Medicare

medicare-services-costs-providers

Introduction

Medicare is a federal health insurance program for people age 65 or older, people of any age with End Stage Renal Disease, or individuals with certain disabilities. Medicare can be confusing, tedious to apply for, and difficult to manage in conjunction with supplemental health insurance plans.

On this page we will present a descriptions of the program, who is eligible, how one applies, the coverage and costs for each part of Medicare and some cautions about the program.  Finally, this page ends with a  listing of resources on Medicare and where you can obtain assistance with coverage, complaints, and addditional information.

NOTE:  Medicare is very complicated and, at times, difficult to understand. The information on this page is an effort to cover the essentials of the  program. Please consult Medicare and You, 2010 for detailed information. This handbook is free and can be downloaded.

What is Medicare?

There are five parts to Medicare:

  • Hospital insurance (Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.
  • Medical insurance (Part B) helps pay for doctors, many medical services and supplies that are not covered by hospital insurance.
  • Medicare Advantage (Part C) formerly known as Medicare + Choice plans is available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.
  • Prescription drug coverage (Part D) helps pay for medications doctors prescribe for treatment.
  • Medigap coverage. This coverage bridges “the gaps” of co-pays and deductibles that apply to your Part B coverage.

Who is eligible for Medicare

If You Already Get Social Security Benefits

You will not need to do anything. You will be automatically enrolled in Medicare Part A and Part B effective the month you are 65. For example, if your 65th birthday is February 20, 2001, your Medicare effective date would be February 1, 2001. (Note: if your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is February 1, 2001, your Medicare effective date would be January 1, 2001.)

Your Medicare card will be mailed to you about 3 months before your 65th birthday. If you do not want Medicare Part B, follow the instructions that come with the card.

If You Want To Apply for Both Social Security Retirement Benefits and Medicare

If you are close to age 65 and not yet getting Social Security benefits or Medicare, you can apply for both at the same time. To make sure that your Medicare Part B coverage start date is not delayed, you should apply three months before the month you turn 65. This is the beginning of your 7 month Initial Enrollment Period. If you wait until you are 65, or in the last 3 months of your Initial Enrollment Period, your Medicare Part B coverage start date will be delayed.

To apply, you can call or visit your local Social Security office or call Social Security at 1-800-772-1213. You can apply online (using the Internet) if you meet certain rules. To apply online, visit www.socialsecurity.gov. You must answer a series of questions that will tell if you can apply online.

For example, you must be at least 61 years and 9 months old; plan to start receiving Social Security retirement benefits within the next 4 months; live in the United States or one of its territories/commonwealths; agree to get your Social Security benefits by direct deposit to your bank or other financial institution. You must answer some other questions as well.

If You Do Not Yet Get Social Security Benefits and You Only Want To Apply for Medicare

If you are close to age 65 and not getting Social Security benefits, you must apply for Medicare. You can apply by calling or visiting your local Social Security office, or by calling Social Security at 1-800-772-1213. You should apply three months before the month you turn 65. This is the beginning of your 7 month Initial Enrollment Period.

If you wait until you are 65, or in the last 3 months of your Initial Enrollment Period, your Medicare Part B coverage start date will be delayed. You currently cannot apply for Medicare only online (using the Internet).

What’s New for Medicare in 2012?

New Dates to Change Plans 
Starting this year, open enrollment begins and ends earlier—
October 15–December 7, 2011.
More Preventive Services
Medicare now covers screening and counseling for alcohol misuse,
depression, and obesity.

New Special Enrollment Period 
You can switch to a Medicare Advantage Plan (like an HMO or PPO)
or Medicare Prescription Drug Plan that has a 5-star rating at any time
during the year.
Continued Help in the Prescription Drug Coverage Gap
If you reach the coverage gap in your Medicare prescription drug
coverage, you will qualify for savings on brand-name and generic drugs.
Fighting Medicare Fraud.
Find out what Medicare is doing and what you can do to protect against
fraud, waste, and abuse.

Medicare Part A: Coverage

Most people do not have to pay a premium for Part A because they (or their spouse) paid for it while they worked.  If you do have to pay Part A premiums, the longer you or your spouse worked and paid into Social Security, the lower your premiums will be.

Employment Your cost per Month
If you or your spouse worked and paid into Social Security:
for 10 or more years $0
between 7.5 and 10 years $254 per month
for less than 7.5 years $461 per month

 

Hospital Costs:

If you are admitted into a hospital , you will pay a deductible of $1,100. You pay this deductible once each time you are admitted into a hospita or skilled nursing facility. If once you leave the hospital but are admitted once again within 60 days you do not pay another deductible.

How Long You Stay What You Pay
Days 1-60 $1,100 deductible, then nothing
Days 61-90 $275 per day
Days 91-150 $550 per dayThese are called “lifetime reserve days” because Medicare will only pay for these extra days once in your lifetime
After 150 days The full cost of your hospital stay

 

Skilled Nursing Facility Costs:

For a skilled nursing facility stay, there is no deductible. Medicare will only cover up to 100 days in a skilled nursing facility though, and only if you meet some very specific criteria. Medicare will NOT cover your stay if your care is limited to personal care such as bathing, eating, dressing.. Here is what you pay.

How Long You Stay What You Pay
Days 1-20 $0
Days 21-100 $137.50 per day
After 100 days All costs

 

Home Health Care Costs:

There is no deductible or co-payment for home health care.  However, you do need to meet a set of very specific criteria in order for Medicare to cover your home health care.

Hospice Costs:

There is no deductible or co-payment for hospice care. You only pay a small share of the costs of medications and inpatient respite care under the Medicare hospice benefit.

Medicare Part A helps pay for care in the following facilities if they are medically necessary based on Medicare requirements, and your eligibility for Medicare Part A.

