Medicare For Dummies

Patricia Barry is a recognized authority on Medicare who has written extensively about the program for consumers. For nearly two decades, as a senior editor of AARP's publications, she wrote hundreds of articles on Medicare and served as the 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 38


Services that may be nice but aren't necessary 38


Distinguishing When Coverage Comes with Limits 39


Limits on hospital stays 40


Limits on skilled nursing facility stays 41


Limits on mental health benefits 41


Limits on therapy services 42


Chapter 3: Understanding What You Pay Toward Your Costs in Medicare 45


Boning Up on Premiums, Deductibles, and Co-payments 46


Part A costs 47


Part B costs 49


Part D costs 50


Medicare Advantage costs 51


Paying Higher-Income Premiums 52


Understanding who's liable for the surcharges 53


Figuring out what the surcharges cost you 56


Getting the surcharges waived 57


Paying Different Premiums than Other People in Certain Years 59


Paying Medicare Taxes While Receiving Medicare Benefits 61


Chapter 4: Reducing Your Out-of-Pocket Expenses in Medicare 63


Purchasing Medigap Insurance 64


Examining Medigap policies 65


Choosing and buying a Medigap policy 70


Qualifying for Help from Your State 70


Medicaid 71


Medicaid medical spend-down programs 72


Medicare Savings Programs 73


PACE plans 74


State Pharmacy Assistance Programs 75


Examining Whether Extra Help Can Lower Your Drug Costs 76


Qualifying for Extra Help 77


Applying for Extra Help 78


Choosing a drug plan with Extra Help 85


Considering Other Ways to Cut Costs 88


Taking income tax deductions for Medicare costs 88


Lowering drug costs without Extra Help 90


Part 2: The Hows and Whens of Medicare 93


Chapter 5: Qualifying for Medicare 95


Hitting the Milestone of Age 65 96


Debunking some qualification myths 96


Meeting the requirements for Parts A, B, and D 97


Qualifying for Part A on your own work record 98


Being eligible for Part A on someone else's work record 100


Qualifying for Medicare under Age 65 on the Basis of Disability 102


Receiving disability payments 103


Suffering from permanent kidney failure (ESRD) 105


Living with Lou Gehrig's disease (ALS) 106


Falling through the Cracks: Health-Care Options if You Can't Get Medicare Yet 106


