THE OFFICIAL U.S. GOVERNMENT MEDICARE HANDBOOK

MEDICARE

AND YOU

 




. 


 

 

 

 

 

You?re getting a

new Medicare card

 

We?ve been mailing new Medicare cards since April 2018. Your new
card has a Medicare Number that?s unique to you, instead of your Social Security
Number. We did this to protect your information and help prevent Medicare fraud.

When you get your new card:

- Destroy your old Medicare card. Make sure you destroy your old card so no one
can get your personal information.

- Start using your new Medicare card right away! Your doctors, other health care
providers, and facilities will ask for your new number, so carry your new card with you
when you need care.

- Keep your other plan cards. If you?re in a Medicare Advantage Plan {like an HMO or
PPO) or a Medicare Drug Plan, keep using that Plan ID card whenever you need care
or prescriptions. However, you should carry your new Medicare card too?you may
be asked to show it.

- Protect your Medicare Number like you do your Social Security Number. Only
give your new Medicare Number to doctors, pharmacists, other health care providers,
your insurer, or people you trust to work with Medicare on your behalf.

Still waiting for your new card? It could be on the way. Here?s how to check:

- Sign in to your edicare.gov account and see when your card is mailed. If
you don?t have a MyMedicare.gov account yet, visit MyMedicare.gov to create one.
Once your new card has mailed, you can sign in anytime to see your new Medicare
Number or print an of?cial copy of your new card.

- Visit Medicare.goleewCard and check the map for the status of card mailings
in your state.

- Ifthe map shows that mailing is completed in your state, and you don 't
have your card, call 1-800-MEDICARE TTY users can call
1-8?7-486-2048. There might be a problem with your mailing address that needs to
be corrected.

 

 

Get the most out of your
Medicare coverage

Use this checklist to help you get started.

Learn about your Medicare choices. Did you know there are different
ways to get your Medicare coverage? See the next few pages to learn more.

Review your current coverage and compare it to other coverage options
for next year to see if there?s a better choice for you. See page 8 for more
information.

If you don?t have Medicare Part A or B, see Section 1, which starts on
page 15, to ?nd out how and when you can sign up. If you don?t have
Medicare prescription drug coverage (Part D), see Section 6, which starts
on page T9. There may be penalties if you don?t sign up when you?re ?rst

eligible.

If you have other health insurance, ?nd out how it works with Medicare.
See pages 20?21.

El Ask your doctor or other health care provider which preventive services
(like screenin s, shots, and tests) you should get. See pages 31?55 and
look for the a to learn more.

Find out if you can get help paying your health and prescription drug
costs. See Section T, which starts on page 93, to see if you?re eligible.

Visit MyMedicare.gov to access your personalized Medicare information.
See pages 115?116.

Help save tax dollars by choosing to access future ?Medicare 3: You?
handbooks electronically. See page 122 to ?nd out how.

El Get free help with your Medicare questions. Visit Medicare. gov, or call
(1?800?633?4227). TTY users can call 1?877?486?2048.
You can also call your State Health Insurance Assistance Program
(SHIP). See the back cover for the phone number. See pages 121?122 to
learn about other resources that are available.

 

 

Your Medicare options

Medicare is health insurance for people 65 or older, certain people under 65 with
disabilities, people with Amyotrophic Lateral Sclerosis (Lou Gehrig?s disease), and
people of any age with End?Stage Renal Disease (ESRD) (permanent kidney failure
requiring dialysis or a kidney transplant).

 

What are the different parts of Medicare?

 

 

 

 

 

 

Medicare Part A (Hospital Insurance) helps cover:
- Inpatient care in hospitals

- Skilled nursing facility care

- Hospice care

- Home health care

See pages 25?29.

 

Medicare Part [Medical Insurance) helps cover:
- Services from doctors and other health care providers

I Outpatient care

- Home health care

- Durable medical equipment

- Many preventive services

See pages 29?55.

 

 

 

 

 

 

 

i555


Medicare Part [Medicare Advantage):
- Includes all bene?ts and services covered under Part A and Part 

- Usually includes Medicare prescription drug coverage (Part D) as part of
the plan

- Run by Medicare?approved private insurance companies that follow
rules set by Medicare

- Plans have a yearly limit on your out?of?pocket costs for medical services
- Usually includes extra bene?ts and services that aren?t covered by
Original Medicare

See pages 61?74.

