medicare&you 2013

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

&Medicare

You

2013 This is the ocial U.S. government

Medicare handbook:

What's new (page 4)

What Medicare covers (page 27)

Don’t forget that Open Enrollment begins and ends

earlier—October 15–December 7. See page 12.

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Now available or e-ReaderVisit www.medicare.gov/publications to download a digital version o thishandbook to your e-Reader. You can get the same important inormationthat’s included in the printed version in an easy-to-read ormat that youcan take anywhere you go. Tis new option is available or the iPad, Nook,Sony e-Reader, Kindle, and all other e-Reader devices.

Please keep this handbook or uture reerence.Inormation was correct when it was printed. Changes may occuraer printing. Visit www.medicare.gov or call 1-800-MEDICARE(1-800-633-4227) to get the most current inormation. Y users shouldcall 1-877-486-2048.

“Medicare & You” isn’t a legal document. Ocial Medicare Program legalguidance is contained in the relevant statutes, regulations, and rulings.

NEW!

http://www.medicare.gov/publications

http://www.medicare.gov/





Marilyn B. avenner

Acting Administrator

Centers or Medicare & MedicaidServices

Kathleen Sebelius

Secretary

U.S. Department o Health and Human Services

Welcome to “Medicare & You” 2013

Tis year’s handbook is ull o important inormation to help answerquestions about your Medicare benets, coverage options, rights, and more.Medicare is stronger than ever and we’re working hard to make sure you havereliable, high-quality health care at a cost you can aord.

We’re excited to continue implementing the new Medicare benets providedto you under the 2010 Aordable Care Act. Tere’s a lot o inormation aboutthis law in the news including many new opportunities or all Americans tocompare plans and get aordable health care coverage. Be assured that you’llstill have access to all o your guaranteed Medicare benets. In act, thisimportant piece o legislation extends the lie o the Medicare program and

oers you real benets. Here are some improvements people with Medicarehave seen so ar because o this law:

■ More than 32.5 million people received one or more preventive service at nocost, helping them nd and treat health problems early.

■ In 2011, 3.6 million people with Medicare received a 50% discount onbrand-name prescription drugs, when they reached the Part D donut hole.Tat’s a savings o about $600 per person.

Our goal is or you to live a healthier, prosperous, and more productive lie.Providing you with high quality aordable health care and adding benets tokeep you healthy will lead us in the right direction.

I you have specic questions about Medicare, visit the newly redesignedwww.medicare.gov to nd the answers you need aster and more easily thanever. You also can call 1-800-MEDICARE (1-800-633-4227). Y usersshould call 1-877-486-2048. For personal assistance, you can turn to yourlocal State Health Insurance Assistance Program (SHIP)—they’ve beenhelping people with Medicare or 20 years. See pages 129–132 or the phonenumber.

Yours in good health,

/s/ /s/





4

What’s New & Important in 2013

More covered

preventive

services

See pages 33, 35, 37, 43, and 46.

Medicare now coversdepression screenings,screenings and counselingor alcohol misuse andobesity, behavioral therapy or cardiovascular disease,and more. Use the checkliston page 51 to ask your healthcare provider which servicesyou need.

Even more help in

the prescription

drug coverage gap

See page 86.

I you reach the coverage gap(donut hole) in your Medicareprescription drug coverage(Part D), you’ll pay only 47.5%or covered brand-name drugsand 79% or generic drugs.

Medicare health

& prescription

drug plans

Visitwww.medicare.gov/nd-a-plan or call 1-800-MEDICARE(1-800-633-4227) to nd plansin your area. Y users shouldcall 1-877-486-2048.

What you pay

for Medicare

(Part A & Part B)

See pages 24–26 and 28–32. Find out your Medicarecosts or 2013.

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

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Contents5

4 What’s New & Important in 2013

7 Index—Find a Specic Topic

12 Important Enrollment Inormation

13 Section 1—Learn How Medicare Works

13 What is Medicare?

13 What are the dierent parts o Medicare?14 What are my Medicare coverage choices?

15 Where can I get my questions answered?

17 Section 2—Sign Up or Medicare

17 How do I sign up or Part A & Part B?

19 I I’m not automatically enrolled, when can I sign up?

20 Should I get Part B?

22 How does my other insurance work with Medicare?

24 How much does Part A coverage cost?

25 How much does Part B coverage cost?

27 Section 3—Find Out i Medicare Covers

Your Test, Service, or Item

27 What does Part A cover?

32 What does Part B cover?

51 Want to keep track o your preventive services?

52 What’s NOT covered by Part A & Part B?

53 Section 4—Choose Your Health &

Prescription Drug Coverage

54 What i I need help deciding how to get my Medicare?

56 What should I consider when choosing or changing my coverage?



6

57 Section 5—Get Inormation about Your

Medicare Health Coverage Choices

57 How does Original Medicare work?

64 What are Medicare Supplement Insurance (Medigap) policies?

68 What are Medicare Advantage Plans (Part C)?

79 Are there other types o Medicare health plans?

81 Section 6—Get Inormation about


81 How does Medicare prescription drug coverage (Part D) work?

95 Section 7—Get Help Paying Your Health

& Prescription Drug Costs95 What i I need help paying my Medicare prescription drug costs?

99 What i I need help paying my Medicare health care costs?

103 Section 8—Know Your Rights & How to

Protect Yoursel rom Fraud

103 What are my Medicare rights?

104 What’s an appeal?

109 How does Medicare use my personal inormation?

112 How can I protect mysel rom identity thet?

112 How can I protect mysel & Medicare rom raud?

117 Section 9—Plan Ahead or Long-Term Care

117 How do I plan or long-term care?

118 How do I pay or long-term care?

120 What are advance directives?

121 Section 10—Get More Inormation

121 Where can I get personalized help?

124 How do I compare the quality o plans and providers?

126 Can I manage my health inormation online?

128 Are resources available or caregivers?

129 State Health Insurance Assistance Programs (SHIPs)

133 Section 11—Denitions

Contents



77

Index Find a Specic Topic

AAbdominal aortic aneurysm 33, 51

Accountable Care Organizations (ACOs) 126

Acupuncture 52

Advance Beneciary Notice o Noncoverage (ABN) 108–

109

Advance directives 120

Advantage Plan (see Medicare Advantage Plan)Alcohol misuse counseling 33, 51

ALS (Amyotrophic Lateral Sclerosis) 17

Ambulance services 33, 49

Ambulatory surgical center 34

Appeal 60, 70, 104–109

Articial limbs 45

Assignment 32, 60–61, 133

BBalance exam 40

Barium enema 36, 51

Benet period 30, 133

Bills 59, 122

Blood 28, 34

Bone mass measurement (bone density) 34, 51

Braces (arm/leg/back/neck) 45

Breast exam (clinical) 35

CCardiac rehabilitation 34

Cardiovascular disease (behavioral therapy) 35, 51

Cardiovascular screenings 35, 51

Caregiving 128

Cataract 39

Catastrophic coverage 86–87

Chemotherapy 35, 70

Children’s Health Insurance Program (CHIP) 102, 127

Chiropractic services 35

C (continued)Claims 58, 60–61

Clinical research studies 36, 70

COBRA 20–21, 93

Colonoscopy 36, 51

Colorectal cancer screenings 36, 51

Community-based programs 118

Contract (private) 62 Coordination o benets 15, 22–23

Cosmetic surgery 52

Cost Plan 79, 81, 85, 135

Costs (copayments, coinsurance, deductibles, and

premiums)

Comparison o plan costs 54

Extra Help paying or Part D 95–98

Help with Part A and Part B costs 99–100

Medicare Advantage Plans 73 Medicare Prescription Drug Plans (Part D) 84–87

Original Medicare 58–59

Part A and Part B 24–26, 28–32

Part D late enrollment penalty 88–89

Yearly changes 12

Coverage determination (Part D) 106

Coverage gap 4, 86–87

Covered services (Part A and Part B) 27–51

Creditable prescription drug coverage 81–82, 88–89,93–94, 133

Custodial care 27, 31, 52, 117–118, 134, 135

DDebrillator (implantable automatic) 37

Denitions 133–136

Demonstrations/Pilot programs 80, 101, 134, 135

Dental care and dentures 52, 68

Department o Deense 15

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

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D (continued)Department o Health and Human Services (Ofce or

Civil Rights) 115

Department o Veterans Aairs 16, 88, 94, 119 Depression (see mental health care) 37, 42, 51

Diabetes 37, 39, 40, 42, 75

Dialysis (kidney dialysis) 41, 74, 124

Discrimination 103, 115

Disenroll 67, 78, 84, 136

Donut hole 4, 86–87

Drug plan

Costs 84–85

Enrollment 83–84 Types o plans 81

What’s covered 90

Yearly changes 12

Drugs (outpatient) 44

Durable medical equipment (like walkers) 13, 28, 29,

38, 41, 44, 61

EEKGs 39, 47

Eldercare locator 116, 119, 128

Electronic handbook 123, 127

Electronic Health Record (EHR) 56, 125

Electronic prescribing 56, 125

Emergency department services 39, 91

Employer group health plan coverage

Costs or Part A may be dierent 28

Enrolling in Part A and B 19–20

Medicare Advantage Plans (Part C) 71, 72 Medigap Open Enrollment 21, 66

Prescription drug coverage 56, 63, 82, 88, 93

End-Stage Renal Disease (ESRD) 13, 18, 20, 22, 41, 72

Enroll

Part A 17–20

Part B 17–20

Part C 70–71, 76

Part D 82–83

E (continued)e-Reader inside ront cover

Exception (Part D) 90, 91, 106

Extra Help (help paying Medicare drug costs) 15, 81, 82,95–98, 134

Eyeglasses 39

FFecal occult blood test 36, 51

Federal Employee Health Benets Program 16, 94

Federally-qualied health center services 39

Flexible sigmoidoscopy 36, 51

Flu shot 39, 51

Foot exam 39

Formulary 56, 84, 90, 106, 134

Fraud 112–115

GGap (coverage) 4, 86–87

General Enrollment Period 19, 20, 25

Glaucoma test 40, 51

HHealth care proxy 120

Health Inormation Technology (Health IT) 125

Health Maintenance Organization (HMO) 69, 74, 136

Health risk assessment 50

Hearing aids 40, 52

Help with costs 95–102

Hepatitis B shot 40, 51

HIV screening 40, 51

Home health care 13, 28, 41, 108

Hospice care 13, 29, 65, 68

Hospital care (inpatient coverage) 30, 133

IIdentity thet 112

Indian Health Service 88, 94

Initial Enrollment Period 19, 25, 88

Inpatient 30, 133

Institution 75, 76, 82, 96, 98, 134


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9

JJoin

Medicare drug plan 53, 55, 63, 82–83

Medicare health plan 55, 68, 70–72

KKidney dialysis 41, 74, 124

Kidney disease education services 41

Kidney transplant 13, 18, 42, 72

LLaboratory services 41, 47

Late enrollment penalty (see Penalty)

Lietime reserve days 30, 134 Limited income 95–102, 134

Living will 120

Long-term care 31, 52, 80, 117–119, 135

Low-Income Subsidy (LIS) (Extra Help) 15, 81, 82,

95–98, 134

MMammogram 34, 51, 74, 75

Medicaid 23, 75, 80, 96–98, 100–102, 114, 118

Medical equipment 13, 28, 29, 38, 41, 44, 61, 118

Medical nutrition therapy 42, 51

Medical Savings Account (MSA) Plans 69, 81

Medically necessary 28, 30, 34, 38, 41, 49, 135

Medicare

Part A 13, 14, 17–19, 27–31

Part B 13, 14, 17–21, 32–50

Part C 13, 14, 68–78

Part D 13, 14, 81–94

Medicare Advantage Plans (like an HMO or PPO)

Costs 73

How they work with other coverage 71

Join, switch, or drop 76–77

Overview 68

Plan ratings 77

Plan types 69, 74–75

M (continued)Medicare Authorization to Disclose Personal Health

Inormation 122

Medicare Beneciary Ombudsman 116 Medicare card (replacement) 15

Medicare Drug Integrity Contractor (MEDIC) 90, 114

Medicare.gov 15, 123

Medicare-Medicaid Plans 101

Medicare prescription drug coverage 81–94

Medicare Savings Programs 96–97, 99–100

Medicare SELECT 64

Medicare Summary Notice (MSN) 59–60, 105, 113

Medicare Supplement Insurance (Medigap) 14, 21, 55,58, 64–67, 93, 117

Medication Therapy Management Program 92

Mental health care 30, 42

MyMedicare.gov 60, 113, 123

NNon-doctor services 38

Nurse practitioner 29, 38, 42

Nursing home 29, 75, 80, 98, 100, 117–118, 124, 134,

135

Nutrition therapy services 42, 51

OObesity screening and counseling 43, 51

Occupational therapy 28, 41, 43

Ofce or Civil Rights 16, 111, 115

Ofce o Personnel Management 16, 94

Ombudsman 116

Open enrollment 12, 21, 66, 76, 77, 104 Original Medicare 14, 27, 32, 57–59, 63

Orthotic items 45

Outpatient hospital services 43

Oxygen 38

Index—Find a Specic Topic


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PPap test 35, 51

Payment options (premium) 26

Pelvic exam 35, 51 Penalty (late enrollment)

Part A 24

Part B 25

Part D 88–89

Personal Health Record (PHR) 126

Pharmaceutical Assistance Programs 101

Physical therapy 28, 31, 41, 44, 136

Physician assistant 38, 42

Pilot/Demonstration programs 80, 101, 135

Pneumococcal shot 44, 51

Power o attorney 120

Preerred Provider Organization (PPO) Plan 69, 73, 74

Prescription drug coverage (Part D)

Appeals 106–107

Coverage under Part A 29–30

Coverage under Part B 44

Join, switch, or drop 82–84

Late enrollment penalty 88–89

Medicare Advantage Plans 71, 74–75

Overview 81–94

Preventive services 32–51, 136

Primary care doctor 33, 35, 43, 46, 58, 74–75, 136

Privacy notice 110–111

Private contract 62

Private Fee-or-Service (PFFS) Plans 69, 75

Programs o All-Inclusive Care or the Elderly (PACE) 80,102, 119, 135

Prostate screening (PSA Test) 45, 51

Proxy (health care) 120

Publications 127

Pulmonary rehabilitation 45

QQuality Improvement Organization (QIO) 16, 52, 107,

136

Quality o care 16, 56, 80, 123–124

RRailroad Retirement Board (RRB) 16, 17–18, 25–26, 60,

85, 98, 122

Reerral

Consider when choosing a plan 56

Denition 136

Medicare Advantage Plans 68, 74–75

Original Medicare 58

Part B-covered services 33, 37, 45

Religious Nonmedical Health Care Institution 31

Respite Care 29

Retiree health insurance (coverage) 20–22, 94

Rights 103–116

Rural health clinic 45

SSecond surgical opinions 46

Senior Medicare Patrol (SMP) Program 114 Service area 71, 76, 80–82, 136

Sexually transmitted inections screening and

counseling 46, 51

Shingles vaccine 90

Shots (vaccinations) 39–40, 44, 51

Sigmoidoscopy 36, 51

Skilled nursing acility (SNF) care 13, 27–31, 41, 65, 70,

136

Smoking cessation (tobacco use cessation) 48, 51 Social Security

Change address on MSN 60

Extra Help paying Part D costs 97–98

Get questions answered 15

Part A and Part B premiums 24–26

Part D premium 85

Sign up or Parts A and B 17–18

Supplemental Security Income benets 102


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11

S (continued)Special Enrollment Period

Part A and Part B 19–20

Part C (Medicare Advantage Plans) 76–77 Part D (Medicare Prescription Drug Plans) 82–83

Special Needs Plans (SNP) 69, 72, 75

Speech-language pathology 28, 41, 46

State Health Insurance Assistance Program (SHIP) 15,

54, 97, 107, 112, 122, 129–132

State Medical Assistance (Medicaid) Ofce 80, 97,

100–102, 114, 118

State Pharmacy Assistance Program (SPAP) 101

Substance abuse 42 Supplemental policy (Medigap)

Drug coverage 93, 104

Medicare Advantage Plans 66

Open enrollment 21, 66

Original Medicare 14, 55, 58, 64

Overview 64–65

Supplemental Security Income (SSI) 96, 102

Supplies (medical) 28, 30, 37–38, 41, 45

Surgical dressing services 47

TTelehealth 47

Tiers (drug ormulary) 56, 84, 90, 106, 134

Tobacco use cessation counseling 48, 51

Transplant services 18, 72

Travel 49, 56, 64, 65

TRICARE 15, 21, 23, 88, 94

TTY 121, 136

UUnion

Costs or Part A may be dierent 28

Enrolling in Part A and Part B 20, 22 Medicare Advantage Plans 71

Medigap Open Enrollment 21, 66

Prescription drug coverage 63, 82, 93

Urgently-needed care 49

VVaccinations (shots) 39, 40, 44, 51, 136

Veterans’ Benets (VA) 55, 94, 119

Vision (eye care) 52, 68

WWalkers 38

Welcome to Medicare Preventive Visit 33, 39, 50, 51

Wellness visit 50, 51

What’s new 4

Wheelchairs 38

www.medicare.gov 15, 123

www.MyMedicare.gov 60, 113, 123

XX-ray 35, 43, 47

Index—Find a Specic Topic


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12

Important Enrollment Inormation

Coverage & costs change yearlyMedicare health plans and prescription drug plans can change costs andcoverage each year. Always review your plan materials or the comingyear to make sure your plan will meet your needs or the ollowing year.I you’re satised that your current plan will meet your needs or nextyear, you don’t need to do anything.

Open Enrollment Period

Mark your calendar with these important dates! In most cases, thismay be the one chance you have each year to make a change to yourhealth and prescription drug coverage.

October 1–

October 15, 2012

Compare your coverage with otheroptions. See pages 53–56.

OPEN ENROLLMENT

October 15–

December 7, 2012

Change your Medicare health orprescription drug coverage or 2013.See pages 76–77 and 82–83 or othertimes when you can switch yourcoverage.

January 1, 2013

New coverage begins i you made achange. New costs and benet changes

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

Health plans and prescription drug plans can decide not to participate inMedicare or the coming year. I your plan decides to leave Medicare orstop providing coverage in your area, you’ll get a letter beore the start o the Open Enrollment Period. See page 104 or more inormation aboutyour rights and options.

Important!

Denitionso blue wordsare on pages133–136.



13

Section 1—

Learn How Medicare Works

S e c t i o n

1

What is Medicare?Medicare is health insurance or:

■ People 65 or older

■ People under 65 with certain disabilities

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

What are the dierent parts o Medicare?

Medicare Part A (Hospital Insurance) helps cover:

■ Inpatient care in hospitals

■ Skilled nursing acility care

■ Hospice care

■ Home health care

Seepages 27–31.

Medicare Part B (Medical Insurance) helps cover:

■ Services rom doctors and other health care providers■ Outpatient care

■ Home health care

■ Durable medical equipment

■ Some preventive services

Seepages

32–51.

Medicare Part C (Medicare Advantage):

■ Run by Medicare-approved private insurance companies

■ Includes all benets and services covered under Part A and Part B

■ Usually includes Medicare prescription drug coverage (Part D) aspart o the plan

■ May include extra benets and services or an extra cost

Seepages

68–78.

Medicare Part D (Medicare prescription drug coverage):

■ Run by Medicare-approved private insurance companies

■ Helps cover the cost o prescription drugs

■ May help lower your prescription drug costs and help protectagainst higher costs in the uture

Seepages

81–94.

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What are my Medicare coverage choices?Tere are 2 main ways to get your Medicare coverage—OriginalMedicare or a Medicare Advantage Plan. Use these steps to help youdecide which way to get your coverage.

Part AHospitalInsurance

Part BMedicalInsurance

MedicareSupplementInsurance(Medigap) policy

Part DPrescriptionDrug Coverage

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

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

Step 2: Decide i you needto add drug coverage.

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

End

End

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

Part D Prescription DrugCoverage(Most MedicareAdvantage Plans coverprescription drugs.You may be able toadd drug coverage insome plan types i notalready included.)

or

Start

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

See page 55 or more details about your coverage choices.

Step 2: Decide i you need toadd drug coverage.

Step 2: Decide i you need toadd drug coverage.



15Section 1—Learn How Medicare Works

Where can I get my questions answered?

1-800-MEDICARE (1-800-633-4227)Get general or claims-specic Medicare inormation.

I you need help in a language other than Englishor Spanish, say “Agent” to talk to a customer servicerepresentative.Y 1-877-486-2048www.medicare.gov

State Health Insurance Assistance Program (SHIP)

Get personalized Medicare counseling at no cost toyou. See pages 129–132 or the phone number. Visit

www.medicare.gov/contacts or call 1-800-MEDICARE toget the phone numbers o SHIPs in other states.

Social Security

Get a replacement Medicare card, change your address orname, nd out i you’re eligible or Part A and/or Part Band how to enroll, apply or Extra Help with Medicareprescription drug costs, ask questions about premiums,and report a death.

1-800-772-1213Y 1-800-325-0778www.socialsecurity.gov

Medicare Coordination o Benets Contractor

Find out i Medicare or your other insurance pays rst,let Medicare know you have other insurance, or reportchanges in your insurance inormation.1-800-999-1118Y 1-800-318-8782

Department o Deense

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


http://www.medicare.gov/contacts

http://www.socialsecurity.gov/

http://www.tricare.mil/mybenefit








Department o Health and Human Services

Oce or Civil Rights I you think you were discriminated against or i yourhealth inormation privacy rights were violated.

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

Department o Veterans Aairs

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

Ofce o Personnel Management

Get inormation about the Federal Employee HealthBenets Program or current and retired ederal employees.1-888-767-6738Y 1-800-878-5707www.opm.gov/insure

Railroad Retirement Board (RRB)

I you have benets rom the RRB, call them to changeyour address or name, check eligibility, enroll in Medicare,replace your Medicare card, or report a death.1-877-772-5772Y 1-312-751-4701www.rrb.gov

Quality Improvement Organization (QIO)

Ask questions or report complaints about the quality o care or a Medicare-covered service or i you think

Medicare coverage or your service is ending too soon.Visit www.medicare.gov/contacts or call 1-800-MEDICAREto get the phone number o your QIO.


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17

S e c t i o n

2

Section 2—

Sign Up or Medicare

How do I sign up or Part A & Part B?

Some people get Part A and Part B automatically

I you’re already getting benets rom Social Security orthe Railroad Retirement Board (RRB), you’ll automatically get Part A and Part B starting the rst day o the month youturn 65. (I your birthday is on the rst day o the month,

Part A and Part B will start the rst day o the prior month.)

I you’re under 65 and disabled, you’ll automatically getPart A and Part B aer you get disability benets rom SocialSecurity or 24 months or certain disability benets rom theRRB or 24 months.

I you’re automatically enrolled,you’ll get your red, white, andblue Medicare card in the mail

3 months beore your 65thbirthday or your 25th month o disability benets. I you don’tneed Part B, ollow the instructionsthat come with the card, and sendthe card back. I you keep thecard, you keep Part B and will pay Part B premiums. See pages 20–21 or help deciding i you need to

sign up or Part B.

