Medicare costs

What Medicare covers

Health and prescription drug plans

Your Medicare rights

Health information technology

Help paying their Medicare prescription drug costs,

but don’t know it. Don’t miss out on a chance to

save. See pages 78–81 to learn more.

signing up to access your future “Medicare & You”

handbooks electronically (also called the

eHandbook). Visit www.MyMedicare.gov to

request future eHandbooks, including the 2011

version. We’ll email you next October when the

new eHandbook is available. The email will include

a link to the handbook on www.medicare.gov. You

won’t get a copy of your handbook in the mail if

you choose to get it electronically.

how your or your spouse’s address is entered in

Social Security’s mailing system. If you would

like to get only one copy in the future, call

1-800-MEDICARE (1-800-633-4227). TTY users

should call 1-877-486-2048.

and official source of answers to your Medicare questions. At the

U.S. Department of Health and Human Services, we are doing

more than ever to carry Medicare into the future. Every day

brings new commitment to advance the goals of health reform by

reducing costs, offering choices, and making sure you have access

to quality, affordable health care.

Your good health is our top priority. On February 17, 2009,

President Obama signed the American Recovery and

Reinvestment Act. This law targets two areas, among many, to

ensure the health and well-being of the Nation:

1. Strengthening preventive care and wellness to enable

Americans to live longer, healthier lives.

2. Investing in health information technology to improve the

quality of health care and reduce medical errors.

There are some things that you can do to help these efforts:

■ Take advantage of Medicare’s preventive services. Use the

checklist on page 40, and ask your doctor or other health care

provider what preventive services you need.

■ Learn about the technology available to help improve your

health care. Look on page 123 to learn more about health

information technology.

This handbook also includes other important facts and changes

you will need for 2010. For the latest information about changes

to Medicare, visit www.medicare.gov or call 1-800-MEDICARE

(1-800-633-4227). TTY users should call 1-877-486-2048.

Yours in good health,

/s/

Kathleen Sebelius

U.S. Department of Health and Human Services

List of topic

areas by section

Alphabetical list

of topics

List of topics

within each

section

Pages 5–6

Pages 7–10

Pages 15, 41, 77,

85, 99, 105

Pages 115–118

Throughout

handbook

Pages 26–38, 40

was correct when it was printed. Call 1-800-MEDICARE

(1-800-633-4227), or visit www.medicare.gov to get the most

the text are

explained in the

in the Text

“Definitions”

section

Highlights

important

information

Highlights

preventive

services

“Medicare & You” isn’t a legal document. Official Medicare

Program legal guidance is contained in the relevant statutes,

regulations, and rulings.

What Is Medicare?

13

Your Medicare Coverage Choices

14

Where to Get Your Medicare Questions Answered

Part A-Covered Services

25

Part B-Covered Services

39

What’s NOT Covered by Part A and Part B?

40

42

Decide How to Get Your Medicare

44

Things to Consider When Choosing or Changing Your Coverage

45

Original Medicare

50

Medicare Advantage Plans (like an HMO or PPO) (Part C)

58

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

60

Other Medicare Health Plans

62

Medicare Prescription Drug Coverage (Part D)

63

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

Who Pays First When You Have Other Insurance?

74

Medigap (Medicare Supplement Insurance) Policies

Extra Help Paying for Medicare Prescription Drug Coverage (Part D)

82

Medicaid

83

Medicare Savings Programs (Help with Medicare Costs)

Your Medicare Rights

86

What Is an Appeal?

