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Patricia Barry. Medicare For Dummies
Medicare For Dummies® To view this book's Cheat Sheet, simply go to www.dummies.com and search for “Medicare For Dummies Cheat Sheet” in the Search box. Table of Contents
List of Tables
List of Illustrations
Guide
Pages
Introduction
About This Book
Foolish Assumptions
Icons Used in This Book
Beyond the Book
Where to Go from Here
Getting Started with Medicare
The Nuts and Bolts of Medicare: What It Is and How It Works
Addressing Some Upfront Questions
Coming to Terms with the ABCs (and D) of Medicare
Part A
Part B
Part C
Part D
Recognizing That You Have Choices and Must Make Timely Decisions
Spelling Out What Medicare Covers (A Lot, but Not Everything)
Understanding What Part A and Part B Cover
Necessary medical care
Preventive care
Specialized care in certain circumstances
Care in a skilled nursing facility
Home health-care services
Hospice care
Palliative care
End-of-life care counseling
Pregnancy and childbirth
Medical supplies and equipment
Knowing What Part D Covers
Making sense of drug coverage that can vary throughout the year
Finding out about formularies
Laying out the drugs Part D plans must cover
Recognizing the drugs Medicare doesn’t pay for
Determining when drugs are covered by Part A, Part B, or Part D
The Gaps: Discovering What Medicare Doesn’t Cover
Routine hearing, vision, dental, and foot care
Home safety items
Nursing home care
Medical services abroad
Services that may be nice but aren’t necessary
Distinguishing When Coverage Comes with Limits
Limits on hospital stays
If you’re enrolled in traditional Medicare
If you’re enrolled in a Medicare Advantage health plan
Limits on skilled nursing facility stays
Limits on mental health benefits
Outpatient psychiatric services
Psychiatric care in a hospital
Mental health benefits in Medicare Advantage plans
Limits on therapy services
Understanding What You Pay Toward Your Costs in Medicare
Boning Up on Premiums, Deductibles, and Co-payments
Part A costs
Premiums
Deductible
Co-payments (hospital and skilled nursing facility)
Co-payments (home health care and hospice care)
Out-of-pocket limits
Part B costs
Premiums
Deductible and co-payments
Out-of-pocket limits
Part D costs
Premiums
Deductible
Co-payments
Out-of-pocket limits
Medicare Advantage costs
Premiums
Deductible
Co-payments
Out-of-pocket limits
Paying Higher-Income Premiums
Understanding who’s liable for the surcharges
Determining when you may be liable, even if your income isn’t high
Recognizing that you may be liable for a Part D surcharge, even without a Part D plan
Figuring out what the surcharges cost you
Getting the surcharges waived
Knowing what qualifies as a life-changing event
Verifying whether other situations qualify for a waiver
Paying Different Premiums than Other People in Certain Years
Paying Medicare Taxes While Receiving Medicare Benefits
Reducing Your Out-of-Pocket Expenses in Medicare
Purchasing Medigap Insurance
Examining Medigap policies
If you live in Massachusetts, Minnesota, or Wisconsin
If you live in a state where “innovative” Medigap policies are sold
If you have a Medigap policy that’s no longer sold
If you’re considering a Medigap policy that won’t be sold after 2019
Choosing and buying a Medigap policy
Qualifying for Help from Your State
Medicaid
Medicaid medical spend-down programs
Medicare Savings Programs
PACE plans
State Pharmacy Assistance Programs
Examining Whether Extra Help Can Lower Your Drug Costs
Qualifying for Extra Help
Applying for Extra Help
How can I obtain the form?
What if English isn’t my first language?
What counts as income?
What counts as assets?
What counts as “single” and “married” for income purposes?
What if I’m supporting other family members?
Who can help me apply?
How do I complete the application process?
What happens after I apply?
What if Social Security turns me down?
If I qualify, how long does my Extra Help last?
How do I know whether my Extra Help will continue?