Medicare Part A Covered Facilities

  • Inpatient care in hospitals (including critical access hospitals)
  • Skilled nursing facilities (SNFs)
  • Long Term Care Hospital (LTCH)
  • Inpatient Rehabilitation Facility (IRF)
  • Hospice care
  • Home health care
  • Beneficiary access to religious nonmedical health care institution (RNHCI) services
  • Inpatient Mental health/psychiatric care
  • Obesity Bariatric Surgery

Medicare Part A helps pay for the following services if they are medically necessary based on Medicare requirements. You must be eligible for Medicare Part A in order to get the following services.

Medicare Part A Covered Services

  • Anesthesia
  • Chemotherapy
  • Room and Board
  • All meals and special diets
  • General nursing
  • Medical social services
  • Physical, occupational, and speech-language therapy
  • Drugs with the exception of some self-administered drugs
  • Blood transfusions
  • Other diagnostic and therapeutic items and services
  • Medical supplies and use of equipment
  • Respite care in hospice
  • Transportation services
  • Inpatient alcohol or substance abuse treatment
  • Part A blood (see the restrictions under noncovered services)
  • Clinical Trials (Inpatient)
  • Kidney Dialysis (Inpatient)

Part A-Covered Services-Detailed Description

Copayments, coinsurance, and deductibles may apply for each service.

Blood

In most cases, the hospital gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

Home Health Services

Limited to medically‐necessary part‐time or intermittent skilled nursing care, or physical therapy, speech‐language pathology, or a continuing need for occupational therapy. A doctor must order your care, and a Medicare‐certified home health agency must provide it. Home health services may also include medical social services, part‐time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort.

Hospice Care

For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling. A Medicare‐approved hospice usually gives hospice care in your home or other facility like a nursing home. Hospice care doesn’t include room and board unless the hospice medical team determines that you need short‐term inpatient stays for pain and symptom management that can’t be addressed in the home. These stays must be in a Medicare‐approved facility, such as a hospice facility, hospital, or skilled nursing facility. Medicare also covers inpatient respite care which is care you get in a Medicare‐approved facility so that your usual caregiver can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness. You can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that you are terminally ill.

Hospital Stays (Inpatient)

Includes semi‐private room, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. Examples include inpatient care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long‐term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care. This doesn’t include private‐duty nursing, a television or telephone in your room (if there is a separate charge for these items), or personal care items like razors or slipper socks. It also doesn’t include a private room, unless medically necessary. If you have Part B, it covers the doctor’s services you get while you are in a hospital.

Skilled Nursing Facility Care

Includes semi‐private room, meals, skilled nursing and rehabilitative services, and other services and supplies after a 3‐day minimum inpatient hospital stay for a related illness or injury. An inpatient stay begins the day you are formally admitted with a doctor’s order to a hospital. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn’t cover long‐term care or custodial care in this setting.

If you join a Medicare Advantage Plan (like an HMO or PPO) or have other insurance (like a Medigap policy, or employer or union coverage), your costs may be different. Contact the plans you are interested in to find out about the costs.

Part A Costs for Covered Services and Items

Note: If you are in a Medicare Advantage Plan, costs vary by plan and may be either higher or lower than those noted above. Check with your plan.

Blood

In most cases, the hospital gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated.

Home Health Care

You pay:

  • $0 for home health care services
  • 20% of the Medicare‐approved amount for durable medical equipment

Hospice Care

You pay:

  • $0 for hospice care
  • A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management

Respite Care

  • 5% of the Medicare‐approved amount for inpatient respite care (short‐term care given by another caregiver, so the usual caregiver can rest)

Medicare doesn’t cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).

Hospital Stay

In 2010, you pay:

  • $1,100 deductible and no coinsurance for days 1–60 each benefit period
  • $275 per day for days 61–90 each benefit period
  • $550 per “lifetime reserve day” after day 90 each benefit period (up to 60 days over your lifetime)
  • All costs for each day after the lifetime reserve days
  • Inpatient mental health care in a psychiatric hospital limited to 190 days in a lifetime

Skilled Nursing Facility Stay

In 2010, you pay:

  • $0 for the first 20 days each benefit period
  • $137.50 per day for days 21–100 each benefit period
  • All costs for each day after day 100 in a benefit period

Medicare Part B: Coverage

Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working.

Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit.

Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered.

Deductibles and Coinsurance. After a beneficiary meets the yearly deductible of $135.00 (in 2009), they will be required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B with the exception of most lab services which are covered at 100%. They are also required to pay an excess charge of 15% for services rendered by non-participating Medicare providers.

What Do I Pay?

All Medicare Part B enrollees pay an insurance premium for this coverage; the standard Part B premium for 2009 is $96.40 per month. A new income-based premium has been in effect since 2007, wherein Part B premiums are higher for beneficiaries with incomes exceeding $85,000 for individuals or $170,000 for married couples. Depending on the extent to which beneficiary earnings exceed the base income, these higher Part B premiums are $134.90, $192.70, $250.50, or $308.30 for 2009, with the highest premium paid by individuals earning more than $213,000, or married couples earning more than $426,000.

Medicare Part B premiums are commonly deducted automatically from beneficiaries’ monthly Social Security checks.

Medicare Part B-Covered Services

There are two kinds of Part B‐covered services:

  1. Medically-necessary services—Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  2. Preventive services—Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best (for example, Pap tests, flu shots, and colorectal cancer screenings).

Here are services covered under Part B:

Abdominal Aortic Aneurysm Screening

A one‐time screening ultrasound for people at risk. Medicare only covers this screening if you get a referral for it as a result of your one‐time “Welcome to Medicare” physical exam. You pay 20% of the Medicare‐approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment.

Ambulance Services

Emergency ground transportation when you need to be transported to a hospital or skilled nursing facility for medically‐necessary services, and transportation in any other vehicle could endanger your health. Medicare will pay for transportation in an airplane or helicopter if you require immediate and rapid ambulance transportation that ground transportation can’t provide.