92

How Medicare Uses Your Personal Information

94

Protect Yourself from Fraud and Identity Theft

96

Protect Yourself and Medicare from Billing Fraud

83, 115, 120–121

Colonoscopy 26, 28, 40

Colorectal Cancer Screenings 28, 40

Community-Based Programs 101

Consolidated Omnibus Budget Reconciliation Act

(COBRA) 22, 24, 71

Contract (private) 48

Coordination of Benefits 14, 73

Copayment 19–20, 26–39, 54, 65–66, 74–75, 78, 115,

120–121

Cosmetic Surgery 39

Costs 16, 21, 25–38, 44–47, 54, 65–66, 74, 78–83,

119–122

Coverage Determination (Part D) 90–91

Coverage Gap 65–66, 78

Covered Services (Part A and Part B) 19–20, 26–38, 40,

120–121

Creditable Prescription Drug Coverage 49, 62, 67,

71–72, 116

Custodial Care 20, 100, 116

74–75, 78, 83, 116, 120–121

Definitions 115–118

Demonstrations/Pilot Programs 13, 61, 117

Dental Care and Dentures 39, 50, 84

Department of Defense 14

Department of Health and Human Services (Office of

Inspector General) 14, 96–97

Department of Veterans Affairs 14, 67, 72

Depression (see Mental Health Care) 33

Diabetes 29–31, 33, 40, 57

Acupuncture 39

Advance Beneficiary Notice 89

Advance Directives 103–104

ALS (Amyotrophic Lateral Sclerosis) 17, 22

Ambulance Services 26, 38

Ambulatory Surgical Center 26, 28

Anxiety (see Mental Health Care) 33

Appeal 86–91, 106–107

Artificial Limbs 35

Assignment 25, 46–47

Barium Enema 28, 40

Benefit Period 115, 120

Bills 46, 73, 89, 96, 107

Blood 19, 26, 120–121

Blue Words 4, 115–118

Bone Mass Measurement (Bone Density) 27, 40

Braces (arm/leg/back/neck) 35

Breast Exam 34, 40

Cataract 30

Catastrophic Coverage 66

Children’s Health Insurance Program 84

Chiropractic Services 27

Claims 45–47, 87, 106–107

Clinical Laboratory Services 27, 121

Clinical Research Studies 20, 27

COBRA 22, 24, 71

107–108

Discrimination 86, 97

Disenroll 52, 59, 118

Drug Plan 43–44, 49, 62–72, 78–81, 90–91, 122

Drugs (outpatient) 35, 69, 120

Drugs (prescription) 12, 35, 44–49, 55–57, 62–72,

78–82, 90–91, 120

Durable Medical Equipment (like walkers) 19, 30, 32,

35, 47, 120–121

Eldercare Locator 101–102

Electronic Handbook inside front cover

Electronic Health Record 44, 123

Emergency Room Services 20, 30, 69, 106

Employer Group Health Plan Coverage 24, 43–45, 49,

52–53, 60, 63, 67, 71, 73, 80, 100

End-Stage Renal Disease (ESRD) 12, 18, 22–23, 32,

51–53, 73

Enroll 17–18, 21–24, 58–59, 63–64, 75, 79–80

Equipment (like walkers) 19, 30, 32, 35, 47, 120–121

ESRD Network Organization 53

Exception (Part D) 69, 90–91

Extra Help (Help Paying Medicare Drug Costs) 49, 62,

78–81, 116

Eye Exam 30, 31

Eyeglasses 30

Federal Employee Health Benefits Program 14, 24, 72

Federally-Qualified Health Center Services 31, 36

Flexible Sigmoidoscopy 26, 28, 40

Flu Shot 31, 40

Foot Exam 31

Formulary 44, 65, 69, 78

Fraud 94–97

General Enrollment Period 18, 22–23

Glaucoma Test 31, 40

Health Information Technology (Health IT) 123

Health Maintenance Organization (HMO) 43, 50, 55

Hearing Aids 31, 39

Help with Costs 49, 54, 78–84

Hepatitis B Shot 31, 40

Home Health Care 16, 19, 32, 82, 89, 107–108,

120–121

Hospice Care 16, 19, 50, 120

Hospital Care (Inpatient Coverage) 16, 20, 30, 120

Immunizations 25, 31, 34–35, 40, 69

Indian Health Service 44, 52, 72

Institution 57–58, 63, 79, 81, 116

Medicare Drug Plan 43, 62–72, 79–80, 90–91, 122

Medicare Health Plan 52, 58–61

Kidney Transplant 12, 18, 33, 37, 53

Part A 18

Part B 21–24

Part D 67, 78, 122

Lifetime Reserve Days 116, 120

Limited Income 49, 54, 78–84, 106

Living Will 103

Low-Income Subsidy (LIS) 49, 62, 78–81, 116

Medicaid 57–58, 61, 63, 73, 79, 81–82, 101

Medical Equipment 19, 30, 32, 35, 47, 120–121

Medical Nutrition Therapy 33, 40

Medical Savings Account (MSA) Plans 56, 58, 62

Medically Necessary 21, 25, 30, 69, 100, 117

Medicare

Part A 16–20, 43, 119–120

Part B 21–38, 43, 119, 121

Part C 43, 50–59, 122

Part D 43–44, 49, 62–72, 78–81, 90–91, 122

Medicare Advantage Plans (like an HMO or PPO) 43,

50–59, 87

Medicare Authorization to Disclose Personal Health

Information 106

Medicare Beneficiary Ombudsman 98

Medicare Card (lost) 14, 17

Medicare Cost Plan 60

Medicare Prescription Drug Coverage 43–44, 49,

62–72, 78–81, 90–91, 122

Medicare Prescription Drug Plans (PDP) 43–44, 49,

62–72, 78–81, 90–91, 122

Medicare Savings Programs 79, 83

Medicare SELECT 74–75

Medicare Summary Notice (MSN) 46, 87, 92, 96–97

Medigap (Medicare Supplement Insurance) 23–24, 43,

45, 48, 52, 59, 71, 74–76

Mental Health Care 20, 33, 57, 120–121

Nurse Practitioner 33

Nursing Home 57–58, 79, 81–82, 100–101, 104, 108

Nutrition Therapy Services 33, 40

Office for Civil Rights 14, 93, 97

Office of Inspector General 14, 96–97

Office of Personnel Management 14, 72, 100

Ombudsman (Medicare Beneficiary) 98

Online 2, 59, 64, 80, 95, 107, 123

Original Medicare 13, 43, 45–49, 74–75, 87–89,

92–93, 120–121

Orthotic Items 35

Outpatient Hospital Services 33–34, 121

Oxygen 30, 106

Part A 16–20, 43, 119–120

Part B 21–38, 39, 43, 119, 121

Part C 43, 50–59, 122

Part D 43–44, 49, 62–72, 78–81, 90–91, 122

Payment Options (premium) 70, 119

Pelvic Exam 34, 40, 55, 57

Penalty

Part A 18

Part B 21–24

Part D 67, 78, 122

Personal Health Record 123

Physical Exam 26, 30, 34, 40

Physical Therapy 19–20, 32–34, 121

Physician Assistant 33

Pilot/Demonstration Programs 13, 61, 117

Pneumococcal Shot 35, 40

Power of Attorney 103

Preferred Provider Organization (PPO) Plan 43, 50, 55

Premium 16–18, 21, 43–45, 49–50, 54, 60, 65–67, 70,

75, 78–79, 83, 92, 96, 117, 119

Prescription Drugs 12, 35, 44–49, 55–57, 62–72,

78–82, 90–91, 115, 120

Preventive Services 25–36, 40, 106–107

Primary Care Doctor 45, 55–57, 117–118

Private Contract 48

Private Fee-for-Service (PFFS) Plans 56, 62

Programs of All-Inclusive Care for the Elderly (PACE) 61,

82, 101

Prostate Screening (PSA Test) 35, 40

Proxy (Health Care) 103–104

Publications 109

Quality Improvement Organization (QIO) 14, 88, 105, 118

106, 119

Referral 26, 30, 34, 44–45, 50–51, 55–57, 118

Religious Nonmedical Health Care Institution 16

Replacing a Medicare Card 14, 17

Retiree Health Insurance 24, 43–45, 49, 52–53, 67,

71–73, 80, 100

Rights 86–93, 97–98

Rural Health Clinic 35–36

Service Area 44, 52, 55, 58, 59, 63–64, 118

Shingles Vaccine 69

Shots (vaccinations) 25, 31, 34–35, 40, 69

Sigmoidoscopy 26, 28, 40

Skilled Nursing Facility (SNF) Care 16, 20, 36, 100, 115,

118, 120

Smoking Cessation 36, 40

SMP (Senior Medicare Patrol) Program 95

Social Security 14, 16–18, 21–23, 70, 80–81, 84, 94, 119

Special Enrollment Period 18, 22–24, 63, 71

Special Needs Plan (SNP) 53, 57

Speech-language Pathology 19, 32–33, 36, 121

State Health Insurance Assistance Program (SHIP) 14,

42, 107–108, 110–113

State Medical Assistance (Medicaid) Office 61, 80,

82–83, 101, 106

State Pharmacy Assistance Program (SPAP) 82

Substance Abuse 33

Supplemental Policy (see Medigap) 23–24, 43, 45,

48, 52, 59, 71, 74–76

Supplemental Security Income (SSI) 79, 84

Supplies (medical) 19–20, 25, 29–36, 46–47, 86,

96, 106

Surgical Dressing Services 36

Tests 27–29, 31–36

Tiers (drug formulary) 69, 90

Transplant Services 37

Travel 38, 44, 74

TRICARE 14, 24, 67, 72–73

TTY 14, 106, 118

100

Urgently-Needed Care 38, 48, 50, 55, 57, 59

Veterans’ Benefits (VA) 14, 67, 72

Vision 30–31, 50

Welcome to Medicare Physical Exam 26, 30, 34, 40

Wheelchairs 30, 106

www.medicare.gov 107

www.MyMedicare.gov 2, 40, 46, 87, 107

■ Medigap (Medicare Supplement Insurance) Policies—Plan changes. See

page 74.

■ Children’s Health Insurance Program—Your children or grandchildren

may qualify for health insurance through this expanded program. See

page 84.

■ Caregiver Information—If you help someone with Medicare-related

decisions, there are two new resources to help you get the information you

need. See page 109.

■ Medicare Health and Prescription Drug Plans—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.

■ What You Pay for Medicare (Part A and Part B)—Costs are on

pages 119–122.

■ New Ways to Manage Your Health Information—Exciting tools to help

reduce paperwork and improve your quality of care. See page 123.

finances, or coverage may have changed in the last year. Look

at what your coverage would be for next year and see if the

cost, coverage, quality, and convenience meet your needs.

See page 13.

See pages 58 and 63 for other times when you can switch your coverage.

begin if you stay with your current coverage.

At the end of the year, health and prescription drug plans can decide not

to participate in Medicare. See page 59 and 64 for more information about

your options.

■ People age 65 or older

■ People under age 65 with certain disabilities

■ People of any age with End-Stage Renal Disease (ESRD) (permanent kidney

failure requiring dialysis or a kidney transplant)

following parts:

See pages 16–20.

■ Helps cover some preventive services to help maintain your health and to keep

certain illnesses from getting worse

See pages 21–38.

under contract with Medicare

■ Includes Part A, Part B, and usually other coverage like prescription drugs

See pages 50–59.

under contract with Medicare

■ Helps cover the cost of prescription drugs

■ May help lower your prescription drug costs and help protect against higher costs in

the future

See pages 62–72.

coverage. Below are brief descriptions of your coverage choices. Section 2 has

more details about these choices and information to help you decide.

Original Medicare

See pages 45–49.

■ Run by the Federal government.

■ Provides your Part A and/or Part B coverage.

■ You can go to any doctor or hospital that accepts Medicare.

■ You can join a Medicare Prescription Drug Plan to add drug coverage.

■ You can buy a Medigap (Medicare Supplement Insurance) policy (sold by

private insurance companies) to help fill the gaps in Part A and Part B.

Medicare Advantage Plans (like an HMO or PPO)

See pages 50–59.

■ Run by private insurance companies approved by and under contract with

Medicare.

■ Provides your Part A and Part B coverage but can charge different amounts

for certain services. May offer extra coverage and prescription drug coverage,

sometimes for an extra cost. Cost for items and services vary by plan.

■ If you want drug coverage, you must get it through your plan (in most cases).

■ You don’t need and you can’t use a Medigap policy with a Medicare

Advantage Plan.

Other Medicare Health Plans

See pages 60–61.

■ Plans that aren’t Medicare Advantage Plans but are still part of Medicare.

■ Include Medicare Cost Plans, Demonstration/Pilot Programs, and Programs

of All-inclusive Care for the Elderly (PACE).

■ Most plans provide Part A and Part B coverage, and some also provide

prescription drug coverage (Part D).

Note: You might also have health and/or prescription drug coverage from a

former or current employer or union that could affect your choices.

telephone numbers.

State Health Insurance Assistance Program (SHIP)

To get free Medicare counseling and personalized help

making coverage decisions; information on programs for

people with limited income and resources; and help with

claims, billing, and appeals.

Social Security

To replace a Medicare card; change your address or name;

get information about Part A and/or Part B eligibility,

Medicare prescription drug costs; ask questions about

Coordination of Benefits Contractor

To get information on whether Medicare or your other

insurance pays first and to report changes in your insurance

information.

See pages 110–113.

1-800-772-1213

TTY 1-800-325-0778

1-800-999-1118

TTY 1-800-318-8782

Department of Defense

1-866-773-0404

To get information about TRICARE for Life.

TTY 1-866-773-0405

Department of Health and Human Services

1-800-447-8477

If you suspect billing fraud.

TTY 1-800-377-4950

1-800-633-4227

Office for Civil Rights

If you think you were discriminated against or if your health

information privacy rights were violated.

Department of Veterans Affairs

If you are a veteran or have served in the U.S. military.

Office of Personnel Management

To get information about the Federal Employee Health

Benefits Program for current and retired Federal employees.

Railroad Retirement Board (RRB)

If you have benefits from the RRB, call them to change your

address or name, check eligibility, enroll in Medicare, replace

your Medicare card, and report a death.

1-800-368-1019

TTY 1-800-537-7697

1-800-827-1000

TTY 1-800-829-4833

1-888-767-6738

TTY 1-800-878-5707

Local RRB office or

1-877-772-5772

to get the telephone

number for your QIO.

To ask questions or report complaints about the quality of

care for a Medicare-covered service or if you think your

service is ending too soon.

and Part B cover and how to enroll.

Section 1 includes information about the following:

Part A (Hospital Insurance)

What is it and signing up . . . . . . . . . . . . . . . . . 16–18

Covered Services . . . . . . . . . . . . . . . . . . . . . . 19–20

Part B (Medical Insurance)

What is it and signing up . . . . . . . . . . . . . . . . . 21–25

Covered Services . . . . . . . . . . . . . . . . . . . . . . 26–38

What’s NOT Covered by Part A and Part B? . . . . . . . . . . . 39

Preventive Services Checklist . . . . . . . . . . . . . . . . . . . 40

doctors’ offices, and other health care settings. Services are either covered

under Medicare Part A (Hospital Insurance) or Medicare Part B (Medical

Insurance). If you have both Part A and Part B, you can get all of the

Medicare-covered services listed here, no matter what type of Medicare

coverage you choose.

See pages 19–20 for a list of services covered by Part A and the conditions

you must meet. See pages 26–38 for the Part B-covered services list.

care)

■ Hospice care services

■ Home health care services

■ Inpatient care in a Religious Nonmedical Health Care Institution

(Medicare will only cover the non-medical, non-religious health care

items and services in this type of facility for people who qualify for

agreement with their religious beliefs.)

your spouse paid Medicare taxes while working.