Nice work if you can get it: Landing a job with benefits 106


Paying for COBRA temporary insurance 107


Purchasing individual insurance through the online Marketplace 107


Buying health insurance outside of the Obamacare Marketplace 109


Getting health care without insurance 110


Chapter 6: Enrolling in Medicare at the Right Time for You 111


At a Glance: Surveying Situations That Affect Enrollment Timing 112


Understanding Your Initial Enrollment Period 114


Using your IEP at age 65 114


Taking advantage of your IEP when you have disabilities 115


Delaying Part B if You'll Qualify for a Special Enrollment Period Later 116


Being able to delay Part B without penalty 117


Knowing what to do about Part A if you delay Part B 119


Heeding a special warning if you have a health savings account at work 120


Using the special enrollment period 122


Enrolling in Other Specific Situations 123


You're a legal permanent resident 123


You live outside the United States 124


You're in a nontraditional marriage or domestic partnership 127


You're incarcerated 128


Deciding Whether and When to Sign Up for Part D Drug Coverage 129


Assessing drug coverage you have from elsewhere 129


Debating whether you need Part D if you don't take medications 131


Figuring the best time to enroll in Part D 132


Understanding the Consequences of Not Signing Up at the Right Time 133


Missing your deadline for Part B 135


Passing your deadline for Part A 138


Neglecting your deadline for Part D 140


Figuring out whether you can get a late penalty revoked 142


Chapter 7: Discovering How to Sign Up for Medicare 145


Being Automatically Enrolled in Medicare Parts A and B 146


Sign Me Up! Applying for Medicare Parts A and B 147


Signing up from inside the United States 148


Enrolling while you're living abroad 152


Opting Out of or Disenrolling from Part A or Part B 153


Declining Part A 154


Opting out of Part B 155


Disenrolling from Part B 157


Knowing When Your Coverage Begins 158


When you sign up during the first three months of your IEP 160


When you sign up during IEP months four through seven 160


When you are awarded Medicare coverage retroactively 161


Transitioning from Obamacare to Medicare 162


Figuring out whether you need to make the switch 163


Knowing how and when to switch from Marketplace to Medicare 165


Chapter 8: Understanding How Medicare Fits In with Other Health Insurance 169


Understanding Medicare's Coordination of Benefits System 170


Helping Medicare help you: Filling out your initial enrollment questionnaire 171


Keeping Medicare informed if your coverage changes 172


Seeing How Medicare Works with an Employer's Health Insurance Plan 172


Working with insurance from a current employer 173


Having insurance from a former employer 176


Figuring Out How Other Federal Health Benefits Fit In with Medicare 180


The Federal Employees Health Benefits Program 180


TRICARE and TRICARE For Life 183


The Veterans Affairs health system 186


The Indian Health Service 188


The Black Lung Program 188


Mixing Medicare with Workers' Comp or No-Fault or Liability Insurance 189


When you first make a claim 190


If the claim isn't settled promptly 190


When the claim has been settled 191


Part 3: Making Smart Choices among Medicare's Many Options 193


Chapter 9: Making Sense of Medicare's Many Options 195


Seeing the Big Picture: Your Starting Point to Navigating the Medicare Maze 196


Understanding the consequences of your choice of system 196


Weighing the two systems 199


Recognizing when you may not have a choice 202


Being on your guard against "auto-enrollment" 203


Digging into the Details of Traditional Medicare versus Medicare Advantage 205


Opting for traditional Medicare 205


Looking at Medicare Advantage plans 207


Checking out three other types of Medicare health plans 211


Discovering How Medigap Policies Differ from Medicare Advantage Plans 212


Chapter 10: Choosing Wisely If You Go with Traditional Medicare 215


Understanding the Need to Compare Part D Plans Carefully 216


Knowing what not to do 216


Defining "the best plan" 217


Recognizing that comparing plans is worth the effort 218


Seeing how comparing plans can save big bucks 219


Getting organized with two crucial lists 221


Picking the Part D Plan That's Best for You 223


Assessing the Plan Finder's reliability 224


Using the Medicare Plan Finder to discover options available to you 225


Drilling down to important bits of info when comparing Part D plans 228


Choosing the Medigap Supplemental Policy That's Best for You 233


Choosing a Medigap policy 233


Buying a Medigap policy at the right time 235


Buying Medigap if you're under 65 237


Suspending a Medigap policy 239


Chapter 11: Making Smart Choices If You Opt for Medicare Advantage 241


Comparing Medicare Advantage Plans 242


Comparing plans' medical benefits 243


Adding prescription drug coverage 247


Choosing the Medicare Advantage Plan That's Right for You 250


Figuring out which providers accept the plans you're considering 250


Enrolling in a Medicare Advantage plan 251


Taking action if you change your mind 252


Chapter 12: Getting Help in Making Medicare Choices 255


One on One: Getting Personal Help on Medicare Issues 256


Asking family and friends 256


Contacting State Health Insurance Assistance Programs 257


Calling Medicare's help line 258


Seeking advice from other sources 260