I you have ALS (Amyotrophic Lateral Sclerosis, alsocalled Lou Gehrig’s disease), you’ll get Part A and Part Bautomatically the month your disability benets begin.

http://-/?-

http://-/?-



18 Section 2—Sign Up for Medicare


Some people have to sign up or Part A and/or Part B

I you’re close to 65, but not getting Social Security or Railroad

Retirement Board (RRB) benets and you want Part A and Part B, you’ll need to sign up. Contact Social Security 3 months beore you turn65. You can also apply or Part A (premium-ree) and Part B (or whichyou pay a monthly premium) at www.socialsecurity.gov/retirement.I you worked or a railroad, contact the RRB.

I you have End-Stage Renal Disease (ESRD), you’ll needto sign up. Visit your local Social Security oce, or callSocial Security at 1-800-772-1213 to nd out when andhow to sign up or Part A and Part B. Y users shouldcall 1-800-325-0778. For more inormation, includingwhen your Medicare coverage will end i you’re only eligible or Medicare because o permanent kidney ailure,

visit www.medicare.gov/publications to view the booklet“Medicare Coverage o Kidney Dialysis and Kidney ransplant Services.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you.Y users should call 1-877-486-2048.

I you live in Puerto Rico and get benets rom Social Security orthe RRB, you’ll automatically get Part A the rst day o the month youturn 65 or aer you get disability benets or 24 months. However,i you want Part B, you’ll need to sign up or it. I you don’t signup or Part B when you’re rst eligible, you may have to pay a lateenrollment penalty. See page 25. Contact your local Social Security oce or RRB or more inormation.

Where can I get more inormation?

Call Social Security at 1-800-772-1213 or more inormation about yourMedicare eligibility, and to sign up or Part A and/or Part B. I youworked or RRB or get RRB benets, call the RRB at 1-877-772-5772.

Visit www.medicare.gov or general inormation about enrolling.You can also get personalized health insurance counseling at no costto you rom your State Health Insurance Assistance Program (SHIP).See pages 129–132 or the phone number.

How do I sign up or Part A & Part B? (continued)

Important!

http://www.socialsecurity.gov/retirement


http://-/?-



http://-/?-


http://www.socialsecurity.gov/retirement



19Section 2—Sign Up for Medicare

I I’m not automatically enrolled, when can I

sign up?I you’re not eligible or premium-ree Part A, you can get Part A by

paying a monthly premium. See page 24. I you want Part A and/orPart B, you can sign up during the ollowing times:

Initial Enrollment Period

You can sign up or Part A and/or Part B during the 7-monthperiod that begins 3 months beore the month you turn 65, includesthe month you turn 65, and ends 3 months aer the month youturn 65.

I you sign up or Part A and/or Part B during the rst 3 months o

your Initial Enrollment Period, in most cases, your coverage startsthe rst day o your birthday month. However, i your birthday ison the rst day o the month, your coverage will start the rst day o the prior month.

I you enroll in Part A and/or Part B the month you turn 65 orduring the last 3 months o your Initial Enrollment Period, yourstart date will be delayed.

General Enrollment PeriodI you didn’t sign up or Part A and/or Part B (or which youmust pay premiums) when you were rst eligible, you can sign upbetween January 1–March 31 each year. Your coverage will beginJuly 1. You may have to pay a higher Part A and/or Part B premiumor late enrollment. See pages 24–25.

Special Enrollment Period

I you didn’t sign up or Part A and/or Part B when you were rst

eligible because you’re covered under a group health plan based oncurrent employment (your own, a spouse’s, or a amily member’si you’re disabled), you can sign up or Part A and/or Part B:

■ Anytime you’re still covered by the group health plan.

■ During the 8-month period that begins the month aer theemployment ends or the coverage ends, whichever happens rst.

Remember, i

you live in Puerto

Rico, you don’t

automaticallyget Part B. You

must call Social

Security at

1-800-772-1213 to

sign up or it. TTY

users should call

1-800-325-0778.

http://-/?-

http://-/?-

http://-/?-

http://-/?-





Usually, you don’t pay a late enrollment penalty i you sign up during a

Special Enrollment Period. Tis Special Enrollment Period doesn’t apply to people with End-Stage Renal Disease (ESRD). See page 18. You may also qualiy or a Special Enrollment Period i you’re a volunteer servingin a oreign country.

COBRA and retiree health plans aren’t considered coverage based oncurrent employment. You’re not eligible or a Special Enrollment Periodwhen that coverage ends. o avoid paying a higher premium, make sureyou sign up or Medicare when you’re rst eligible. See page 93 or moreinormation about COBRA.

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

Should I get Part B?Te ollowing inormation can help you decide.

Employer or union coverage—I you or your spouse (or amily memberi you’re disabled) is still working and you have health coverage throughthat employer or union, contact your employer or union benetsadministrator to nd out how your coverage works with Medicare. Tisincludes ederal or state employment, but not military service. It may beto your advantage to delay Part B enrollment.

You can sign up or Part B without penalty any time you have healthcoverage based on current employment. COBRA and retiree healthcoverage don’t count as current employer coverage. See page 22 to nd outhow your other insurance will work with Medicare.

Once the employment ends, 3 things happen:

1. You have 8 months to sign up or Part B without a penalty. Tis periodwill run whether or not you choose COBRA. I you choose COBRA,don’t wait until your COBRA ends to enroll in Part B. I you don’tenroll in Part B during the 8 months, you may have to pay a penalty.You won’t be able to enroll until the next General Enrollment Periodand you’ll have to wait beore your coverage begins. See page 19.

I I’m not automatically enrolled, when can I

sign up? (continued)

Important!






2. You may be able to get COBRA coverage, which continues yourhealth insurance through the employer’s plan (in most cases oronly 18 months) and probably at a higher cost to you.

■ I you already have COBRA coverage when you enroll inMedicare, your COBRA will probably end.

■ I you become eligible or COBRA coverage aer you’realready enrolled in Medicare, you must be allowed to take theCOBRA coverage. It will always be secondary to Medicare(unless you have End-Stage Renal Disease (ESRD)).

3. When you sign up or Part B, your Medigap Open EnrollmentPeriod begins. See below.

RICARE—I you have Part A and RICARE (insurance or

active-duty military or retirees and their amilies), you must havePart B to keep your RICARE coverage. However, i you’re anactive-duty service member, or the spouse or dependent child o anactive-duty service member:

■ You don’t have to enroll in Part B to keep your RICAREcoverage while the service member is on active duty.

■ Beore the active-duty service member retires, you must enroll inPart B to keep RICARE without a break in coverage.

■ You can get Part B during a Special Enrollment Period i you haveMedicare because you’re 65 or older, or you’re disabled.

■ You should enroll in Part A and Part B when you’re rst eligiblebased on ESRD.

When can I get a Medicare Supplement

Insurance (Medigap) Policy?Medicare Supplement Insurance (Medigap) policies, sold by privateinsurance companies, help pay some o the health care costs thatMedicare doesn’t cover. You have a one-time 6-month MedigapOpen Enrollment Period which starts the rst month you’re 65and enrolled in Part B. Tis period gives you a guaranteed right tobuy any Medigap policy sold in your state regardless o your healthstatus. Once this period starts, it can’t be delayed or replaced.See pages 64–67 or more inormation about Medigap.





How does my other insurance work with Medicare?When you have other insurance (like employer group health coverage),there are rules that decide whether Medicare or your other insurance paysrst.

Use this chart to see who pays rst.

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

Medicare pays rst.

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

Your group health planpays rst.

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

Medicare pays rst.

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

or more employees…

Your group health planpays rst.

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

Medicare pays rst.

I you have Medicare because o End-Stage Renal Disease (ESRD)…

Your group health planwill pay rst or the rst

30 months aer youbecome eligible to enrollin Medicare. Medicarewill pay rst aer this30-month period.

Note: In some cases, your employer may join with other employers orunions to orm a multiple employer plan. I this happens, the size o thelargest employer/union determines whether Medicare pays rst or second.




Here are some important acts to remember:

■ Te insurance that pays rst (primary payer) pays up to the limitso its coverage.

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

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

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

Medicare may pay second i you’re in an accident or have a workers’compensation case in which other insurance covers your injury oryou’re suing another entity or medical expenses. In these situations

you or your lawyer should tell Medicare as soon as possible. Tesetypes o insurance usually pay rst or services related to each type:

■ No-ault insurance (including automobile insurance)

■ Liability (including automobile and sel-insurance)

■ Black lung benets

■ Workers’ compensation

Medicaid and RICARE never pay rst or services that arecovered by Medicare. Tey only pay aer Medicare, employer grouphealth plans, and/or Medicare Supplement Insurance have paid.

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

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

Important!







How much does Part A coverage cost?You usually don’t pay a monthly premium or Part A coverage i you or your spouse paid Medicare taxes while working. Tis issometimes called premium-ree Part A.

I you aren’t eligible or premium-ree Part A, you may be able tobuy Part A i:

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

■ You’re under 65, disabled, and your premium-ree Part A coverageended because you returned to work. (I you’re under 65 anddisabled, you can continue to get premium-ree Part A or up to8 1/2 years aer you return to work.)

Note: People who have to buy Part A will pay up to $441 eachmonth in 2013.

In most cases, i you choose to buy Part A, you must also havePart B and pay monthly premiums or both. I you have limitedincome and resources, your state may help you pay or Part A and/orPart B. See pages 99–100. Call Social Security at 1-800-772–1213 ormore inormation about the Part A premium. Y users should call1-800-325-0778.

What is the Part A late enrollment penalty?

I you aren’t eligible or premium-ree Part A, and you don’t buy itwhen you’re rst eligible, your monthly premium may go up 10%.You’ll have to pay the higher premium or twice the number o yearsyou could have had Part A, but didn’t sign up.

Example: I you were eligible or Part A or 2 years but didn’t

sign up, you’ll have to pay the higher premium or 4 years.Usually, you don’t have to pay a penalty i you meet certainconditions that allow you to sign up or Part A during a SpecialEnrollment Period. See pages 19–20.




How much does Part B coverage cost?You pay the Part B premium each month. Most people will pay thestandard premium amount, which is $104.90 in 2013. However, i your modied adjusted gross income as reported on your IRS taxreturn rom 2 years ago (the most recent tax return inormationprovided to Social Security by the IRS) is above a certain amount,you may pay more.

Your modied adjusted gross income is your adjusted grossincome plus your tax exempt interest income. Each year, SocialSecurity will notiy you i you have to pay more than the standardpremium. Te amount you pay can change each year depending onyour income. I you have to pay a higher amount or your Part B

premium and you disagree (or example, i your income goesdown), call Social Security at 1-800-772-1213. Y users shouldcall 1-800-325-0778. I you get benets rom RRB, you should alsocontact Social Security. RRB doesn’t make income determinations.

I Your Yearly Income in 2011 was You pay

File Individual Tax Return File Joint Tax Return

$85,000 or less $170,000 or less $104.90

above $85,000 up to$107,000

above $170,000 up to$214,000

$146.90

above $107,000 up to$160,000

above $214,000 up to$320,000

$209.80

above $160,000 up to$214,000

above $320,000 up to$428,000

$272.70

above $214,000 above $428,000 $335.70

Remember, i you live in Puerto

Rico, you don’t

automatically

get Part B. You

must call Social

Security at

1-800-772-1213 to

sign up or it. TTY

users should call1-800-325-0778.





What is the Part B late enrollment penalty?

I you don’t sign up or Part B when you’re rst eligible, you may

have to pay a late enrollment penalty or as long as you haveMedicare. Your monthly premium or Part B may go up 10% oreach ull 12-month period that you could have had Part B, but didn’tsign up or it. Usually, you don’t pay a late enrollment penalty i youmeet certain conditions that allow you to sign up or Part B during aSpecial Enrollment Period. See pages 19–20.

Example: Mr. Smith’s Initial Enrollment Period endedSeptember 30, 2010. He waited to sign up or Part B until the

General Enrollment Period in March 2013. His Part B premiumpenalty is 20%. (While Mr. Smith waited a total o 30 months tosign up, this included only 2 ull 12-month periods.)

I you have limited income and resources, see pages 99–100 orinormation about help paying your Medicare premiums.

How can I pay my Part B premium?

I you get Social Security, RRB, or Civil Service benets, your Part B

premium will be deducted rom your benet payment. I you don’tget these benet payments and choose to sign up or Part B, you’llget a bill. I you choose to buy Part A, you’ll always get a bill oryour premium.

You can mail your premium payments to:

Medicare Premium Collection CenterP.O. Box 790355St. Louis, Missouri 63179-0355

I you get a bill rom the RRB, mail your premium payments to:

RRBMedicare Premium PaymentsP.O. Box 979024St. Louis, Missouri 63197-9000

I you have questions about your premiums, call Social Security at1-800-772-1213. Y users should call 1-800-325-0778.

How much does Part B coverage cost? (continued)



Section X—27

S e c t i o n

3

Section 3—

Find Out i Medicare Covers

Your Test, Service, or Item

What services does Medicare cover?Medicare covers certain medical services and supplies inhospitals, doctors’ oces, and other health care settings.Services are either covered under Part A or Part B. I you have

both Part A and Part B, you can get all o the Medicare-coveredservices listed in this section, whether you have OriginalMedicare or a Medicare health plan.

What does Part A cover?Part A (Hospital Insurance) helps cover:

■ Inpatient care in hospitals

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

■ Hospice care services

■ Home health care services

■ Inpatient care in a Religious Nonmedical Health CareInstitution

You can nd out i you have Part A by looking at your Medicarecard. I you have Original Medicare, you’ll use this card to getyour Medicare-covered services. I you join a Medicare healthplan, in most cases, you must use the card rom the plan to get

your Medicare-covered services.



28 Section 3—Find Out if Medicare Covers Your Test, Service, or Item

What do I pay or Part A-covered services?Copayments, coinsurance, or deductibles may apply or each servicelisted in the ollowing chart. Visit www.medicare.gov , or call1-800-MEDICARE (1-800-633-4227) to get specic cost inormation.Y users should call 1-877-486-2048.

I you’re in a Medicare health plan or have other insurance (likea Medicare Supplement Insurance (Medigap) policy, or employeror union coverage), your costs may be dierent. Contact the plansyou’re interested in to nd out about the costs, or visit the MedicarePlan Finder at www.medicare.gov/nd-a-plan.

Part A-covered servicesBlood I the hospital gets blood rom a blood bank at no charge, you

won’t have to pay or it or replace it. I the hospital has to buy blood or you, you must either pay the hospital costs or the rst3 units o blood you get in a calendar year or have the blooddonated by you or someone else.

Home

health

services

Medicare covers medically-necessary part-time or intermittentskilled nursing care, and/or physical therapy, speech-language

pathology services, and/or services or people with a continuingneed or occupational therapy. A doctor enrolled in Medicare,or certain health care providers who work with the doctor,must see you ace-to-ace beore the doctor can certiy that youneed home health services. Tat doctor must order your careand a Medicare-certied home health agency must provide it.Home health services may also include medical social services,part-time or intermittent home health aide services, andmedical supplies or use at home. You must be homebound,

which means leaving home is a major eort.■ You pay nothing or covered home health care services.

■ You pay 20% o the Medicare-approved amount or durablemedical equipment. See page 38.







29Section 3—Find Out if Medicare Covers Your Test, Service, or Item

Hospice

care

o qualiy or hospice care, your doctor must certiy thatyou’re terminally ill and expected to live 6 months or less.I you’re already getting hospice care, a hospice doctor or nursepractitioner will need to see you about 6 months aer youenter hospice to certiy that you’re still terminally ill. Coverageincludes drugs or pain relie and symptom management;medical, nursing, and social services; certain durable medicalequipment; and other covered services, as well as servicesMedicare usually doesn’t cover, like spiritual and grie counseling. A Medicare-approved hospice usually gives hospicecare in your home or other acility where you live, like a nursinghome.

Hospice care doesn’t pay or your stay in a acility (roomand board) unless the hospice medical team determines thatyou need short-term inpatient stays or pain and symptommanagement that can’t be addressed at home. Tese staysmust be in a Medicare-approved acility, like a hospice acility,hospital, or skilled nursing acility which contracts with thehospice. Medicare also covers inpatient respite care which is

care you get in a Medicare-approved acility so that your usualcaregiver can rest. You can stay up to 5 days each time you getrespite care. Medicare will pay or covered services or healthproblems that aren’t related to your terminal illness. You cancontinue to get hospice care as long as the hospice medicaldirector or hospice doctor recerties that you’re terminally ill.

■ You pay nothing or hospice care.

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

management.

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

Part A-covered services (continued)




Hospital

care

(inpatient)

Medicare covers semi-private rooms, meals, general nursing,and drugs as part o your inpatient treatment, and otherhospital services and supplies. Tis includes care you getin acute care hospitals, critical access hospitals, inpatientrehabilitation acilities, long-term care hospitals, inpatient careas part o a qualiying clinical research study, and mental healthcare. Tis doesn’t include private-duty nursing, a televisionor phone in your room (i there’s a separate charge or theseitems), or personal care items, like razors or slipper socks. It alsodoesn’t include a private room, unless medically necessary .I you have Part B, it covers the doctor’s services you get whileyou’re in a hospital.

■ You pay $1,184 and no copayment or days 1–60 each benetperiod.

■ You pay $296 or days 61–90 each benet period.

■ You pay $592 per “lietime reserve day ” aer day 90 eachbenet period (up to 60 days over your lietime).

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

■ Inpatient mental health care in a psychiatric hospital is limited

to 190 days in a lietime.

Note: Staying overnight in a hospital doesn’t always meanyou’re an inpatient. You’re considered an inpatient the day adoctor ormally admits you to a hospital with a doctor’s order.Always ask i you’re an inpatient or an outpatient since itaects what you pay and whether you’ll qualiy or Part Acoverage in a skilled nursing acility . For more inormation,

visit www.medicare.gov/publications to view the act sheet “Are

You a Hospital Inpatient or Outpatient? I You Have Medicare—Ask!” You can also call 1-800-MEDICARE (1-800-633-4227) tond out i a copy can be mailed to you. Y users should call1-877-486-2048.








Religious

nonmedical

health care

institution

(inpatient

care)

Medicare will only cover the non-medical, non-religioushealth care items and services (like room and board) inthis type o acility i you qualiy or hospital or skillednursing acility care, but medical care isn’t in agreementwith your religious belies. Only non-medical items andservices that don’t require a doctor’s order or prescription,like unmedicated wound dressings or use o a simple walkerduring your stay, are available. Medicare doesn’t cover thereligious portion o care.

Skilled

nursingacility care

Medicare covers semi-private rooms, meals, skilled nursing

and rehabilitative services, and other medically-necessary services and supplies aer a 3-day minimummedically-necessary inpatient hospital stay or a relatedillness or injury. An inpatient hospital stay begins the day you’re ormally admitted with a doctor’s order and doesn’tinclude the day you’re discharged. o qualiy or care in askilled nursing acility, your doctor must certiy that youneed daily skilled care like intravenous injections or physicaltherapy. Medicare doesn’t cover long-term care or custodial

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

■ You pay $148 per day or days 21–100 each benet period.

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




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

Pages 33–50 include a list o common Part B-covered services and generaldescriptions. Medicare may cover some services and tests more oen thanthe timerames listed i needed to diagnose a condition. o nd out i Medicare covers a service not on this list, visit www.medicare.gov/coverage,or call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048. For more details about Medicare-covered services, visitwww.medicare.gov/publications to view the booklet “Your Medicare

Benets.” Call 1-800-MEDICARE to nd out i a copy can be mailed to you.

You’ll see this apple next to the preventive services on pages 33–50. Use the preventive services checklist on page 51 to ask your doctor orother health care provider which preventive services you should get.

What do I pay or Part B-covered services?Te alphabetical list on the ollowing pages gives general inormation aboutwhat you pay i you have Original Medicare and see doctors or other health

care providers who accept assignment. You’ll pay more i you see doctors orproviders who don’t accept assignment. I you’re in a Medicare AdvantagePlan (like an HMO or PPO) or have other insurance, your costs may bedierent. Contact your plan or benets administrator directly to ndout about the costs.

Under Original Medicare, i the Part B deductible ($147 in 2013) appliesyou must pay all costs until you meet the yearly Part B deductible beoreMedicare begins to pay its share. Ten, aer your deductible is met, youtypically pay 20% o the Medicare-approved amount o the service, i thedoctor or other health care provider accepts assignment. Tere’s no yearly limit or what you pay out-o-pocket. Visit www.medicare.gov , or call1-800-MEDICARE to get specic cost inormation.

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

See pages 60–61 or more inormation about assignment.

Denitionso blue wordsare on pages

133–136.

Important!

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http://www.medicare.gov/coverage


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What does Part B cover?

Abdominal

aortic

aneurysmscreening

Medicare covers a one-time screening abdominal aorticaneurysm ultrasound or people at risk. You must get a

reerral or it as part o your one-time “Welcome to Medicare”preventive visit. See page 50. You pay nothing or the screeningi the doctor or other qualied health care provider acceptsassignment.

Alcohol

misuse

counseling

Medicare covers 1 alcohol misuse screening per year or adultswith Medicare (including pregnant women) who use alcohol,but don’t meet the medical criteria or alcohol dependency. I your primary care doctor or other primary care practitioner

determines you’re misusing alcohol, you can get up to 4 brie ace-to-ace counseling sessions per year (i you’re competentand alert during counseling). A qualied primary care doctoror other primary care practitioner must provide the counselingin a primary care setting (like a doctor’s oce). You pay nothingi the qualied primary care doctor or other primary carepractitioner accepts assignment.

Ambulance

services

Medicare covers ground ambulance transportation when you

need to be transported to a hospital, critical access hospital, orskilled nursing acility or medically-necessary services, andtransportation in any other vehicle could endanger your health.Medicare may pay or emergency ambulance transportation inan airplane or helicopter to a hospital i you need immediateand rapid ambulance transportation that ground transportationcan’t provide.

In some cases, Medicare may pay or limited non-emergency ambulance transportation i you have a written order rom

your doctor stating that ambulance transportation is necessary due to your medical condition. Medicare will only coverambulance services to the nearest appropriate medical acility that’s able to give you the care you need. You pay 20% o theMedicare-approved amount, and the Part B deductible applies.

NEW!

= Preventive service




What does Part B cover? (continued)

Ambulatory

surgical centers

Medicare covers the acility ees or approved surgicalprocedures in an ambulatory surgical center (acility where

surgical procedures are perormed, and the patient is expectedto be released within 24 hours). Except or certain preventiveservices (or which you pay nothing), you pay 20% o theMedicare-approved amount to both the ambulatory surgicalcenter and the doctor who treats you, and the Part B deductible applies. You pay all acility ees or procedures Medicare doesn’tcover in ambulatory surgical centers.

Blood I the provider gets blood rom a blood bank at no charge,you won’t have to pay or it or replace it. However, you’ll pay acopayment or the blood processing and handling services orevery unit o blood you get, and the Part B deductible applies.I the provider has to buy blood or you, you must either pay theprovider costs or the rst 3 units o blood you get in a calendaryear or have the blood donated by you or someone else.

Bone mass

measurement

(bone density)

Tis test helps to see i you’re at risk or broken bones. It’scovered once every 24 months (more oen i medically necessary ) or people who have certain medical conditions or

meet certain criteria. You pay nothing or this test i the doctoror other qualied health care provider accepts assignment.