If you aren’t eligible for premium-free Part A, you may be able to buy

Part A if you meet one of the following conditions:

■ You are age 65 or older, and you are entitled to (or enrolling in) Part B

and meet the citizenship or residency requirements.

■ You are under age 65, disabled, and your premium-free Part A coverage

ended because you returned to work.

Call Social Security at 1-800-772-1213 for more information about the

Note: The premium amount for people who buy Part A is on page 119.

in the text

are defined

on pages

115–118.

You can find out if you have Part A by

looking at your Medicare card.

Note: Keep this card safe. If you have

Original Medicare, you will use this card

to get your Medicare-covered services.

use the card from the plan to get your

Medicare-covered services.

get benefits from the Railroad Retirement Board (RRB), visit

www.rrb.gov, and select “Benefit Online Services,” or call the RRB at

1-877-772-5772.

Board (RRB), you automatically get Part A starting the first day of

the month you turn age 65. If you are under age 65 and disabled, you

automatically get Part A after you get disability benefits from Social

Security or certain disability benefits from the RRB for 24 months.

You will get your Medicare card in the mail 3 months before your 65th

birthday or your 25th month of disability.

If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou

Gehrig’s disease), you automatically get Part A the month your

disability benefits begin.

you are still working), you will need to sign up for Part A (even if you are

3 months before you turn age 65. If you worked for a railroad, contact the

RRB to sign up.

in the text

are defined

on pages

115–118.

■ Initial Enrollment Period—When you are first eligible for Medicare.

(This is a 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.)

■ General Enrollment Period—Between January 1–March 31 each year.

Your coverage will begin July 1. You may have to pay a higher premium

for late enrollment. See below.

■ Special Enrollment Period—If you or your spouse (or family member

if you are disabled) is currently working, and you are covered by a

group health plan through the employer or union. See page 22.

■ Special Enrollment Period for International Volunteers—If you are

serving as a volunteer in a foreign country. See page 22.

If you aren’t eligible for premium-free Part A, you may be able to buy

it. However, if you don’t buy Part A when you are first eligible, your

monthly premium may go up 10%. You will have to pay the higher

premium for twice the number of years you could have had Part A, but

didn’t join. For example, if you were eligible for Part A, but didn’t join for

2 years, you will have to pay the higher premium for 4 years. You don’t

have to pay a penalty if you are eligible for a special enrollment period.

For more information on Part A, call Social Security, or visit

www.socialsecurity.gov. If you get benefits from the RRB, call

1-877-772-5772.

If you have End-Stage Renal Disease (ESRD), different rules apply. Visit

your local Social Security office, or call Social Security at 1-800-772-1213

information, visit www.medicare.gov/Publications/Pubs/pdf/10128.pdf

to view the booklet, “Medicare Coverage of Kidney Dialysis and Kidney

Transplant Services.”

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.

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 (see page 30), and medical supplies

for use at home. You must be homebound, which means that

leaving home is a major effort.

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, 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).

Medicare covers some 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.

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

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

covers the doctor and emergency room services you get while you

are in a hospital.

Includes semi-private room, meals, skilled nursing and

rehabilitative services, and other services and supplies (only after

a 3-day minimum inpatient hospital stay for a related illness or

injury). 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

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.

outpatient care, home health services, and other medical services.

Part B also covers some preventive services. You can find out if you

have Part B by looking at your Medicare card.

standard premium amount. However, if your modified adjusted gross

income as reported on your IRS tax return from 2 years ago is above a

certain amount, you may pay more.

Your modified adjusted gross income is your taxable income plus

your tax exempt interest income. Social Security will notify you if you

have to pay more than the standard premium. If you have to pay a

higher amount for your Part B premium and you disagree (even if you

get RRB benefits), call Social Security at 1-800-772-1213. TTY users

should call 1-800-325-0778.

See page 119 to find out if your Part B premium will be higher based

on your income.

If you don’t sign up for Part B when you are first eligible, you may have

to pay a late enrollment penalty. See page 23.

If you have limited income and resources, see page 83 for

See page 121 for other Part B costs.

Board (RRB), in most cases, you will automatically get Part B starting

the first day of the month you turn age 65. If your birthday is on the

first day of the month, your Part B will start the first day of the prior

month. If you are under age 65 and disabled, you will automatically get

Part B after you get disability benefits from Social Security or certain

disability benefits from the RRB for 24 months. You will get your

Medicare card in the mail about 3 months before your 65th birthday

or your 25th month of disability. If you don’t want Part B, follow the

instructions that come with the card, and send the card back. If you

keep the card, you keep Part B and will pay Part B premiums.

in the text

are defined

on pages

115–118.

Gehrig’s disease), you automatically get Part B the month your

disability benefits begin.

may be able to sign up during one of these times:

■ General Enrollment Period—Between January 1–March 31 each

year. Your coverage will begin on July 1. You may have to pay a

late enrollment penalty.

■ Special Enrollment Period—If you wait to sign up for Part B

because you or your spouse is currently working, and you are

covered by a group health plan based on that work, or if you are

disabled and you or a family member is working, and you are

covered by a group health plan based on that work. You can sign

up for Part B anytime while you have group health plan coverage

based on current employment or during the 8-month period that

begins the month after the employment ends, or the group health

plan coverage ends, whichever happens first. If you have COBRA

coverage, you must enroll during the 8-month period that begins

the month after the employment ends. This Special Enrollment

Period doesn’t apply to people with End-Stage Renal Disease

(ESRD).

■ Special Enrollment Period for International Volunteers—If

you waited to sign up for Part B because you had health

insurance while volunteering outside of the U.S. for a tax exempt

organization for at least a year. You can sign up during the

6-month period that begins the first month that any one of the

following happens:

1. You are no longer volunteering outside the U.S.

2. The sponsoring organization is no longer tax exempt.

3. You no longer have health insurance coverage outside the

U.S.

you can sign up for Part B when you sign up for Part A. See page 18.

If you delay signing up for Part B, you can only get it during

the general enrollment period, and you may have to pay a late

enrollment penalty.

If you live in Puerto Rico, and you want Part B, you will need to

sign up for it. Contact your local Social Security office for more

information.

If you aren’t getting Social Security or RRB benefits, and you want

to get Part B, you will need to sign up for Part B during your initial

enrollment period (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 don’t sign up for Part B when you are first eligible, you

may have to pay a late enrollment penalty for as long as you

10% for each full 12-month period that you could have had

Part B, but didn’t sign up for it. Usually, you don’t pay a late

enrollment penalty if you sign up for Part B during a special

enrollment period.

Note: If you are age 65 or older, after you sign up for Part B, you

have a 6-month Medigap open enrollment period which gives you a

guaranteed right to buy a Medigap (Medicare Supplement Insurance)

policy. Once this period starts, it can’t be delayed or replaced. See

page 75.

Call Social Security at 1-800-772-1213 for more information about

should call 1-800-325-0778. If you get RRB benefits, call the RRB at

1-877-772-5772. For general information about enrolling, visit

www.medicare.gov, and select “Find Out if You Are Eligible

for Medicare and When You Can Enroll.” You can also get free,

personalized health insurance counseling from your State Health

Insurance Assistance Program (SHIP). See pages 110–113 for the

telephone number.

in the text

are defined

on pages

115–118.

your TRICARE coverage. However, if you are an active-duty service

member, or the spouse or dependent child of an active-duty service

member, the following applies to you:

■ You don’t have to enroll in Part B to keep your TRICARE coverage

while the service member is on active duty.

■ When the active-duty service member retires, you must enroll in

Part B to keep your TRICARE coverage.

■ You can get Part B during a special enrollment period if you have

Medicare because you are age 65 or older, or you are disabled.

Note: If you are in a Medicare Advantage Plan or choose to join a plan,

tell the plan that you have TRICARE, so your bills can be paid correctly.

Health Benefits Program) or union while you or your spouse is still

working can affect your Part B enrollment rights. You should contact

your employer or union benefits administrator to find out how your

insurance works with Medicare and if it would be to your advantage to

delay Part B enrollment.

When the employment ends, three things happen:

1. You may get a chance to elect COBRA coverage, which continues

your health coverage through the employer’s plan (in most cases for

only 18 months) and probably at a higher cost to you.

2. You may get a special enrollment period to sign up for Part B

without a penalty. This period will run for 8 months and begins the

month after your employment ends. This period will run whether

or not you elect COBRA. If you elect COBRA, don’t wait until

your COBRA ends to enroll in Part B. If you enroll in Part B after

the 8-month special enrollment period, you may have to pay a late

enrollment penalty.

3. When you sign up for Part B, you have a 6-month Medigap open

enrollment period which gives you a guaranteed right to buy a

Medigap (Medicare Supplement Insurance) policy. Once this period

starts, it can’t be delayed or repeated. See page 75.

to diagnose or treat your medical condition and that meet accepted

standards of medical practice.

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).

Use the chart on page 40 to talk to your doctor or other health care

provider about Medicare’s preventive services and ask which services

you need.

You will see this symbol next to the preventive services on the

Pages 26–38 include an alphabetical list of common services that

Medicare Part B covers. To find out if Medicare covers a service not on

this list, visit www.medicare.gov, and select “Find Out What Medicare

should call 1-877-486-2048.

pages give general information about what you must pay if you have

Original Medicare. For some services, there are no costs, but you may

must pay all costs until you meet the yearly Part B deductible before

Medicare begins to pay its share. See page 121 for the Part B deductible

amount. Then, after your deductible is met, you typically pay 20% of

you choose doctors or providers who accept assignment. See page 47.

You also may be able to save money on your Medicare costs if you have

limited income and resources. See pages 78–84.