Choosing a drug plan with Extra Help
Understanding the automatic enrollment system
Clarifying zero premiums
Considering Other Ways to Cut Costs
Taking income tax deductions for Medicare costs
Lowering drug costs without Extra Help
Taking a hard look at your meds
Switching to less-expensive drugs
Switching to a less-expensive Part D drug plan
Using mail order or preferred pharmacies
Finding free or low-cost prescription drugs
The Hows and Whens of Medicare
Qualifying for Medicare
Hitting the Milestone of Age 65
Debunking some qualification myths
Meeting the requirements for Parts A, B, and D
Part A
Part B
Part D
Qualifying for Part A on your own work record
Being eligible for Part A on someone else’s work record
Your current/former spouse has enough credits
Neither you nor your spouse has 40 work credits
You’re the foreign spouse of a U.S. citizen or legal resident
You’re in a same-sex marriage
You are unmarried but live in a domestic partnership
Qualifying for Medicare under Age 65 on the Basis of Disability
Receiving disability payments
How does the 24-month waiting period work?
How long does Medicare coverage last?
Does railroad retirement disability work in the same way?
Suffering from permanent kidney failure (ESRD)
Living with Lou Gehrig’s disease (ALS)
Falling through the Cracks: Health-Care Options if You Can’t Get Medicare Yet
Nice work if you can get it: Landing a job with benefits
Paying for COBRA temporary insurance
Purchasing individual insurance through the online Marketplace
Buying health insurance outside of the Obamacare Marketplace
Getting health care without insurance
Enrolling in Medicare at the Right Time for You
At a Glance: Surveying Situations That Affect Enrollment Timing
Understanding Your Initial Enrollment Period
Using your IEP at age 65
Taking advantage of your IEP when you have disabilities
Delaying Part B if You’ll Qualify for a Special Enrollment Period Later
Being able to delay Part B without penalty
“For whom you or your spouse still actively work”
“That employer has 20 or more employees”
“Until this employment or the health coverage ends (whichever comes first)”
Knowing what to do about Part A if you delay Part B
Heeding a special warning if you have a health savings account at work
Using the special enrollment period
Enrolling in Other Specific Situations
You’re a legal permanent resident
You live outside the United States
Working overseas
Not qualifying for premium-free Part A
Signing up for Part D drug coverage
You’re in a nontraditional marriage or domestic partnership
You’re in a same-sex marriage
You’re in a domestic partnership
You’re incarcerated
Deciding Whether and When to Sign Up for Part D Drug Coverage
Assessing drug coverage you have from elsewhere
Coverage that’s creditable
Coverage that you need to check out
Coverage that isn’t creditable
Coverage that isn’t coverage
Debating whether you need Part D if you don’t take medications
Figuring the best time to enroll in Part D
Understanding the Consequences of Not Signing Up at the Right Time
PENALTIES ON BENEFITS? WHAT WERE THEY THINKING?
Missing your deadline for Part B
Going without health coverage
Paying more for Part B services than you need to
Passing your deadline for Part A
Neglecting your deadline for Part D
Being without drug coverage
Understanding how Part D late penalties are calculated
Figuring out whether you can get a late penalty revoked
If you think the late penalty is a mistake
If you were given wrong information
Discovering How to Sign Up for Medicare
Being Automatically Enrolled in Medicare Parts A and B
Sign Me Up! Applying for Medicare Parts A and B
Signing up from inside the United States
One … two … three ways to sign up
If you live in different places for parts of the year
If English isn’t your first language
Enrolling while you’re living abroad
Applying if you qualify for full Medicare benefits
Applying if you aren’t fully insured for Medicare
Contacting Social Security from outside the United States
Opting Out of or Disenrolling from Part A or Part B
Declining Part A
Opting out of Part B
Knowing when to turn down Part B if you’re 65 or older
Understanding when to turn down Part B if you’re under 65
Recognizing when turning down Part B at any age is risky
Disenrolling from Part B
Knowing When Your Coverage Begins
When you sign up during the first three months of your IEP
When you sign up during IEP months four through seven
When you are awarded Medicare coverage retroactively
Transitioning from Obamacare to Medicare
Figuring out whether you need to make the switch
“If I’m happy with the Marketplace plan I currently have, must I switch to Medicare?”
“My employer bought my Marketplace insurance through SHOP. If I keep working after 65, must I enroll in Medicare?”
“I don’t have enough work credits for premium-free Part A. Can I stay on my Marketplace plan until I’ve earned enough?”
“I’m in Part A but missed my deadline for Part B sign-up. Can I enroll in a Marketplace plan until Part B coverage kicks in?”