Breast cancer

screening

(mammograms)

Medicare covers screening mammograms to check or breastcancer once every 12 months or all women with Medicare 40and older. Medicare covers 1 baseline mammogram or womenbetween 35–39. You pay nothing or the test i the doctor orother qualied health care provider accepts assignment.

Cardiac

rehabilitation

Medicare covers comprehensive programs that include exercise,

education, and counseling or patients who meet certainconditions. Medicare also covers intensive cardiac rehabilitationprograms that are typically more rigorous or more intense thanregular cardiac rehabilitation programs. You pay 20% o theMedicare-approved amount i you get the services in a doctor’soce. In a hospital outpatient setting, you also pay the hospitala copayment. Te Part B deductible applies.






Cardiovascular

disease

(behavioraltherapy)

Medicare will cover 1 visit per year with your primary care doctor in a primary care setting (like a doctor’s oce) to help lower your

risk or cardiovascular disease. During this visit, your doctor may discuss aspirin use (i appropriate), check your blood pressure, andgive you tips to make sure you’re eating well. You pay nothing i thedoctor or other qualied health care provider accepts assignment.

Cardiovascular

screenings

Tese screenings include blood tests that help detect conditionsthat may lead to a heart attack or stroke. Medicare covers thesescreening tests every 5 years to test your cholesterol, lipid,lipoprotein, and triglyceride levels. You pay nothing or the tests,

but you generally have to pay 20% o the Medicare-approvedamount or the doctor’s visit.

Cervical and

vaginal cancer

screening

Medicare covers Pap tests and pelvic exams to check or cervicaland vaginal cancers. As part o the exam, Medicare also covers aclinical breast exam to check or breast cancer. Medicare coversthese screening tests once every 24 months. Medicare covers thesescreening tests once every 12 months i you’re at high risk orcervical or vaginal cancer or i you’re o child-bearing age and had

an abnormal Pap test in the past 36 months. You pay nothing i thedoctor or other qualied health care provider accepts assignment.

Chemotherapy Medicare covers chemotherapy in a doctor’s oce, reestandingclinic, or hospital outpatient setting or people with cancer. Forchemotherapy given in a doctor’s oce or reestanding clinic,you pay 20% o the Medicare-approved amount. I you getchemotherapy in a hospital outpatient setting, you pay a copayment or the treatment. For chemotherapy in a hospital inpatient setting

covered under Part A, see Hospital Care (Inpatient) on page 30.Chiropractic

services

(limited)

Medicare covers these services to help correct a subluxation (when1 or more o the bones o your spine move out o position) usingmanipulation o the spine. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies.

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

NEW!




Clinical

research

studies

Clinical research studies test how well dierent types o medicalcare work and i they’re sae. Medicare covers some costs, like

oce visits and tests, in qualiying clinical research studies.You may pay 20% o the Medicare-approved amount, and thePart B deductible may apply.

Note: I you’re in a Medicare Advantage Plan (like an HMO orPPO), some costs may be covered by Medicare and some may becovered by your plan.

Colorectal

cancer

screenings

Medicare covers these screenings to help nd precancerousgrowths or nd cancer early, when treatment is most eective.One or more o the ollowing tests may be covered:

■ Fecal occult blood test—Tis test is covered once every 12months i you’re 50 or older. You pay nothing or the test i the doctor or other qualied health care provider acceptsassignment.

■ Flexible sigmoidoscopy —Tis test is generally covered onceevery 48 months i you’re 50 or older, or 120 months aer aprevious screening colonoscopy or those not at high risk.

You pay nothing or the test i the doctor or other qualiedhealth care provider accepts assignment.

■ Colonoscopy —Tis test is generally covered once every 120months (high risk every 24 months) or 48 months aer aprevious fexible sigmoidoscopy. Tere is no minimum age.You pay nothing or the test i the doctor or other qualiedhealth care provider accepts assignment. Note: I a polyp orother tissue is ound and removed during the colonoscopy, youmay have to pay 20% o the Medicare-approved amount or

the doctor’s services and a copayment in a hospital outpatientsetting.

■ Barium enema—Tis test is generally covered once every 48months i you’re 50 or older (high risk every 24 months) whenused instead o a sigmoidoscopy or colonoscopy. You pay 20%o the Medicare-approved amount or the doctor services.In a hospital outpatient setting, you also pay the hospital acopayment.






Debrillator

(implantable

automatic)

Medicare covers these devices or some people diagnosed with heartailure. I the surgery takes place in an outpatient setting, you pay

20% o the Medicare-approved amount or the doctor’s services.I you get the device as a hospital outpatient, you also pay the hospitala copayment, but no more than the Part A hospital stay deductible.Te Part B deductible applies. Surgeries to implant debrillators in ahospital inpatient setting are covered under Part A.

Depression

screening

Medicare covers 1 depression screening per year. Te screening must bedone in a primary care setting (like a doctor’s oce) that can provideollow-up treatment and reerrals. You pay nothing or this test i thedoctor or other qualied health care provider accepts assignment, but

you generally have to pay 20% o the Medicare-approved amount orthe doctor’s visit.

Diabetes

screenings

Medicare covers these screenings i your doctor determines you’re atrisk or diabetes. You may be eligible or up to 2 diabetes screeningseach year. You pay nothing or the test i your doctor or other qualiedhealth care provider accepts assignment.

Diabetes sel-

management

training

Medicare covers a program to help people cope with and managediabetes. Te program may include tips or eating healthy, being active,monitoring blood sugar, taking medication, and reducing risks. Youmust have diabetes and a written order rom your doctor or otherhealth care provider. You pay 20% o the Medicare-approved amount,and the Part B deductible applies.

Diabetes

supplies

Medicare covers blood sugar testing monitors, blood sugar teststrips, lancet devices and lancets, blood sugar control solutions, andtherapeutic shoes (in some cases). Medicare only covers insulin i usedwith an external insulin pump. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies.

Note: Medicare prescription drug coverage (Part D) may cover insulin,certain medical supplies used to inject insulin (like syringes), and someoral diabetic drugs.

I you live in a Durable Medical Equipment (DME) competitive biddingarea (see page 38), and get your diabetes supplies by mail, the amountyou pay may change starting in January 2013. From January throughJune 2013, you can get your supplies rom any supplier. Starting in July 2013, you’ll need to use a Medicare contract supplier or Medicare topay or your mail order diabetic testing supplies. Tis national mailorder program will help save you money.


NEW!

Important!




Doctor

and other

health careprovider

services

Medicare covers medically-necessary doctor services (includingoutpatient and some doctor services you get when you’re a hospital

inpatient) and covered preventive services. Medicare also coversservices provided by other health care providers, like physicianassistants, nurse practitioners, social workers, physical therapists, andpsychologists. Except or certain preventive services (or which youmay pay nothing), you pay 20% o the Medicare-approved amount,and the Part B deductible applies.

Durable

medical

equipment(DME) (like

walkers)

Medicare covers items like oxygen equipment and supplies,wheelchairs, walkers, and hospital beds ordered by a doctor or other

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

For more inormation, visit www.medicare.gov/publications to view the booklet “Medicare Coverage o Durable Medical Equipmentand Other Devices.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y users should call 1-877-486-2048.

DME Competitive Bidding Program: o get certain items insome areas o the country, you must use specic suppliers called“contract suppliers,” or Medicare won’t pay or the item and youlikely will pay ull price.

Tis program is eective in certain areas in these states: Caliornia,

Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio,Pennsylvania, South Carolina, and exas. I you need durable medicalequipment or supplies, visit www.medicare.gov/supplier to ndMedicare-approved suppliers. I your ZIP code is in a competitivebidding area, the items included in the program are marked with anorange star. You can also call 1-800-MEDICARE.

Te program is scheduled to expand to 91 more areas around thecountry in July 2013. Medicare will provide more inormation beorechanges occur in those areas.


Important!


http://www.medicare.gov/supplier






EKG

(electrocardiogram)

screening

Medicare covers a one-time screening EKG i reerredby your doctor or other health care provider as part o

your one-time “Welcome to Medicare” preventive visit.See page 50. You pay 20% o the Medicare-approvedamount. An EKG is also covered as a diagnostic test.See page 47. I you have the test at a hospital or a hospitalowned clinic, you also pay the hospital a copayment.

Emergency

department

services

Tese services are covered when you have an injury,a sudden illness, or an illness that quickly gets muchworse. You pay a specied copayment or the hospital

emergency department visit, and you pay 20% o theMedicare-approved amount or the doctor’s or otherhealth care provider’s services. Te Part B deductible applies. However, your costs may be dierent i you’readmitted to the hospital.

Eyeglasses (limited) Medicare covers 1 pair o eyeglasses with standardrames (or 1 set o contact lenses) aer cataract surgery that implants an intraocular lens. You pay 20% o theMedicare-approved amount, and the Part B deductible

applies.

Federally-qualied

health center

services

Medicare covers many outpatient primary care andpreventive services you get through certain community-based organizations. Generally, you pay 20% o thecharges. You pay nothing or most preventive services.

Flu shots Medicare generally covers fu shots once per fu seasonin the all or winter. You pay nothing or getting the fushot i the doctor or other qualied health care provideraccepts assignment or giving the shot.

Foot exams and

treatment

Medicare covers oot exams and treatment i you havediabetes-related nerve damage and/or meet certainconditions. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies. In a hospitaloutpatient setting, you also pay the hospital a copayment.






Glaucoma

tests

Tese tests are covered once every 12 months or peopleat high risk or the eye disease glaucoma. You’re at high

risk i you have diabetes, a amily history o glaucoma, areArican-American and 50 or older, or are Hispanic and 65 orolder. An eye doctor who is legally allowed by the state mustdo the tests. You pay 20% o the Medicare-approved amount,and the Part B deductible applies or the doctor’s visit. Ina hospital outpatient setting, you also pay the hospital acopayment.

Hearing

and balanceexams

Medicare covers these exams i your doctor or other health

care provider orders them to see i you need medicaltreatment. You pay 20% o the Medicare-approved amount,and the Part B deductible applies. In a hospital outpatientsetting, you also pay the hospital a copayment.

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

Hepatitis B

shots

Medicare covers these shots or people at high or mediumrisk or Hepatitis B. You pay nothing or the shot i the doctor

or other qualied health care provider accepts assignment.

HIV

screening

Medicare covers HIV (Human Immunodeciency Virus)screenings or people at increased risk or the virus, anyonewho asks or the test, and pregnant women. Medicare coversthis test once every 12 months or up to 3 times duringa pregnancy. You pay nothing or the HIV screening i the doctor or other qualied health care provider acceptsassignment.






Home health

services

Medicare covers medically-necessary part-time orintermittent skilled nursing care, and/or physical

therapy, speech-language pathology services,and/or services or people with a continuing need oroccupational therapy. A doctor enrolled in Medicare, orcertain health care providers who work with the doctor,must see you ace-to-ace beore the doctor can certiy that you need home health services. Tat doctor mustorder your care, and a Medicare-certied home healthagency must provide it.

Home health services may also include medical socialservices, part-time or intermittent home health aideservices, durable medical equipment, and medicalsupplies or use at home. You must be homebound,which means leaving home is a major eort. Youpay nothing or covered home health services. ForMedicare-covered durable medical equipmentinormation, see page 38.

Kidney dialysis

services and

supplies

Generally, Medicare covers dialysis treatment 3 timesa week i you have End-Stage Renal Disease (ESRD).Tis includes dialysis drugs, laboratory tests, homedialysis training, and related equipment and supplies.Te dialysis acility is responsible or coordinatingyour dialysis services (at home or in a acility). You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Kidney disease

educationservices

Medicare covers up to 6 sessions o kidney disease

education services i you have Stage IV kidney disease,and your doctor or other health care provider reers youor the service. You pay 20% o the Medicare-approvedamount, and the Part B deductible applies.

Laboratory

services

Medicare covers laboratory services including certainblood tests, urinalysis, and some screening tests. Youpay nothing or these services i the doctor or otherhealth care provider accepts assignment.





Medical

nutrition

therapyservices

Medicare may cover medical nutrition therapy and certainrelated services i you have diabetes or kidney disease, or you

have had a kidney transplant in the last 36 months, and yourdoctor or other health care provider reers you or the service.You pay nothing or these services i the doctor or otherqualied health care provider accepts assignment.

Mental

health care

(outpatient)

Medicare covers mental health care services to help withconditions like depression or anxiety. Coverage includesservices generally provided in an outpatient setting (likea doctor’s or other health care provider’s oce or hospital

outpatient department), including visits with a psychiatristor other doctor, clinical psychologist, nurse practitioner,physician assistant, clinical nurse specialist, or clinical socialworker; certain treatment or substance abuse; and lab tests.Certain limits and conditions apply.

What you pay will depend on whether you’re being diagnosedand monitored or whether you’re getting treatment.

■ For visits to a doctor or other health care provider

to diagnose your condition, you pay 20% o theMedicare-approved amount.

■ Generally, or outpatient treatment o your condition(like counseling or psychotherapy), you pay 35% o theMedicare-approved amount. Tis coinsurance amount willdecrease to 20% in 2014.

Te Part B deductible applies or both visits to diagnose ortreat your condition.

Note: Inpatient mental health care is covered under Part A.See Hospital care (inpatient) on pages 30.






Obesity

screening and

counseling

I you have a body mass index (BMI) o 30 or more, Medicarecovers intensive counseling to help you lose weight. Tis

counseling may be covered i you get it in a primary caresetting (like a doctor’s oce), where it can be coordinatedwith your personalized prevention plan. alk to your primary care doctor or primary care practitioner to nd out more. Youpay nothing or this service i the primary care doctor or otherqualied primary care practitioner accepts assignment.

Occupational

therapy

Medicare covers evaluation and treatment to help youperorm activities o daily living (like dressing or bathing)

aer an illness or accident when your doctor or other healthcare provider certies you need it. Tere may be a limit on theamount Medicare will pay or these services in a single yearand there may be certain exceptions to these limits. You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Outpatient

hospital

services

Medicare covers many diagnostic and treatment services inparticipating hospital outpatient departments. Generally, you

pay 20% o the Medicare-approved amount or the doctor’sor other health care provider’s services. You may pay moreor services you get in a hospital outpatient setting than you’llpay or the same care in a doctor’s oce. In addition to theamount you pay the doctor, you’ll usually pay the hospital acopayment or each service you get in a hospital outpatientsetting, except or certain preventive services or which there’sno copayment. Te Part B deductible applies, except orcertain preventive services.

Outpatient

medical

and surgical

services and

supplies

Medicare covers approved procedures like X-rays, casts, orstitches. You pay 20% o the Medicare-approved amountor the doctor’s or other health care provider’s services.You generally pay the hospital a copayment or each serviceyou get in a hospital outpatient setting. Te Part B deductibleapplies, and you pay all charges or items or services thatMedicare doesn’t cover.


NEW!




Physical

therapy

Medicare covers evaluation and treatment or injuries anddiseases that change your ability to unction when your doctor

or other health care provider certies your need or it. Tere may be a limit on the amount Medicare will pay or these services ina single year and there may be certain exceptions to these limits.You pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Pneumococcal

shot

Medicare covers pneumococcal shots to help preventpneumococcal inections (like certain types o pneumonia).Most people only need this shot once in their lietime. alk with

your doctor or other health care provider to see i you should getthis shot. You pay nothing i the doctor or other qualied healthcare provider accepts assignment or giving the shot.

Prescription

drugs (limited)

Medicare covers a limited number o drugs like injections youget in a doctor’s oce, certain oral cancer drugs, drugs used withsome types o durable medical equipment (like a nebulizer orexternal inusion pump), and under very limited circumstances,certain drugs you get in a hospital outpatient setting. You pay

20% o the Medicare-approved amount or these covered drugsand the Part B deductible applies.

I the covered drugs you get in a hospital outpatient setting arepart o your outpatient services, you pay the copayment or theservices. However, other types o drugs in a hospital outpatientsetting (sometimes called “sel-administered drugs” or drugsyou would normally take on your own), aren’t covered by Part B.What you pay depends on whether you have Part D or otherprescription drug coverage, whether your drug plan covers the

drug, and whether the hospital’s pharmacy is in your drug plan’snetwork. Contact your prescription drug plan to nd out whatyou pay or drugs you get in a hospital outpatient setting thataren’t covered under Part B. See page 91 or more inormation.

Other than the examples above, you pay 100% or mostprescription drugs, unless you have Part D or other drugcoverage.





Prostate cancer

screenings

Medicare covers a Prostate Specic Antigen (PSA) test anda digital rectal exam once every 12 months or men over 50

(beginning the day aer your 50th birthday). You pay nothing orthe PSA test i the doctor or other health care provider acceptsassignment. You pay 20% o the Medicare-approved amount,and the Part B deductible applies or the digital rectal exam. In ahospital outpatient setting, you also pay the hospital a copayment.

Prosthetic/

orthotic items

Medicare covers arm, leg, back, and neck braces; articial eyes;articial limbs (and their replacement parts); some types o breastprostheses (aer mastectomy); and prosthetic devices needed

to replace an internal body part or unction (including ostomy supplies, and parenteral and enteral nutrition therapy) whenordered by a doctor or other health care provider enrolled inMedicare. For Medicare to cover your prosthetic or orthotic, youmust go to a supplier that’s enrolled in Medicare. You pay 20%o the Medicare-approved amount, and the Part B deductibleapplies.

DMEPOS Competitive Bidding Program: o get enteral nutritiontherapy in some areas o the country, you must use specicsuppliers called “contract suppliers,” or Medicare won’t pay andyou’ll likely pay ull price. See page 38 or more inormation.

Pulmonary

rehabilitation

Medicare covers a comprehensive pulmonary rehabilitationprogram i you have moderate to very severe chronic obstructivepulmonary disease (COPD) and have a reerral rom the doctortreating this chronic respiratory disease. You pay 20% o theMedicare-approved amount i you get the service in a doctor’soce. You also pay the hospital a copayment per session i

you get the service in a hospital outpatient setting. Te Part Bdeductible applies.

Rural health

clinic services

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



Important!




Second

surgical

opinions

Medicare covers second surgical opinions in some cases orsurgery that isn’t an emergency. In some cases, Medicare

covers third surgical opinions. You pay 20% o the Medicare-approved amount, and the Part B deductible applies.

Sexually

transmitted

inections

screening and

counseling

Medicare covers sexually transmitted inection (SI)screenings or chlamydia, gonorrhea, syphilis and/orHepatitis B. Tese screenings are covered or people withMedicare who are pregnant and/or or certain people whoare at increased risk or an SI when the tests are orderedby a primary care doctor or other primary care practitioner.

Medicare covers these tests once every 12 months or atcertain times during pregnancy.

Medicare also covers up to 2 individual 20 to 30 minute,ace-to-ace, high-intensity behavioral counseling sessionseach year or sexually-active adults at increased risk or SIs.Medicare will only cover these counseling sessions i they are provided by a primary care doctor or other primary carepractitioner and take place in a primary care setting (like adoctor’s oce). Counseling conducted in an inpatient setting,like a skilled nursing acility, won’t be covered as a preventiveservice.

You pay nothing or these services i the primary caredoctor or other qualied primary care practitioner acceptsassignment.

Speech-

language

pathologyservices

Medicare covers evaluation and treatment given to regainand strengthen speech and language skills, including

cognitive and swallowing skills, when your doctor or otherhealth care provider certies you need it. Tere may be alimit on the amount Medicare will pay or these services ina single year, and there may be certain exceptions to theselimits. You pay 20% o the Medicare-approved amount, andthe Part B deductible applies.


NEW!





Surgical

dressing

services

Medicare covers these services or treatment o a surgicalor surgically-treated wound. You pay 20% o the Medicare-

approved amount or the doctor’s or other health careprovider’s services. You pay a xed copayment or theseservices when you get them in a hospital outpatient setting.You pay nothing or the supplies. Te Part B deductible applies.

Telehealth Medicare covers limited medical or other health services,like oce visits and consultations provided using aninteractive two-way telecommunications system (like real-

time audio and video) by an eligible provider who isn’t atyour location. Tese services are available in some ruralareas, under certain conditions, and only i you’re located atone o the ollowing places: a doctor’s oce, hospital, ruralhealth clinic, ederally-qualied health center, hospital-based dialysis acility, skilled nursing acility, or community mental health center. For most o these services, you pay 20% o the Medicare-approved amount, and the Part Bdeductible applies.

Tests (other

than lab

tests)

Medicare covers X-rays, MRIs, C scans, EKGs, and someother diagnostic tests. You pay 20% o the Medicare-approved amount, and the Part B deductible applies. I youget the test at a hospital as an outpatient, you also pay thehospital a copayment that may be more than 20% o theMedicare-approved amount, but it can’t be more than thePart A hospital stay deductible. See Laboratory services onpage 41 or other Part B-covered tests.





Tobacco use

cessation

counseling

I you use tobacco and you’re diagnosed with an illnesscaused or complicated by tobacco use, or you take a

medicine that’s aected by tobacco, Medicare covers up to8 ace-to-ace visits in a 12-month period. You pay 20% o the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay thehospital a copayment.

I you haven’t been diagnosed with an illness caused orcomplicated by tobacco use, Medicare coverage o tobaccouse cessation counseling is considered a covered preventive

service. You pay nothing or the counseling sessions i the doctor or other qualied health care provider acceptsassignment.

Transplants and

immunosuppressive

drugs

Medicare covers doctor services or heart, lung, kidney, pancreas,intestine, and liver transplants under certain conditions and only in a Medicare-certied acility. Medicare covers bone marrow and cornea transplants under certain conditions.

Medicare covers immunosuppressive drugs i the transplant

was eligible or Medicare payment, or an employer or uniongroup health plan was required to pay beore Medicare paidor the transplant. You must have Part A at the time o thetransplant, and you must have Part B at the time you getimmunosuppressive drugs. You pay 20% o the Medicare-approved amount, and the Part B deductible applies.

I you’re thinking about joining a Medicare Advantage Plan(like an HMO or PPO) and are on a transplant waiting list or

believe you need a transplant, check with the plan beore you join to make sure your doctors, other health care providers,and hospitals are in the plan’s network. Also, check the plan’scoverage rules or prior authorization.

Note: Medicare drug plans (Part D) may coverimmunosuppressive drugs, even i Medicare or an employeror union group health plan didn’t pay or the transplant.

You pay nothing or these services i the doctor or health care

provider accepts assignment.





Travel

(health care

neededwhen

traveling

outside

the United

States)

Medicare generally doesn’t cover health care while you’retraveling outside the U.S. (the “U.S.” includes the 50

states, the District o Columbia, Puerto Rico, the U.S.Virgin Islands, Guam, the Northern Mariana Islands, andAmerican Samoa). Tere are some exceptions, includingsome cases where Medicare may pay or services that youget while on board a ship within the territorial watersadjoining the land areas o the U.S. Medicare may pay orinpatient hospital, doctor, or ambulance services you get in aoreign country in these rare cases:

1. You’re in the U.S. when an emergency occurs and theoreign hospital is closer than the nearest U.S. hospitalthat can treat your medical condition.