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.

in the text

are defined

on pages

115–118.

of your one-time “Welcome to Medicare” physical exam. See

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%

Facility fees for approved surgical procedures provided in an

Ambulatory Surgical Center (facility 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.

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.

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.

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.

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.

Includes certain blood tests, urinalysis, some screening tests,

and more. No cost to you.

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.

cancer early, when treatment is most effective. One or more of

the following tests may be covered. Talk to your doctor.

■ 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

■ 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.

■ 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.

■ 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.

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.

For some people diagnosed with heart failure. You pay 20% of

the Medicare-approved amount for the doctor’s services. You

outpatient. The Part B deductible applies.

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,

For people with diabetes. Your doctor or other health care

provider must provide a written order. You pay 20% of the

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).

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.

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 (see page 47), and your

out-of-pocket costs may be less.

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. See page 36.

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

department visit, and you pay 20% of the Medicare-approved

amount for the doctor’s services. The Part B deductible applies.

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, and the Part B

deductible applies.

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.

you get through certain community-based organizations.

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.

If you have diabetes-related nerve damage and/or meet certain

conditions. You pay 20% of the Medicare-approved amount,

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.

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.

fitting hearing aids.

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, and the Part B deductible applies.

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

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.

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.

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.

services if you have diabetes or kidney disease, or you have had

a kidney transplant in the last 36 months, and your doctor refers

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 department,

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 (which is lower than

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. See page 20.

Talk to your doctor if you feel sad, have little interest in things

you used to enjoy, feel dependent on drugs or alcohol, or have

thoughts about ending your life.

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.

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.

pay more for a doctor’s care in an outpatient department of a hospital

than you will pay for the same care in a doctor’s office. You pay a

deductible applies.

For approved procedures (like X-rays, a cast, or stitches). 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.

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

pelvic and breast exams.

A one-time review of your health, and education and counseling

about preventive services, including certain screenings, shots, and

you get it within the first 12 months you have Part B. You pay 20% of

the Medicare-approved amount. When you make your appointment,

let your doctor’s office know that you would like to schedule your

“Welcome to Medicare” physical exam.

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.

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.

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

you get in a hospital outpatient department are part of the service

get other types of drugs in a hospital outpatient department, what

you pay depends on whether you have Part D or other prescription

drug coverage, whether the drug is covered by your drug plan, 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 department. Keep in mind that under Part B,

you pay 100% for most prescription drugs, unless you have Part D

or other drug coverage. See page 69 for more information.

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

the doctor’s visit. You pay nothing for the PSA test.

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.

Includes many outpatient primary care services. You pay 20% of the

amount charged, and the Part B deductible applies.

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.

if you are diagnosed with an illness caused or complicated

by tobacco use, or you take a medicine that is affected by

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.

For treatment of a surgical or surgically-treated wound.

You pay 20% of the Medicare-approved amount for doctor

you get them in a hospital outpatient department. You pay

nothing for the supplies. The Part B deductible applies.

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.

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. See “Clinical

Laboratory Services” on page 27 for other Part B-covered

tests. If you get the test at a hospital as an outpatient, you

pay a specified 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. See page 120.

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

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.

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

To treat a sudden illness or injury that isn’t a medical

emergency. You pay 20% of the Medicare-approved amount, and

the Part B deductible applies.

Medicare doesn’t cover, you will have to pay out-of-pocket unless

you have other insurance to cover the costs. Even if Medicare covers

Items and services that Medicare doesn’t cover include, but aren’t

limited to, long-term care (see page 100), routine dental care,

dentures, cosmetic surgery, acupuncture, hearing aids, and exams for

fitting hearing aids.

To find out if Medicare covers a service you need, visit

www.medicare.gov, and select “Find Out What Medicare Covers,”

1-877-486-2048.

in the text

are defined

on pages

115–118.

which preventive services are right for you. You can also keep track of

your preventive services by visiting www.MyMedicare.gov. See page 107.

Screening

Bone Mass Measurement

Cardiovascular Screenings

Colorectal Cancer Screenings

Fecal Occult Blood Test

Flexible Sigmoidoscopy

Colonoscopy

Barium Enema

Diabetes Screenings

Diabetes Self-management Training

EKG Screening

Flu Shots

Glaucoma Tests

Hepatitis B Shots

Mammogram (screening)

Medical Nutrition Therapy Services

Pap Test and Pelvic Exam

(includes breast exam)

Physical Exam (one-time “Welcome

Pneumococcal Shot

Prostate Cancer Screenings

Smoking Cessation

(counseling to stop smoking)

26

27

27

28

28

28

28

28

29

29

30

31

31

31

32

33

34

34

35

35

36

For some services, you will need to wait a full 12 or 24 months before getting the

service again. See the page numbers listed for more information.

as much as you can about the types of coverage available to you.

Section 2 includes information about the following:

Decide How to Get Your Medicare . . . . . . . . . . . . . . 42–44

Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . 45–49

Medicare Advantage Plans (Part C) . . . . . . . . . . . . . . 50–59

Other Medicare Health Plans . . . . . . . . . . . . . . . . . 60–61

Medicare Prescription Drug Coverage (Part D) . . . . . . . 62–72

Who Pays First When You Have Other Insurance . . . . . . . . 73

Medigap (Medicare Supplement Insurance) Policies . . . . 74–76

This handbook has basic information. You will need more

choose Original Medicare and you want drug coverage, you must

join a Medicare Prescription Drug Plan (Part D). If you choose to

join a Medicare Advantage Plan, the plan may include Medicare

prescription drug coverage. In most cases, if you don’t make a

choice, you will have Original Medicare. See the next page for more

information about your coverage choices and the decisions you need

to make.

Note: If you have End-Stage Renal Disease (ESRD), you will usually

get your health care through Original Medicare. See page 53 for

more information.

Each year you should review your health and prescription needs

because your health, finances, or plan’s coverage may have changed.

If you decide other coverage will better meet your needs, you can

switch plans during certain times. See pages 58 and 63. If you are

satisfied with your current plan’s coverage for the following year, you

don’t need to change plans.

and Medigap Policies in Your Area” or “Compare Medicare

Prescription Drug Plans.”

in the text

are defined

on pages

115–118.

See pages 110–113 for the telephone number of your State Health

Insurance Assistance Program (SHIP).

3. Call 1-800-MEDICARE (1-800-633-4227), and say “Agent.”

language other than English or Spanish, let the customer service

representative know.

information to other entities as permitted or required by law

including for treatment, payment, health care operations, and for

research and other purposes. See pages 92–93 to find out more about

how Original Medicare uses and releases your personal information.

If you have a Medicare Advantage Plan, contact your plan.

■ You have your choice of doctors, hospitals,

and other providers.

■ Generally, you or your supplemental

Part B.

See pages 45–49.

and join a Medicare Prescription Drug Plan.

■ These plans are run by private companies

approved by Medicare.

See pages 62–70.

gaps in Original Medicare coverage. You

can choose to buy a Medigap (Medicare

Supplement Insurance) policy from a private

company.

■ Costs vary by policy and company.

■ Employers/unions may offer similar coverage.

See pages 74–76.

Medicare provide this coverage.

■ In most plans, you need to use plan doctors,

hospitals, and other providers or you pay more

or all of the costs.

■ You usually pay a monthly premium (in

addition to your Part B premium) and a

■ Costs, extra coverage, and rules vary by plan.

See pages 50–59.

it’s offered by your plan, in most cases you

must get it through your plan.

■ If your plan doesn’t offer drug coverage, you

can choose and join a Medicare Prescription

Drug Plan.

See pages 55–57.

Note: If you join a Medicare Advantage

Plan, you don’t need a Medigap policy. If you

already have a Medigap policy, you can’t use

it to pay for out-of-pocket costs you have

under the Medicare Advantage Plan. If you

already have a Medicare Advantage Plan, you

can’t be sold a Medigap policy.

See pages 74–76.

choices if you have limited income and resources. See pages 77–84. You may also have other

coverage, like employer or union, military, or Veterans’ benefits. See pages 71–72.

■ Your other coverage—Do you have, or are you eligible for, other types

of health or prescription drug coverage? If so, read the materials you get

from your insurer or plan, or call them to find out how the coverage works

with, or is affected by, Medicare. If you have coverage through a former or

current employer or union, or get your health care from an Indian Health

or Tribal Health Program, talk to your benefits administrator, insurer, or

plan before making any changes to your coverage.

much do you pay for services like hospital stays or doctor visits? Is there

a yearly limit on what you could pay out-of-pocket for medical services?

Your costs vary and may be different if you don’t follow the coverage rules.

■ Doctor and hospital choice—Do your doctors accept the coverage?

Are the doctors you want to see accepting new patients? Do you have to

choose your hospital and health care providers from a network? Do you

■ Prescription drugs—What are your drug needs? Do you need to join a

your prescription drugs cost under each plan? Are your drugs covered

under the plan’s formulary (drug list)?

■ Quality of care—The quality of care and services given by plans and

other health care providers can vary. Medicare has information to help

you compare plans and providers. See page 108.

■ Convenience—Where are the doctors’ offices? What are their hours?

Which pharmacies can you use? Can you get your prescriptions by mail?

Do the doctors use electronic health records or E-prescribe? See

page 123.

■ Travel—Will the plan cover you in another state?

and Annual Notice of Change (ANOC) your plan sends you each year.

The EOC gives you details about what the plan covers, how much you

pay, and more. The ANOC includes any changes in coverage, costs, or

or ANOC, contact your plan.

in the text

are defined

on pages

115–118.

that is enrolled in Medicare and is accepting new Medicare

patients.

With a few exceptions (see pages 20 and 35), most prescriptions

aren’t covered. You can add comprehensive drug coverage by

joining a Medicare Prescription Drug Plan (Part D).