 

Medicare Part (Medicare prescription drug coverage):
- Helps cover the cost of prescription drugs

- Run by Medicare?approved drug plans that ?ollovv rules set by Medicare
See pages 79?92.

When you ?rst enroll in Medicare and during certain times of the year, you can choose
how you get your Medicare coverage. Here are the main ways to get your Medicare
coverage. These topics are explained in more detail on the next page and throughout
this book. Original Medicare is explained in Section 3 (starting on page 57), and
Medicare Advantage Plans are explained in Section 4 (starting on page 61).

Option 1:

Original Medicare

Option 2:

 

[See pages 
This includes Pa rt A and B.

aFIia
Part A

Hospital Insurance



Part 

Medical Insurance

You can add:

 

(See pages 

6):

Part 

Medicare Prescription Drug Coverage

You can also add:

{See pages P'E?i??l



Supplemental coverage
Supplemental insurance helps pay your
out? of-pocket costs in Original Medicare. Som 
examples include coverage from a former
employer or union, or Medicare Supplement
Insurance [Medigapl policies.

 

Medicare Advantage {Part C)

[See pages a 1? 3'4}

These plans are like HMDsor and
typicallyr include Part A, B, and D.

Plans offer bene?ts that Original Medicare doesn?t
cover like vision, hearing, or dental.

aFFla
Pa rt A

Hospital Insurance



Part 

Medical Insurance



We

Part 
Medicare Prescription Drug Coverage
Most plans cover prescription drug s.



Supple mental coverage
Your cost sharing is lower [or included) in a
Medicare Advantage Plan.You can't use [and
can't he sold] a Medigap policy ifyou're in a
Medicare Advantage Plan.

Things to consider when choosing
your Medicare coverage

These topics are explained in more detail throughout this boolc. Original Medicare is explained
in Section 3 (starting on page and Medicare Advantage Plans are explained in Section 4
(starting on page 61).

Option 1: I Option 2:
Original Medicare - Medicare Advantage

There?s no limit on how much you Cost Plans have a yearly limit on your out-
pay out- of pocket per year unless you of-poclcet costs. If you join a Medic are
have supplemental CWEMSE- Advantage Plan, once you reach a
certain limit, you?ll pay nothing for
covered services for the rest of the year.

 

 

Medicare covers medical services Coverage* Plans must cover all of the services that
and supplies in hospitals, doctors? Original Medicare covers. Plans may
of?ces, and other health care settings. offer bene?ts that Original Medicare
Services are either covered under doesn?t cover like vision, hearing, or

 

 

Part A or Part B. dental.
You can add a Medigap policy to Supplemental It may be more cost effective for you
help pay your out-of-p oclcet costs coverage to join a Medicare Advantage Plan

in Original Medicare, like your
deductible and coinsurance.

because your cost sharing is lower (or
included). You can?t use (and can?t be
sold) a Medigap policy if you?re in a
Medicare Advantage Plan.

 

 

 

 

You?ll need to join a Medicare Prescription Most Medicare Advantage Plans
Prescription Drug Plan to get drug drugs?f' include drug coverage.

coverage.

You can go to any doctor that accepts Doctor and You may need to use health care
Medicare. hospital choice providers who participate in the plan?s

network. If so, ?nd out how close the
network?s doctors or pharmacies are
to your home. Some plans o?'er out-of-
networlc coverage.

 

 

You cannot ?nd out if the procedure Coverage and cost You can check with the plan before you
is covered until the procedure has determinations get a service or supply to ?nd out if it?s
been performed. covered and what your costs may be.

 

 

Original Medicare generally doesn?t
cover care outside the U.S. You
may be able to buy supplemental
insurance that offers travel coverage.

Plans usually don?t cover care you get
outside of the 

 

 

 

If you have other es of health or prescription drug coverage, check to see how it works with the
type of coverage you?re considering before you make any decisions or changes.

7

Important Enrollment Information

You don?t need to sign up for Medicare each year. However, each year you?ll have a
chance to review your Medicare health and prescription drug coverage and make

changes.

Coverage and costs change yearly

Medicare health plans and prescription drug plans can make changes each year?
things like cost, coverage, and which providers and pharmacies are in their networks.
Plans also can change their provider networks throughout the year. If you?re in a
Medicare health or prescription drug plan, always review the materials your plan sends
you (like the Annual Notice of Change and Evidence of Coverage) and make sure

your plan will still meet your needs for the following year. If you?re satis?ed that your
current plan will meet your needs for next year and it?s still being offered, you don?t

need to do anything.