Buyer Beware! Avoiding Scams and Hard-Sell Marketing 261


Steering clear of outright scams 262


Resisting hard-sell marketing tactics 265


Part 4: Navigating Medicare from the Inside 269


Chapter 13: Starting Out as a New Medicare Beneficiary 271


Playing Your Cards Right 272


Understanding when to use each card 272


Replacing your cards 275


Beyond the Cards: Checking Out the Extent and Limits of Your Coverage 275


Managing Premiums 277


Discovering different ways to pay Medicare premiums 277


Knowing what can happen when you don't pay your premiums on time 281


Keeping Track of Your Expenses 284


Understanding Medicare Summary Notices 284


Maintaining hard-copy records you can rely on 287


Tracking information online 288


Dealing with Doctors 288


Finding doctors who accept Medicare patients 289


Understanding what doctors can charge you 289


Filling Prescriptions for the First Time with a Part D Plan 292


When does my coverage begin? 292


Which kind of pharmacy can I use? 293


What happens if I go to an out-of-network pharmacy? 295


How do I prove I have Part D coverage? 296


How can I ensure I get my meds? 297


Chapter 14: Getting the Inside Scoop on Using Certain Medicare Benefits 301


Taking a Closer Look at Part A 302


Understanding hospital benefit periods 302


Taking note of the three-day rule 304


Defining observation status 305


Being aware of the improvement standard 308


Fighting premature hospital discharge 309


Proceeding if the hospital makes a mistake 310


Knowing your rights in a skilled nursing facility 310


Zooming In on Part B 314


Checking on whether Medicare will cover your treatment 314


Receiving a notice saying that Medicare may not pay 315


Determining whether you can find out a service's cost in advance 317


Maximizing your chances for coverage 318


Recognizing your right to second opinions 319


Filing a claim directly to Medicare 320


Delving into Part D 321


Understanding how a plan may restrict your drug coverage 322


Grappling with the tier system of co-pays 324


Navigating the doughnut hole 327


Using Part D to get the shingles vaccine 328


Taking advantage of free Medication Therapy Management benefits 329


Chapter 15: Changing Your Medicare and Medigap Coverage 331


Switching Coverage during Open Enrollment or Disenrollment 332


The open enrollment period 332


The disenrollment period 333


Taking Advantage of Special Enrollment Periods 334


Recognizing when you can use SEPs to change plans 335


Making sure your records and prescriptions are transferred 339


Dropping a Plan (Or Being Dropped) 341


Leaving a plan on your own 341


Getting the boot from your plan 342


Deciding Whether to Stay or Switch to Another Plan for Next Year 344


Reading your Annual Notice of Change to understand plan alterations 344


Comparing plans (yes, all over again!) 346


Looking at extra factors influencing your decision 347


Changing to Another Medigap Policy 348


Knowing the consequences of switching Medigap policies 349


Exploring a change of Medigap coverage 350


Exercising your right to a 30-day free look 350


Chapter 16: Knowing Your Rights 351


Understanding Your Right to Accurate Information 351


Knowing whom to call 352


Seeking a second opinion 353


Asking for an Investigation 354


Requesting equitable relief 354


Contacting an ombudsman 355


Reaching out to your Quality Improvement Organization 355


Getting ahold of your plan 356


Filing a grievance 356


Taking Steps toward an Appeal 357


Obtaining a formal denial 358


Requesting a coverage determination 358


Having a game plan in mind before you move ahead with an appeal 360


Filing a Formal Appeal 361


Walking through the five levels of appeal 361


Getting help in making an appeal 366


Part 5: The Part of Tens 367


Chapter 17: Top Ten Medicare Mistakes 369


Thinking You Must Reach Full Retirement Age before Signing Up 370


Assuming You Don't Qualify If You Haven't Worked Long Enough 370


Failing to Enroll in Part B When You Should 371


Believing You Don't Need Part B If You Have Retiree or COBRA Coverage 371


Not Signing Up for Part D Because You Don't Use Prescription Drugs 372


Picking a Part D Drug Plan for the Wrong Reasons 372


Misunderstanding Enrollment Periods 373


Being Too Late to Buy Medigap with Full Protections 373


Failing to Read Your Annual Notice of Change 374


Not Realizing You May Qualify for Help to Lower Your Costs 375


Chapter 18: Ten Ways to Stay Healthier beyond Age 65 377


Taking Action to Avoid Falls 377


Exercising Regularly 379


Quitting Smoking 379


Eating Healthfully 380


Cutting Out Soft Drinks and Extra Sugar 381


Keeping an Eye on Prescription Drugs 381


Continuing to Work or Stay Active 382


Staying Connected and Engaged 382


Keeping Your Brain in Shape 383


Addressing Tough Choices before They're Necessary 383


Part 6: Appendixes 385


Appendix A: Sources of Help and Information 387


Government Help Lines and Websites 387


The Centers for Medicare & Medicaid Services 388


The Social Security Administration 388


State Health Insurance Assistance Programs 389


The Eldercare Locator 394


Independent Sources of Direct Help 394


The Medicare Rights Center 394


The National Alliance for Hispanic Health 395


The National Asian Pacific Center on Aging 395


Resources for Saving Money 396


Consumer Information and Advocacy Organizations 397


Sources for Updates on Medicare 398


Appendix B: Glossary 399


Index 405