“If I enroll in Medicare, I’ll have to pay high Part B premiums due to high income. Can I stay on my cheaper Marketplace plan? ”
Knowing how and when to switch from Marketplace to Medicare
“I have a Marketplace plan on my own. How do I switch from that plan to Medicare? ”
“My family is on a Marketplace plan, but I’ll be eligible for Medicare soon. Can my family stay on the plan after I leave?”
“My Marketplace plan provides dental coverage. Does Medicare do so?”
“Can I sign up for any Medicare plans through the online Marketplace?”
“If I need help in cancelling my Marketplace plan or starting Medicare coverage, whom should I call?”
Understanding How Medicare Fits In with Other Health Insurance
Understanding Medicare’s Coordination of Benefits System
Helping Medicare help you: Filling out your initial enrollment questionnaire
Keeping Medicare informed if your coverage changes
Seeing How Medicare Works with an Employer’s Health Insurance Plan
Working with insurance from a current employer
Is my employer insurance primary or secondary to Medicare?
Do I get the same health benefits at work as I get now?
How else does having an employer plan affect me?
Can I choose to drop my employer plan and have just Medicare?
How does my ESRD-qualified Medicare work with my employer coverage?
Having insurance from a former employer
Are retiree/COBRA benefits primary or secondary to Medicare?
How do my retiree benefits work with Medicare?
Can I choose to drop my retiree benefits and have just Medicare?
How does COBRA work with Medicare?
What if I have prescription drug coverage from my retiree or COBRA plan?
Figuring Out How Other Federal Health Benefits Fit In with Medicare
The Federal Employees Health Benefits Program
What if I become eligible for Medicare while I’m still working?
How does Medicare fit in with my plan after I retire?
How does my FEHB coverage work if I have Medicare due to disability or ESRD?
TRICARE and TRICARE For Life
What if I become eligible for Medicare while I am (or my spouse is) still on active duty or I have coverage from another job?
What if I become eligible for Medicare based on disability?
How does Medicare fit in with my TRICARE For Life benefits?
The Veterans Affairs health system
The Indian Health Service
The Black Lung Program
Mixing Medicare with Workers’ Comp or No-Fault or Liability Insurance
When you first make a claim
If the claim isn’t settled promptly
When the claim has been settled
Making Smart Choices among Medicare’s Many Options
Making Sense of Medicare’s Many Options
Seeing the Big Picture: Your Starting Point to Navigating the Medicare Maze
Understanding the consequences of your choice of system
Considerations for choosing one system over the other
An important limitation on your choice
Weighing the two systems
Overall costs
Premium costs
Co-pay costs
Cost and benefit stability
Care stability
Provider choice and care coordination
Extra benefits
Geographical area
Quality measures
Recognizing when you may not have a choice
Being on your guard against “auto-enrollment”
Digging into the Details of Traditional Medicare versus Medicare Advantage
Opting for traditional Medicare
Looking at Medicare Advantage plans
Health maintenance organizations (HMOs)
Preferred provider organizations (PPOs)
Private Fee-for-Service (PFFS) plans
Special Needs Plans (SNPs)
Medical Savings Account (MSA) plans
Checking out three other types of Medicare health plans
Discovering How Medigap Policies Differ from Medicare Advantage Plans
Choosing Wisely If You Go with Traditional Medicare
Understanding the Need to Compare Part D Plans Carefully
Knowing what not to do
Defining “the best plan”
Recognizing that comparing plans is worth the effort
Seeing how comparing plans can save big bucks
WILL YOU AVOID PART D BUYER’S REMORSE?
Getting organized with two crucial lists
Creating an accurate list of your meds
Drawing up a list of your plan preferences
Picking the Part D Plan That’s Best for You
Assessing the Plan Finder’s reliability
Using the Medicare Plan Finder to discover options available to you
Walking through a few steps
Homing in on handy features of the “plan results” page
Drilling down to important bits of info when comparing Part D plans
Finding out your month-by-month costs
Lowering your drug costs
Examining retail pharmacy choices
WHERE DID ALL THESE PART D PLANS COME FROM?