2. You’re traveling through Canada without unreasonabledelay by the most direct route between Alaska andanother state when a medical emergency occurs and theCanadian hospital is closer than the nearest U.S. hospitalthat can treat the emergency.

3. You live in the U.S. and the oreign hospital is closer

to your home than the nearest U.S. hospital that cantreat your medical condition, regardless o whether anemergency exists.

Medicare may cover medically-necessary ambulancetransportation to a oreign hospital only with admission ormedically-necessary covered inpatient hospital services.

You pay 20% o the Medicare-approved amount, and thePart B deductible applies.

Urgently-

needed care

Medicare covers urgently-needed care to treat a suddenillness or injury that isn’t a medical emergency. You pay 20%o the Medicare-approved amount or the doctor’s or otherhealth care provider’s services, and the Part B deductibleapplies. In a hospital outpatient setting, you also pay thehospital a copayment.





“Welcome to

Medicare”

preventive visit

During the rst 12 months that you have Part B, you can geta “Welcome to Medicare” preventive visit. Tis visit includes

a review o your medical and social history related to yourhealth and education and counseling about preventiveservices, including certain screenings, shots, and reerrals orother care i needed. When you make your appointment, letyour doctor’s oce know that you would like to schedule your“Welcome to Medicare” preventive visit.

You pay nothing or the “Welcome to Medicare” preventive visit i the doctor or other qualied health care provider

accepts assignment.*

Yearly “Wellness”

visit

I you’ve had Part B or longer than 12 months, you can geta yearly “Wellness” visit to develop or update a personalizedplan to prevent disease based on your current health and risk actors. Tis visit is covered once every 12 months.

Your provider will ask you to ll out a short questionnaire,called a Health Risk Assessment, as part o this visit.Answering these questions can help you and your provider

develop a personalized prevention plan to help you stay healthy and get the most out o your visit. Te questionsare based on years o medical research and advice rom theCenters or Disease Control and Prevention (CDC).

Note: Your rst yearly “Wellness” visit can’t take place within12 months o your enrollment in Part B or your “Welcome toMedicare” visit. However, you don’t need to have a “Welcometo Medicare” visit beore your yearly “Wellness” visit.

You pay nothing or the yearly “Wellness” visit i the doctor orother qualied health care provider accepts assignment.*

*I your doctor or other health care provider perormsadditional tests or services during the same visit that aren’tcovered under these preventive benets, you may have to pay coinsurance, and the Part B deductible may apply.


Important!





Want to keep track o your preventive services?Medicare now covers more preventive services to help you stay healthy. alk with your health care provider about which o theseservices are right or you. Medicare coverage o preventive servicescan change at any time. o learn more about new services that may be available to you at no cost, visit www.medicare.gov . You can alsocall 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

Page Medicare-covered

preventive service

I need

(yes/no)

50 “Welcome to Medicare”

preventive visit (one-time)

50 Yearly “Wellness” visit

33 Abdominal aorticaneurysm screening

33 Alcohol misuse counseling

34 Bone mass measurement

34 Breast cancer screening(mammogram)

35 Cardiovascular disease(behavioral therapy)

35 Cardiovascular screenings

35 Cervical and vaginal cancerscreening

36 Colorectal cancerscreenings

Fecal occult blood test

Flexible sigmoidoscopy

Colonoscopy

Barium enema

Page Medicare-covered

preventive service

I need

(yes/no

37 Depression screening

37 Diabetes screenings

37 Diabetes sel-managementtraining

39 Flu shots

40 Glaucoma tests

40 Hepatitis B shots

40 HIV screening

42 Medical nutrition therapy services

43 Obesity screening andcounseling

44 Pneumococcal shot

45 Prostate cancer screenings

46 Sexually transmittedinections screening andcounseling

48 obacco use cessationcounseling (counselingor people with no sign o tobacco-related disease)






What’s NOT covered by Part A & Part B?Medicare doesn’t cover everything. I you need certain servicesthat Medicare doesn’t cover, you’ll have to pay or them yoursel unless:

■ You have other insurance (or Medicaid) to cover the costs.

■ You’re in a Medicare health plan that covers these services.

Even i Medicare covers a service or item, you generally have to pay deductibles, coinsurance, and copayments.

Some o the items and services that Medicare doesn’t cover include:

■ Long-term care (also called custodial care). See pages 117–120.

■ Routine dental or eye care.

■ Dentures.

■ Cosmetic surgery.

■ Acupuncture.

■ Hearing aids and exams or tting them.

I you have Original Medicare, visit www.medicare.gov/coverage,or call 1-800-MEDICARE (1-800-633-4227) to nd out i Medicarecovers a service you need. Y users should call 1-877-486-2048.I you’re in a Medicare health plan, contact your plan.

I you have a question or complaint about the quality o aMedicare-covered service, call your local Quality ImprovementOrganization (QIO). Visit www.medicare.gov/contacts to get yourQIO’s phone number. You can also call 1-800-MEDICARE.

Note: o get Medicare-covered Part A and/or Part B services, youmust be a U.S. citizen or be lawully present in the U.S.








53

Section 4—

Choose Your Health &


S e c t i o n

4

Tis handbook has basic inormation. You’ll need moredetailed inormation than this handbook provides tomake an inormed choice. Beore making any decisions,learn as much as you can about the types o coverageavailable to you.

How can I get my Medicare coverage?You can choose dierent ways to get your Medicarecoverage.

1. You can choose Original Medicare and i you wantprescription drug coverage, you must join a MedicarePrescription Drug Plan (Part D).

2. You can choose to join a Medicare health plan, and

the plan may include Medicare prescription drugcoverage. In most cases, you must take the drugcoverage that comes with the Medicare health plan.

I you don’t join a Medicare health plan, you’llhave Original Medicare. See the next page or moreinormation about your coverage choices, and thedecisions you need to make.

Each all, you should review your health and prescription

needs because your health, nances, or plan’s coveragemay have changed. I you decide other coverage willbetter meet your needs, you can switch plans betweenOctober 15–December 7. See pages 76–77 and 82–83. I you’re satised with your current plan’s coverage or theollowing year, you don’t need to do anything.



54 Section 4—Choose Your Health & Prescription Drug Coverage

What i I need help deciding how to get my

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

to nd and compare plans in your area. Medicare Plan Finderlets you compare plans by plan type and nd out what yourestimated costs would be in each plan. Here’s an example o whatyou may see when using this tool:

2. Get personalized counseling about choosing coverage. Seepages 129–132 or the phone number o your State HealthInsurance Assistance Program (SHIP).

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





55Section 4—Choose Your Health & Prescription Drug Coverage

What are my Medicare coverage choices?Tere are 2 main choices or how you get your Medicare coverage.Use these steps to help you decide.

In addition to the options listed above, you may be able to join other types o Medicare healthplans. See pages 79–80. Some people may have other coverage like employer or union, Medicaid,military, or Veterans’ benets. See pages 100–101 and 93–94.

Note: I you join a Medicare Advantage Plan,you can’t use Medicare Supplement Insurance(Medigap) to pay or out-o-pocket costs youhave in the Medicare Advantage Plan. I youalready have a Medicare Advantage Plan, youcan’t be sold a Medigap policy. You can only use a Medigap policy i you disenroll romyour Medicare Advantage Plan and return toOriginal Medicare. See page 67.

Decide i you want Original Medicare or a Medicare Advantage Plan

Original Medicare includesPart A (Hospital Insurance)

and/or Part B (Medical Insurance)

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

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

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

Part B.See pages 57–63.

Decide i you want prescription

drug coverage (Part D)

Decide i you want prescription

drug coverage (Part D)

Decide i you want

supplemental coverage

Medicare Advantage Plan

(like an HMO or PPO)

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

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

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

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

■ Costs, extra coverage, and rules vary by plan.See pages 68–78.

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

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

approved by Medicare.See pages 81–94.

■ I you want drug coverage, and it’s oeredby your plan, in most cases you must get itthrough your plan.

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

See pages 74–75.

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

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

■ Costs vary by policy and company.■ Employers/unions may oer similar coverage.See pages 64–67.

Step 2

Step 3

Step 2



56 Section 4—Choose Your Health & Prescription Drug Coverage

What should I consider when choosing or changing my

coverage?

Coverage Does the plan cover the services you need?

Your other

coverage

Do you have, or are you eligible or, other types o health orprescription drug coverage (like rom a ormer or currentemployer or union)? I so, read the materials rom your insurer orplan, or call them to nd out how the coverage works with, or isaected by, Medicare. I you have coverage through a ormer orcurrent employer or union or other source, talk to your benetsadministrator, insurer, or plan beore making any changes to yourcoverage. I you drop your coverage, you may not be able to get itback.

Cost

How much are your premiums, deductibles, and other costs? How much do you pay or services like hospital stays or doctor visits? Isthere a yearly limit on what you pay out-o-pocket? Your costs vary and may be dierent i you don’t ollow the coverage rules.

Doctor and

hospital

choice

Do your doctors and other health care providers accept thecoverage? Are the doctors you want to see accepting new patients?Do you have to choose your hospital and health care providersrom a network? Do you need to get reerrals?

Prescription

drugs

Do you need to join a Medicare drug plan? Do you already havecreditable prescription drug coverage? Will you pay a penalty i you join a drug plan later? How much will you have to pay or yourprescription drugs under each plan? Are your drugs covered underthe plan’s ormulary ? Are there any coverage rules that apply toyour prescriptions? Is the pharmacy you use in the plan’s network?

Quality o

care

Are you satised with your medical care? Te quality o care andservices given by plans and other health care providers can vary.

Medicare has inormation to help you compare how well plans andproviders work to give you the best care possible. See page 124.

Convenience

Where are the doctors’ oces? What are their hours? Whichpharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records or prescribeelectronically? Can you get an electronic copy o your inormationby email or to store in a personal health record? See page 125.

Travel Will you have coverage in another state or outside the U.S.?

http://-/?-

http://-/?-



57

Section 5—

Get Inormation about Your

Medicare Health CoverageChoices

S e c t i o n

5

How does Original Medicare work?Original Medicare is one o your health coverage choices

as part o Medicare. You’ll have Original Medicare unlessyou choose a Medicare health plan.

Original Medicare is coverage managed by the ederalgovernment. Generally, there’s a cost or each service.See the next page or the general rules or how it works.



59Section 5—Get Information about Your Medicare Health Coverage Choices


What do I pay?Your out-o-pocket costs in Original Medicare depend on the ollowing:

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

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

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

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

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

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

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

■ Whether you and your doctor or other health care provider sign aprivate contract. See page 62.

For more inormation on how other insurance works with Medicare,see pages 22–23. For more inormation about help to cover the costs thatOriginal Medicare doesn’t cover, see pages 99–100.

What are Medicare Summary Notices?I you have Original Medicare, you’ll get a Medicare Summary Notice(MSN) in the mail every 3 months i you get Part A and Part B-coveredservices. Starting in 2013, your MSN will look dierent. Te new MSNwill help to make Medicare inormation clearer, more accessible, andeasier to understand. Te notice shows all your services or supplies thatproviders and suppliers billed to Medicare during the 3-month period,what Medicare paid, and what you may owe the provider. Tis noticeisn’t a bill. Read it careully and do the ollowing:

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

■ Keep your receipts and bills, and compare them to your noticeto be sure you got all the services, supplies, or equipment listed.See pages 112–115 or inormation on Medicare raud.

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

■ I an item or service is denied, call your doctor’s or other health careprovider’s oce to make sure they submitted the correct inormation.

I not, the oce may resubmit.

http://-/?-

http://-/?-



60 Section 5—Get Information about Your Medicare Health Coverage Choices


I you disagree with any decision made, you can le an appeal.See pages 104–107.

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

Check your MSN on MyMedicare.gov

You don’t have to wait or your MSN to view your Medicare claimsor le an appeal. Visit www.MyMedicare.gov to look at yourMedicare claims or view electronic MSNs. See page 123. Your

claims generally will be available or viewing within 24 hours aerprocessing.

What is assignment?Assignment means that your doctor, provider, or supplier agrees (oris required by law) to accept the Medicare-approved amount as ullpayment or covered services.

Make sure your doctor, provider, or supplier accepts assignment

Most doctors, providers, and suppliers accept assignment, but youshould always check to make sure. Participating providers havesigned an agreement to accept assignment or all Medicare-coveredservices.

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

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

■ Tey agree to charge you only the Medicare deductible and

coinsurance amount and usually wait or Medicare to pay its sharebeore asking you to pay your share.

■ Tey have to submit your claim directly to Medicare and can’tcharge you or submitting the claim.

What are Medicare Summary Notices? (continued)

Important!

http://www.mymedicare.gov/





I your doctor, provider, or supplier doesn’t accept assignment

Non-participating providers haven’t signed an agreement toaccept assignment or all Medicare-covered services, but they can still choose to accept assignment or individual services.Tese providers are called “non-participating.”

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

■ You might have to pay the entire charge at the time o service.Your doctor, provider, or supplier is supposed to submit a claim toMedicare or any Medicare-covered services they provide to you.Tey can’t charge you or submitting a claim. I they don’t submitthe Medicare claim once you ask them to, call 1-800-MEDICARE

(1-800-633-4227). Y users should call 1-877-486-2048.Note: In some cases, you might have to submit your own claimto Medicare using orm CMS-1490S to get paid back. Visitwww.medicare.gov/medicareonlineormsor the orm andinstructions, or call 1-800-MEDICARE.

■ Tey can charge you more than the Medicare-approvedamount, but there’s a limit called “the limiting charge.”Te provider can only charge you up to 15% over the amount thatnon-participating providers are paid. Non-participating providersare paid 95% o the ee schedule amount. Te limiting chargeapplies only to certain Medicare-covered services and doesn’tapply to some supplies and durable medical equipment.

o nd out i your doctors and other health care providersaccept assignment or participate in Medicare, visitwww.medicare.gov/physician or www.medicare.gov/supplier.You can also call 1-800-MEDICARE, or ask your doctor, provider,or supplier i they accept assignment.

Important!

http://www.medicare.gov/medicareonlineforms

http://www.medicare.gov/physician



http://www.medicare.gov/physician






What are private contracts?A “private contract” is a written agreement between you and adoctor or other health care provider who has decided not to provideservices to anyone through Medicare. Te private contract only applies to the services provided by the doctor or other provider whoasked you to sign it.

Rules or private contracts

You don’t have to sign a private contract. You can always go toanother provider who gives services through Medicare. I you sign aprivate contract with your doctor or other provider:

■ Medicare won’t pay any amount or the services you get rom

this doctor or provider, even i it’s a Medicare-covered service. ■ You’ll have to pay the ull amount o whatever this providercharges you or the services you get.

■ I you have a Medicare Supplement Insurance (Medigap) policy, itwon’t pay anything or the services you get. Call your insurancecompany beore you get the service i you have questions.

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

■ Your provider must tell you i he or she has been excluded rom

Medicare.■ You can always get services not covered by Medicare i you choose

to pay or them yoursel.

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

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 129–132 or thephone number.




Can I add drug coverage (Part D) to Original

Medicare?In Original Medicare, i you don’t already have creditable

prescription drug coverage (or example, rom a current or ormeremployer or union) and you would like Medicare prescription drugcoverage, you must join a Medicare Prescription Drug Plan. Teseplans are available through private companies under contract withMedicare. I you don’t currently have creditable prescription drugcoverage, you should think about joining a Medicare PrescriptionDrug Plan as soon as you’re eligible. I you don’t join a MedicarePrescription Drug Plan when you’re rst eligible and you decideto join later, you may have to pay a late enrollment penalty.

See pages 88–89 or more inormation.

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

People with limited income and resources may qualiy or ExtraHelp paying their Medicare prescription drug coverage costs.See pages 95–98 to nd out i you qualiy.





What are Medicare Supplement Insurance

(Medigap) policies?Original Medicare pays or many, but not all, health care services

and supplies. A Medicare Supplement Insurance policy, sold by private companies, can help pay some o the health care costs thatOriginal Medicare doesn’t cover, like copayments, coinsurance, anddeductibles. Medicare Supplement Insurance policies are alsocalled Medigap policies.

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

covered health care costs. Ten, your Medigap policy pays its share.You have to pay the premiums or a Medigap policy.

Are Medigap policies standardized?

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

choose which one meets your needs. In Massachusetts, Minnesota,and Wisconsin, Medigap policies are standardized in a dierent way.

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

How do I compare Medigap policies?

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

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




Te chart below shows basic inormation about the dierentbenets that Medigap policies cover. I a percentage appears,the Medigap plan covers that percentage o the benet.

Note: You’ll need more details than this chart provides to compare andchoose a policy. For more details, visit www.medicare.gov/publications to view the booklet “Choosing a Medigap Policy: A Guide toHealth Insurance or People with Medicare.” You can also call1-800-MEDICARE (1-800-633-4227) to nd out i a copy can bemailed to you. Y users should call 1-877-486-2048.

Medicare Supplement Insurance (Medigap) Plans

Benets A B C D F* G K L M N**

Medicare Part Acoinsurance and hospitalcosts (up to an additional365 days aer Medicarebenets are used)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Medicare Part Bcoinsurance or copayment

100% 100% 100% 100% 100% 100% 50% 75% 100% 100%

Blood (rst 3 pints) 100% 100% 100% 100% 100% 100% 50% 75% 100% 100%

Part A hospice care

coinsurance or copayment

100% 100% 100% 100% 100% 100% 50% 75% 100% 100%

Skilled nursing acility care coinsurance

100% 100% 100% 100% 50% 75% 100% 100%

Medicare Part A deductible 100% 100% 100% 100% 100% 50% 75% 50% 100%

Medicare Part B deductible 100% 100%

Medicare Part B excesscharges

100% 100%

Foreign travel emergency (up to plan limits)

100% 100% 100% 100% 100% 100%

Out-o-pocket

limit in 2013$4,800 $2,400

* Plan F also oers a high-deductible plan in some states. I you choose this option, this meansyou must pay or Medicare-covered costs (coinsurance, copayments, deductibles) up to thedeductible amount o $2,110 in 2013 beore your policy pays anything.

** Plan N pays 100% o the Part B coinsurance, except or a copayment o up to $20 or someoce visits and up to a $50 copayment or emergency room visits that don’t result in aninpatient admission.







What else should I know about Medicare

Supplement Insurance (Medigap)?

Important acts

■ You must have Part A and Part B.■ You pay a monthly premium or your Medigap policy in addition to

your monthly Part B premium.

■ A Medigap policy only covers one person. Spouses must buy separatepolicies.

■ You can’t have prescription drug coverage in both your Medigap policy and a Medicare drug plan. See page 93.

■ It’s important to compare Medigap policies since the costs can vary and

may go up as you get older. Some states limit Medigap premium costs.

When to buy

■ Te best time to buy a Medigap policy is during your Medigap OpenEnrollment Period. Tis 6-month period begins on the rst day o themonth in which you’re 65 or older and enrolled in Part B. (Some stateshave additional open enrollment periods.) Aer this enrollment period,your option to buy a Medigap policy may be limited and it may costmore.

■ I you delay enrolling in Part B because you have group health coveragebased on your (or your spouse’s) current employment, your MedigapOpen Enrollment Period won’t start until you sign up or Part B.

■ Federal law doesn’t require insurance companies to sell Medigappolicies to people under 65. I you’re under 65, you might not be ableto buy the Medigap policy you want, or any Medigap policy, until youturn 65. However, some states require Medigap insurance companies tosell Medigap policies to people under 65.

How does Medigap work with Medicare Advantage Plans?■ I you have a Medigap policy and join a Medicare Advantage Plan (like

an HMO or PPO), you may want to drop your Medigap policy. YourMedigap policy can’t be used to pay your Medicare Advantage Plancopayments, deductibles, and premiums. I you want to cancel yourMedigap policy, contact your insurance company. In most cases, i you drop your Medigap policy to join a Medicare Advantage Plan, youwon’t be able to get it back.




■ I you have a Medicare Advantage Plan, it’s illegal or anyoneto sell you a Medigap policy unless you’re switching back toOriginal Medicare. I you want to switch to Original Medicareand buy a Medigap policy, nd out what policies are available

to you and contact your Medicare Advantage Plan to disenroll.You’ll need to let the Medigap insurer know the date your plancoverage will end. I you don’t intend to leave your MedicareAdvantage Plan, and someone tries to sell you a Medigap policy,report it to your State Insurance Department.

■ I you join a Medicare Advantage Plan or the rst time, andyou aren’t happy with the plan, you’ll have special rights to buy a Medigap policy i you return to Original Medicare within 12months o joining.

—I you had a Medigap policy beore you joined, you may be able to get the same policy back i the company stillsells it. I it isn’t available, you can buy another Medigappolicy.

—I you joined a Medicare Advantage Plan when you wererst eligible or Medicare, you can choose rom any Medigap policy.

—Te Medigap policy can no longer have prescription drug

coverage even i you had it beore, but you may be able to join a Medicare Prescription Drug Plan.

Where can I get more inormation about

Medicare Supplement Insurance (Medigap)?■ Visit www.medicare.gov/publications to view the booklet

“Choosing a Medigap Policy: A Guide to Health Insurance orPeople with Medicare.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you.Y users should call 1-877-486-2048.

■ Visit www.medicare.gov/medigap to nd policies in your area.

■ Call your State Insurance Department. Visitwww.medicare.gov/contacts or call 1-800-MEDICARE to getthe phone number.

■ Call your State Health Insurance Assistance Program (SHIP).See pages 129–132 or the phone number.


http://www.medicare.gov/medigap



http://www.medicare.gov/medigap





What are Medicare Advantage Plans (Part C)?A Medicare Advantage Plan (like an HMO or PPO) is another Medicarehealth plan choice you may have as part o Medicare. Medicare AdvantagePlans, sometimes called “Part C” or “MA Plans,” are oered by privatecompanies approved by Medicare. I you join a Medicare Advantage Plan,you still have Medicare. You’ll get your Part A (Hospital Insurance) andPart B (Medical Insurance) coverage rom the Medicare Advantage Plan,not Original Medicare.

Medicare Advantage Plans cover all Medicare services

In all types o Medicare Advantage Plans, you’re always covered oremergency and urgent care. Medicare Advantage Plans must cover all o the services that Original Medicare covers except hospice care and somecare in qualiying clinical research studies. Original Medicare covers

hospice care and some costs or clinical research studies even i you’re in a Medicare Advantage Plan.

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

Medicare Advantage Plans must ollow Medicare’s rules

Medicare pays a xed amount or your care every month to the companiesoering Medicare Advantage Plans. Tese companies must ollow rules setby Medicare. However, each Medicare Advantage Plan can charge dierentout-o-pocket costs and have dierent rules or how you get services(like whether you need a reerral to see a specialist or i you have to go todoctors, acilities, or suppliers that belong to the plan or non-emergency ornon-urgent care). Tese rules can change each year. Te plan must notiy

you about any changes beore the start o the next enrollment year.

Read the inormation you get rom your plan

I you’re in a Medicare plan, review the “Evidence o Coverage” (EOC)and “Annual Notice o Change” (ANOC) your plan sends you each all.Te EOC gives you details about what the plan covers, how much you pay,and more. Te ANOC includes any changes in coverage, costs, or servicearea that will be eective in January. I you don’t get these importantdocuments, contact your plan.

Important!