In some cases, Medicare may pay for limited non‐emergency transportation if you have orders from your doctor. Medicare will only cover services to the nearest appropriate medical facility that is able to give you the care you need. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Ambulatory Surgical Centers

Facility fees for approved surgical procedures provided in an ambulatory surgical center where surgical procedures are performed, and the patient is released within 24 hours. You pay 20% of the Medicare‐approved amount (except for screening flexible sigmoidoscopies and screening colonoscopies, for which you pay 25%), and the Part B deductible applies. You pay all facility charges for procedures Medicare doesn’t allow in ambulatory surgical centers.

Blood

In most cases, the provider gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.

Bone Mass Measurement (Bone Density)

Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Cardiac Rehabilitation

Medicare covers comprehensive programs that include exercise, education, and counseling for patients who meet certain conditions with a doctor’s referral. Medicare also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. You pay 20% of the Medicare‐approved amount if you get the services in a doctor’s office. In a hospital outpatient setting, you pay a copayment.

Cardiovascular Screenings

Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the test, but you generally have to pay 20% of the Medicare‐approved amount for the doctor’s visit.

Chiropractic Services

Helps correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. Note: You pay all costs for any services or tests ordered by a chiropractor.

Clinical Laboratory Services

Includes certain blood tests, urinalysis, some screening tests, and more. No cost to you.

Clinical Research Studies

Clinical research studies test different types of medical care, like how well a cancer drug works. They help doctors and researchers see if the new care works and if it’s safe. Medicare covers some costs, like doctor visits and tests, in qualifying clinical research studies. You pay 20% of the Medicare‐ approved amount, and the Part B deductible applies.

Colorectal Cancer Screenings

To help find precancerous growths and help prevent or find cancer early, when treatment is most effective. One or more of the following tests may be covered.

  • Fecal Occult Blood Test—Once every 12 months if age 50 or older. No cost for the test, but you generally have to pay 20% of the Medicare‐approved amount for the doctor’s visit.
  • Flexible Sigmoidoscopy—Generally, once every 48 months if age 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. You pay 20% of the Medicare‐approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment.
  • Colonoscopy—Generally once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. No minimum age. You pay 20% of the Medicare‐approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment.
  • Barium Enema—Once every 48 months if age 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare‐approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment.

Note: If you get a screening flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare‐approved amount.

Defibrillator (Implantable Automatic)

For some people diagnosed with heart failure. You pay 20% of the Medicare‐approved amount for the doctor’s services. You pay a copayment but no more than the Part A hospital stay deductible (see page 120) if you get the device as a hospital outpatient. The Part B deductible applies.

Diabetes Screenings

Checks for diabetes. Medicare covers these screenings if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests are also covered if you answer yes to two or more of the following questions:

  • Are you age 65 or older?
  • Are you overweight?
  • Do you have a family history of diabetes (parents, siblings)?
  • Do you have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds?

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare‐approved amount for the doctor’s visit.

Diabetes Self‐Management Training

For people with diabetes. Your doctor or other health care provider must provide a written order. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Diabetes Supplies

Including blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes (in some cases). Insulin is covered only if used with an insulin pump. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

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

Doctor Services

Services that are medically necessary (includes outpatient and some doctor services you get when you are a hospital inpatient) or covered preventive services. Doesn’t cover routine physicals except for the one‐time “Welcome to Medicare” physical exam. See “Physical Exam.” You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Durable Medical Equipment

Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds your doctor orders for use in the home. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. You must get your covered equipment or supplies from a supplier enrolled in Medicare. You should also check if the supplier is a participating supplier. Participating suppliers must accept assignment and your out‐of‐pocket costs may be less.

EKG Screening

Medicare covers a one‐time screening EKG if you get a referral for it as a result of your one‐time “Welcome to Medicare” physical exam. See “Physical Exam.” You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. An EKG is also covered as a diagnostic test.

Emergency Department Services

When you believe your health is in serious danger. You may have a bad injury, a sudden illness, or an illness that quickly gets much worse. You pay a specified copayment for the hospital emergency department visit, and you pay 20% of the Medicare‐approved amount for the doctor’s services. The Part B deductible applies.

Eye Exams for People with Diabetes

Checks for diabetic retinopathy once every 12 months by an eye doctor who is legally allowed by the state to do the test. You pay 20% of the Medicare‐approved amount for the doctor’s services, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Eyeglasses-Cataract Surgery

One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Federally‐ Qualified Health Center Services

Includes many outpatient primary care and preventive services you get through certain community‐based organizations. You pay 20% of the Medicare‐approved amount.

Flu Shots

Helps prevent influenza or flu virus. Covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor accepts assignment for giving the shot.

Foot Exams and Treatment

If you have diabetes‐related nerve damage and/or meet certain conditions. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Glaucoma Tests

Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African‐American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests.

You pay 20% of the Medicare‐approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you pay a copayment.

Hearing and Balance Exams

If your doctor orders it to see if you need medical treatment. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Medicare doesn’t cover hearing aids and exams for fitting hearing aids.

Hepatitis B Shots

Helps protect people from getting Hepatitis B. This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End‐Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare‐approved amount for shots given in a doctor’s office, and the Part B deductible applies. You pay a copayment for a Hepatitis B shot given in a hospital outpatient setting.

HIV Screening

Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. There is no cost for the test, but you generally have to pay 20% of the Medicare‐approved amount for the doctor’s visit.

Home Health Services

Limited to medically‐necessary part‐time or intermittent skilled nursing care, or physical therapy, speech‐language pathology, or a continuing need for occupational therapy. A doctor must order it, and a Medicare‐certified home health agency must provide it. Home health services may also include medical social services, part‐time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home.