No.

No.

You may already have employer or union coverage that may pay

costs that Original Medicare doesn’t. If not, you may want to

buy a Medigap (Medicare Supplement Insurance) policy.

■ You generally pay a set amount for your health care

120–121 to find out what you pay.

for more information about Medicare Savings Programs.

■ You generally don’t need to file Medicare claims. The law

requires providers (like doctors, hospitals, skilled nursing

facilities, and home health agencies) and suppliers to file

Medicare claims for the covered services and supplies you get.

the Medicare Program. You will be in Original Medicare unless you

cost for each service). The Federal government manages it. Here are

the general rules for how it works:

■ Whether you have Part A and/or Part B (most people have both).

■ Whether your doctor or supplier accepts “assignment.” See the next page.

■ Whether you and your doctor sign a private contract. See page 48.

■ The type of health care you need and how often you need it.

■ Whether you choose to get services or supplies Medicare doesn’t cover.

If you do, you pay all the costs for these services.

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

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

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

For more information on who pays first when you have other insurance,

see page 73. For more information about help to cover the costs that

Original Medicare doesn’t cover, see pages 74–83.

Notice (MSN) in the mail. The MSN shows all the services or supplies that

providers and suppliers billed to Medicare during each 3-month period,

what Medicare paid, and what you may owe the provider. The MSN isn’t a

bill. When you get your MSN, read it carefully and do the following:

■ If you have other insurance, check to see if it covers anything that

Medicare didn’t.

■ Keep your receipts and bills, and compare them to your MSN to be sure

you got all the services, supplies, or equipment listed. See page 96 for

information on billing fraud.

■ If you paid a bill before you got your MSN, compare your MSN with the

bill to make sure you paid the right amount for your services.

■ If an item or service is denied, call your doctor’s office to make sure the

claim is coded correctly. If not, the office can resubmit. If you want to file

an appeal, see page 87.

MSNs are mailed every 3 months. If Medicare owes you a refund, the

MSN will be mailed as soon as the claim is processed. If you need to

change your address on your MSN, call Social Security at 1-800-772-1213.

RRB at 1-877-772-5772.

Visit www.MyMedicare.gov to track your Medicare claims. See page 107.

has signed an agreement with Medicare to accept the

Most doctors, providers, and suppliers accept assignment, but you

should always check to make sure. You may also want to find out

how much you have to pay for each service or supply before you get

it. In some cases they must accept assignment, like when they have

a participation agreement with Medicare and give you Medicare-

covered services.

If your doctor, provider, or supplier accepts assignment:

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

■ They have to submit your claim to Medicare directly. They can’t

charge you for submitting the claim.

If your doctor, provider, or supplier doesn’t accept assignment:

■ They still must submit a claim to Medicare when they give you

Medicare-covered services. If they don’t submit the claim, ask

them to file a Medicare claim for your services. If they still don’t

file your claim, call 1-800-MEDICARE (1-800-633-4227).

entire charge at the time of service, and then submit your claim to

Medicare to get paid back.

■ They may charge you more than the Medicare-approved amount,

but there is a limit called “the limiting charge.” They can only

charge you up to 15% over the Medicare-approved amount.

The limiting charge applies only to certain services and doesn’t

apply to some supplies and durable medical equipment.

To find doctors and suppliers who accept assignment (participate

in Medicare), visit www.medicare.gov and select, “Find a Doctor

or Other Healthcare Professional” or “Find Suppliers of Medical

Equipment in Your Area.” You can also call 1-800-MEDICARE.

in the text

are defined

on pages

115–118.

or other health care provider who has decided not to provide services

to anyone through Medicare. The private contract only applies to the

services provided by the doctor or other provider who asked you to

sign it. You don’t have to sign a private contract. You can always go to

another doctor who does provide services through Medicare.

If you sign a private contract with your doctor or other provider,

the following rules apply:

■ Medicare won’t pay any amount for the services you get from this

■ You will have to pay the full amount of whatever this doctor charges

you for the services you get.

■ If you have a Medigap (Medicare Supplement Insurance) policy,

it won’t pay anything for the services you get. Call your Medigap

insurance company before you get the service if you have questions.

■ Your doctor must tell you if the service is one that Medicare would

pay for if you got it from another doctor who accepts Medicare.

■ Your doctor must tell you if he or she has been excluded from

Medicare.

You can’t be asked to sign a private contract for emergency or urgent

care.

You are always free to get services not covered by Medicare if you

choose to pay for a service yourself.

You may want to contact your State Health Insurance Assistance

Program (SHIP) to get help before signing a private contract with

any doctor or other health care provider. See pages 110–113 for the

telephone number.

See pages 86–98 for information about your appeal rights and

how to protect yourself and Medicare from fraud.

coverage, you must join a Medicare Prescription Drug Plan.

These plans are available through private companies approved

by and under contract with Medicare. If you don’t currently

have creditable prescription drug coverage, you should think

about joining a Medicare Prescription Drug Plan as soon as you

are eligible. If you don’t join a Medicare Prescription Drug Plan

when you are first eligible and you decide to join later, you may

have to pay a late enrollment penalty. See pages 62–72 for more

information.

If you have creditable prescription drug coverage, call your

employer or union’s benefits administrator before you make any

changes to your 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.

If you automatically qualify for Extra Help, you won’t pay

don’t automatically qualify, you may still get help to pay your

prescription drug costs. See pages 78–81 to find out if you may

qualify for Extra Help.

in the text

are defined

on pages

115–118.

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

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

facilities, or suppliers that belong to the plan).

Medicare Advantage Plans include the following:

■ Health Maintenance Organization (HMO) Plans. See page 55.

■ Preferred Provider Organization (PPO) Plans. See page 55.

■ Private Fee-for-Service (PFFS) Plans. See page 56.

■ Medical Savings Account (MSA) Plans. See page 56.

■ Special Needs Plans (SNP). See page 57.

Make sure you understand how a plan works before you

join. See pages 55–57 for more information about Medicare

Advantage Plan types.

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.

protections, including the right to appeal. See pages 86–89.

■ Check with the plan before you get a service to find out whether

they will cover the service and what your costs may be.

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

Medicare. See page 59.

in the text

are defined

on pages

115–118.

the plan. If you are in a Medicare Advantage Plan that

■ 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

conditions:

■ You have Part A and Part B.

■ 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.

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

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.

in the text

are defined

on pages

115–118.

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.

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.”

following:

Part B premium.

■ Whether the plan pays any of the monthly Part B premium. Some

plans offer this option, usually for an extra cost.

deductibles.

■ 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.

If you have limited income and resources, you may qualify for the

drug coverage costs. See pages 78–81.

■ Help from your state to pay your Part B premium. See page 83.

in the text

are defined

on pages

115–118.

care and services from doctors

or hospitals in the plan’s network

(except emergency care, out-of-area

urgent care, or out-of-area dialysis).

In some plans, you may be able

to go out-of-network for certain

services usually for a higher cost.

In most cases, yes. Ask the plan.

If you want drug coverage, you

must join an HMO Plan that offers

prescription drug coverage.

In most cases, yes.

In most cases, yes. Yearly screening

mammograms and in-network

Pap tests and pelvic exams (at least

every other year) don’t require a

referral.

■ If your doctor leaves the plan,

your plan will notify you. You can

choose another doctor in the plan.

■ If you get health care outside the

plan’s network, you may have to

pay the full cost.

■ It’s important that you follow

the plan’s rules, like getting prior

approval for a certain service

when needed.

Yes. PPOs have network doctors

and hospitals, but you can also

use out-of-network providers for

covered services, usually for a

higher cost.

In most cases, yes. Ask the plan.

If you want drug coverage, you

must join a PPO Plan that offers

prescription drug coverage.

No.

No.

■ There are two types of PPOs—

Regional PPOs and Local

PPOs.

■ Regional PPOs serve one of 26

regions set by Medicare.

■ Local PPOs serve the counties

the PPO Plan chooses to

Sometimes. If your PFFS Plan

doesn’t offer drug coverage, you

can join a Medicare Prescription

Drug Plan to get coverage.

Yes. Some plans may have preferred

doctors and hospitals you could go to

for a lower cost.

No. You can join a Medicare

Prescription Drug Plan to get drug

coverage.

No.

No.

No.

No.

■ PFFS Plans aren’t the same

■ The plan decides how much

you must pay for services.

■ Doctors, hospitals, and other

■ For each service you get, check

to make sure your doctors,

hospitals, and other providers

will agree to treat you under the

plan, and that they will accept

the PFFS Plan’s payment terms.

■ In an emergency, doctors,

hospitals, and other providers

must agree to treat you.

■ Medicare MSA Plans have two parts:

a bank account. Medicare gives the

plan an amount each year for your

health care, and the plan deposits

a portion of this money into your

account. The amount deposited is

less than your deductible amount, so

you will have to pay out-of-pocket

before your coverage begins.

■ Money spent for Medicare-covered

Part A and Part B services counts

toward your plan’s deductible.

After you reach your out-of-pocket

limit, your plan will cover your

Medicare-covered services in full.

■ Any money left in your account at

the end of the year remains in your

account along with the deposit for

next year.

in the plan’s network (except emergency care, out-of-area urgent care, or

out-of-area dialysis). Plans typically have specialists for the diseases or

conditions that affect their members.

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

Generally, yes, or you may need to have a care coordinator to help plan

your care.

In most cases, yes. Yearly screening mammograms and an in-network

Pap test and pelvic exam (at least every other year) don’t require a

referral.

■ A plan must limit plan membership to people in one of the following

or who require nursing care at home, or 2) people who are eligible

for both Medicare and Medicaid, or 3) people who have one or more

specific chronic or disabling conditions (like diabetes, congestive heart

failure, a mental health condition, or HIV/AIDS).