There are diferent types o Medicare Advantage Plans:

■ Health Maintenance Organization (HMO) Plans—In most HMOs,you can only go to doctors, other health care providers, or hospitalsin the plan’s network except in an emergency. You may also need toget a reerral rom your primary care doctor. See page 74.

■ Preerred Provider Organization (PPO) Plans—In a PPO, you pay less i you use doctors, hospitals, and other health care providersthat belong to the plan’s network. You usually pay more i you usedoctors, hospitals, and providers outside o the network. See page 74.

■ Private Fee-or-Service (PFFS) Plans—PFFS plans are similar toOriginal Medicare in that you can generally go to any doctor, otherhealth care provider, or hospital as long as they agree to treat you.

Te plan determines how much it will pay doctors, other health careproviders, and hospitals, and how much you must pay when you getcare. See page 75.

■ Special Needs Plans (SNP)—SNPs provide ocused and specializedhealth care or specic groups o people, like those who have bothMedicare and Medicaid, who live in a nursing home, or have certainchronic medical conditions. See page 75.

■ HMO Point-o-Service (HMOPOS) Plans—Tese are HMO plansthat may allow you to get some services out-o-network or a higher

copayment or coinsurance.■ Medical Savings Account (MSA) Plans—Tis is a plan that

combines a high deductible health plan with a bank account.Medicare deposits money into the account (usually less than thedeductible). You can use the money to pay or your health careservices during the year. For more inormation about MSAs, visitwww.medicare.gov/publications to view the booklet “Your Guideto Medicare Medical Savings Account Plans.” You can also call1-800-MEDICARE (1-800-633-4227) to nd out i a copy can be

mailed to you. Y users should call 1-877-486-2048.

Make sure you understand how a plan works beore you join.See pages 74–75 or more inormation about Medicare Advantage Plantypes. I you want more inormation about a Medicare AdvantagePlan, you can call any plan and request a “Summary o Benets” (SB)document. Contact your State Health Insurance Assistance Program(SHIP) or help comparing plans. See pages 129–132 or the phonenumber.

Important!







What else should I know about Medicare

Advantage Plans?

Important acts

■ You have Medicare rights and protections, including the right toappeal. See pages 103–107.

■ You can check with the plan beore you get a service to nd out i it’scovered and what your costs may be.

■ You must ollow plan rules. It’s important to check with the plan orinormation about your rights and responsibilities.

■ I you go to a doctor, other health care provider, acility, or supplierthat doesn’t belong to the plan, your services may not be covered, or

your costs could be higher. In most cases, this applies to MedicareAdvantage HMOs and PPOs.

■ I you join a clinical research study, some costs may be covered by Medicare and some by your plan.

■ Medicare Advantage Plans can’t charge more than Original Medicareor certain services, like chemotherapy, dialysis, and skilled nursingacility care.

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

out-o-pocket amount can be dierent between Medicare AdvantagePlans and can change each year. You should consider this when youchoose a plan.

Joining & leaving

■ You can join a Medicare Advantage Plan even i you have apre-existing condition, except or End-Stage Renal Disease (ESRD).See page 72.

■ You can only join or leave a plan at certain times during the year.

See pages 76–77.■ Each year, Medicare Advantage Plans can choose to leave Medicare or

make changes to the services they cover and what you pay. I the plandecides to stop participating in Medicare, you’ll have to join anotherMedicare health plan or return to Original Medicare. See page 104.

■ Medicare Advantage Plans must ollow certain rules when givingyou inormation about how to join their plan. See page 78 or moreinormation about these rules and how to protect your personalinormation.




Prescription drug coverage

You usually get prescription drug coverage (Part D) throughthe Medicare Advantage Plan. In some types o plansthat don’t oer drug coverage, you can join a MedicarePrescription Drug Plan. I your Medicare AdvantagePlan includes prescription drug coverage and you join aMedicare Prescription Drug Plan, you’ll be disenrolledrom your Medicare Advantage Plan and returned toOriginal Medicare.

Who can join?You must meet these conditions to join a Medicare Advantage Plan:

■ You have Part A and Part B.■ You live in the plan’s service area.

■ You don’t have End-Stage Renal Disease (ESRD), except asexplained on page 72.

What i I have other coverage?alk to your employer, union, or other benets administrator abouttheir rules beore you join a Medicare Advantage Plan. In somecases, joining a Medicare Advantage Plan might cause you to lose

employer or union coverage. I you lose coverage or yoursel, youmay also lose coverage or your spouse and dependants. In othercases, i you join a Medicare Advantage Plan, you may still be ableto use your employer or union coverage along with the plan you

join. Remember, i you drop your employer or union coverage, you may not be able to get it back.

What i I have a Medicare Supplement

Insurance Policy?You can’t use (and can’t be sold) a Medicare Supplement Insurance(Medigap) policy while you’re in a Medicare Advantage Plan.You can’t use it to pay or any expenses (copayments, deductibles,and premiums) you have under a Medicare Advantage Plan. I youalready have a Medigap policy and join a Medicare AdvantagePlan, you’ll probably want to drop your Medigap policy. I youdrop your Medigap policy, you may not be able to get it back. See pages 64–67.





What i I have End-Stage Renal Disease (ESRD)?I you have End-Stage Renal Disease (ESRD), you can only join aMedicare Advantage Plan in certain situations:

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

■ I you’re in a Medicare Advantage Plan, and the plan leavesMedicare or no longer provides coverage in your area, you have aone-time right to join another plan.

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

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

■ You may be able to join a Medicare Special Needs Plan (SNP) orpeople with ESRD i one is available in your area.

For more inormation

Visit www.medicare.gov/publications to view the booklet“Medicare Coverage o Kidney Dialysis and Kidney ransplant

Services.” You can also call 1-800-MEDICARE (1-800-633-4227)to nd out i a copy can be mailed to you. Y users should call1-877-486-2048.

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






What do I pay?Your out-o-pocket costs in a Medicare Advantage Plan depend onthe ollowing:

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

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

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

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

■ Whether you go to a doctor or supplier who accepts assignment (i you’re in a Preerred Provider Organization, PrivateFee-or-Service Plan, or Medical Savings Account Plan and yougo out-o-network). See pages 60–61 or more inormation aboutassignment.

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

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

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

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

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

Read the inormation you get rom your planSee page 68 or more inormation about the “Evidence o Coverage”

(EOC) and “Annual Notice o Change” (ANOC) your plan sendsyou each all.

Important!






How do Medicare Advantage Plans work?

Health Maintenance Organization

(HMO) Plan

Preerred Provider

Organization (PPO) Plan

Can I get my

health care

rom any doctor,

other health

care provider, or

hospital?

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

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

Are prescription

drugs covered?

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

Plan that oers prescription drug coverage.

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

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

Do I need to

choose a primary

care doctor?

In most cases, yes. No.

Do I have to get

a reerral to see

a specialist?

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

In most cases, no.

What else do Ineed to know

about this type

o plan?

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

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

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

■ PPO Plans aren’t the same asOriginal Medicare orMedigap.

■ Medicare PPO Plans usually oer extra benets thanOriginal Medicare, but youmay have to pay extra orthese benets.

Tere may be several private companies that oer dierent types o Medicare Advantage Plansin your area. Each plan can vary. Read individual plan materials careully to make sure youunderstand the plan’s rules. You may want to contact the plan to nd out i the service you need iscovered and how much it costs. Visit the Medicare Plan Finder at www.medicare.gov/nd-a-plan,to nd plans in your area. You can also call 1-800-MEDICARE (1-800-633-4227). Y users

should call 1-877-486-2048.






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

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

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

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

get coverage.

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

No. Generally, yes.

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

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

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

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

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

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

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

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

i you’re eligible.■ Plans should coordinate the services and

providers you need to help you stay healthy and ollow doctor’s or other health careprovider’s orders.

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

■ I you live in an institution, make sure that

plan providers serve people where you live.





When can I join, switch, or drop a Medicare

Advantage Plan?■ When you rst become eligible or Medicare, you can join during

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

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

■ Between October 15–December 7 anyone can join, switch, or dropa Medicare Advantage Plan. Your coverage will begin on January 1,as long as the plan gets your request by December 7.

Can I make changes to my coverage ater December 7?

Between January 1–February 14, i you’re in a Medicare AdvantagePlan, you can leave your plan and switch to Original Medicare.I you switch to Original Medicare during this period, you’ll haveuntil February 14 to also join a Medicare Prescription Drug Planto add drug coverage. Your coverage will begin the rst day o themonth aer the plan gets your enrollment request.

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

■ Switch rom one Medicare Advantage Plan to another.

■ Switch rom one Medicare Prescription Drug Plan to another.

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

Special Enrollment Periods

In most cases, you must stay enrolled or the calendar year startingthe date your coverage begins. However, in certain situations, you

may be able to join, switch, or drop a Medicare Advantage Planduring a Special Enrollment Period. Contact your plan i:

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

■ You have Medicaid.

■ You qualiy or Extra Help. See pages 95–98.

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




5-Star Special Enrollment Period

Medicare uses inormation rom member satisaction surveys,plans, and health care providers to give overall perormance starratings to plans. A plan can get a rating between 1 and 5 stars.A 5-star rating is considered excellent. Tese ratings help youcompare plans based on quality and perormance. Tese ratingsare updated each all and can change each year.

You can switch to a Medicare Advantage Plan that has 5 starsor its overall plan rating rom December 8, 2012 throughNovember 30, 2013.

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

■ You can only join a 5-star Medicare Advantage Plan i one isavailable in your area.

■ You can only use this Special Enrollment Period once during theabove timerame.

Visit the Medicare Plan Finder at www.medicare.gov/nd-a-plan to search or plans. For more inormation about overall planratings, visit www.medicare.gov .

You may lose your prescription drug coverage i you move roma Medicare Advantage Plan that has drug coverage to a 5-starMedicare Advantage Plan that doesn’t. You’ll have to wait until thenext Open Enrollment Period to get drug coverage, and you may have to pay a late enrollment penalty. See pages 88–89.

How do I join?You can join a Medicare Advantage Plan by:

■ Enrolling on the plan’s website or on www.medicare.gov .

■ Completing a paper enrollment orm.■ Calling the plan.

■ Calling 1-800-MEDICARE.

When you join a Medicare Advantage Plan, you’ll have to provideyour Medicare number and the date your Part A and/or Part Bcoverage started. Tis inormation is on your Medicare card.

Important!













Don’t give out personal inormation

In most cases, Medicare Advantage Plans can’t:

■ Call you to enroll you in a plan.

■ Ask you or nancial inormation, including credit card or bank account numbers, over the phone. Don’t give your personalinormation to anyone who calls you to enroll in a plan.

■ Call you or come to your home uninvited to sell Medicare products.

See pages 112–115 or more inormation about how to protect yoursel rom identity the and raud. I you believe a plan has misled you, call1-800-MEDICARE. Y users should call 1-877-486-2048.

How do I switch?Follow these steps i you’re already in a Medicare Advantage Plan andwant to switch:

■ o switch to a new Medicare Advantage Plan, simply join the planyou choose during one o the enrollment periods explained on pages76–77. You’ll be disenrolled automatically rom your old plan whenyour new plan’s coverage begins.

■ o switch to Original Medicare, contact your current plan, or call1-800-MEDICARE. I you don’t have drug coverage, you should

careully consider Medicare prescription drug coverage (Part D).You may also want to consider a Medicare Supplement Insurance(Medigap) policy i you’re eligible. See pages 64–67 or moreinormation about buying a Medigap policy.

For more inormation on joining, dropping, and switching plans, visitwww.medicare.gov/publications to view the act sheet “UnderstandingMedicare Enrollment Periods.” You can also call 1-800-MEDICARE tond out i a copy can be mailed to you.

Important!






Are there other types o Medicare health plans?Some types o Medicare health plans that provide health carecoverage aren’t Medicare Advantage Plans but are still part o Medicare. Some o these plans provide Part A (Hospital Insurance)and Part B (Medical Insurance) coverage, while most othersprovide only Part B coverage. In addition, some also provide Part Dprescription drug coverage. Tese plans have some o the samerules as Medicare Advantage Plans. However, each type o plan hasspecial rules and exceptions, so you should contact any plans you’reinterested in to get more details.

Medicare Cost Plans

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

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

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

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

■ You can leave anytime and return to Original Medicare.

■ You can either get your Medicare prescription drug coveragerom the plan (i oered), or you can join a Medicare PrescriptionDrug Plan. Note: You can add or drop Medicare prescriptiondrug coverage only at certain times. See pages 82–83.

Tere’s another type o Medicare Cost Plan that only providescoverage or Part B services. Tese plans are either sponsored by employer or union group health plans or oered by companies thatdon’t provide Part A services. Part A services are covered through

Original Medicare. Tese plans never include Part D.For more inormation about Medicare Cost Plans, contact the plansyou’re interested in. You can also visit the Medicare Plan Finderat www.medicare.gov/nd-a-plan. Your State Health InsuranceAssistance Program (SHIP) can also give you more inormation.See pages 129–132 or the phone number.







Programs o All-inclusive Care or the Elderly (PACE)

PACE is a Medicare and Medicaid program oered in many states thatallows people who otherwise need a nursing home-level o care to remainin the community.

o qualiy or PACE, you must meet these conditions:

■ You’re 55 or older.

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

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

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

PACE provides coverage or prescription drugs, doctor or other health

care provider visits, transportation, home care, hospital visits, and evennursing home stays whenever necessary. I you have Medicaid, you won’thave to pay a monthly premium or the long-term care portion o thePACE benet. I you have Medicare but not Medicaid, you’ll be chargeda monthly premium to cover the long-term care portion o the PACEbenet and a premium or Medicare Part D drugs. However, in PACEthere’s never a deductible or copayment or any drug, service, or careapproved by the PACE team o health care proessionals.

Visit www.pace4you.org or call your State Medical Assistance (Medicaid)oce to nd out i you’re eligible and i there’s a PACE site near you.You can also visit www.medicare.gov/publications to view the actsheet “Quick Facts about Programs o All-inclusive Care or the Elderly (PACE).” You can call 1-800-MEDICARE (1-800-633-4227) to nd out i a copy can be mailed to you. Y users should call 1-877-486-2048.

Medicare Innovation Projects

Medicare develops innovative models, demonstrations, and pilot projectsto test and measure the eect o potential changes in Medicare coverage,payment, and quality o care. Tese projects help to nd new ways toimprove your health care and reduce costs. Usually, they operate only or a limited time or a specic group o people and/or are oered only in specic areas. Check with the demonstration or pilot project (or withyour health care provider) or more inormation about how it works.

o nd out about current Medicare models, demonstrations, andpilot projects, visit www.innovations.cms.gov . You can also call1-800-MEDICARE.

http://www.pace4you.org/


http://www.innovations.cms.gov/

http://www.innovations.cms.gov/


http://www.pace4you.org/



81

Get Inormation about


Section 6—

How does Medicare prescription drug

coverage (Part D) work?Medicare oers prescription drug coverage to everyone withMedicare. Even i you don’t take many prescriptions now,

you should consider joining a Medicare drug plan. I youdecide not to join a Medicare drug plan when you’re rsteligible, and you don’t have other creditable prescriptiondrug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty i you join a plan later. See pages88–89. o get Medicare prescription drug coverage, you must

join a plan run by an insurance company or other privatecompany approved by Medicare. Each plan can vary in costand specic drugs covered.

Tere are 2 ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. Tese plans(sometimes called “PDPs”) add drug coverage to OriginalMedicare, some Medicare Cost Plans, some MedicarePrivate Fee-or-Service (PFFS) Plans, and MedicareMedical Savings Account (MSA) Plans.

2. Medicare Advantage Plans (like an HMO or PPO)or other Medicare health plans that oer Medicare

prescription drug coverage. You get all o your Part Aand Part B coverage, and prescription drug coverage(Part D), through these plans. Medicare Advantage Planswith prescription drug coverage are sometimes called“MA-PDs.” You must have Part A and Part B to join aMedicare Advantage Plan.

In either case, you must live in the service area o theMedicare drug plan you want to join. Both types o plans

are called “Medicare drug plans” in this handbook.

S e c t i o n

6



82 Section 6—Get Information about Prescription Drug Coverage


I you have employer or union coverage

Call your benets administrator beore you make any changes, orbeore you sign up or any other coverage. I you drop your employeror union coverage, you may not be able to get it back. You also may notbe able to drop your employer or union drug coverage without alsodropping your employer or union health (doctor and hospital) coverage.I you drop coverage or yoursel, you may also have to drop coverageor your spouse and dependants. I you want to know how Medicareprescription drug coverage works with other drug coverage you may have, see pages 93–94.

When can I join, switch, or drop a Medicare drug

plan?■ When you’re rst eligible or Medicare, you can join during the7-month period that begins 3 months beore the month you turn 65,includes the month you turn 65, and ends 3 months aer the monthyou turn 65.

■ I you get Medicare due to a disability, you can join during the7-month period that begins 3 months beore your 25th month o disability benets and ends 3 months aer your 25th month o disability. You’ll have another chance to join during the 7-month period

that begins 3 months beore the month you turn 65 and ends 3 monthsaer the month you turn 65.

■ Between October 15–December 7, anyone can join, switch, or drop aMedicare drug plan. Te change will take eect on January 1 as longas the plan gets your request by December 7.

■ Anytime, i you qualiy or Extra Help.

Special Enrollment Periods

You generally must stay enrolled or the calendar year. However, in

certain situations like the ollowing, you may be able to join, switch, ordrop Medicare drug plans at other times:

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

■ I you lose other creditable prescription drug coverage

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

Important!



83Section 6—Get Information about Prescription Drug Coverage

5-Star Special Enrollment Period

You can switch to a Medicare Prescription Drug Plan that has 5stars or its overall plan rating rom December 8, 2012 throughNovember 30, 2013. Te overall plan ratings are available atwww.medicare.gov/nd-a-plan. Tese ratings are updated each alland can change each year. See page 77 or more inormation.

■ You can only switch to a 5-star Medicare Prescription Drug Plani one is available in your area.

■ You can only use this Special Enrollment Period once during theabove timerame.

Visit the Medicare Plan Finder at www.medicare.gov/nd-a-plan tosearch or plans. For more inormation about overall plan ratings,

visit www.medicare.gov .

Call your State Health Insurance Assistance Program (SHIP) ormore inormation. See pages 129–132 or the phone number. Youcan also call 1-800-MEDICARE (1-800-633-4227). Y usersshould call 1-877-486-2048.

How do I join?You can join a Medicare drug plan by:

■ Enrolling on the plan’s website or on www.medicare.gov .■ Completing a paper enrollment orm.

■ Calling the plan.

■ Calling 1-800-MEDICARE.

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

I you have a Medicare Advantage PlanI your Medicare Advantage Plan includes prescription drugcoverage and you join a Medicare Prescription Drug Plan, you’ll bedisenrolled rom your Medicare Advantage Plan and returned toOriginal Medicare.

Important!

http://www.medicare.gov/findaplan







http://www.medicare.gov/findaplan





Don’t give out personal inormation

In most cases, Medicare drug plans aren’t allowed to call you toenroll you in a plan. I this happens, don’t give out your personalinormation. Call 1-800-MEDICARE (1-800-633-4227) to report a planthat does this. Y users should call 1-877-486-2048.

How do I switch?You can switch to a new Medicare drug plan simply by joining anotherdrug plan during one o the times listed on pages 82–83. You don’tneed to cancel your old Medicare drug plan. Your old Medicare drugplan coverage will end when your new drug plan begins. You shouldget a letter rom your new Medicare drug plan telling you when your

coverage with the new plan begins.

How do I drop a Medicare drug plan?I you want to drop your Medicare drug plan and you don’t want to joina new plan, you can do so during one o the times listed on page 82.You can disenroll by calling 1-800-MEDICARE. You can also send aletter to the plan to tell them you want to disenroll. I you drop yourplan and want to join another Medicare drug plan later, you have towait or an enrollment period. You may have to pay a late enrollment

penalty. See pages 88–89.

What do I pay?Below and continued on the next page are descriptions o what you pay in your Medicare drug plan. Your actual drug plan costs will vary depending on the ollowing:

■ Your prescriptions and whether they’re on your plan’s ormulary (druglist)

■ Te plan you choose

■ Which pharmacy you use (preerred, non preerred, out-o-network, ormail order)

■ Whether you get Extra Help paying your Part D costs




Monthly premium

Most drug plans charge a monthly ee that varies by plan. You pay this inaddition to the Part B premium. I you’re in a Medicare Advantage Plan(like an HMO or PPO) or a Medicare Cost Plan that includes Medicareprescription drug coverage, the monthly premium may include an amountor prescription drug coverage.

Note: Contact your drug plan (not Social Security or RRB) i you want yourpremium deducted rom your monthly Social Security payment. I youwant to stop premium deductions and get billed directly, contact your drugplan.

What you pay or Part D coverage could be higher based on your income.Tis includes Part D coverage you get rom a Medicare Prescription DrugPlan, a Medicare Advantage Plan, a Medicare Cost Plan, or employergroup Medicare Advantage Plan that includes Medicare prescriptiondrug coverage. I your income is above a certain limit, you’ll pay an extraamount in addition to your plan premium. Usually, the extra amount willbe deducted rom your Social Security check or billed by the RRB i you getbenets rom the RRB. I you’re billed the amount by Medicare or the RRB,you must pay the extra amount to Medicare or the RRB and not your plan.I you have to pay an extra amount and you disagree (or example, you havea lie event that lowers your income), call Social Security at 1-800-772-1213.Y users should call 1-800-325-0778.

I Your Yearly Income in 2011 was You pay

File Individual Tax Return File Joint Tax Return

$85,000 or less $170,000 or less Your PlanPremium

above $85,000 up to$107,000

above $170,000 up to$214,000

$11.60 + YourPlan Premium

above $107,000 up to$160,000

above $214,000 up to$320,000


above $160,000 up to$214,000

above $320,000 up to$428,000


above $214,000 above $428,000 $66.60 + YourPlan Premium

Yearly deductible

Tis is the amount you must pay beore your drug plan begins to pay its

share o your covered drugs. Some drug plans don’t have a deductible.

Important!





Copayments or coinsurance

Tese are the amounts you pay or your covered prescriptions aer thedeductible (i the plan has one). You pay your share and your drug plan paysits share or covered drugs. Tese amounts may vary.

Coverage gap

Most Medicare drug plans have a coverage gap (also called the “donut hole”Tis means that there’s a temporary limit on what the drug plan will coveror drugs. Te coverage gap begins aer you and your drug plan have spenta certain amount or covered drugs. In 2013, once you enter the coveragegap, you pay 47.5% o the plan’s cost or covered brand-name drugs and 79%o the plan’s cost or covered generic drugs until you reach the end o thecoverage gap. Not everyone will enter the coverage gap.

Tese items all count toward you getting out o the coverage gap:

■ Your yearly deductible, coinsurance, and copayments

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

■ What you pay in the coverage gap

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

Some plans oer additional coverage during the gap, like or generic drugs,

but they may charge a higher monthly premium. Check with the plan rst tosee i your drugs would be covered during the gap.