You must be homebound, which means that leaving home is a major effort. No cost to you for home health services. For Medicare‐covered durable medical equipment, you pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Kidney Dialysis Services and Supplies

For people with End‐Stage Renal Disease (ESRD). Medicare covers dialysis either in a facility or at home when your doctor orders it. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Kidney Disease Education Services

Medicare may cover kidney disease education services if you have kidney disease, and your doctor refers you for the service. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Mammograms (screening)

A type of X‐ray to check women for breast cancer before they or their doctor may be able to find it. Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39. You pay 20% of the Medicare‐approved amount.

Medical Nutrition Therapy Services

Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Mental Health Care (outpatient)

To get help with mental health conditions such as depression, anxiety, or substance abuse. Includes services generally given outside a hospital or in a hospital outpatient setting, including visits with a doctor, psychiatrist, clinical psychologist, or clinical social worker, and lab tests. Certain limits and conditions apply.

What you pay will depend on whether you are being diagnosed and monitored or whether you are getting treatment.

  • For visits to a doctor or other health care provider to diagnose your condition, or to monitor or change your prescriptions, you pay 20% of the Medicare‐approved amount.
  • For outpatient treatment of your condition (such as counseling or psychotherapy), you pay 45% in 2010 of the Medicare‐approved amount. This coinsurance amount will continue to decrease over the next 4 years. In a hospital outpatient setting, you pay a copayment.

The Part B deductible applies for both visits to diagnose or monitor your condition as well as treatment.

Note: Inpatient mental health care is covered under Part A hospital stays.

Non‐doctor Services

Medicare covers services provided by non‐doctors, such as physician assistants and nurse practitioners. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Occupational Therapy

Evaluation and treatment to help you return to usual activities (such as dressing or bathing) after an illness or accident when your doctor certifies you need it. There may be limits on physical therapy, occupational therapy, and speech‐language pathology services and exceptions to these limits. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Outpatient Hospital Services

Services you get as an outpatient as part of a doctor’s care. You pay 20% of the Medicare‐approved amount for the doctor’s services. You may pay more for a doctor’s care in a hospital outpatient setting than you will pay for the same care in a doctor’s office. You pay a specified copayment for each service you get in an outpatient hospital setting. The copayment can’t be more than the Part A hospital stay deductible. The Part B deductible applies.

Outpatient Medical and Surgical Services and Supplies

For approved procedures (like X‐rays, a cast, or stitches). You pay 20% of the Medicare‐approved amount for the doctor’s services. You pay a copayment for each service you get in an outpatient hospital setting. For each service, this amount can’t be more than the Part A hospital stay deductible. See page 120. The Part B deductible applies, and you pay all charges for items or services that Medicare doesn’t cover.

Pap Tests and Pelvic Exams (includes clinical breast exam)

Checks for cervical, vaginal, and breast cancers. Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child‐bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. You pay 20% of the Medicare‐approved amount for Pap test specimen collection, and pelvic and breast exams. If the pelvic exam was provided in a hospital outpatient setting, you pay a copayment.

Physical Exam (one‐time “Welcome to Medicare” physical exam)

A one‐time review of your health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months you have Part B. You pay 20% of the Medicare‐approved amount. In a hospital outpatient setting, you pay a copayment. When you make your appointment, let your doctor’s office know that you would like to schedule your “Welcome to Medicare” physical exam.

Physical Therapy

Evaluation and treatment for injuries and diseases that change your ability to function when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Pneumococcal Shot

Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot.

Prescription Drugs (limited)

Includes a limited number of drugs such as injections you get in a doctor’s office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or infusion pump) and under very limited circumstances, certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare‐ approved amount for these covered drugs. If the covered drugs you get in a hospital outpatient setting are part of the service you get, you pay the copayment for the services. However, if you get other types of drugs in a hospital outpatient setting, what you pay depends on whether you have Part D or other prescription drug coverage, whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting. Keep in mind that under Part B, you pay 100% for most prescription drugs, unless you have Part D or other drug coverage.

Prostate Cancer Screenings

Helps detect prostate cancer. Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies for the doctor’s visit. In a hospital outpatient setting, you pay a copayment. You pay nothing for the PSA test.

Prosthetic/ Orthotic Items

Including arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); some types of breast prostheses (after mastectomy); and prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and parenteral and enteral nutrition therapy) when your doctor orders it. For Medicare to cover your prosthetic or orthotic, you must go to a supplier that is enrolled in Medicare. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Pulmonary Rehabilitation

Medicare covers a comprehensive program of pulmonary rehabilitation if you have moderate to very severe chronic obstructive pulmonary disease (COPD) and have a referral for pulmonary rehabilitation from the doctor treating your chronic respiratory disease. You pay 20% of the Medicare‐ approved amount if you get the service in a doctor’s office. You pay a copayment per session if you get the service in a hospital outpatient setting.

Rural Health Clinic Services

Includes many outpatient primary care services. You pay 20% of the amount charged, and the Part B deductible applies.

Second Surgical Opinions

Covered in some cases for surgery that isn’t an emergency. In some cases, Medicare covers third surgical opinions. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Smoking Cessation (counseling to stop smoking)

Includes up to 8 face‐to‐face visits in a 12‐month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Speech‐Language Pathology Services

Evaluation and treatment given to regain and strengthen speech and language skills including cognitive and swallowing skills when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Surgical Dressing Services

For treatment of a surgical or surgically‐treated wound. You pay 20% of the Medicare‐approved amount for the doctor’s services. You pay a fixed copayment for these services when you get them in a hospital outpatient setting. You pay nothing for the supplies. The Part B deductible applies.

Telehealth

Includes a limited number of medical or other health services, like office visits and consultations provided using an interactive two‐way telecommunications system (like real‐time audio and video) by an eligible provider who is at a location different from the patient’s. Available in some rural areas, under certain conditions, and only if the patient is located at one of the following places: a doctor’s office, hospital, rural health clinic, federally‐qualified health center, hospital‐based dialysis facility, skilled nursing facility, or community mental health center. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Tests

Including X‐rays, MRIs, CT scans, EKGs, and some other diagnostic tests. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies. If you get the test at a hospital as an outpatient, you pay a copayment that may be more than 20% of the Medicare‐approved amount, but it can’t be more than the Part A hospital stay deductible.