Choosing the Medigap Supplemental Policy That’s Best for You
Choosing a Medigap policy
Buying a Medigap policy at the right time
Buying Medigap if you’re under 65
Suspending a Medigap policy
Making Smart Choices If You Opt for Medicare Advantage
Comparing Medicare Advantage Plans
Comparing plans’ medical benefits
Moving through the Plan Finder
Digging for plan details
Walking through an example
Adding prescription drug coverage
Entering your drugs into the Plan Finder
Checking out an example
Choosing the Medicare Advantage Plan That’s Right for You
Figuring out which providers accept the plans you’re considering
Enrolling in a Medicare Advantage plan
Taking action if you change your mind
Getting Help in Making Medicare Choices
One on One: Getting Personal Help on Medicare Issues
Asking family and friends
Contacting State Health Insurance Assistance Programs
Calling Medicare’s help line
Seeking advice from other sources
Doctors and pharmacists
Insurance agents
Seminars and information sessions
Businesses dedicated to Medicare help
Buyer Beware! Avoiding Scams and Hard-Sell Marketing
Steering clear of outright scams
Watching out for red flags
Surveying some common scams targeting seniors
Reporting a scam
Taking steps if you’re ripped off
Resisting hard-sell marketing tactics
Knowing which marketing methods are (and aren’t) allowed
Thinking and checking before you sign
Taking action if you’re misled into joining a plan
Navigating Medicare from the Inside
Starting Out as a New Medicare Beneficiary
Playing Your Cards Right
Understanding when to use each card
Your Medicare ID card
Your Medicaid ID card
Your Medicare Advantage plan membership card
LAMINATING YOUR MEDICARE CARD
Your stand-alone Part D prescription plan membership card
Your Medigap supplemental insurance card
Replacing your cards
Beyond the Cards: Checking Out the Extent and Limits of Your Coverage
Managing Premiums
Discovering different ways to pay Medicare premiums
Having Part B premiums deducted from benefit checks
Receiving a bill for Part A and Part B premiums
Transitioning from direct billing to Social Security deductions
Paying premiums in a Medicare drug or health plan
Knowing what can happen when you don’t pay your premiums on time
When you’re in traditional Medicare
When you’re enrolled in a Medicare drug or health plan
The consequences of disenrollment
Keeping Track of Your Expenses
Understanding Medicare Summary Notices
WHERE HAVE ALL THE DOCTORS GONE?
Maintaining hard-copy records you can rely on
Tracking information online
Dealing with Doctors
Finding doctors who accept Medicare patients
Understanding what doctors can charge you
Doctors who opt out of Medicare
Doctors who provide concierge or boutique services
Filling Prescriptions for the First Time with a Part D Plan
When does my coverage begin?
Which kind of pharmacy can I use?
Retail pharmacies
Mail-order pharmacies
Specialty pharmacies
Long-term-care pharmacies
What happens if I go to an out-of-network pharmacy?
How do I prove I have Part D coverage?
How can I ensure I get my meds?
If the pharmacist can’t confirm your enrollment in a plan
If the pharmacist says the plan won’t pay for one of your meds
If the pharmacist charges you more than you think is correct
If the pharmacist says your doctor isn’t an approved Medicare prescriber
Getting the Inside Scoop on Using Certain Medicare Benefits
Taking a Closer Look at Part A
Understanding hospital benefit periods
Hospital coverage in traditional Medicare
Skilled nursing care in traditional Medicare
Hospital and SNF coverage in Medicare Advantage plans
Taking note of the three-day rule
Defining observation status
Understanding the consequences of being in observation status
Protecting yourself against big bills
Being aware of the improvement standard
Fighting premature hospital discharge
Proceeding if the hospital makes a mistake
Knowing your rights in a skilled nursing facility
Leaving the SNF for short periods
Moving out of SNF care (and later returning)
Seeing the doctor of your choice
Filing a claim even if you’re told Medicare won’t pay
Zooming In on Part B
Checking on whether Medicare will cover your treatment
Receiving a notice saying that Medicare may not pay
The options on an ABN
A word about ambulance services
Determining whether you can find out a service’s cost in advance
Maximizing your chances for coverage
Recognizing your right to second opinions
Filing a claim directly to Medicare
If the doctor fails to file a claim
If you need Medicare to deny a claim
Delving into Part D
Understanding how a plan may restrict your drug coverage
Defining prior authorization, quantity limits, and step therapy
Requesting an exception with your doctor’s help
Obtaining a prescription from the right doctor
Grappling with the tier system of co-pays
What are pricing tiers?