In addition to the discount on covered brand-name prescriptiondrugs, there will be increasing coverage or drugs in the coverage gapeach year until the gap closes in 2020. For more inormation, visitwww.medicare.gov/publications to view the act sheet “Closing the CoverageGap—Medicare Prescription Drugs Are Becoming More Aordable.”You can also call 1-800-MEDICARE (1-800-633-4227) to nd out i a copy

can be mailed to you. Y users should call 1-877-486-2048.

Catastrophic coverage

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

Note: I you get Extra Help, you won’t have some o these costs. See pages95–98.






Te example below shows costs or covered drugs in 2013 or aplan that has a coverage gap.

Ms. Smith joins the ABC Prescription Drug Plan. Her coverage

begins on January 1, 2013. She doesn’t get Extra Help and uses herMedicare drug plan membership card when she buys prescriptions.

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

1. Yearly

deductible

2. Copayment or

coinsurance

(what you pay

at the pharmacy)

3. Coverage gap 4. Catastrophic

coverage

Ms. Smith paysthe rst $325 o her drug costsbeore her planstarts to pay itsshare.

Ms. Smith pays acopayment, and herplan pays its share oreach covered druguntil their combinedamount (plus thedeductible) reaches

$2,970.

Once Ms. Smith and herplan have spent $2,970or covered drugs, she’sin the coverage gap. In2013, she pays 47.5% o the plan’s cost or hercovered brand-name

prescription drugs and79% o the plan’s cost orcovered generic drugs.What she pays (and thediscount paid by thedrug company) counts asout-o-pocket spending,and helps her get out o the coverage gap.

Once Ms. Smithhas spent $4,750out-o-pocket or theyear, her coveragegap ends. Now sheonly pays a smallcoinsurance or

copayment or eachcovered drug untilthe end o the year.

o get specic Medicare drug plan costs, call the plansyou’re interested in. Visit the Medicare Plan Finder atwww.medicare.gov/nd-a-plan to get plan contact inormation andto compare costs. For help comparing plan costs, contact your StateHealth Insurance Assistance Program (SHIP). See pages 129–132 or the phone number. You can also call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048.

Important!

http://www.medicare.gov/finda-plan

http://www.medicare.gov/finda-plan





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

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

3 ways to avoid paying a penalty:

1. Join a Medicare drug plan when you’re rst eligible. You won’thave to pay a penalty.

2. Don’t go 63 days or more in a row without a Medicare drug

plan or other creditable coverage. Creditable prescriptiondrug coverage could include drug coverage rom a current orormer employer or union, RICARE, Indian Health Service, theDepartment o Veterans Aairs, or health insurance coverage.Your plan must tell you each year i your drug coverage iscreditable coverage. Tis inormation may be sent to you ina letter or included in a newsletter rom the plan. Keep thisinormation, because you may need it i you join a Medicare drugplan later.

3. ell your plan about any drug coverage you had i they ask about it. When you join a Medicare drug plan, and theplan believes you went at least 63 days in a row without othercreditable prescription drug coverage, the plan will send youa letter. Te letter will include a orm asking about any drugcoverage you had. Complete the orm and return it to your drugplan. I you don’t tell the plan about your creditable prescriptiondrug coverage, you may have to pay a penalty.




How much more will I pay?Te cost o the late enrollment penalty depends on how long youdidn’t have creditable prescription drug coverage. Currently, thelate enrollment penalty is calculated by multiplying 1% o the“national base beneciary premium” ($31.17 in 2013) times thenumber o ull, uncovered months that you were eligible but didn’t

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

Example: Mrs. Jones didn’t join when she was rst eligible—by May 1, 2009. She joined a Medicare drug plan with aneective date o January 1, 2013. Since Mrs. Jones didn’t joinwhen she was rst eligible and went without other creditabledrug coverage or 43 months (June 2009–December 2012),she will be charged a monthly penalty o $13.40 in 2013($31.17 X .01 = $.3117 X 43 = $13.40) in addition to her plan’smonthly premium.

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

What i I don’t agree with the penalty?I you don’t agree with your late enrollment penalty, you can ask ora review or reconsideration. You’ll need to ll out a reconsiderationrequest orm (that your Medicare drug plan will send you), and

you’ll have the chance to provide proo that supports your case, likeinormation about previous creditable prescription drug coverage.I you need help, call your Medicare plan. You can also contactyour State Health Insurance Assistance Program (SHIP). Seepages 129–132 or the phone number.





What drugs are covered?Inormation about a plan’s list o covered drugs (called a ormulary )isn’t included in this handbook because each plan has its ownormulary. Many Medicare drug plans place drugs into dierent“tiers” on their ormularies. Drugs in each tier have a dierent cost.For example, a drug in a lower tier will generally cost you less thana drug in a higher tier. In some cases, i your drug is in a higher tierand your prescriber (your doctor or other health care provider whois legally allowed to write prescriptions) thinks you need that druginstead o a similar drug in a lower tier, you or your prescriber canask your plan or an exception to get a lower copayment.

Contact the plan or its current ormulary, or visit the plan’s

website. You can also visit the Medicare Plan Finder atwww.medicare.gov/nd-a-plan, or call 1-800-MEDICARE(1-800-633-4227). Y users should call 1-877-486-2048. Your planwill notiy you o any ormulary changes.

Note: Medicare drug plans must cover all medically-necessary commercially-available vaccines, not already covered under Part B(like the shingles vaccine).

Each month that you ll a prescription, your drug plan mails

you an “Explanation o Benets” (EOB) notice. Tis notice givesyou a summary o your prescription drug claims and your costs.Review your notice and check it or mistakes. Contact your plan i you have questions or nd mistakes. I you suspect raud, call theMedicare Drug Integrity Contractor (MEDIC) at 1-877-7SAFERX(1-877-772-3379). See page 114 or more inormation about theMEDIC.

Important!






Plans may have the ollowing coverage rules:

■ Prior authorization—You and/or your prescriber must contactthe drug plan beore you can ll certain prescriptions. Yourprescriber may need to show that the drug is medically necessary or the plan to cover it.

■ Quantity limits—Limits on how much medication you can get ata time.

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

I you or your prescriber believe that one o these coverage rulesshould be waived, you can ask or an exception. See page 106.

Note: In most cases, the prescription drugs (sometimes called“sel-administered drugs” or drugs you would usually take onyour own) you get in an outpatient setting, like an emergency department, or during observation services, aren’t covered by Part B. Your Medicare drug plan may cover these drugs undercertain circumstances. You’ll likely need to pay out-o-pocket orthese drugs and submit a claim to your drug plan or a reund.Or, i you get a bill or sel-administered drugs you got in a doctor’soce, call your Medicare drug plan (Part D) or more inormation.

Visit www.medicare.gov/publications to view the act sheet, “How Medicare Covers Sel-Administered Drugs Given in HospitalOutpatient Settings.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y users should call 1-877-486-2048.







Medication Therapy Management Program

I you’re in a Medicare drug plan and take medications or dierentmedical conditions, you may be eligible to get services, at no cost toyou, through a Medication Terapy Management (MM) program.Tis program helps you and your doctor make sure that yourmedications are working to improve your health. A pharmacist orother health proessional will give you a comprehensive medicationreview o all your medications and talk with you about:

■ How to get the most benet rom the drugs you take

■ Any concerns you have, like medication costs and drug reactions

■ How best to take your medications

■ Any questions or problems you have about your prescription and

over-the-counter medication

You’ll get a written summary o this discussion to have availablewhen you talk with your health care providers. Te summary has amedication action plan that recommends what you can do to makethe best use o your medications, with space or you to take notesor write down any ollow-up questions. You’ll also get a personalmedication list that will include all the medications you’re taking andwhy you take them.

Your drug plan may enroll you in this program i you meet all o the ollowing:

1. You have more than one chronic health condition.

2. You take several dierent medications.

3. Your medications have a combined cost o more than $3,144per year. Tis dollar amount (which can change each year) isestimated based on your out-o-pocket costs and the costs yourplan pays or the medications each calendar year. Your plan can

help you nd out i you may reach this dollar limit.Visit www.medicare.gov/nd-a-plan to get general inormation aboutprogram eligibility or your Medicare drug plan or or other plansthat interest you. Contact each drug plan or specic details.






How do other insurance and programs work with Part D?Te charts on the next 2 pages provide inormation about how other insuranceyou have works with, or is aected by, Medicare prescription drug coverage(Part D).

Employer or union health coverage—Health coverage rom your, your spouse’s,or other amily member’s current or ormer employer or union. I you haveprescription drug coverage based on your current or previous employment, youremployer or union will notiy you each year to let you know i your prescriptiondrug coverage is creditable. Keep the inormation you get. Call your benetsadministrator or more inormation beore making any changes to your coverage.Note: I you join a Medicare drug plan, you, your spouse, or your dependantsmay lose your employer or union health coverage.

COBRA—A ederal law that may allow you to temporarily keep employer orunion health coverage aer the employment ends or aer you lose coverage asa dependant o the covered employee. As explained on pages 20–21, there may be reasons why you should take Part B instead o, or in addition to, COBRA.However, i you take COBRA and it includes creditable prescription drugcoverage, you’ll have a Special Enrollment Period to join a Medicare drug planwithout paying a penalty when the COBRA coverage ends. alk with your State

Health Insurance Assistance Program (SHIP) to see i COBRA is a good choiceor you. See pages 129–132 or the phone number.

Medicare Supplement Insurance (Medigap) policy with prescription drug coverage—You may choose to join a Medicare drug plan because most Medigapdrug coverage isn’t creditable and you may pay more i you join a drug plan later.See pages 88–89. Medigap policies can no longer be sold with prescription drugcoverage, but i you have drug coverage under a current Medigap policy, you cankeep it. I you join a Medicare drug plan, your Medigap insurance company must

remove the prescription drug coverage under your Medigap policy and adjustyour premiums. Call your Medigap insurance company or more inormation.

Note: Keep any creditable prescription drug coverage inormation you get romyour plan. You may need it i you decide to join a Medicare drug plan later.Don’t send creditable coverage letters/certicates to Medicare.




How does other government insurance work with Part D?Te types o insurance listed on this page are all considered creditable prescriptiondrug coverage. I you have one o these types o insurance, in most cases, it will beto your advantage to keep your current coverage.

Federal Employee Health Benets (FEHB) Program—Health coverage orcurrent and retired ederal employees and covered amily members. FEHB plansusually include prescription drug coverage, so you don’t need to join a Medicaredrug plan. However, i you decide to join a Medicare drug plan, you can keep yourFEHB plan, and your plan will let you know who pays rst. For more inormation, visit www.opm.gov/insure or contact the Oce o Personnel Management at1-888-767-6738. Y users should call 1-800-878-5707. You can also call your plani you have questions.

Veterans’ benets—Health coverage or veterans and people who have served inthe U.S. military. You may be able to get prescription drug coverage through theU.S. Department o Veterans Aairs (VA) program. You may join a Medicare drugplan, but i you do, you can’t use both types o coverage or the same prescriptionat the same time. For more inormation, visit www.va.gov or call the VA at1-800-827-1000. Y users should call 1-800-829-4833.

RICARE (military health benets)—Health care plan or active-duty servicemembers, retirees, and their amilies. Most people with RICARE who are

entitled to Part A must have Part B to keep RICARE prescription drug benets.I you have RICARE, you don’t need to join a Medicare Prescription Drug Plan.However, i you do, your Medicare drug plan pays rst and RICARE pays second.I you join a Medicare Advantage Plan (like an HMO or PPO) with prescriptiondrug coverage, your Medicare Advantage Plan and RICARE may coordinate theirbenets i your Medicare Advantage Plan network pharmacy is also a RICAREnetwork pharmacy. For more inormation, visit www.tricare.mil/mybenet or callthe RICARE Pharmacy Program at 1-877-363-1303. Y users should call1-877-540-6261.

Indian Health Services—Health care services or American Indians and AlaskaNatives. Many Indian health acilities participate in the Medicare prescription drugprogram. I you get prescription drugs through an Indian health acility, you’llcontinue to get drugs at no cost to you and your coverage won’t be interrupted.Joining a Medicare drug plan may help your Indian health acility because the drugplan pays the Indian health acility or the cost o your prescriptions. alk to yourlocal Indian health benets coordinator who can help you choose a plan that meetsyour needs and tell you how Medicare works with the Indian health care system.


http://www.va.gov/



http://www.va.gov/




95

Section 7—

Get Help Paying Your Health

& Prescription Drug Costs

S e c t i o n

7

What i I need help paying my Medicare

prescription drug costs?I you have limited income and resources, you may qualiy orhelp to pay or some health care and prescription drug costs.

Extra Help is a Medicare program to help people with limitedincome and resources pay Medicare prescription drug costs. You may qualiy or Extra Help, also called the low-incomesubsidy (LIS), i your yearly income and resources are below these limits in 2012:

■ Single person—Income less than $16,755 and resources lessthan $13,070

■ Married person living with a spouse and no other

dependants—Income less than $22,695 and resources lessthan $26,120

Tese amounts may change in 2013. You may qualiy even i you have a higher income (like i you still work, live in Alaskaor Hawaii, or have dependants living with you). Resourcesinclude money in a checking or savings account, stocks, bonds,mutual unds, and Individual Retirement Accounts (IRAs).Resources don’t include your home, car, household items,burial plot, up to $1,500 or burial expenses (per person), or lieinsurance policies.

I you qualiy or Extra Help and join a Medicare drug plan,you’ll:

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

■ Have no coverage gap

■ Have no late enrollment penalty



96 Section 7—Get Help Paying Your Health & Prescription Drug Costs

You automatically qualiy or Extra Help i you have Medicare and meet

any o these conditions:■ You have ull Medicaid coverage.

■ You get help rom your state Medicaid program paying your Part Bpremiums (in a Medicare Savings Program). See pages 99–100.

■ You get Supplemental Security Income (SSI) benets.

o let you know you automatically qualiy or Extra Help, Medicare willmail you a purple letter that you should keep or your records. You don’tneed to apply or Extra Help i you get this letter.

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

■ I you don’t join a Medicare drug plan, Medicare may enroll you in one.I Medicare enrolls you in a plan, you’ll get a yellow or green letter lettingyou know when your coverage begins.

■ Dierent plans cover dierent drugs. Check to see i the plan you’reenrolled in covers the drugs you use and i you can go to the pharmaciesyou want. Visit www.medicare.gov/nd-a-plan, or call 1-800-MEDICARE(1-800-633-4227) to compare with other plans in your area. Y usersshould call 1-877-486-2048.

■ I you’re getting Extra Help, you can switch to another Medicare drugplan anytime. Your new coverage will be eective the rst day o the nextmonth.

■ I you have Medicaid and live in certain institutions (like a nursinghome) or get home and community-based services (see page 118), you pay nothing or your covered prescription drugs.

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

want only your employer or union coverage), call the plan listed in yourletter, or call 1-800-MEDICARE. ell them you don’t want to be in aMedicare drug plan (you want to “opt out”). I you continue to qualiy orExtra Help or i your employer or union coverage is creditable prescriptiondrug coverage, you won’t have to pay a penalty i you join later.

I you have employer or union coverage and you join a Medicare drug plan,you may lose your employer or union coverage even i you qualiy or ExtraHelp. Call your employer’s benets administrator beore you join.

Extra Help paying or Medicare prescription drug coverage

(continued)

Important!





97Section 7—Get Help Paying Your Health & Prescription Drug Costs


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

■ Visit www.socialsecurity.gov/i1020 to apply online.

■ Call Social Security at 1-800-772-1213 to apply or Extra Help by phone or to get a paper application. Y users should call1-800-325-0778.

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

Note: With your consent, Social Security will orward inormationto the Medicaid oce in your state to start an application or a

Medicare Savings Program. See pages 99–100.

Drug costs in 2013 or most people who qualiy will be no morethan $2.65 or each generic drug and $6.60 or each brand namedrug. Look on the Extra Help letters you get, or contact your planto nd out your exact costs.

o get answers to your questions about Extra Help and helpchoosing a drug plan, call your State Health Insurance AssistanceProgram (SHIP). See pages 129–132 or the phone number. You can

also call 1-800-MEDICARE.

Paying the right amount

Medicare gets inormation rom your state or Social Security thattells whether you qualiy or Extra Help. I Medicare doesn’t havethe right inormation, you may be paying the wrong amount oryour prescription drug coverage.

I you automatically qualiy or Extra Help, you can show your

drug plan the colored letter you got rom Medicare as proo thatyou qualiy. I you applied or Extra Help, you can show your“Notice o Award” rom Social Security as proo that you qualiy.

You can also give your plan any o the documents listed on thenext page (also called “Best Available Evidence”) as proo that youqualiy or Extra Help. Your plan must accept these documents.Each item must show that you were eligible or Medicaid during amonth aer June o 2012.

http://www.socialsecurity.gov/i1020

http://www.socialsecurity.gov/i1020





Paying the right amount (continued)

Proo you have Medicaid and

live in an institution or get

home and community-basedservices

Other proo you have

Medicaid

■ A bill rom the institution (likea nursing home) or a copy o astate document showing Medicaidpayment to the institution or atleast a month

■ A print-out rom your state’sMedicaid system showing thatyou lived in the institution or atleast a month

■ A document rom your state thatshows you have Medicaid and aregetting home and community-based services

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

■ A copy o a state document thatshows you have Medicaid

■ A print-out rom a stateelectronic enrollment le or

rom your state’s Medicaidsystem that shows you haveMedicaid

■ Any other document romyour state that shows you haveMedicaid

I you aren’t already enrolled in a Medicare drug plan and paid orprescriptions since you qualied or Extra Help, you may be ableto get back part o what you paid. Keep your receipts, and callMedicare’s Limited Income Newly Eligible ransition (NE) Programat 1-800-783-1307 or more inormation. Y users should call1-877-801-0369.

For more inormation, visit www.medicare.gov/publications to view theact sheet “I You Get Extra Help, Make Sure You’re Paying the RightAmount.” You can also call 1-800-MEDICARE (1-800-633-4227) to nd

out i a copy can be mailed to you. Y users should call 1-877-486-2048.

Note: Keep all inormation you get rom Medicare, Social Security, RRB,your Medicare plan, Medicare Supplement Insurer, or employer or union.Tis may include notices o award or denial, Annual Notices o Change,notices o creditable prescription drug coverage, or Medicare Summary Notices. You may need these documents to apply or the programsexplained in this section. Also keep copies o all applications you submit.




What i I need help paying my Medicare health care

costs?

Medicare Savings Programs

I you have limited income and resources, you may be able to get helprom your state to pay your Medicare costs i you meet certain conditions.

Tere are 4 kinds o Medicare Savings Programs:

1. Qualied Medicare Beneciary (QMB) Program—Helps pay or Part A and/or Part B premiums, deductibles, coinsurance, andcopayments.

2. Specied Low-Income Medicare Beneciary (SLMB) Program—Helps pay Part B premiums only.

3. Qualiying Individual (QI) Program—Helps pay Part B premiumsonly. You must apply every year or QI benets and the applicationsare granted on a rst-come rst-served basis.

4. Qualied Disabled and Working Individuals (QDWI) Program—Helps pay Part A premiums only. You may qualiy or this program i you have a disability and are working.

Te names o these programs and how they work may vary by state.Medicare Savings Programs aren’t available in Puerto Rico and the U.S.

Virgin Islands.

How do I qualiy?

In most cases, to qualiy or a Medicare Savings Program, you must have:

■ Part A

■ Monthly income less than $1,277 and resources less than $6,940—oneperson

■ Monthly income less than $1,723 and resources less than $10,410—

married and living togetherNote: Tese amounts may change each year. Many states gure yourincome and resources dierently, so you may qualiy in your state eveni your income or resources are higher than the amounts listed above. I you have income rom working, you may qualiy or benets even i yourincome is higher than the limits above. Resources include money in achecking or savings account, stocks, bonds, mutual unds, and IndividualRetirement Accounts (IRAs). Resources don’t include your home, car,burial plot, burial expenses up to your state’s limit, urniture, or other

household items. Some states don’t have any limits on resources.

Important!





For more inormation

■ Call or visit your State Medical Assistance (Medicaid) oce,

and ask or inormation on Medicare Savings Programs. Calli you think you qualiy or any o these programs, even i you aren’t sure. o get the phone number or your state, visitwww.medicare.gov/contacts. You can also call 1-800-MEDICARE(1-800-633-4227), and say “Medicaid.” Y users should call1-877-486-2048.

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

■ Contact your State Health Insurance Assistance Program (SHIP).See pages 129–132 or the phone number.

Medicaid

Medicaid is a joint ederal and state program that helps pay medicalcosts i you have limited income and resources and meet otherrequirements. Some people qualiy or both Medicare and Medicaidand are called “dual eligibles.”

What does Medicaid cover?■ I you have Medicare and ull Medicaid coverage, most o your

health care costs are covered. You can get your Medicare coveragethrough Original Medicare or a Medicare Advantage Plan (like anHMO or PPO).

■ I you have Medicare and ull Medicaid, Medicare covers yourPart D prescription drugs. Medicaid may still cover some drugsand other care that Medicare doesn’t cover.

■ People with Medicaid may get coverage or services that Medicare

doesn’t ully cover, like nursing home care and personal careservices.

Medicare Savings Programs (continued)








How do I qualiy?

■ Medicaid programs vary rom state to state. Tey may also havedierent names, like “Medical Assistance” or “Medi-Cal.”

■ Each state has dierent income and resource requirements.

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

■ Call your State Medical Assistance (Medicaid) oceor more inormation and to see i you qualiy. Visitwww.medicare.gov/contacts. You can also call 1-800-MEDICARE(1-800-633-4227), and say “Medicaid” to get the phone numberor your State Medical Assistance (Medicaid) oce. Y usersshould call 1-877-486-2048.

Demonstration plans or people who have both Medicare andMedicaid

Medicare is working with several states and health plans to createdemonstration plans or certain people who have both Medicareand Medicaid, reerred to as Medicare-Medicaid Plans. Tese planswill be available in mid 2013 and will include all your Medicareand Medicaid benets, including drug coverage. I you’re interestedin joining a Medicare-Medicaid Plan, visit

www.medicare.gov/nd-a-plan to nd out i one is available in yourarea. Contact your State Medical Assistance (Medicaid) Oce or1-800-MEDICARE or more inormation.

State Pharmacy Assistance Programs (SPAPs)

Many states have SPAPs that help certain people pay orprescription drugs based on nancial need, age, or medicalcondition. Each SPAP makes its own rules on how to provide drugcoverage to its members. o nd out i there’s an SPAP in your

state and how it works, call your State Health Insurance AssistanceProgram (SHIP). See pages 129–132 or the phone number.

Pharmaceutical Assistance Programs (also called Patient

Assistance Programs)

Many major drug manuacturers oer assistance programsor people with Medicare drug coverage who meet certainrequirements. Visit www.medicare.gov/pap/index.asp to learn moreabout Pharmaceutical Assistance Programs.

NEW!



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

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






Programs o All-inclusive Care or the Elderly (PACE)

PACE is a Medicare and Medicaid program oered in many statesthat allows people who need a nursing home-level o care to remainin the community. See page 80 or more inormation.

Supplemental Security Income (SSI) Benets

SSI is a cash benet paid by Social Security to people with limitedincome and resources who are disabled, blind, or 65 or older.SSI benets help people meet basic needs or ood, clothing, andshelter. SSI benets aren’t the same as Social Security benets.