Transplants and Immunosuppressive Drugs

Including doctor services for heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and only in a Medicare‐certified facility. Medicare covers bone marrow and cornea transplants under certain conditions.

Immunosuppressive drugs are covered if Medicare paid for the transplant, or an employer or union group health plan that was required to pay before Medicare paid for the transplant. You must have been entitled to Part A at the time of the transplant, and you must be entitled to Part B at the time you get immunosuppressive drugs. You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

If you are thinking about joining a Medicare Advantage Plan and are on a transplant waiting list or believe you need a transplant, check with the plan before you join to make sure your doctors and hospitals are in the plan’s network. Also, check the plan’s coverage rules for prior authorization.

Note: Medicare drug plans (Part D) may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant.

Health Care Needed When Traveling Outside the United States

Medicare generally doesn’t cover health care while you are traveling outside the U.S. (the “U.S.” includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa).

There are some exceptions including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. In rare cases, Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following situations:

1) If an emergency arose within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition

2) If you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency

3) If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists

You pay 20% of the Medicare‐approved amount, and the Part B deductible applies.

Urgent Care

To treat a sudden illness or injury that isn’t a medical emergency. You pay 20% of the Medicare‐approved amount for the doctor’s services, and the Part B deductible applies.

Medicare Part C: Advantage Health Plans

A Medicare Advantage Plan (like an HMO or PPO) is another health coverage choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. In all plan types, you are always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you are in a Medicare Advantage Plan. Medicare Advantage Plans aren’t considered supplemental coverage.

Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage. In addition to your Part B premium, you usually pay one monthly premium for the services provided.

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out‐of‐pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan).

Medicare Advantage Plans include the following:

  • Health Maintenance Organization (HMO) Plans.
  • Preferred Provider Organization (PPO) Plans.
  • Private Fee‐for‐Service (PFFS) Plans.
  • Medical Savings Account (MSA) Plans.
  • Special Needs Plans (SNP). Make sure you understand how a plan works before you join.

There are other less common types of Medicare Advantage Plans that may be available:

  • Point of Service (POS) Plans—Similar to HMOs, but you may be able to get some services out‐of‐network for a higher cost.
  • Provider Sponsored Organizations (PSOs)—Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.

Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs. Find out what types of plans are available in your area by visiting www.medicare.gov and selecting “Compare Health Plans and Medigap Policies in Your Area.” You can also call 1‐800‐MEDICARE (1‐800‐633‐4227). TTY users should call 1‐877‐486‐2048. Contact the plans you are interested in to get more information.

More About Medicare Part C: Advantage Plans

  • As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
  • Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
  • You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.
  • You can join a Medicare Advantage Plan even if you have a pre‐existing condition, except for End‐Stage Renal Disease.
  • You can only join a plan at certain times during the year. See page 58. In most cases, you are enrolled in a plan for a year.
  • If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
  • If the plan decides to stop participating in Medicare, you will have to join another Medicare health plan or return to Original Medicare.
  • You usually get prescription drug coverage (Part D) through the plan. If you are in a Medicare Advantage Plan that includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.
  • You don’t need to buy (and can’t be sold) a Medigap (Medicare Supplement Insurance) policy while you are in a Medicare Advantage Plan. It won’t cover your Medicare Advantage Plan deductibles, copayment, or coinsurance.

Who Can Join?

You can generally join a Medicare Advantage Plan if you meet these conditions:

  • You have Part A and Part B.
  • You live in the service area of the plan.
  • You don’t have End‐Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) except as explained on page 53.

Note: In most cases, you can join a Medicare Advantage Plan only at certain times during the year. See page 58.

If You Have Other Coverage

Talk to your employer, union, or Indian or Tribal Health Program benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose employer or union coverage. In other cases, if you join a Medicare Advantage Plan, you may still be able to use your employer or union coverage along with the plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back.

If You Have a Medigap (Medicare Supplement Insurance) Policy

If you already have a Medigap policy, you can’t use it to pay for any expenses you have under a Medicare Advantage Plan. If you drop your Medigap policy to join a Medicare Advantage Plan, in most cases, you won’t be able to get it back. See pages 74–75.

If You Have End‐Stage Renal Disease (ESRD)

If you have End‐Stage Renal Disease (ESRD) and Original Medicare, you may join a Medicare Prescription Drug Plan. However, you usually can’t join a Medicare Advantage Plan.

  • If you are already in a Medicare Advantage Plan when you develop ESRD, you can stay in your plan or join another plan offered by the same company under certain circumstances.
  • If you have an employer or union health plan or other health coverage through a company that offers Medicare Advantage Plans, you may be able to join one of their Medicare Advantage Plans.
  • If you’ve had a successful kidney transplant, you may be able to join a Medicare Advantage Plan.

If you have ESRD and are in a Medicare Advantage Plan, and the plan leaves Medicare or no longer provides coverage in your area, you have a one‐time right to join another Medicare Advantage Plan.

You don’t have to use your one‐time right to join a new plan immediately. If you go directly to Original Medicare after your plan leaves or stops providing coverage, you will still have a one‐time right to join a Medicare Advantage Plan later.

You may also be able to join a Medicare Special Needs Plan (SNP) for people with ESRD if one is available in your area.

For questions or complaints about kidney dialysis services, call your local ESRD Network Organization. An ESRD Network Organization is a group of kidney care experts paid by the Federal government to check and improve the care given to Medicare patients who get dialysis treatments for kidney care. Call 1‐800‐MEDICARE (1‐800‐633‐4227) to get the telephone number. TTY users should call 1‐877‐486‐2048.