How can you find out your plan’s pricing tiers?
What if your drug is suddenly switched to a higher price tier?
Navigating the doughnut hole
Using Part D to get the shingles vaccine
Taking advantage of free Medication Therapy Management benefits
Changing Your Medicare and Medigap Coverage
Switching Coverage during Open Enrollment or Disenrollment
The open enrollment period
The disenrollment period
Taking Advantage of Special Enrollment Periods
Recognizing when you can use SEPs to change plans
You move permanently outside your plan’s service area
You move into or leave a nursing home or other long-term-care facility
You’re in a Medicare Advantage plan and want to change to traditional Medicare
You dropped a Medigap policy to enroll in a Medicare Advantage plan for the first time
You want to switch to a high-quality five-star plan
Your plan withdraws service from your area, doesn’t renew its contract with Medicare, or closes down
You lose drug coverage from an employer or union, COBRA, or retiree benefits
You lose Medicaid or Medicare Savings Program eligibility
A plan violates its contract with you
You were misled into joining a Medicare Advantage plan
A federal employee made a mistake when processing your enrollment or disenrollment in a plan
Making sure your records and prescriptions are transferred
Dropping a Plan (Or Being Dropped)
Leaving a plan on your own
Getting the boot from your plan
Deciding Whether to Stay or Switch to Another Plan for Next Year
Reading your Annual Notice of Change to understand plan alterations
BEWARE OF IGNORING YOUR ANNUAL NOTICE OF CHANGE
Comparing plans (yes, all over again!)
Looking at extra factors influencing your decision
Carrying over exceptions from your current plan
Switching to a Medicare Advantage plan
Changing to Another Medigap Policy
Knowing the consequences of switching Medigap policies
Exploring a change of Medigap coverage
Exercising your right to a 30-day free look
Knowing Your Rights
Understanding Your Right to Accurate Information
Knowing whom to call
Social Security Administration
Centers for Medicare & Medicaid Services
Seeking a second opinion
Asking for an Investigation
Requesting equitable relief
Contacting an ombudsman
Reaching out to your Quality Improvement Organization
Getting ahold of your plan
Filing a grievance
Taking Steps toward an Appeal
Obtaining a formal denial
Requesting a coverage determination
Having a game plan in mind before you move ahead with an appeal
Filing a Formal Appeal
Walking through the five levels of appeal
Level 1: Redetermination by Medicare or your plan
Level 2: Reconsideration by an independent panel
Level 3: Hearing with an administrative law judge
Level 4: Review by the Medicare Appeals Council
Level 5: Hearing in federal court
Getting help in making an appeal
The Part of Tens
Top Ten Medicare Mistakes
Thinking You Must Reach Full Retirement Age before Signing Up
Assuming You Don’t Qualify If You Haven’t Worked Long Enough
Failing to Enroll in Part B When You Should
Believing You Don’t Need Part B If You Have Retiree or COBRA Coverage
Not Signing Up for Part D Because You Don’t Use Prescription Drugs
Picking a Part D Drug Plan for the Wrong Reasons
Misunderstanding Enrollment Periods
Being Too Late to Buy Medigap with Full Protections
Failing to Read Your Annual Notice of Change
Not Realizing You May Qualify for Help to Lower Your Costs
Ten Ways to Stay Healthier beyond Age 65
Taking Action to Avoid Falls
Exercising Regularly
Quitting Smoking
Eating Healthfully
Cutting Out Soft Drinks and Extra Sugar
Keeping an Eye on Prescription Drugs
Continuing to Work or Stay Active
Staying Connected and Engaged
Keeping Your Brain in Shape
Addressing Tough Choices before They’re Necessary
Appendixes
Sources of Help and Information
Government Help Lines and Websites
The Centers for Medicare & Medicaid Services
The Social Security Administration
State Health Insurance Assistance Programs
The Eldercare Locator
Independent Sources of Direct Help
The Medicare Rights Center
The National Alliance for Hispanic Health
The National Asian Pacific Center on Aging
Resources for Saving Money
Consumer Information and Advocacy Organizations
Sources for Updates on Medicare
Glossary
Index. Numbers
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Z
About the Author
Author’s Acknowledgments
WILEY END USER LICENSE AGREEMENT