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

benets. Call Social Security at 1-800-772-1213 or contact yourlocal Social Security oce or more inormation. Y users shouldcall 1-800-325-0778. Note: People who live in Puerto Rico, the U.S.Virgin Islands, Guam, or American Samoa can’t get SSI.

Programs or people who live in the U.S. territories

Tere are programs in Puerto Rico, the U.S. Virgin Islands, Guam,the Northern Mariana Islands, and American Samoa to helppeople with limited income and resources pay their Medicare costs.

Programs vary in these areas. Call your local Medical Assistance(Medicaid) oce to learn more, or call 1-800-MEDICARE(1-800-633-4227) and say “Medicaid” or more inormation.Y users should call 1-877-486-2048.

Children’s Health Insurance Program (CHIP)

Do you have children or grandchildren who need healthinsurance? CHIP provides low-cost health insurance coverageto children in amilies who earn too much income to qualiy or

Medicaid, but not enough to buy private health insurance. Eachstate has its own program, with its own eligibility rules. Visitwww.insurekidsnow.gov or call 1-877-KIDS-NOW (1-877-543-7669)or more inormation about CHIP in your state.


http://www.insurekidsnow.gov/

http://www.insurekidsnow.gov/




103


Section 8—

Know Your Rights & How to

Protect Yoursel rom Fraud

What are my Medicare rights?No matter how you get your Medicare, you have certainrights and protections. All people with Medicare have theright to:

■ Be treated with dignity and respect at all times■ Be protected rom discrimination

■ Have your personal and health inormation kept private

■ Get inormation in a way you understand rom Medicare,health care providers, and Medicare contractors

■ Have questions about Medicare answered

■ Have access to doctors, other health care providers,specialists, and hospitals

■ Learn about your treatment choices in clear language thatyou can understand, and participate in treatment decisions

■ Get emergency care when and where you need it

■ Get a decision about health care payment, coverage o services, or prescription drug coverage

■ Request a review (appeal) o certain decisions about healthcare payment, coverage o services, or prescription drugcoverage

■ File complaints (sometimes called grievances), including

complaints about the quality o your care S e c t i o n

8



104 Section 8—Know Your Rights & How to Protect Yourself from Fraud


What i my plan stops participating in Medicare?Medicare health and prescription drug plans can decide not to participatein Medicare or the coming year. Plans that choose to leave Medicareentirely or in certain areas are “non-renewing.” In these cases, yourcoverage under the plan will end aer December 31. Te plan will sendyou a letter about your options beore Open Enrollment. You can alwayschoose another plan eective January 1 i you do so between October 15–December 7. I your plan is non-renewing or the next year, you’ll also havea special right to join another Medicare plan until February 28, 2013.

I you want to continue to have Medicare prescription drug coverage(Part D) or a Medicare Advantage Plan (like an HMO or PPO), without anyinterruption in coverage, you’ll need to join a new plan by December 31.

I you don’t join a new Medicare Advantage Plan by December 31, you’llcontinue to have Medicare coverage through Original Medicare onJanuary 1, but i you don’t join a Part D plan by that date, you won’t haveMedicare drug coverage.

■ Generally, i you’re in a Medicare health plan, you’ll automatically returnto Original Medicare i you don’t choose to join another Medicare healthplan. You’ll also have the right to buy certain Medigap policies within 63days aer your plan coverage ends. I you return to Original Medicare,you can also join a Medicare Prescription Drug Plan.

■ I you’re in a Medicare drug plan, you’ll have the right to join anotherMedicare drug plan or a Medicare health plan with drug coverage. I youdon’t join a new plan, you won’t have Part D.

What’s an appeal?An appeal is the action you can take i you disagree with a coverage orpayment decision by Medicare or your Medicare plan. For example, youcan appeal i Medicare or your plan denies:

■ A request or a health care service, supply, item, or prescription drug thatyou think you should be able to get

■ A request or payment o a health care service, supply, item, orprescription drug you already got

■ A request to change the amount you must pay or a health care service,supply, item, or prescription drug

You can also appeal i Medicare or your plan stops providing or paying orall or part o an item or service you think you still need.



105Section 8—Know Your Rights & How to Protect Yourself from Fraud

I you decide to le an appeal, you can ask your doctor or other healthcare provider or supplier or any inormation that may help your case.Keep a copy o everything you send to Medicare as part o your appeal.

How do I le an appeal?How you le an appeal depends on the type o Medicare coverage youhave:

I you have Original Medicare

1. Get the “Medicare Summary Notice” (MSN) that shows the itemor service you’re appealing. Your MSN is the notice you get every 3months that lists all the services billed to Medicare and tells you i Medicare paid or the services. See pages 59–60.

2. Circle the item(s) you disagree with on the MSN, and write anexplanation o why you disagree with the decision on the MSN or ona separate piece o paper and attach it to the MSN.

3. Include your name, phone number, and Medicare number on theMSN and sign it. Keep a copy or your records.

4. Send the MSN, or a copy, to the company that handles billsor Medicare listed on the MSN. You can include any otheradditional inormation you have about your appeal. Or you can

use CMS Form 20027, and le it with the Medicare contractorat the address listed on the notice. o view or print this orm,

visit www.cms.gov/cmsorms/downloads/cms20027.pd , or call1-800-MEDICARE (1-800-633-4227) to nd out i a copy can bemailed to you. Y users should call 1-877-486-2048.

5. You must le the appeal within 120 days o the date you get the MSNin the mail.

You’ll generally get a decision rom the Medicare contractor within 60

days aer they get your request. I Medicare will cover the item(s) orservice(s), it will be listed on your next MSN.

I you have a Medicare health plan

Learn how to le an appeal by looking at the materials your plan sendsyou, calling your plan, or visiting www.medicare.gov/publications to view the booklet “Medicare Appeals.” You can also call1-800-MEDICARE to nd out i a copy can be mailed to you.

In some cases, you can le a ast appeal. See materials rom your plan

and page 107.

http://www.cms.gov/cmsforms/downloads/cms20027.pdf



http://www.cms.gov/cmsforms/downloads/cms20027.pdf




I you have a Medicare Prescription Drug Plan

You have the right to do all o the ollowing (even beore you buy acertain drug):

■ Get a written explanation (called a “coverage determination”) romyour Medicare drug plan. A coverage determination is the rstdecision made by your Medicare drug plan (not the pharmacy) aboutyour benets, including whether a certain drug is covered, whetheryou’ve met the requirements to get a requested drug, how much youpay or a drug, and whether to make an exception to a plan rule whenyou request it.

■ Ask or an exception i you or your prescriber (your doctor or otherhealth care provider who is legally allowed to write prescriptions)

believes you need a drug that isn’t on your plan’s ormulary .■ Ask or an exception i you or your prescriber believes that a coverage

rule (like prior authorization) should be waived.

■ Ask or an exception i you think you should pay less or a higher tier(more expensive) drug because you or your prescriber believes youcan’t take any o the lower tier (less expensive) drugs or the samecondition.

How do I ask or a coverage determination?

You or your prescriber must contact your plan to ask or a coveragedetermination or an exception. I your network pharmacy can’t ll aprescription, the pharmacist will give you a notice that explains how tocontact your Medicare drug plan so you can make your request. I thepharmacist doesn’t give you this notice, ask or a copy.

You or your prescriber may make a standard request by phone or inwriting, i you’re asking or prescription drug benets you haven’tgotten yet. I you’re asking to get paid back or prescription drugs youalready bought, your plan can require you or your prescriber to makethe standard request in writing.

You or your prescriber can call or write your plan or an expedited(ast) request. Your request will be expedited i you haven’t gotten theprescription and your plan determines, or your prescriber tells yourplan, that your lie or health may be at risk by waiting.

I you’re requesting an exception, your prescriber must provide astatement explaining the medical reason why the exception should beapproved.

Important!





How can I get help ling an appeal?

For more inormation about the dierent levels o appeals in aMedicare drug plan, visit www.medicare.gov/publications to view thebooklet “Medicare Appeals.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y usersshould call 1-877-486-2048.

You can get help ling an appeal rom your State Health InsuranceAssistance Program (SHIP). See pages 129–132 or the phone number.

What are my rights i I think my services are ending

too soon?I you’re getting Medicare services rom a hospital, skillednursing acility, home health agency, comprehensive outpatientrehabilitation acility, or hospice, and you think yourMedicare-covered services are ending too soon, you can ask or a ast appeal. Your provider will give you a notice beoreyour services end that will tell you how to ask or a ast appeal.You should read this notice careully. I you don’t get thisnotice, ask your provider or it.

How do I ask or a ast appeal?

With a ast appeal, an independent reviewer, called a Quality Improvement Organization (QIO), will decide i your services shouldcontinue.

■ Ask your doctor or other health care provider or any inormation thatmay help your case i you decide to le a ast appeal.

■ Call your QIO to request a ast appeal no later than the time shown onthe notice you get rom your provider. Use the phone number or yourQIO listed on your notice to request your appeal.

■ I you miss the deadline, you still have appeal rights:—I you have Original Medicare, call your QIO.

—I you’re in a Medicare health plan, read your notice careully and ollow the instructions or ling an appeal with your plan.You can also call your plan.

Visit www.medicare.gov/contacts or call 1-800-MEDICARE to get thephone number or the QIO in your state.

Important!









What’s an Advance Beneciary Notice o

Noncoverage (ABN)?I you have Original Medicare, your doctor, other health care

provider, or supplier may give you a notice called an “AdvanceBeneciary Notice o Noncoverage” (ABN). Tis notice saysMedicare probably (or certainly) won’t pay or some services incertain situations.

What happens i I get an ABN?

■ You’ll be asked to choose whether to get the items or services listedon the ABN.

■ I you choose to get the items or services listed on the ABN, you’re

agreeing to pay i Medicare doesn’t.■ You’ll be asked to sign the ABN to say that you’ve read and

understood it.

■ Doctors, other health care providers, and suppliers don’t have to(but still may) give you an ABN or services that Medicare nevercovers. See page 52.

■ An ABN isn’t an ocial denial o coverage by Medicare. Youcould choose to get the items listed on the ABN and still ask yourhealth care provider or supplier to submit the claim to Medicare

or another insurer. I Medicare denies payment, you can still lean appeal. However, you’ll have to pay or the items or services i Medicare determines that the items or services aren’t covered (andno other insurer is responsible or payment).

Can I get an ABN or other reasons?

■ You may get a Home Health ABN or other reasons, like whenyour doctor or other health care provider makes changes to orreduces your home health care.

■ You may get a Skilled Nursing Facility ABN when the acility believes Medicare will no longer cover your stay or other items andservices.

http://-/?-

http://-/?-




What i I didn’t get an ABN?

■ I your provider was required to give you an ABN but didn’t, inmost cases your provider must pay you back what you paid or theitem or service.

For more inormation i you’re in a Medicare plan, call your plan tond out i a service or item will be covered.

Visit www.medicare.gov/publications to view the booklet“Medicare Appeals.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y users should call 1-877-486-2048.

How does Medicare use my personal

inormation?Medicare protects the privacy o your health inormation. Te next2 pages describe how your inormation may be used and given outby law and explain how you can get this inormation.






Notice o Privacy Practices or Original MedicareTis notice describes how medical inormation about you may be used and disclosed

and how you can get access to this inormation. Please review it careully.

By law, Medicare is required to protect the privacy o your personal medical inormation.Medicare is also required to give you this notice to tell you how Medicare may use and giveout (“disclose”) your personal medical inormation held by Medicare.

Medicare must use and give out your personal medical inormation to provide inormationto the ollowing:

■ o you or someone who has the legal right to act or you (your personal representative)

■ o the Secretary o the Department o Health and Human Services, i necessary, to makesure your privacy is protected

■ Where required by law

Medicare has the right to use and give out your personal medical inormation to pay oryour health care and to operate the Medicare Program. Examples include the ollowing:

■ Companies that pay bills or Medicare use your personal medical inormation to pay ordeny your claims, to collect your premiums, to share your payment inormation withyour other insurer(s), or to prepare your “Medicare Summary Notice.”

■ Medicare may use your personal medical inormation to make sure you and other peoplewith Medicare get quality health care, to provide customer service to you, to resolve any complaints you have, or to contact you about research studies.

Medicare may use or give out your personal medical inormation or the ollowing

purposes under limited circumstances:■ Where allowed by ederal law to state and other ederal agencies that need Medicare data

or their program operations (like to make sure Medicare is making proper payments orto coordinate benets between programs)

■ o your health care providers so they know what other treatments you’ve gotten and tocoordinate your care (or example, or programs to ensure the delivery o quality healthcare)

■ For public health activities (like reporting disease outbreaks)

■ For government health care oversight activities (like raud and abuse investigations)

■ For judicial and administrative proceedings (like in response to a court order)

■ For law enorcement purposes (like providing limited inormation to locate a missingperson)

■ For research studies, including surveys, that meet all privacy law requirements (likeresearch related to the prevention o disease or disability)

■ o avoid a serious and imminent threat to health or saety

■ o contact you about new or changed coverage under Medicare

■ o create a collection o inormation that can no longer be traced back to you




By law, Medicare must have your written permission (an “authorization”) to use or giveout your personal medical inormation or any purpose that isn’t set out in this notice.You may take back (“revoke”) your written permission anytime, except to the extent thatMedicare has already acted based on your permission.

By law, you have the right to take these actions:

■ See and get a copy o your personal medical inormation held by Medicare.

■ Have your personal medical inormation amended i you believe that it is wrong or i inormation is missing, and Medicare agrees. I Medicare disagrees, you may have astatement o your disagreement added to your personal medical inormation.

■ Get a listing o those getting your personal medical inormation rom Medicare.Te listing won’t cover your personal medical inormation that was given to you or yourpersonal representative, that was given out to pay or your health care or or Medicareoperations, or that was given out or law enorcement purposes i it would likely get in

the way o these purposes.■ Ask Medicare to communicate with you in a dierent manner or at a dierent place (or

example, by sending materials to a P.O. Box instead o your home address).

■ Ask Medicare to limit how your personal medical inormation is used and given out topay your claims and run the Medicare Program. Please note that Medicare may not beable to agree to your request.

■ Get a separate paper copy o this notice.

Visit www.medicare.gov or more inormation on the ollowing:

■ Exercising your rights set out in this notice.

■ Filing a complaint, i you believe Original Medicare has violated these privacy rights.Filing a complaint won’t aect your coverage under Medicare.

You can also call 1-800-MEDICARE (1-800-633-4227) to get this inormation. Ask tospeak to a customer service representative about Medicare’s privacy notice. Y usersshould call 1-877-486-2048.

You may le a complaint with the Secretary o the Department o Health and HumanServices. Call the Oce or Civil Rights at 1-800-368-1019. Y users should call1-800-537-7697. You can also visit www.hhs.gov/ocr/privacy .

By law, Medicare is required to ollow the terms in this privacy notice. Medicare has the

right to change the way your personal medical inormation is used and given out.I Medicare makes any changes to the way your personal medical inormation is used andgiven out, you’ll get a new notice by mail within 60 days o the change.

Te Notice o Privacy Practices or Original Medicare became eective April 14, 2003.


http://www.hhs.gov/ocr/privacy

http://www.hhs.gov/ocr/privacy






How can I protect mysel rom identity thet?Identity the happens when someone uses your personal inormationwithout your consent to commit raud or other crimes. Personalinormation includes things like your name and your Social Security,Medicare, credit card, or bank account numbers. Guard your card.Protect your Medicare number. Keep this inormation sae.

Only give personal inormation, like your Medicare number,to doctors, other health care providers, and plans approved by Medicare; any insurer who pays benets on your behal; and totrusted people in the community who work with Medicare, like

your State Health Insurance Assistance Program (SHIP) or SocialSecurity. Call 1-800-MEDICARE (1-800-633-4227) i you aren’t

sure i a provider is approved by Medicare. Y users should call1-877-486-2048.

I you suspect identity the, or eel like you gave your personalinormation to someone you shouldn’t have, call your local policedepartment and the Federal rade Commission’s ID Te Hotlineat 1-877-438-4338. Y users should call 1-866-653-4261. Visitwww.c.gov/idthe to learn more about identity the.

How can I protect mysel & Medicare rom raud?Most doctors, pharmacists, plans, and other health care providers whowork with Medicare are honest. Unortunately, there may be some whoare dishonest. Medicare raud happens when Medicare is billed orservices or supplies you never got. Medicare raud costs Medicare a loto money each year.

http://www.ftc.gov/idtheft

http://www.ftc.gov/idtheft




Check your statements or mistakes

When you get health care services, record the dates on a calendarand save the receipts and statements you get rom providers to check or mistakes. I you think you see an error or are billed or servicesyou didn’t get, do the ollowing to nd out what was billed:

■ Check your “Medicare Summary Notice” (MSN) i you haveOriginal Medicare to see i the service was billed to Medicare.I you’re in a Medicare plan, check the statements you get romyour plan.

■ I you know the health care provider or supplier, call and ask or anitemized statement. Tey should give this to you within 30 days.

■ Visit www.MyMedicare.gov to view your Medicare claims i

you have Original Medicare. Your claims are generally availableonline within 24 hours aer processing. Te sooner you see andreport errors, the sooner we can stop raud. You can also call1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

I you’ve contacted the provider and you suspect that Medicare isbeing charged or a service or supply that you didn’t get, or youdon’t know the provider on the claim, call 1-800-MEDICARE.

For more inormation on protecting yoursel rom Medicareraud and tips or spotting and reporting raud, visitwww.stopmedicareraud.gov , or contact your local SMP Program.See page 114.

You can also visit www.oig.hhs.gov or call the raud hotline o theDepartment o Health and Human Services Oce o the InspectorGeneral at 1-800-HHS-IPS (1-800-447-8477). Y users should call1-800-377-4950.


http://www.stopmedicarefraud.gov/

http://www.oig.hhs.gov/

http://www.oig.hhs.gov/







Plans must ollow rules

Medicare plans must ollow certain rules when marketing their plans and

getting your enrollment inormation. Tey can’t ask you or credit card orbanking inormation over the phone or via email, unless you’re already amember o that plan. Medicare plans can’t enroll you into a plan over thephone unless you call them and ask to enroll.

Call 1-800-MEDICARE (1-800-633-4227) to report any plans that:

■ Ask or your personal inormation over the phone

■ Call to enroll you in a plan

■ Use alse inormation to mislead you

You can also call the Medicare Drug Integrity Contractor (MEDIC)at 1-877-7SAFERX (1-877-772-3379). Te MEDIC helps preventinappropriate activity and ghts raud, waste, and abuse in MedicareAdvantage (Part C) and Medicare Prescription Drug (Part D) Programs.

For more inormation on the rules that Medicare plans must ollow, visit www.medicare.gov/publications to view the booklet “ProtectingMedicare and You rom Fraud.” You can also call 1-800-MEDICARE(1-800-633-4227) to nd out i a copy can be mailed to you. Y users

should call 1-877-486-2048.

Reporting suspected Medicaid raudYou can report Medicaid raud to your State Medical Assistance(Medicaid) oce. Visit www.cms.gov/raudabuseorconsumers to learnmore. Medicaid raud can also be reported to the OIG National Fraudhotline at 1-800-HHS-IPS (1-800-447-8477).

What is the Senior Medicare Patrol (SMP) Program ?Te SMP Program educates and empowers people with Medicare to takean active role in detecting and preventing health care raud and abuse.Te SMP Program not only protects people with Medicare, it also helpspreserve Medicare. Tere’s an SMP Program in every state, the District o Columbia, Guam, the U.S. Virgin Islands, and Puerto Rico. Contact yourlocal SMP Program to get personalized counseling and to nd out aboutcommunity events in your area. For more inormation or to nd yourlocal SMP Program, visit www.smpresource.org, or call 1-877-808-2468.

You can also call 1-800-MEDICARE.

Important!


http://www.cms.gov/fraudabuseforconsumers

http://www.smpresource.org/

http://www.smpresource.org/

http://www.cms.gov/fraudabuseforconsumers





Fighting raud can payYou may get a reward i you meet certain conditions. Formore inormation, visit www.stopmedicareraud.gov or call1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

Investigating raud takes timeMedicare takes all reports o suspected raud seriously. When youreport raud, you may not hear o an outcome right away. It takestime to investigate your report and build a case.

Am I protected rom discrimination?

Every company or agency that works with Medicare must obey the law. You can’t be treated dierently because o your race, color,national origin, disability, age, religion, or sex. I you think thatyou haven’t been treated airly or any o these reasons, call theDepartment o Health and Human Services, Oce or Civil Rightsat 1-800-368-1019. Y users should call 1-800-537-7697. You canalso visit www.hhs.gov/ocr or more inormation.









What is the Medicare Beneciary Ombudsman?An “ombudsman” is a person who reviews complaints and helpsresolve them. Te Medicare Beneciary Ombudsman makes sureinormation about the ollowing is available to all people withMedicare:

■ Your Medicare coverage

■ Inormation to help you make good health care decisions

■ Your Medicare rights and protections

■ How you can get issues resolved

Te Ombudsman reviews the concerns raised by people withMedicare through 1-800-MEDICARE and through your State

Health Insurance Assistance Program (SHIP).Visit www.medicare.gov/ombudsman/resources.asp orinormation on inquiries and complaints, activities o theOmbudsman, and what people with Medicare need to know.

What is the Long-term Care Ombudsman?Residents o long-term care acilities (like nursing homes, assistedliving, and board and care homes) also have access to a long-termcare ombudsman. Tese ombudsmen provide inormation abouthow to nd a acility, how to get quality care, and can help you withcomplaints.

Te long-term care ombudsman is unded by the Older AmericansAct and is available to any long-term care acility resident. Formore inormation, visit www.ltcombudsman.org. You can also callthe ElderCare Locator at 1-800-677-1116 to get the phone numberor your local ombudsman program oce.

http://www.medicare.gov/ombudsman/resources.asp

http://www.ltcombudsman.org/

http://www.ltcombudsman.org/

http://www.medicare.gov/ombudsman/resources.asp



117

S e c t i o n

9

Plan Ahead or Long-Term Care

Section 9—

How do I plan or long-term care?Long-term care includes medical and non-medicalcare or people who have a chronic il lness or disability.Non-medical care includes non-skilled personal careassistance, like help with everyday activities, includingdressing, bathing, and using the bathroom. At least 70%o people over 65 will need long-term care services atsome point. Medicare and most health insurance plans,including Medicare Supplement Insurance (Medigap)policies, don’t pay or this type o care, also called“custodial care.” Long-term care can be provided athome, in the community, in an assisted living acility,or in a nursing home. It’s important to start planningor long-term care now to maintain your independenceand to make sure you get the care you may need in theuture.



Section 9—Plan Ahead for Long-Term Care118


How do I pay or long-term care?Long-term care insurance—Tis type o private insurance can help pay or many types o long-term care, including both skilled and non-skilled(custodial) care. Long-term care insurance policies can vary widely.Some policies may cover only nursing home care. Others may includecoverage or a range o services, like adult day care, assisted living,medical equipment, and inormal home care.

Note: Long-term care insurance doesn’t replace your Medicare coverage.

