer or union coverage, you may not be able to get itback. You also may not be able to drop your employer or

union drugcoverage without also dropping your employeror union health (doctor and hospital) coverage. I you dropcoverage or yoursel, you may also have to drop coverage oryour spouse and dependants.

Help Paying or a Medicare Drug PlanPeople with limited income and resources may qualiy or extrahelp paying their Medicare prescription drug coverage costs. I

you automatically qualiy or extra help, you wont pay a premiumi you join certain Medicare drug plans. I you dont automaticallyqualiy, you may still get help to pay your prescription drug costs.See pages 7881 to nd out i you may qualiy or extra help.


are denedon pages

115118.


50/128


Medicare Advantage Plans (Part C)Medicare Advantage Plans are health plan options (like an HMOor PPO) approved by Medicare and oered by private companies.

Tese plans are part o Medicare and are sometimes calledPart C or MA Plans. Medicare pays a xed amount or yourcare every month to the companies oering Medicare AdvantagePlans. Tese companies must ollow rules set by Medicare.Medicare Advantage Plans provide your Medicare healthcoverage and usually Medicare drug coverage. Tey arentsupplemental insurance.

Not all Medicare Advantage Plans work the same way, so nd outthe plans rules beore joining. See the chart that starts on page 54

or an outline o these various plans rules. In all plan types, youare always covered or emergency and urgent care.

Medicare Advantage Plans include the ollowing:

Preerred Provider Organization (PPO) Plans. See page 54.

Health Ma

medicare&you 2009

Documents