■ Plans may further limit membership within these groups.

■ Plans should coordinate the services and providers you need to help

you stay healthy and follow your doctor’s orders.

■ If you have Medicare and Medicaid, your plan should make sure that

all of the plan doctors or other health care providers you use accept

Medicaid.

■ If you live in an institution, make sure that plan doctors or other health

care providers serve people where you live.

your area. TTY users should call 1-877-486-2048.

■ 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:

(see pages 78–81)

You can call your State Health Insurance Assistance Program (SHIP) for

more information. See pages 110–113 for the telephone number.

No one should call you or come to your home uninvited to sell

Medicare products. See pages 94–97 for more information about

how to protect yourself from identity theft and fraud. If you believe

a plan has misled you, call 1-800-MEDICARE (1-800-633-4227).

in the text

are defined

on pages

115–118.

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

1-877-486-2048. Talk with the plan to find out how you can join.

When you join a Medicare Advantage Plan, you will have to provide

your Medicare number and the date your Part A and/or Part B

coverage started. This information is on your Medicare card.

this is what you need to do:

■ To switch to a new Medicare Advantage Plan, simply join the plan

you choose. You will be disenrolled automatically from your old plan

when your new plan’s coverage begins.

■ To switch to Original Medicare, contact your current plan, or

call 1-800-MEDICARE (1-800-633-4227). TTY users should call

1-877-486-2048. You will also need to decide about Medicare

prescription drug coverage (Part D).

Note: You can only switch plans at certain times. See page 58.

automatically return to Original Medicare if you don’t choose to join

another Medicare Advantage Plan. You will also have the right to buy

certain Medigap policies.

other Medicare Advantage Plans in your area. If your plan offers this

option, you must agree to travel to the plan’s service area to get all your

services (except for emergency and urgently-needed care). If your

plan doesn’t have this option, you will automatically return to Original

Medicare. In this case you will have the right to buy a Medigap policy.

If you decide to return to Original Medicare and you want drug

coverage, you will need to join a Medicare Prescription Drug Plan.

aren’t Medicare Advantage Plans but are still part of Medicare.

Some of these plans provide Part A (Hospital Insurance) and/or

Part B (Medical Insurance) coverage, and some also provide Part D

(Medicare prescription drug coverage). These plans have some of

the same rules as Medicare Advantage Plans. Some of these rules are

explained briefly below and on the next page. However, each type of

plan has special rules and exceptions, so you should contact any plans

you’re interested in to get more details.

in certain areas of the country. Here’s what you should know about

Medicare Cost Plans:

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

■ If you go to a non-network provider, the services are covered under

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

■ You can leave anytime and return to Original Medicare.

■ You can either get your Medicare prescription drug coverage from

the plan (if offered), or you can join a Medicare Prescription Drug

Plan to add prescription drug coverage.

There is another type of Medicare Cost Plan that only provides

coverage for Part B services. These plans never include Part D. Part A

services are covered through Original Medicare. These plans are either

sponsored by employer or union group health plans or offered by

companies that don’t provide Part A services.

For more information about Medicare Cost Plans, contact the plans

you’re interested in. You can also visit www.medicare.gov. Your State

Health Insurance Assistance Program (SHIP) can also give you more

information. See pages 110–113 for the telephone number.

in the text

are defined

on pages

115–118.

studies,” are special projects that test improvements in Medicare

coverage, payment, and quality of care. They usually operate only

for a limited time for a specific group of people and/or are offered

only in specific areas. Check with the demonstration or pilot

program for more information about how it works.

For more information about current Medicare demonstrations and

pilot programs, visit www.medicare.gov, or call 1-800-MEDICARE

1-877-486-2048.

prescription drug coverage for frail elderly and disabled people.

This program provides community-based care and services to

people who otherwise need a nursing home-level of care.

To qualify for PACE, you must meet the following conditions:

■ You are age 55 or older.

■ You are certified by your state as meeting the need for a nursing

home-level of care.

■ At the time you join, you are able to live safely in the community

with the help of PACE services.

PACE uses Medicare and Medicaid funds to cover all of your

Medicare or Medicaid or both to join PACE. Call your State

Medical Assistance (Medicaid) office to find out if you are eligible

and if there is a PACE site near you. For more information, you can

also visit www.medicare.gov/Publications/Pubs/pdf/11341.pdf to

view the fact sheet, “Quick Facts about Programs of All-inclusive

Care for the Elderly (PACE).”

See pages 100–102 for more information about PACE and

long-term care.

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

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.

consider joining a Medicare drug plan. See page 43 for a list of things

to consider when choosing a plan. If you decide not to join a Medicare

drug plan when you are first eligible, and you don’t have other

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.

If you have limited income and resources, you may qualify

coverage. You may also be able to get help from your state.

See pages 78–84.

in the text

are defined

on pages

115–118.

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.

to join.

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.

■ 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.

■ Between January 1–March 31 of each year if you already have Medicare

prescription drug coverage.

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

more information. See pages 110–113 for the telephone number.

should call 1-877-486-2048.

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

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

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

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.

in the text

are defined

on pages

115–118.

but all plans must provide at least a standard level of coverage set

by Medicare.

Below and continued on the next page 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

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.

before your plan begins to pay. Some drug plans don’t have a

deductible.

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). See pages 110–113 for the telephone

number. You can also visit www.medicare.gov and select “Compare

Medicare Prescription Drug Plans.”

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

the year.

a coverage gap and will pay only a small or no copayment once you

reach catastrophic coverage. See pages 78–81.

The example below shows costs for covered drugs in 2010 for a plan

that has a coverage gap.

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

Ms. Smith pays a

Once Ms. Smith

Once Ms. Smith

the first $310 of

copayment, and her and her plan have

has spent $4,550

her drug costs

plan pays its share

spent $2,830 for

out-of-pocket

before her plan

for each covered

covered drugs, she

for the year, her

starts to pay its

drug until what

is in the coverage

coverage gap ends.

share.

they both pay (plus gap. She will have

Now she only pays

to pay all of her

a small copayment

reaches $2,830.

drug costs until she for each drug until

has spent $4,550.

the end of the year.

Call the plans you’re interested in to get specific Medicare drug plan

costs. You can also visit www.medicare.gov, or call 1-800-MEDICARE

(1-800-633-4227). TTY users should call 1-877-486-2048.

■ You didn’t join a Medicare drug plan when you were first eligible for

■ You had a break in your Medicare prescription drug coverage or other

creditable coverage of at least 63 days in a row.

Here are a few ways to avoid paying a penalty:

■ Join a Medicare drug plan when you’re first eligible. You won’t have to

pay a penalty, even if you’ve never had prescription drug coverage before.

■ Don’t go for more than 63 days in a row without a Medicare drug plan

or other creditable coverage. Creditable prescription drug coverage

could include drug coverage from a current or former employer or

union, TRICARE, or the Department of Veterans Affairs. Your plan will

tell you each year if your drug coverage is creditable coverage. Keep this

information, because you may need it if you join a Medicare drug plan later.

■ Let your Medicare drug plan know if you had other creditable coverage.

When you join a plan, you may get a letter asking if you have creditable

coverage. Complete the form they send you. If you don’t tell the plan about

your creditable coverage, you may have to pay a penalty.

penalty, and what your premium will be. To estimate your penalty amount,

count the number of full months that you didn’t have creditable coverage after

you were eligible to join a Medicare drug plan. If you multiply this number

by the “1% penalty calculation” which is $.32 in 2010, you can estimate the

amount that will be added each month to your Medicare drug plan’s premium

for the current year. This penalty amount may increase every year.

ask Medicare for a review or reconsideration. You will need to fill out a

reconsideration request form (that your drug plan will send you), and

you will have the chance to provide proof that supports your case such as

information about previous prescription drug coverage.

in the text

are defined

on pages

115–118.

you begin to use your coverage.

you will get a letter from the plan letting you know they got

your information. You should get a welcome package with your

membership card within 5 weeks or sooner. If you need to go to the

pharmacy before your membership card arrives, you can use any of

the following as proof of membership in your Medicare drug plan:

■ A letter from the plan

■ An enrollment confirmation number that you got from the plan,

the plan name, and telephone number

You should also bring your Medicare and/or Medicaid

card, proof of any other prescription drug coverage, and

more information about what you can use as proof of

Extra Help. If you don’t have any of the items listed above,

and your pharmacist can’t get your drug plan information

any other way, you may have to pay out-of-pocket for

your prescriptions. If you do, save the receipts and

If you want to know how Medicare prescription drug coverage works

with other drug coverage you may have, see pages 71–72.

Once you consider your options and choose a plan, join

early to give the plan time to mail your membership card,

acknowledgement letter, and welcome package before your

coverage becomes effective. This way, even if you go to the

pharmacy on your first day of coverage, you can get your

prescriptions filled without delay. If you don’t get these items,

call your plan.

■ Prior authorization—You and/or your prescriber (your doctor or other

health care provider who is legally allowed to write prescriptions) must

contact the drug plan before you can fill certain prescriptions. Your

the plan to cover it.

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

■ Step therapy—You must try one or more similar, lower cost drugs

before the plan will cover the prescribed drug.

If your prescriber believes that one of these coverage rules should be

waived, you can ask for an exception. See pages 90–91.

each tier have a different cost. For example, a drug in a lower tier will

cost you less than a drug in a higher tier. In some cases, if your drug is on

a higher tier and your prescriber thinks you need that drug instead of a

similar drug on a lower tier, you can file an exception and ask your plan

vaccines (like the shingles vaccine) when medically necessary to prevent

illness except for vaccines that are covered under Part B. Information

about a plan’s list of covered drugs (called a formulary) isn’t included in

this handbook because each plan has its own formulary. Formularies can

change. Contact the plan for its current formulary, or visit the plan’s Web

site. You can also visit www.medicare.gov and select “Compare Medicare

Prescription Drug Plans.”