For more information about ESRD, visit www.medicare.gov/Publications/Pubs/pdf/10128.pdf to view the booklet, “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”

Medicare Advantage Plans: What You Pay

Your out‐of‐pocket costs in a Medicare Advantage Plan depend on the following:

  • Whether the plan charges a monthly premium in addition to your Part B premium.
  • Whether the plan pays any of the monthly Part B premium. Some plans offer this option, usually for an extra cost.
  • Whether the plan has a yearly deductible or any additional deductibles.
  • How much you pay for each visit or service (copayments).
  • The type of health care services you need and how often you get them.
  • Whether you follow the plan’s rules, like using network providers.
  • Whether you need extra coverage and what the plan charges for it.
  • Whether the plan has a yearly limit on your out‐of‐pocket costs for all medical services.

To learn more about your costs in specific Medicare Advantage Plans, contact the plans you are interested in to get more details. Visit www.medicare.gov, or call 1‐800‐MEDICARE (1‐800‐633‐4227) to find plans in your area. TTY users should call 1‐877‐486‐2048.

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

You can join, switch, or drop a Medicare Advantage Plan at these times:

  • When you first become eligible for Medicare (the 7‐month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65).
  • If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability. You will have another chance to join 3 months before the month you turn age 65 to 3 months after the month you turn age 65.
  • Between November 15–December 31 each year. Your coverage will begin on January 1 of the following year, as long as the plan gets your enrollment request by December 31.
  • Between January 1–March 31 of each year. Your coverage will begin the first day of the month after the plan gets your enrollment form. During this period, you can’t do the following:
  • Join or switch to a plan with prescription drug coverage unless you already have Medicare prescription drug coverage (Part D).
  • Drop a plan with prescription drug coverage. ■ Join, switch, or drop a Medicare Medical Savings Account Plan.

In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan at other times. Some of these situations include the following:

  • If you move out of your plan’s service area
  • If you have both Medicare and Medicaid
  • If you qualify for Extra Help to pay for your prescription drug costs (see pages 78–81)
  • If you live in an institution (like a nursing home)

Medicare Prescription Drug Coverage (Part D)

Medicare offers prescription drug coverage (Part D) to everyone with Medicare. To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.

There are two ways to get Medicare prescription drug coverage:

  1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee‐for‐Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
  2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA‐PDs.”

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

Why Join a Medicare Drug Plan?

Even if you don’t take a lot of prescription drugs now, you should still consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you are first eligible, and you don’t have other creditable prescription drug coverage (also called creditable coverage), you will likely pay a late enrollment penalty (higher premiums) if you join later. See page 67 for more information on creditable coverage and the late enrollment penalty.

Note: Discount cards, doctor samples, free clinics, drug discount Web sites, and manufacturer’s pharmacy assistance programs aren’t considered prescription drug coverage and aren’t creditable coverage.

Who Can Get Medicare Drug Coverage?

To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or Part B. If you would like to get prescription drug coverage through a Medicare Advantage Plan, you must have Part A and Part B. You must also live in the service area of the Medicare drug plan you want to join.

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

You can join, switch, or drop a Medicare drug plan at these times:

  • When you are first eligible for Medicare (the 7‐month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65).
  • If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability. You will have another chance to join 3 months before the month you turn age 65 to 3 months after the month you turn age 65.
  • Between November 15–December 31 each year. Your coverage will begin on January 1 of the following year, as long as the plan gets your enrollment request by December 31.
  • Anytime, if you qualify for Extra Help or if you have both Medicare and Medicaid.

In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop Medicare drug plans during a special enrollment period (like if you move out of the service area, lose other creditable prescription drug coverage, or live in an institution).

If you have employer or union coverage, call your benefits administrator before you make any changes, or before you sign up for any other coverage. If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependants.

Call your State Health Insurance Assistance Program (SHIP) for more information. Click SHIP to your left for contact information in your state.  You can also call 1‐800‐MEDICARE (1‐800‐633‐4227). TTY users should call 1‐877‐486‐2048.

How Do You Join?

Once you choose a Medicare drug plan, you may be able to join by completing a paper application, calling the plan, or enrolling on the plan’s Web site or on www.medicare.gov. You can also enroll by calling 1‐800‐MEDICARE. Medicare drug plans aren’t allowed to call you to enroll you in a plan. Call 1-800-MEDICARE to report a plan that does this.

Contact the plan to find out how you can join. When you join a Medicare drug plan, you will have to provide your Medicare number and the date your Part A or Part B coverage started. This information is on your Medicare card. Visit www.medicare.gov, or call 1-800-MEDICARE for a list of the Medicare plans in your area.

How Do You Switch?

Depending on your circumstances, you can switch to a new Medicare drug plan simply by joining another drug plan during one of the times listed on page 63. You don’t need to cancel your old Medicare drug plan or send them anything. Your old Medicare drug plan coverage will end when your new drug plan begins. You should get a letter from your new Medicare drug plan telling you when your coverage begins.

After you join a Medicare drug plan, the plan will mail you membership materials, including a card to use when you get your prescriptions filled.

Note: If your Medicare Prescription Drug Plan decides not to participate in Medicare or stops providing service in your area, your plan will send you a letter about your options. You will have the opportunity to join a different Medicare Prescription Drug Plan. If you have a Medicare Advantage Plan with prescription drug coverage, see page 59 for more information.

What You Pay

Exact coverage and costs are different for each Medicare drug plan, but all plans must provide at least a standard level of coverage set by Medicare.

Below are descriptions of the payments you make throughout the year in a Medicare drug plan. After the descriptions is an example of what someone may pay in a Medicare drug plan. Your actual drug plan costs will vary depending on the prescriptions you use, the plan you choose, whether you go to a pharmacy in your plan’s network, whether your drugs are on your plan’s formulary, and whether you qualify for Extra Help paying your Part D costs.

