Medicare For Dummies

Patricia Barry is a recognized authority on Medicare who has written extensively about the program for consumers. For 18 years, as a senior editor of AARP's publications, she wrote hundreds of articles on Medicare and served as its online "Ask Ms. Medicare" columnist, answering thousands of questions sent by Medicare beneficiaries across the nation.

Introduction 1


About This Book 2


Foolish Assumptions 3


Icons Used in This Book 4


Beyond the Book 4


Where to Go from Here 5


Part 1: Getting Started with Medicare 7


Chapter 1: The Nuts and Bolts of Medicare: What It Is and How It Works 9


Addressing Some Upfront Questions 10


Coming to Terms with the ABCs (and D) of Medicare 12


Part A 13


Part B 14


Part C 15


Part D 15


Recognizing That You Have Choices and Must Make Timely Decisions 16


Chapter 2: Spelling Out What Medicare Covers (A Lot, but Not Everything) 19


Understanding What Part A and Part B Cover 20


Necessary medical care 20


Preventive care 21


Specialized care in certain circumstances 24


Medical supplies and equipment 28


Knowing What Part D Covers 30


Making sense of drug coverage that can vary throughout the year 30


Finding out about formularies 32


Determining when drugs are covered by Part A, Part B, or Part D 34


The Gaps: Discovering What Medicare Doesn’t Cover 35


Routine hearing, vision, dental, and foot care 35


Home safety items 36


Nursing home care 37


Medical services abroad 37


Services that may be nice but aren’t necessary 38


Distinguishing When Coverage Comes with Limits 39


Limits on hospital stays 39


Limits on skilled nursing facility stays 40


Limits on mental health benefits 41


Limits on therapy services 42


Chapter 3: Understanding What You Pay toward Your Costs in Medicare 43


Boning Up on Premiums, Deductibles, and Co-payments 44


Part A costs 45


Part B costs 47


Part D costs 48


Medicare Advantage costs 49


Paying Higher-Income Premiums 50


Understanding who’s liable for the surcharges 51


Figuring out what the surcharges cost you 53


Getting the surcharges waived 54


Paying Different Premiums than Other People in Certain Years 57


Paying Medicare Taxes While Receiving Medicare Benefits 58


Chapter 4: Reducing Your Out-of-Pocket Expenses in Medicare 59


Purchasing Medigap Insurance 60


Examining Medigap policies 61


Choosing and buying a Medigap policy 65


Qualifying for Help from Your State 66


Medicaid 66


Medicaid medical spend-down programs 68


Medicare Savings Programs 68


PACE plans 69


State Pharmacy Assistance Programs 71


Examining Whether Extra Help Can Lower Your Drug Costs 71


Qualifying for Extra Help 72


Applying for Extra Help 74


Choosing a drug plan with Extra Help 80


Considering Other Ways to Cut Costs 83


Taking income tax deductions for Medicare costs 83


Lowering drug costs without Extra Help 84


Part 2: The Hows and Whens of Medicare 89


Chapter 5: Qualifying for Medicare 91


Hitting the Milestone of Age 65 92


Debunking some qualification myths 92


Meeting the requirements for Parts A, B, and D 93


Qualifying for Part A on your own work record 94


Being eligible for Part A on someone else’s work record 96


Qualifying for Medicare under Age 65 on the Basis of Disability 98


Receiving disability payments 98


Suffering from permanent kidney failure (ESRD) 101


Living with Lou Gehrig’s disease (ALS) 101


Falling through the Cracks: Health-Care Options if You Can’t Get Medicare Yet 102