In most cases the prescription drugs you get in an outpatient setting

like an emergency room (sometimes called “self-administered

drugs”) aren’t covered by Part B. Your Medicare drug plan may cover

these drugs under certain circumstances. You will likely need to pay

out-of-pocket for these drugs and submit a claim to your drug plan

for a refund. Call your plan for more information. You can also visit

www.medicare.gov/Publications/Pubs/pdf/11333.pdf to view the

fact sheet, “How Medicare Covers Self-Administered Drugs Given in

Hospital Outpatient Settings.”

in the text

are defined

on pages

115–118.

able to pay your Medicare drug plan premium in one of four ways:

Deducted from your checking or savings account.

Billed to you each month directly by the plan. Some plans bill

in advance for coverage the next month. Send your payment to

4. Deducted from your monthly Social Security payment.

Contact your drug plan (not Social Security) to ask for this

payment option. With this option, your first deductions usually

take 3 months to start, and 3 months of premiums will likely be

collected at one time. You may also see a delay in premiums being

withheld if you switch or leave plans.

For more information about your Medicare drug plan premium or

ways to pay for it, contact your drug plan.

Use the following resources to get more information about

■ 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

■ Contact your State Health Insurance Assistance Program (SHIP)

for free, personalized health insurance counseling. See

pages 110–113 for the telephone number.

1.

2. Charged to a credit or debit card.

3.

insurance you have works with, or is affected by, Medicare prescription drug

coverage (Part D).

Employer or Union Health Coverage—Health coverage from your, your

spouse’s, or other family member’s current or former employer or union.

If you have prescription drug coverage based on your current or previous

employment, your employer or union will notify you each year to let you

know if your drug coverage is creditable. Keep the information you get.

Call your benefits administrator for more information before making any

changes to your coverage.

COBRA—A Federal law that may allow you to temporarily keep employer

or union health coverage after the employment ends or after you lose

coverage as a dependent of the covered employee. As explained on page

24, there may be reasons why you should take Part B instead of COBRA.

plan without paying a penalty when the COBRA coverage ends. Talk with

your State Health Insurance Assistance Program (SHIP) to see if COBRA is

a good choice for you. See pages 110–113 for the telephone number.

Medigap (Medicare Supplement Insurance) Policy with Prescription

Drug Coverage—Medigap policies can no longer be sold with prescription

drug coverage, but if you have drug coverage under a current Medigap

policy, you can keep it. However, it may be to your advantage to join a

Medicare drug plan because most Medigap drug coverage isn’t creditable.

If you join a Medicare drug plan, your Medigap insurance company must

remove the prescription drug coverage under your Medigap policy and

information.

Note: Keep any creditable coverage information you get from your plan.

You may need it if you decide to join a Medicare drug plan later. Don’t send

creditable coverage letters/certificates to Medicare.

current and retired Federal employees and covered family members. If you

join a Medicare drug plan, you can keep your FEHBP plan, and your plan

will let you know who pays first. For more information, contact the Office

of Personnel Management at 1-888-767-6738, or visit www.opm.gov/insure.

questions.

Veterans’ Benefits—Health coverage for veterans and people who have

served in the U.S. military. You may be able to get prescription drug coverage

through the U.S. Department of Veterans Affairs (VA) program. You may join

a Medicare drug plan, but if you do, you can’t use both types of coverage for

the same prescription. For more information, call the VA at 1-800-827-1000,

or visit www.va.gov. TTY users should call 1-800-829-4833.

TRICARE (Military Health Benefits)—Health care plan for active-duty

service members, retirees, and their families. Most people with TRICARE

who are entitled to Part A must have Part B to keep TRICARE prescription

drug benefits. If you have TRICARE, you aren’t required to join a Medicare

Prescription Drug Plan. If you do, your Medicare drug plan pays first,

and TRICARE pays second. If you join a Medicare Advantage Plan with

prescription drug coverage, TRICARE won’t pay for your prescription

drugs. For more information, call the TRICARE pharmacy contractor at

1-877-363-8779, or visit www.tricare.mil. TTY users should call

1-877-540-6261.

Indian Health Services—Health care for people who are American Indian/

Alaska Native through an Indian health care provider. If you get prescription

drugs through an Indian health pharmacy, you pay nothing and your

coverage won’t be interrupted. Joining a Medicare drug plan may help your

Indian health provider with costs, because the drug plan pays part of the cost

of your prescriptions. Talk to your benefits coordinator who can help you

choose a plan that meets your needs and tell you how Medicare works with

your health care system.

cases, it will be to your advantage to keep your current coverage.

coverage), there are rules that decide whether Medicare or your

other insurance pays first. The insurance that pays first is called the

“primary payer” and pays up to the limits of its coverage. The one that

pays second, called the “secondary payer,” only pays if there are costs

left uncovered by the primary coverage.

If your other coverage is from an employer or union group health

plan, these rules apply:

■ If you are retired, Medicare pays first.

■ If your group health plan coverage is based on your or a family

member’s current employment, who pays first depends on your

age, the size of the employer, and whether you have Medicare based

on age, disability, or End-Stage Renal Disease (ESRD):

— If you are under age 65 and disabled, your plan pays first if the

employer has 100 or more employees or at least one employer

in a multiple employer plan has more than 100 employees.

— If you are over age 65 and still working, your plan pays first

if the employer has 20 or more employees or at least one

employer in a multiple employer plan has more than 20

employees.

■ If you have Medicare because you have ESRD, your plan pays first

for the first 30 months you have Medicare.

The following types of coverage usually pay first:

■ No-fault insurance (including automobile insurance)

■ Liability (including automobile insurance)

■ Black lung benefits

■ Workers’ compensation

Medicaid and TRICARE never pay first. They only pay after

Medicare, employer group health plans, and/or Medigap have paid.

If you have other insurance, tell your doctor, hospital, and

pharmacy. If you have questions about who pays first, or you

need to update your other insurance information, call Medicare’s

should call 1-800-318-8782. You may need to give your Medicare

number to your other insurers (once you have confirmed their

identity) so your bills are paid correctly and on time.

supplies. A Medigap policy, sold by private insurance companies, can

help pay some of the health care costs (“gaps”) that Original Medicare

Medigap policies also offer coverage for services that Original Medicare

doesn’t cover, like medical care when you travel outside the U.S. If you

have Original Medicare and you buy a Medigap policy, both plans will

costs. Medicare doesn’t pay any of the costs for a Medigap policy.

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 sell you only a

“standardized” Medigap policy identified in most states by letters, Plans

A through N. All plans offer the same basic benefits but some offer

additional benefits, so you can choose which one meets your needs.

Note: In Massachusetts, Minnesota, and Wisconsin, Medigap policies are

standardized in a different way.

NEW: Starting June 1, 2010, the types of Medigap Plans that you

1. There will be two new Medigap Plans offered—Plans M and N.

2. Plans E, H, I, and J will no longer be available to buy. If you

already have or you buy Plan E, H, I, or J before June 1, 2010, you

can keep that plan. Contact your plan for more information.

same Medigap coverage. As you shop for a Medigap policy, be sure you

are comparing the same Medigap policy (for example, compare Plan A

from one company with Plan A from another company).

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 coverage).

in the text

are defined

on pages

115–118.

insurer, and you pay your monthly Part B premium. See page 119.

■ A Medigap policy only covers one person. If you and your spouse both

want Medigap coverage, you must each buy separate policies.

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

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

■ The best time to buy a Medigap policy is during the 6-month period that

begins on the first day of the month in which you are both age 65 or older

and enrolled in Part B. (Some states have additional open enrollment

periods.) After this initial enrollment period, your option to buy a

Medigap policy may be limited.

■ If you are under age 65, you may have additional rights to buy a Medigap

policy, depending on the laws in your state.

■ If you have a Medigap policy and join a Medicare Advantage Plan (like an

HMO or PPO), you may want to consider dropping your Medigap policy.

You can continue to pay your Medigap premium, but your policy can’t be

■ If you want to drop your Medigap policy, you must contact your

insurance company to cancel the policy.

■ If you already have a Medicare Advantage Plan, it’s illegal for anyone

to sell you a Medigap policy unless you are switching back to Original

Medicare.

with the plan, you will have special rights to buy a Medigap policy if you

return to Original Medicare within 12 months of joining.

— If you had a Medigap policy before you joined, you may be able to

get the same plan back if the company still sells it.

— The Medigap policy can no longer have prescription drug coverage

even if you had it before, but you may be able to join a Medicare

Prescription Drug Plan.

— If you joined a Medicare health plan when you were first eligible for

Medicare, you can choose from any policy.

■ If you buy a Medicare SELECT policy you also have rights to change your

mind within 12 months and switch to a standard Medigap policy.

■ You can’t have drug coverage in both your Medigap policy and a

Medicare drug plan. See page 71.

view the booklet, “Choosing a Medigap Policy: A Guide to

Health Insurance for People with Medicare.”

■ Call your State Insurance Department to get more information.

Call 1-800-MEDICARE (1-800-633-4227) to get the telephone

Plans and Medigap Policies in Your Area.”

■ Call 1-800-MEDICARE.

■ Call your State Health Insurance Assistance Program (SHIP).

See pages 110–113 for the telephone number.

in the text

are defined

on pages

115–118.

health care and prescription drug costs or provide extra income.