  • Monthly premium—Most drug plans charge a monthly fee that varies by plan. You pay this in addition to the Part B premium. If you belong to a Medicare Advantage Plan (like an HMO or PPO) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium may include an amount for prescription drug coverage.
  • Yearly deductible—Amount you pay for your prescriptions before your plan begins to pay. Some drug plans don’t have a deductible.
  • Copayments or coinsurance—Amounts you pay at the pharmacy for your covered prescriptions after the deductible. You pay your share, and your drug plan pays its share for covered drugs.
  • Coverage gap—Most Medicare drug plans have a coverage gap. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out‐ of‐pocket for your prescriptions up to a yearly limit. Your yearly deductible, your coinsurance or copayments, and what you pay in the coverage gap all count toward this out‐of‐pocket limit.

The limit doesn’t include the drug plan’s premium or what you pay for drugs that aren’t on your plan’s formulary.

There are plans that offer some coverage during the gap, like for generic drugs. However, plans with gap coverage may charge a higher monthly premium. Check with the drug plan first to see if your drugs would be covered during the gap.

For help comparing plan costs, contact your State Health Insurance Assistance Program (SHIP). You can also visit www.medicare.gov and select “Compare Medicare Prescription Drug Plans.”

Catastrophic coverage—Once you reach your plan’s out‐of‐pocket limit during the coverage gap, you automatically get “catastrophic coverage.” Catastrophic coverage assures that once you have spent up to your plan’s out‐of‐pocket limit for covered drugs, you only pay a small coinsurance amount or copayment for the drug for the rest of the year.

Note: If you get Extra Help paying your drug costs, you won’t have a coverage gap and will pay only a small or no copayment once you reach catastrophic coverage.

The example below shows costs for covered drugs in 2010 for a plan that has a coverage gap.

Use the following resources to get more information about Medicare prescription drug coverage:

  • Contact the plans you are interested in.
  • Visit www.medicare.gov/pdphome.asp to get general information, view publications, and compare plans in your area.
  • Call 1‐800‐MEDICARE (1‐800‐633‐4227), and say “Drug Coverage.” TTY users should call 1‐877‐486‐2048.
  • Contact your State Health Insurance Assistance Program (SHIP) for free, personalized health insurance counseling. Click SHIP to your left for contact information in your state.

What is a Medigap policy?

A Medigap (also called “Medicare Supplement Insurance”) policy is private health insurance that is designed to supplement Original Medicare. This means it helps pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover (like copayments, coinsurance, and deductibles). Medigap policies may also cover certain things that Medicare doesn’t cover. If you are in Original Medicare and you have a Medigap policy, Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap policy pays its share. (Note: Medicare doesn’t pay any of the costs for you to get a Medigap policy.) Also, a Medigap policy is different than a Medicare Advantage Plan (like an HMO or PPO) because it’s not a way to get Medicare benefits.

Every Medigap policy must follow Federal and state laws designed to protect you, and it must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies can only sell you a “standardized” Medigap policy identified by letters

A through L. Each standardized Medigap policy must offer the same basic benefits, no matter which insurance company sells it. Cost is usually the only difference between Medigap policies sold by different insurance companies.

In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. In some states, you may be able to buy another type of Medigap policy called Medicare SELECT (a Medigap policy that requires you to use specific hospitals and in some cases specific doctors to get full benefits).

What Medigap Policies Don’t Cover

Medigap policies don’t cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, and private-duty nursing.

What types of Medigap policies can insurance companies sell?

In most cases, Medigap insurance companies can sell you only a “standardized” Medigap policy. All Medigap policies must have specific benefits so you can compare them easily.  If you live in Massachusetts, Minnesota, or Wisconsin.

Insurance companies that sell Medigap policies don’t have to offer every Medigap policy (Medigap Plans A through L). However, they must offer Medigap Plan A if they offer any other Medigap policy. Each insurance company decides which Medigap policies it wants to sell, although state law might affect which ones they offer.

In some cases, an insurance company must sell you a Medigap policy, even if you have health problems. Listed below are certain times that you are guaranteed the right to buy a Medigap policy:

  • When you are in your Medigap open enrollment period.
  • If you have a guaranteed issue right.

You may also be able to buy a Medigap policy at other times, but the insurance company is allowed to deny you a Medigap policy based on your health. Also, in some cases it may be illegal for the insurance company to sell you a Medigap policy (such as if you already have Medicaid or a Medicare Advantage Plan).

What to Know About Medigap policies

  • Generally, you must have Medicare Part A and Part B to buy a Medigap policy.
  • You pay a premium for your Medigap policy to the private insurance company, in addition to the monthly Part B premium that you pay to Medicare.
  • A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, most likely, you each will have to buy separate Medigap policies.
  • You can buy a Medigap policy from any insurance company that is licensed in your state to sell one to you.
  • Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
  • Although some Medigap policies sold in the past cover prescription drugs, no new Medigap policies are allowed to include prescription drug coverage.
  • If you want prescription drug coverage, you may want to join a Medicare Prescription Drug Plan (Part D) offered by private companies approved by Medicare.

Click here to learn more about Medicare prescription drug coverage or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Best Time to Buy a Medigap Policy

The best time to buy a Medigap policy is during your Medigap open enrollment period. This period lasts for 6 months and begins on the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B. Some states have additional open enrollment periods. During this period, an insurance company can’t use medical underwriting. This means the insurance company can’t do any of the following:

  • Refuse to sell you any Medigap policy it sells
  • Make you wait for coverage to start (except as explained below)
  • Charge you more for a Medigap policy because of your health problems

While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage of a pre-existing condition. A pre-existing condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months. This is called a “pre-existing condition waiting period.” Coverage for a pre-existing condition can only be excluded in a Medigap policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medigap policy. (Remember, for Medicare-covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t cover your out-of-pocket costs.)