Nice work if you can get it: Landing a job with benefits 102


Paying for COBRA temporary insurance 103


Purchasing individual insurance through the online Marketplace 103


Buying health insurance outside of the Obamacare Marketplace 105


Getting health care without insurance 106


Chapter 6: Enrolling in Medicare at the Right Time for You 107


At a Glance: Surveying Situations That Affect Enrollment Timing 108


Understanding Your Initial Enrollment Period 110


Using your IEP at age 65 110


Taking advantage of your IEP when you have disabilities 111


Delaying Part B if You’ll Qualify for a Special Enrollment Period Later 112


Being able to delay Part B without penalty 113


Knowing what to do about Part A if you delay Part B 115


Heeding a special warning if you have a health savings account at work 116


Using the special enrollment period 118


Enrolling in Other Specific Situations 119


You’re a legal permanent resident 119


You live outside the United States 120


You’re in a nontraditional marriage or domestic partnership 123


You’re incarcerated 124


Deciding Whether and When to Sign Up for Part D Drug Coverage 125


Assessing drug coverage you have from elsewhere 125


Debating whether you need Part D if you don’t take medications 128


Figuring the best time to enroll in Part D 128


Understanding the Consequences of Not Signing Up at the Right Time 129


Missing your deadline for Part B 131


Passing your deadline for Part A 134


Neglecting your deadline for Part D 136


Figuring out whether you can get a late penalty revoked 138


Chapter 7: Discovering How to Sign Up for Medicare 141


Being Automatically Enrolled in Medicare Parts A and B 142


Sign Me Up! Applying for Medicare Parts A and B 143


Signing up from inside the United States 144


Enrolling while you’re living abroad 147


Opting Out of or Disenrolling from Part A or Part B 149


Declining Part A 150


Opting out of Part B 151


Disenrolling from Part B 153


Knowing When Your Coverage Begins 154


When you sign up during the first three months of your IEP 156


When you sign up during IEP months four through seven 156


When you are awarded Medicare coverage retroactively 157


Transitioning from Obamacare to Medicare 158


Figuring out whether you need to make the switch 158


Knowing how and when to switch from Marketplace to Medicare 161


Chapter 8: Understanding How Medicare Fits In with Other Health Insurance 165


Understanding Medicare’s Coordination of Benefits System 166


Helping Medicare help you: Filling out your initial enrollment questionnaire 167


Keeping Medicare informed if your coverage changes 168


Seeing How Medicare Works with an Employer’s Health Insurance Plan 168


Working with insurance from a current employer 169


Having insurance from a former employer 172


Figuring Out How Other Federal Health Benefits Fit In with Medicare 176


The Federal Employees Health Benefits Program 176


TRICARE and TRICARE For Life 178


The Veterans Affairs health system 182


The Indian Health Service 183


The Black Lung Program 184


Mixing Medicare with Workers’ Comp or No-Fault or Liability Insurance 185


When you first make a claim 185


If the claim isn’t settled promptly 186


When the claim has been settled 187


Part 3: Making Smart Choices among Medicare’s Many Options 189


Chapter 9: Making Sense of Medicare’s Many Options 191


Seeing the Big Picture: Your Starting Point to Navigating the Medicare Maze 192


Understanding the consequences of your choice of system 192


Weighing the two systems 195


Recognizing when you may not have a choice 198


Being on your guard against “auto-enrollment” 199


Digging into the Details of Traditional Medicare versus Medicare Advantage 200


Opting for traditional Medicare 201


Looking at Medicare Advantage plans 202


Checking out three other types of Medicare health plans 206


Discovering How Medigap Policies Differ from Medicare Advantage Plans 207


Chapter 10: Choosing Wisely If You Go with Traditional Medicare 211


Understanding the Need to Compare Part D Plans Carefully 212


Knowing what not to do 212


Defining “the best plan” 213


Recognizing that comparing plans is worth the effort 214


Seeing how comparing plans can save big bucks 215


Getting organized with two crucial lists 217


Picking the Part D Plan That’s Best for You 219


Assessing the plan finder’s reliability 220


Using the Medicare plan finder to discover options available to you 221


Drilling down to important bits of info when comparing Part D plans 224


Choosing the Medigap Supplemental Policy That’s Best for You 230


Choosing a Medigap policy 231


Buying a Medigap policy at the right time 232


Buying Medigap if you’re under 65 235


Suspending a Medigap policy 236


Chapter 11: Making Smart Choices If You Opt for Medicare Advantage 239


Comparing Medicare Advantage Plans 240


Comparing plans’ medical benefits 241


Adding prescription drug coverage 246


Choosing the Medicare Advantage Plan That’s Right for You 248


Figuring out which providers accept the plans you’re considering 249


Enrolling in a Medicare Advantage plan 250


Taking action if you change your mind 250


Chapter 12: Getting Help in Making Medicare Choices 253


One on One: Getting Personal Help on Medicare Issues 254


Asking family and friends 254


Contacting State Health Insurance Assistance Programs 255


Calling Medicare’s help line 256


Seeking advice from other sources 258


Buyer Beware! Avoiding Scams and Hard-Sell Marketing 259