Section 3 includes information about the following:

Drug Coverage (Part D) . . . . . . . . . . . . . . . . . . . 78–81

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

State Pharmacy Assistance Programs (SPAPs) . . . . . . . . . . 82

Programs of All-inclusive Care for the Elderly (PACE) . . . . . 82

Medicare Savings Programs . . . . . . . . . . . . . . . . . . . . 83

Supplemental Security Income (SSI) Benefits . . . . . . . . . . 84

Programs for People Who Live in the U.S. Territories . . . . . . 84

Keep all information you get from Medicare, Social Security,

your Medicare health or prescription drug plan, Medigap

insurer, or employer or union. This may include notices

of award or denial, Annual Notices of Change, notices of

Notices. You may need these documents to apply for the

programs explained in this section. Also keep copies of any

applications you submit.

pay for some health care and prescription drug costs.

The U.S. Virgin Islands, Guam, American Samoa, the Commonwealth

of Puerto Rico, and the Commonwealth of Northern Mariana Islands

provide their residents help with Medicare drug costs. This help isn’t the

from Medicare to pay prescription drug costs if your yearly income and

resources are below the following limits in 2009:

■ Single person—Income less than $16,245 and resources less than $12,510

■ Married person living with a spouse and no other dependents—Income

less than $21,855 and resources less than $25,010

These amounts will change in 2010. You may qualify even if you have a

higher income (like if you still work, or if you live in Alaska or Hawaii, or

have dependents living with you). Resources include money in a checking

or savings account, stocks, and bonds. Resources don’t include your home,

car, household items, burial plot, up to $1,500 for burial expenses (per

person), or life insurance policies.

If you qualify for Extra Help and join a Medicare drug plan, you will get

the following:

on your income and resources and your drug plan’s premium, you

may pay a reduced premium or no premium for a basic plan. For an

enhanced drug plan (a plan that may cover more drugs and generally has

a higher monthly premium), you must pay more for the extra coverage.

are on your plan’s formulary (list of covered drugs). You generally pay

all costs for drugs that aren’t on your plan’s formulary unless you are

granted an exception. See page 90.

■ No coverage gap.

■ No late enrollment penalty.

in the text

are defined

on pages

115–118.

meet one of these conditions:

■ You have full Medicaid coverage.

■ You get help from your state Medicaid program paying your

■ You get Supplemental Security Income (SSI) benefits.

Medicare will mail you a purple letter to let you know you

automatically qualify for Extra Help. You don’t need to apply for

Extra Help if you get this letter.

■ Keep the letter for your records.

■ If you aren’t already in a plan, you must join a Medicare drug plan

to get this Extra Help.

■ If you don’t join a drug plan, Medicare may enroll you in one.

If Medicare enrolls you in a plan, Medicare will send you a yellow

or green letter letting you know when your coverage begins.

■ Different plans cover different drugs. Check to see if the plan you

are enrolled in covers the drugs you use and if you can go to the

pharmacies you want. Compare with other plans in your area.

■ If you’re getting Extra Help, you can switch to another Medicare

drug plan anytime. Your coverage will be effective the first day of

the next month.

■ In most cases, you will pay only a small amount for each covered

prescription.

■ If you have Medicaid, Medicare will provide you with prescription

drug coverage instead of Medicaid. Medicaid may still cover some

drugs that Medicare prescription drug coverage doesn’t cover.

Medicaid may still cover other care that Medicare doesn’t cover.

nursing home), you pay nothing for your covered prescription

drugs.

If you qualify, your drug costs in 2010 will be no more than $2.50

for each generic drug and $6.30 for each brand-name drug. Look

on the Extra Help letters you get, or contact your plan to find out

your exact costs.

because you want to keep your employer or union coverage

instead), call 1-800-MEDICARE (1-800-633-4227) or the plan

Tell them you don’t want to be in a Medicare drug plan (you want

have to pay a penalty if you join later. See page 67.

If you didn’t automatically qualify for Extra Help, you can apply:

■ Call Social Security at 1-800-772-1213 to apply by phone or to get

a paper application. TTY users should call 1-800-325-0778.

■ Visit www.socialsecurity.gov to apply online.

■ Apply at your State Medical Assistance (Medicaid) office. Call

1-800-MEDICARE, and say “Medicaid” to get the telephone

number, or visit www.medicare.gov.

Note: You can apply for Extra Help at any time.

To get answers to your questions about Extra Help, call your State

Health Insurance Assistance Program (SHIP). See pages 110–113

for the telephone number. You can also call 1-800-MEDICARE.

If you apply and qualify for Extra Help, you must join a Medicare

drug plan to get this help. If you don’t join a drug plan, Medicare

may enroll you in one. If Medicare enrolls you in a plan, Medicare

will send you a green letter letting you know when your coverage

begins. Check to see if the plan you are enrolled in covers the drugs

you use and if you can go to the pharmacies you want. If not, you

can switch plans at anytime.

If you have employer or union coverage and you join a Medicare

drug plan, you may lose your employer or union coverage even

if you qualify for Extra Help. Call your employer’s benefits

administrator for more information before you join.

Medicare gets data from your state or Social Security that tells

whether you qualify for Extra Help. If Medicare doesn’t have the

right information, you may be paying the wrong amount for your

prescription drug coverage.

in the text

are defined

on pages

115–118.

■ A copy of a state document that

shows you have Medicaid

■ A print-out from a state electronic

enrollment file or screen print from

your state’s Medicaid systems that

shows you have Medicaid

■ Any other document from your

state that shows you have Medicaid

a nursing home) or a copy of a

state document showing Medicaid

payment to the institution for at

least a month

■ A screen print from your state’s

Medicaid systems showing that you

lived in the institution for at least a

month

letter and the yellow or green letter you got from Medicare as proof

“Notice of Award” from Social Security as proof that you qualify.

You can also give your plan any of the following documents (also called

“Best Available Evidence”) as proof that you qualify for extra help. Your

plan must accept these documents. Each item listed below must show

that you were eligible for Medicaid during a month after June of 2009.

information. If you think you qualify for Extra Help because you have

Medicaid, but you don’t have proof, ask your drug plan for help.

They must help you.

If you paid for prescriptions since you qualified for Extra Help,

If your drug plan doesn’t correct a problem to help you pay the right

amount, doesn’t respond to your request for help, or takes longer than

expected to get back to you, call 1-800-MEDICARE (1-800-633-4227)

■ If you have Medicare and full Medicaid coverage, most of your

health care costs are covered. You have the option of Original

Medicare or a Medicare Advantage Plan (like an HMO or PPO).

■ Medicaid programs vary from state to state. They may also be called

by different names, such as “Medical Assistance” or “Medi-Cal.”

■ People with Medicaid may get coverage for services that Medicare

doesn’t fully cover, such as nursing home and home health care.

■ Each state has different Medicaid eligibility income and resource

limits and other eligibility requirements.

■ In some states, you may need to apply for Medicare to be eligible

for Medicaid.

■ Call your State Medical Assistance (Medicaid) office for more

information and to see if you qualify. Call 1-800-MEDICARE

(1-800-633-4227) and say “Medicaid” to get the telephone number

should call 1-877-486-2048. You can also visit www.medicare.gov.

help certain people pay for prescription drugs based on financial

need, age, or medical condition. Each SPAP makes its own rules

about how to provide drug coverage to its members. Depending on

your state, the SPAP will help you in different ways. To find out about

the SPAP in your state, call your State Health Insurance Assistance

Program (SHIP). See pages 110–113 for the telephone number.

prescription drug coverage for frail elderly and disabled people.

This program allows people who need a nursing home-level of care

to remain in the community. See page 101 for more information.

costs if you have limited income and resources and meet other

eligibility requirements. Some people qualify for both Medicare and

Medicaid (these people are also called “dual-eligibles”).

in the text

are defined

on pages

115–118.

These programs help people with Medicare save money each year.

To qualify for a Medicare Savings Program, you must meet all of

these conditions:

■ Have Part A

■ Single person—Have monthly income less than $1,239 and

resources less than $8,100

■ Married and living together—Have monthly income less than

$1,660 and resources less than $12,910

Note: These amounts may change each year. Many states figure your

income and resources differently or may not have limits at all, so you

may qualify in your state even if your income is higher. Resources

include money in a checking or savings account, stocks, and bonds.

Resources don’t include your home, car, burial plot, up to $1,500 for

burial expenses (per person), furniture, or other household items.

ask for information on Medicare Savings Programs. The names of

these programs and how they work may vary by state. Call if you

think you qualify for any of these programs, even if you aren’t sure.

■ Call 1-800-MEDICARE (1-800-633-4227), and say “Medicaid”

1-877-486-2048.

■ Visit www.medicare.gov/Publications/Pubs/pdf/10126.pdf to

view the brochure, “Get Help With Your Medicare Costs: Getting

Started.”

■ Contact your State Health Insurance Assistance Program (SHIP)

for free health insurance counseling. See pages 110–113 for the

telephone number.

income and resources who are disabled, blind, or age 65 or older. SSI

benefits provide cash to meet basic needs for food, clothing, and shelter.

SSI benefits aren’t the same as Social Security benefits.

To get SSI benefits, you must also meet these conditions:

■ Be a resident of the U.S. (includes the Northern Mariana Islands, but not

the territories listed below).

■ Not be out of the country for a full calendar month or more than

30 consecutive days.

■ Be either a U.S. citizen or national, or in one of certain categories of

eligible non–citizens. People who live in Puerto Rico, the Virgin Islands,

Guam, or American Samoa generally can’t get SSI. You can visit

www.socialsecurity.gov, and use the “Benefit Eligibility Screening Tool”

to find out if you may be eligible for SSI or other benefits. Call Social

Security at 1-800-772-1213, or contact your local Social Security office