Even if you have a pre-existing condition, if you buy a Medigap policy during your Medigap open enrollment period and if you recently had certain kinds of health coverage called “creditable coverage,” it is possible to avoid or shorten waiting periods for pre-existing conditions. Prior creditable coverage is generally any other health coverage you recently had before applying for a Medigap policy. If you have had at least 6 months of prior creditable coverage, the Medigap insurance company can’t make you wait before it covers your pre-existing conditions.

There are many types of health care coverage that may count as creditable coverage for Medigap policies, but they will only count if you didn’t have a break in coverage for more than 63 days. If there was any time that you had no health coverage of any kind and were without coverage for more than 63 days, you can only count creditable coverage you had after that break in coverage.

Talk to your Medigap insurance company. It will be able to tell you if your previous coverage will count as creditable coverage for this purpose. You can also call your State Health Insurance Assistance Program.

If you buy a Medigap policy when you have a guaranteed issue right (also called “Medigap protection”), the insurance company can’t use a pre-existing condition waiting period at all.

Note: You can send in your application for a Medigap policy before your Medigap open enrollment period starts. This may be important if you currently have coverage that will end when you turn age 65. This will allow you to have continuous coverage.

Why is it important to buy a Medigap policy when I am first eligible?

It is very important to understand your Medigap open enrollment period. Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application, and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health. If you apply for Medigap coverage after your open enrollment period, there is no guarantee that an insurance company will sell you a Medigap policy at all if you don’t meet the medical underwriting requirements.

It is also important to understand that your Medigap rights may depend on when you choose to enroll in Part B. If you are age 65 or over, your Medigap open enrollment period begins when you enroll in Part B, and can’t be changed or repeated. In most cases it makes sense to enroll when you are first eligible for Part B, because you might otherwise have to pay a late enrollment penalty.

However, if you have group health coverage through an employer or union, either because you are currently working or your spouse is, you may want to wait to enroll in Part B. This is because employer plans often provide coverage similar to Medigap, so you don’t need a Medigap policy. When your employer coverage ends, you will get a chance to enroll in Part B without a late enrollment penalty, and your Medigap open enrollment period will start when you are ready to take advantage of it. If you enrolled in Part B while you still had the employer coverage, your Medigap open enrollment period would start, and unless you bought a Medigap policy before you needed it, you would miss your open enrollment period entirely.

How insurance companies set prices for Medigap policies

Each insurance company decides how it will set the price, or premium, for its Medigap policies. It is important to ask how an insurance company prices its policies. The way they set the price affects how much you pay now and in the future. Medigap policies can be priced or “rated” in three ways:

  1. Community-rated (also called “no-age-rated”)
  2. Issue-age-rated
  3. Attained-age-rated

Each of these ways of pricing Medigap policies is described in the chart on the next page. The examples show how your age affects your premiums, and why it is important to look at how much the Medigap policy will cost you now and in the future. The amounts in the examples aren’t actual costs.

Watch out for illegal insurance practices

It is illegal for anyone to do the following:

  • Pressure you into buying a Medigap (Medicare Supplement Insurance) policy, or lie to or mislead you to switch from one company or policy to another.
  • Sell you a second Medigap policy when they know that you already have one, unless you tell the insurance company in writing that you plan to cancel your existing Medigap policy.
  • Sell you a Medigap policy if they know you have Medicaid, except in certain situations.
  • Sell you a Medigap policy if they know you are in a Medicare Advantage Plan (like an HMO, PPO, or Private Fee-for-Service Plan) (unless your coverage under the Medicare Advantage Plan will end before the effective date of the Medigap policy).
  • Claim that a Medigap policy is part of the Medicare Program or any other Federal program. Medigap is private health insurance.
  • Claim that a Medicare Advantage Plan is a Medigap policy.
  • Sell you a Medigap policy that can’t legally be sold in your state. Check with your State Insurance Department to make sure that the Medigap policy you are interested in can be sold in your state.
  • Misuse the names, letters, or symbols of the U.S. Department of Health &Human Services (HHS), Social Security Administration (SSA), Centers for Medicare & Medicaid Services (CMS), or any of their various programs like Medicare. (For example, they can’t suggest the Medigap policy has been approved or recommended by the Federal government.)
  • Claim to be a Medicare representative if they work for a Medigap insurance company.
  • Sell you a Medicare Advantage Plan when you say you want to stay in Original Medicare and buy a Medigap policy. A Medicare Advantage Plan isn’t the same as Original Medicare.  If you enroll in a Medicare Advantage Plan you will be disenrolled from Original Medicare and can’t use a Medigap policy.

If you believe that a Federal law has been broken, call the Inspector General’s hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950. Your State Insurance Department can help you with other insurance-related problems.

Source: “2009 Chosing a Medigap Policy: A Guide to Health Insurance for People with Medicare”. (2009) Washington, D.C. Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC).

The information, telephone numbers, and web addresses in this guide were correct at the time of printing. Changes may occur after printing. To get the most up-to-date information and Medicare telephone numbers, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

The “2009 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.

Resources

Medicare Rights is a non-profit organization provding information on the following:

  • Medicare coverage basics
  • Medicare Eligibility
  • Enrolling in Medicare
  • Medicare Plan options
  • Original Medicare costs
  • Private Health & Drug Plan Costs
  • Filing Gaps in Medicare
  • Medicare rights and Protections

Tips to Facilitate the Medicare Enrollment Process is a useful guide written by Health and Human Services that provides direct steps to take when enrolling in Medicare. This is a very useful document which is short, and to the point!

The National Consumers League Internet Fraud Watch has complied a list of tips for preventing fraud when you are considering a Medicare prescription drug plan.

My Medicare Matters is a site provided by the National Council on Aging. Here you will find easy to use navigation to learn more about the following:

  • How to switch or choose Medicare Part D (Drugs) plans
  • Services that Medicare pays to keep you healthy
  • A summary of the basic coverages provided by Medicare
  • An easy to use question form where you submit a queston and staff at the National Council on Aging will provide you a written response by e-mail