Your current or ormer employer or union may oer long-term careinsurance. Current and retired ederal employees, active and retiredmembers o the uniormed services, and their qualied relatives can

apply or coverage under the Federal Long-erm Care InsuranceProgram. I you have questions, visit www.opm.gov/insure/ltc, or callthe Federal Long-erm Care Insurance Program at 1-800-582-3337.Y users should call 1-800-843-3557.

Personal resources—You can use your own resources to pay orlong-term care. Some insurance companies let you use your lieinsurance policy to pay or long-term care. Ask your insurance agenthow this works.

Other private options—Besides long-term care insurance and personalresources, you may choose to pay or long-term care through a trust orannuity. Te best option or you depends on your age, health status, risk o needing long-term care, and your personal nancial situation. Visitwww.longtermcare.gov or more inormation about your options.

Medicaid—Medicaid is a joint ederal and state program that pays orcertain health services or people with limited income and resources. I you qualiy, you may be able to get help to pay or nursing home care orother health care costs.

I you’re already eligible or Medicaid, you or your amily membersmay be able to get help with the costs o services that help you stay inyour home instead o moving to a nursing home. Examples o homeand community-based services include homemaker services, personalcare, and respite care. For more inormation, contact your State MedicalAssistance (Medicaid) oce. Visit www.medicare.gov/contacts or call1-800-MEDICARE (1-800-633-4227), and say “Medicaid” to get thephone number. Y users should call 1-877-486-2048. See page 100 or

more inormation about Medicaid.

http://www.opm.gov/insure/ltc

http://www.longtermcare.gov/




http://www.opm.gov/insure/ltc



Section 9—Plan Ahead for Long-Term Care 119

Veterans’ benets—Te Department o Veterans Aairs (VA)may provide long-term care or service-related disabilities or orcertain eligible veterans. Te VA also has a Housebound andan Aid and Attendance Allowance Program that provides cash

grants to eligible disabled veterans and surviving spouses insteado ormally-provided homemaker, personal care, and otherservices needed or help at home. For more inormation, visitwww.va.gov , or call the VA at 1-800-827-1000.

Programs o All-inclusive Care or the Elderly (PACE)—PACE is aMedicare and Medicaid program oered in many states that allowspeople who otherwise need a nursing home-level o care to remainin the community. See page 80 or more inormation.

Long-term care contactsUse these resources to get more inormation about long-term care:

■ Visit www.medicare.gov/ltcplanning. You can visitwww.medicare.gov/nhcompare to compare nursing homes orwww.medicare.gov/hhcompare to compare home health agenciesin your area.

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

■ Visit www.longtermcare.gov to learn more about planning orlong-term care.

■ Call your State Insurance Department to get inormation aboutlong-term care insurance. Call 1-800-MEDICARE to get thephone number.

■ Call your State Health Insurance Assistance Program (SHIP). Seepages 129–132 or the phone number.

■ Call the National Association o Insurance Commissioners at

1-866-470-6242 to get a copy o “A Shopper’s Guide to Long-ermCare Insurance.”

■ Visit the Eldercare Locator, a public service o the U.S.Administration on Aging, at www.eldercare.gov to nd your localAging and Disability Resource Center (ADRC). You can alsocall 1-800-677-1116. ADRCs oer a ull range o long-term careservices and support in a single, coordinated program.

http://www.va.gov/

http://www.medicare.gov/ltcplanning

http://www.medicare.gov/nhcompare

http://www.medicare.gov/hhcompare


http://www.eldercare.gov/



http://www.medicare.gov/hhcompare

http://www.medicare.gov/nhcompare

http://www.medicare.gov/ltcplanning

http://www.va.gov/



Section 9—Plan Ahead for Long-Term Care120


What are advance directives?Advance directives are legal documents that allow you to put inwriting what kind o health care you would want or name someonewho can speak or you i you were too ill to speak or yoursel.

Tese legal documents help ensure your wishes areollowed, but it’s important to talk to your amily,riends, and health care providers about your wishes.You should also make sure that your amily, riends,and health care providers have copies o your legaldocuments. It’s better to think about these importantdecisions and have plans in place beore you’re ill or acrisis strikes.

Advance directives most ofen include:

■ A health care proxy (sometimes called a “durable power o attorney or health care”). Tis is used to name the person youwant to make health care decisions or you i you aren’t able tomake them yoursel.

■ A living will. Tis is another way to make sure your voice is heard.It states which medical treatment you would accept or reuse i your lie is threatened.

■ Afer-death wishes. Tese may include choices like organ andtissue donation.

Each state has its own laws or creating advance directives.Some states may allow you to combine your advance directives inone document.

What i I already have advance directives?

ake time now to review them to be sure you’re still satised withyour decisions and the person you identiy in your health careproxy is still willing and able to carry out your plans. Find out how to cancel or update them in your state i they no longer refect yourwishes.

For more inormation, contact your health care provider, anattorney, your local Area Agency on Aging, your state healthdepartment, or visit www.eldercare.gov .





121

S e c t i o n

1 0

Section 10—

Get More Inormation

Where can I get personalized help?

1-800-MEDICARE (1-800-633-4227)

TTY users call 1-877-486-2048

Get inormation 24 hours a day, including weekends

■ Speak clearly, have your Medicare card in ront o you,

and be ready to provide your Medicare number. Tishelps reduce the amount o time you may wait to speak to a customer service representative. It also allows us toplay messages that may specically impact your coverageand may help us get you to a representative more quickly.

■ o enter your Medicare number, speak the numbers andletter(s) clearly one at a time. Or, enter your Medicarenumber on the phone keypad. Use the star key toindicate any place there may be a letter. For example,

i your Medicare number is 000-00-0000A, you wouldenter 0-0-0-0-0- 0-0-0-0-*. Te voice system will thenask you or that letter.

■ Use 1 or 2 words to briefy say what you’re calling about.

ip: You can say “Agent” at anytime to talk to a customer service representative.

I you need help in a language other thanEnglish or Spanish, let the customer service

representative know.



Section 10—Get More Information122


I you want someone to be able to call 1-800-MEDICARE onyour behal, you need to let Medicare know in writing. You can

ll out a “Medicare Authorization to Disclose Personal HealthInormation” orm so Medicare can give your personal healthinormation to someone other than you. You can do this by

visiting www.medicare.gov/medicareonlineormsor by calling1-800-MEDICARE (1-800-633-4227) to get a copy o the orm. Y usersshould call 1-877-486-2048. You may want to do this now in case youbecome unable to do it later.

People who get benets rom the Railroad Retirement Board (RRB)should call 1-800-833-4455 with questions about Part B services and bills.

Did your household get more than one copy o “Medicare & You?”

I you want to get only one copy in uture, call 1-800-MEDICARE, andsay “Agent.” I you get RRB benets, call 1-877-772-5772.

What are State Health Insurance Assistance

Programs (SHIPs)?SHIPs are state programs that get money rom the ederal government

to give local health insurance counseling to people with Medicare.SHIPs aren’t connected to any insurance company or health plan. SHIP

volunteers work hard to help you with the ollowing Medicare questionsor concerns:

■ Your Medicare rights

■ Billing problems

■ Complaints about your medical care or treatment

■ Plan choices

■ How Medicare works with other insuranceSee pages 129–132 or the phone number o your local SHIP. I youwould like to become a volunteer SHIP counselor, contact the SHIPin your state to learn more.

Where can I get personalized help? (continued)

Important!





Section 10—Get More Information 123

Where can I nd Medicare inormation online?

Need general inormation about Medicare?

Visit www.medicare.gov

■ Get detailed inormation about the Medicare health and prescriptiondrug plans in your area, including what they cost and what servicesthey provide.

■ Find doctors or other health care providers and suppliers whoparticipate in Medicare.

■ See what Medicare covers, including preventive services.

■ Get Medicare appeals inormation and orms.

■ Get inormation about the quality o care provided by plans, nursing

homes, hospitals, home health agencies, and dialysis acilities.■ Look up helpul websites and phone numbers.

Need personalized Medicare inormation?

Register at www.MyMedicare.gov

■ Complete your “Initial Enrollment Questionnaire” so your claimscan get paid correctly.

■ Manage your personal inormation (like medical conditions,allergies, and implanted devices).

■ Sign up to get this handbook electronically. You won’t get a printedcopy i you choose to get it electronically.

■ Manage your personal drug list and pharmacy inormation.

■ Search or, add to, and manage a list o your avorite providersand access quality inormation about them.

■ rack Original Medicare claims and your Part B deductible status.

■ View and order copies o your “Medicare Summary Notice.”

■ Get access to your personal health inormation by using Medicare’s

“Blue Button.”

Need help nding other health insurance options?

Visit www.healthcare.gov

■ ake control o your health care with new inormation and resourcesthat will help you access quality and aordable health coverage.

■ Find public and private health coverage options tailored to yourneeds in a single easy-to-use tool.



http://www.healthcare.gov/

http://www.healthcare.gov/







How do I compare the quality o plans and

providers?You can’t always plan ahead when you need health care, but when

you can, take time to compare. Medicare collects inormationabout the quality and saety o medical care and services givenby most Medicare plans and health care providers. Medicare alsohas inormation about the experiences o people with the care andservices they get.

Compare the quality o care (how well plans and providers work to give you the best care possible) and services given by health andprescription drug plans or health care providers nationwide by

visiting www.medicare.gov or by calling your State Health InsuranceAssistance Program (SHIP). See pages 129–132 or the phone number.

When you, a amily member, riend, or SHIP counselor visitwww.medicare.gov , under “Resource Locator,” select:

■ “Hospital Compare”

■ “Nursing Home Compare”

■ “Home Health Compare”

■ “Dialysis Facility Compare”

■ “Physician Compare”■ “Medicare Plan Finder”

Tese search tools on www.medicare.gov give you a “snapshot” o thequality o care and services some plans and providers give. MedicarePlan Finder and Nursing Home Compare both eature a star ratingsystem to help you compare plans and quality o care measures thatare important to you. Find out more about the quality o care andservices by:

■ Asking what your plan or provider does to ensure and improve thequality o care and services. Each plan and health care providershould have someone you can talk to about quality.

■ Asking your doctor or other health care provider what he orshe thinks about the quality o care or services the plan or otherproviders give. You can also talk to your doctor or other healthcare provider about Medicare’s inormation on quality o care andservices.










What’s Medicare doing to better coordinate my

care?Medicare continues to look or ways to better coordinate your care

and to make sure that you get the best health care possible. Healthinormation technology (also called Health I) and improved waysto deliver your care can help manage your health inormation,improve how you communicate with your health care providers,and improve the quality and coordination o your health care. Tesetools also reduce paperwork, medical errors, and health care costs.

Here are examples o how your health care providers can bettercoordinate your care:

Electronic Health Records (EHRs)—A record that your doctor,other health care provider, medical oce sta, or a hospital keepson a computer about your health care or treatments.

■ EHRs can help lower the chances o medical errors, eliminateduplicate tests, and may improve your overall quality o care.

■ Your doctor’s EHR may be able to link to a hospital, lab,pharmacy, or other doctors, so the people who care or you canhave a more complete picture o your health. You also have theright to get a copy o your health inormation or your own

personal use and to make sure the inormation is complete andaccurate.

Electronic prescribing—An electronic way or your prescribers(your doctor or other health care provider who is legally allowedto write prescriptions) to send your prescriptions directly to yourpharmacy. Electronic prescribing can save you money, time, andhelp keep you sae.

■ You don’t have to drop o and wait or your prescription. Your

prescription may be ready when you arrive.■ Prescribers can check which drugs your insurance covers and

may be able to prescribe a drug that costs you less.

■ Electronic prescriptions are easier or the pharmacist to read thanhandwritten prescriptions. Tis means there’s less chance thatyou’ll get the wrong drug or dose.

■ Prescribers can be alerted to potential drug interactions, allergies,and other warnings.




Denitionso blue words

are on pages133–136.

Accountable Care Organizations (ACOs)—An ACO is a group o doctorsand other health care providers who agree to work together with Medicare togive you the best possible care by making sure they have the most up-to-dateinormation about you. ACOs are designed to help your providers work

together more closely to give you a more coordinated patient-centeredexperience.

I you have Original Medicare and your doctor has decided to participate inan ACO, you’ll be notied, either in person or by letter, that your doctor isparticipating in an ACO and that the ACO may request your personal healthinormation to better coordinate your care. Te notice will allow you to declinehaving your claims inormation shared with the ACO. Your Medicare benets,services, and protections won’t change, and you still have the right to use any doctor or hospital that accepts Medicare at any time, the same way you do now

For more inormation, visit www.medicare.gov/acos.html or call1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

Can I manage my health inormation online?Here’s what you can do to help manage your health inormation:

Personal Health Records (PHRs)—A record with inormation about yourhealth that you or someone helping you keeps on a computer or easy reerence

■ Tese tools can help you manage your health inormation rom anywhere youhave Internet access.

■ With a PHR, you can keep track o health inormation, like the date o yourlast yearly “Wellness” visit, major illnesses, operations, allergies, or a list o your prescriptions.

■ PHRs are oen oered by providers, health plans, and private companies.Some are ree, while others charge ees.

■ When you use a PHR, make sure that it’s on a secure website. With a securewebsite, you usually have to create a unique user ID and password, and the

inormation you type is encrypted (put in code) so other people can’t read it.■ Read the PHR’s notice o privacy practices. It should tell you how the PHR isprotecting your inormation and how it may use or disclose your inormation

Tere are ederal and state laws that protect the privacy and security o your inormation. PHRs that aren’t sponsored or maintained by healthplans or health care providers may not have to ollow ederal or statelaws that protect the privacy o your health inormation.

Important!

http://www.medicare.gov/acos.html

http://www.medicare.gov/acos.html




Are there other ways to get Medicare

inormation?

Publications

Visit www.medicare.gov/publications to view, print, or downloadcopies o booklets, brochures, or act sheets on dierent Medicaretopics. You can search by keyword (like “rights” or “mentalhealth”), or select “View All Publications.”

I the publication you want has a check box aer “OrderPublication,” you can have a printed copy mailed to you. Youcan also call 1-800-MEDICARE (1-800-633-4227) and say “Publications” to nd out i a printed copy can be mailed to you.

Y users should call 1-877-486-2048. Some publications are alsoavailable as podcasts that you can download and listen to.

Videos

Visit www.Youube.com/cmshhsgov to see videos coveringdierent health care topics on Medicare’s Youube channel.

Messages/Tweets

Follow ocial Medicare inormation at @CMSGov and the

Children’s Health Insurance Program at @IKNGov.

Blogs

Visit http://blog.medicare.gov/eed/ or http://blog.cms.gov/eed/ or up-to-date news and activity inormation rom our websites.

Save tax dollars and help the environment by signing up toget your uture “Medicare & You” handbooks electronically (also called the “eHandbook”). Visit www.MyMedicare.gov torequest eHandbooks. We’ll send you an email next Septemberwhen the new eHandbook is available. You won’t get a printedcopy o your handbook in the mail i you choose to get itelectronically.

Important!


http://www.youtube.com/cmshhsgov

http://blog.medicare.gov/feed/

http://blog.cms.gov/feed/



http://blog.cms.gov/feed/

http://blog.medicare.gov/feed/

http://www.youtube.com/cmshhsgov





Are resources available or caregivers?Yes, Medicare has resources to help you get the inormation youneed. o nd out more:

■ Visit “Ask Medicare” at www.medicare.gov/caregivers to helpsomeone you care or choose a drug plan, compare nursinghomes, get help with billing, and more.

■ Sign up or the bi-monthly “Ask Medicare” electronic newsletter(e-Newsletter) when you go to www.medicare.gov/caregivers .Te e-Newsletter has the latest inormation including importantdates, Medicare changes, and resources in your community.

■ Visit the Eldercare Locator, a public service o the U.S.Administration on Aging, at www.eldercare.gov , or call

1-800-677-1116 to nd caregiver support services in your area.

http://www.medicare.gov/caregivers









State Health Insurance Assistance Programs (SHIPs)For help with questions about appeals, buying other insurance, choosing ahealth plan, buying a Medigap policy, and Medicare rights and protections.

Tis page has been intentionally le blank. Te printed version containsphone number inormation. For the most recent phone number inormation,please visit www.medicare.gov/contacts. Tank you.





133

Section 11—

Denitions

S e

c t i o n

1 1

Assignment—An agreement by your doctor, other healthcare provider, or supplier to be paid directly by Medicare,to accept the payment amount Medicare approves or theservice, and not to bill you or any more than the Medicaredeductible and coinsurance.

Benet period—Te way that Original Medicare measures

your use o hospital and skilled nursing acility (SNF)services. A benet period begins the day you’re admittedas an inpatient in a hospital or skilled nursing acility. Tebenet period ends when you haven’t received any inpatienthospital care (or skilled care in a SNF) or 60 days in a row.I you go into a hospital or a skilled nursing acility aer onebenet period has ended, a new benet period begins. Youmust pay the inpatient hospital deductible or each benetperiod. Tere’s no limit to the number o benet periods.

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

Copayment—An amount you may be required to pay asyour share o the cost or a medical service or supply, likea doctor’s visit, hospital outpatient visit, or prescription. Acopayment is usually a set amount, rather than a percentage.

For example, you might pay $10 or $20 or a doctor’s visit orprescription.

Creditable prescription drug coverage—Prescriptiondrug coverage (or example, rom an employer or union)that’s expected to pay, on average, at least as much asMedicare’s standard prescription drug coverage. People whohave this kind o coverage when they become eligible orMedicare can generally keep that coverage without payinga penalty, i they decide to enroll in Medicare prescription

drug coverage later.



Section 11—Defnitions134

Critical access hospital—A small acility that provides outpatientservices, as well as inpatient services on a limited basis, to people inrural areas.

Custodial care—Nonskilled personal care, such as help withactivities o daily living like bathing, dressing, eating, getting in orout o a bed or chair, moving around, and using the bathroom. Itmay also include the kind o health-related care that most people dothemselves, like using eye drops. In most cases, Medicare doesn’tpay or custodial care.

Deductible—Te amount you must pay or health care orprescriptions beore Original Medicare, your prescription drug plan,or your other insurance begins to pay.

Demonstrations—Special projects, sometimes called “pilotprograms” or “research studies,” that test changes in Medicarecoverage, payment, and quality o care. Tey usually operate or alimited time, or a specic group o people, and in specic areas.

Extra help—A Medicare program to help people with limitedincome and resources pay Medicare prescription drug plan costs,such as premiums, deductibles, and coinsurance.

Formulary—A list o prescription drugs covered by a prescriptiondrug plan or another insurance plan oering prescription drugbenets.

Inpatient rehabilitation acility—A hospital, or part o a hospital,that provides an intensive rehabilitation program to inpatients.

Institution—For the purposes o this publication, an institution is aacility that provides short-term or long-term care, such as a nursinghome, skilled nursing acility (SNF), or rehabilitation hospital.

Private residences, such as an assisted living acility or group home,aren’t considered institutions or this purpose.

Lietime reserve days—In Original Medicare, these are additionaldays that Medicare will pay or when you’re in a hospital or morethan 90 days. You have a total o 60 reserve days that can be usedduring your lietime. For each lietime reserve day, Medicare paysall covered costs except or a daily coinsurance.



Section 11—Defnitions 135

Long-term care—A variety o services that help people with theirmedical and non-medical needs over a period o time. Long-termcare can be provided at home, in the community, or in variousother types o acilities, including nursing homes and assisted

living acilities. Most long-term care is custodial care. Medicaredoesn’t pay or this type o care i this is the only kind o care youneed.

Long-term care hospital—Acute care hospitals that providetreatment or patients who stay, on average, more than 25 days.Most patients are transerred rom an intensive or critical care unit.Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management.

Medically necessary—Services or supplies that are needed orthe diagnosis or treatment o your medical condition and meetaccepted standards o medical practice.

Medicare-approved amount—In Original Medicare, this is theamount a doctor or supplier that accepts assignment can be paid.It may be less than the actual amount a doctor or supplier charges.Medicare pays part o this amount and you’re responsible or thedierence.

Medicare health plan—Generally, a plan oered by a privatecompany that contracts with Medicare to provide Part A andPart B benets to people with Medicare who enroll in the plan.Medicare health plans include all Medicare Advantage Plans,Medicare Cost Plans, and in some cases, plans available underDemonstration/Pilot Projects. Programs o All-inclusive Care orthe Elderly (PACE) organizations are special types o Medicarehealth plans that can be oered by public or private entities, andthat provide Part D and other benets in addition to Part A andPart B benets.

Medicare plan—Reers to any way other than Original Medicarethat you can get your Medicare health or prescription drugcoverage. Tis term includes all Medicare health plans andMedicare Prescription Drug Plans.

Premium—Te periodic payment to Medicare, an insurancecompany, or a health care plan or health or prescription drugcoverage.



Section 11—Defnitions136

Preventive services—Health care to prevent illness or detectillness at an early stage, when treatment is likely to work best (orexample, preventive services include Pap tests, fu shots, and screeningmammograms).

Primary care doctor—Your primary care doctor is the doctor you seerst or most health problems. He or she makes sure you get the careyou need to keep you healthy. He or she also may talk with other doctorsand health care providers about your care and reer you to them. Inmany Medicare Advantage Plans, you must see your primary care doctorbeore you see any other health care provider.

Primary care practitioner—A doctor who has a primary specialty in amily medicine, internal medicine, geriatric medicine, or pediatric

medicine; or a nurse practitioner, clinical nurse specialist, or physicianassistant.

Quality Improvement Organization (QIO)—A group o practicingdoctors and other health care experts paid by the ederal government tocheck and improve the care given to people with Medicare.

Reerral—A written order rom your primary care doctor or youto see a specialist or to get certain medical services. In many HealthMaintenance Organizations (HMOs), you need to get a reerral beoreyou can get medical care rom anyone except your primary care doctor.I you don’t get a reerral rst, the plan may not pay or the services.

Service area—A geographic area where a health insurance plan acceptsmembers i it limits membership based on where people live. For plansthat limit which doctors and hospitals you may use, it’s also generally thearea where you can get routine (non-emergency) services. Te plan may disenroll you i you move out o the plan’s service area.

Skilled nursing acility (SNF) care—Skilled nursing care andrehabilitation services provided on a daily basis, in a skilled nursingacility. Examples o skilled nursing acility care include physical therapy or intravenous injections that can only be given by a registered nurse ordoctor.

TTY—A teletypewriter (Y) is a communication device used by peoplewho are dea, hard-o-hearing, or have a severe speech impairment.People who don’t have a Y can communicate with a Y userthrough a message relay center (MRC). An MRC has Y operators

available to send and interpret Y messages.



137



138

Part C and Part D (Medicare health and

prescription drug plans) costs or covered

services and supplies

Cost inormation or the Medicare plans in your area is availableat www.medicare.gov . You can also contact the plan, or call1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048. You can also call your State Health InsuranceAssistance Program (SHIP). See pages 129–132 or the phonenumber.

Medicare Advantage Plans (like an HMO or PPO) must cover allPart A and Part B-covered services and supplies. Check your plan’s

materials or actual amounts.





Medicare cares about what you think. I you havegeneral comments about this handbook, email us [email protected] . We can’t respond to every comment, but we’ll consider your eedback when writinguture versions.

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National Medicare Handbook

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CMS Product No. 10050Revised November 2012

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