Steering clear of outright scams 260


Resisting hard-sell marketing tactics 262


Part 4: Navigating Medicare from the Inside 267


Chapter 13: Starting Out as a New Medicare Beneficiary 269


Playing Your Cards Right 270


Understanding when to use each card 270


Protecting your cards from loss or theft 273


Replacing your cards 274


Beyond the Cards: Checking Out the Extent and Limits of Your Coverage 274


Managing Premiums 276


Discovering different ways to pay Medicare premiums 276


Knowing what can happen when you don’t pay your premiums on time 280


Keeping Track of Your Expenses 283


Understanding Medicare Summary Notices 283


Maintaining hard-copy records you can rely on 285


Tracking information online 287


Dealing with Doctors 287


Finding doctors who accept Medicare patients 288


Understanding what doctors can charge you 288


Filling Prescriptions for the First Time with a Part D Plan 291


When does my coverage begin? 291


Which kind of pharmacy can I use? 292


What happens if I go to an out-of-network pharmacy? 294


How do I prove I have Part D coverage? 295


How can I ensure I get my meds? 296


Chapter 14: Getting the Inside Scoop on Using Certain Medicare Benefits 299


Taking a Closer Look at Part A 300


Understanding hospital benefit periods 300


Taking note of the three-day rule 302


Defining observation status 303


Being aware of the improvement standard 305


Fighting premature hospital discharge 306


Proceeding if the hospital makes a mistake 307


Knowing your rights in a skilled nursing facility 308


Zooming In on Part B 311


Checking on whether Medicare will cover your treatment 311


Receiving a notice saying that Medicare may not pay 312


Determining whether you can find out a service’s cost in advance 314


Maximizing your chances for coverage 315


Recognizing your right to second opinions 316


Filing a claim directly to Medicare 317


Delving into Part D 318


Understanding how a plan may restrict your drug coverage 318


Grappling with the tier system of co-pays 321


Navigating the doughnut hole 323


Using Part D to get the shingles vaccine 325


Taking advantage of free Medication Therapy Management benefits 326


Chapter 15: Changing Your Medicare and Medigap Coverage 327


Switching Coverage during Open Enrollment or Disenrollment 328


The open enrollment period 328


The disenrollment period 329


Taking Advantage of Special Enrollment Periods 330


Recognizing when you can use SEPs to change plans 331


Making sure your records and prescriptions are transferred 335


Dropping a Plan (Or Being Dropped) 336


Leaving a plan on your own 337


Getting the boot from your plan 338


Deciding Whether to Stay or Switch to Another Plan for Next Year 339


Reading your Annual Notice of Change to understand plan alterations 340


Comparing plans (yes, all over again!) 341


Looking at extra factors influencing your decision 342


Changing to Another Medigap Policy 344


Knowing the consequences of switching Medigap policies 345


Exploring a change of Medigap coverage 345


Exercising your right to a 30-day free look 346


Chapter 16: Knowing Your Rights 347


Understanding Your Right to Accurate Information 347


Knowing whom to call 348


Seeking a second opinion 349


Asking for an Investigation 350


Requesting equitable relief 350


Contacting an ombudsman 351


Reaching out to your Quality Improvement Organization 351


Getting ahold of your plan 352


Filing a grievance 352


Taking Steps toward an Appeal 353


Obtaining a formal denial 354


Requesting a coverage determination 354


Having a game plan in mind before you move ahead with an appeal 356


Filing a Formal Appeal 357


Walking through the five levels of appeal 357


Getting help in making an appeal 361


Part 5: The Part of Tens 363


Chapter 17: Top Ten Medicare Mistakes 365


Thinking You Must Reach Full Retirement Age before Signing Up 366


Assuming You Don’t Qualify If You Haven’t Worked Long Enough 366


Failing to Enroll in Part B When You Should 367


Believing You Don’t Need Part B If You Have Retiree or COBRA Coverage 367


Not Signing Up For Part D Because You Don’t Use Prescription Drugs 368


Picking a Part D Drug Plan for the Wrong Reasons 368


Misunderstanding Enrollment Periods 369


Being Too Late to Buy Medigap with Full Protections 369


Failing to Read Your Annual Notice of Change 370


Not Realizing You May Qualify for Help to Lower Your Costs 371


Chapter 18: Ten Ways to Stay Healthier beyond Age 65 373


Taking Action to Avoid Falls 373


Exercising Regularly 375


Quitting Smoking 375


Eating Healthfully 376


Cutting Out Soft Drinks and Extra Sugar 377


Keeping an Eye on Prescription Drugs 377


Continuing to Work or Stay Active 378


Staying Connected and Engaged 378


Keeping Your Brain in Shape 379


Addressing Tough Choices before They’re Necessary 379


Part 6: Appendixes 381


Appendix A: Sources of Help and Information 383


Government Help Lines and Websites 383


The Centers for Medicare & Medicaid Services 383


The Social Security Administration 384


State Health Insurance Assistance Programs 384


The Eldercare Locator 389


Independent Sources of Direct Help 389


The Medicare Rights Center 389


The National Alliance for Hispanic Health 390


The National Asian Pacific Center on Aging 390


Resources for Saving Money 391


Consumer Information and Advocacy Organizations 392


Sources for Updates on Medicare 393


Appendix B: Glossary 395


Index 401