Mark your calendar with these important dates! This may be the only chance you
have each year to make a change to your Medicare health and prescription drug
coverage.

 

Start comparing your coverage with other options. You
October 2018 may be able to save money. See Section 11, which starts on
page 129, or visit Medicaregovf?nd-a-plan.

 

October 15? Change your Medicare health or prescription drug
December 7'Jr 201 3 coverage for 2019, if you decide to.

 

New coverage begins if you made a change. New costs
and bene?t changes also begin if you keep your existing

 

January 1' 2019 Medicare health or prescription drug coverage and your
plan makes changes.
The Medicare Advantage Open Enrollment Period gives
January 1_ you an opportunity to try out a Medicare Advantage Plan.
March 31! 2019 It also lets you switch back to Original Medicare depending

on which coverage works better for you. During this
period, you can make up to 1 switch to a different Medicare
Advantage Plan. See page 71.

 

 

Other ways to read this
handbook

Want to go paperless and read this information
oane?

Sign up at Medicaregovfgopaperless to get your future ?Medicare

3: You? information electronically (also called the ?eHandbook?).

We?ll send you an email next September when the new eHandbook is
available. The online version contains all the same information, but
unlike the paper version, it?s updated regularly throughout the year. This
means you can instantly ?nd the most up?to?date Medicare information
you need. You won?t get a printed copy of your ?Medicare 3: You?
handbook in the mail if you choose to get it electronically.

Have an eReader (like an iPad, NOOK, Sony Reader,

or Kindle)?

Visit Medicaregov!? publications to download a free digital version of
this handbook to your eReader. This option is available for all eReader
devices. You can get the same important information that?s included

in the printed version in an easy?to?read format that you can take
anywhere you go. You?ll still get a printed copy of the ?Medicare 3: You?
handbook in the mail if you choose to download the digital version.

Contents

Topics 10

Section 1:
Signing up for Medicare Part A 8: Part 15

Section 2:
Find out if Medicare covers your test, service, or item 25

Section 3:
Original Medicare 5?

Section 4:
Learn about Medicare Advantage Plans 8: other options 61

Section 5:
Medicare Supplement Insurance {Medigap} Policies 75

Section 6:
Medicare prescription drug coverage {Part T9

Section 
Get help paying your health 8: prescription drug costs 93

Section 8:
Know your rights 8: protect yourself from fraud 99

Section 9:
Get more information 113

Section 10:
De?nitions 123

Section 11:
Compare health 8: prescription drug plans in your area 12?

1o 

Topics

 

 

Note: The page numbers shown in bold provide the most detailed information.

 

 

A

Abdominal aortic aneurysm 31

ABN. See Advance Bene?ciary Notice of Noncoverage.
Accountable Care Organizations (ACOs) 
Acupuncture 55

Advance Bene?ciary Notice of Noncoverage (ABN) 103?

104
Advance Care Planning 31
Advantage Plan. See Medicare Advantage Plan.
Alcohol misuse screening and counseling 31

ALS. See Amyotrophic lateral Sclerosis (also known as
lou Gehrig's disease)

ambulance services 32, 53
Ambulatory surgical center 32
Amyotrophic Lateral Sclerosis 15
Appeal 63100?104, 11A

Arti?cial limbs 49

Assignment 50,613, 123


Balance exam 42
Barium enema 3?

Bene?ciary and Family Centered Care Quality
Improvement Organizations 103, 121

Bene?t period 22?23, 123

Bills 23?24, 59, 101

Blood 26,32

BlueButton 111

Bone mass measurement (bone density) 33
Braces (arm, leg back, neck) 49

Breast exam (clinical) 34


Cardiac rehabilitation 33
Cardiovascular disease (behavioral therapy) 34

Cardiovascularscreenings 3A
Cataract A1
Catastrophiccoverage 84
Chemotherapy 35, 6A, 123
Chiropractic services 35

Chronic Care Management Services 35
Claims 60, 111, 115?116

Clinical research studies 36, 62
COBRA 13?1990

Colonoscopy 36

Colorectal cancer screenings 36

Consolidated Omnibus Budget Reconciliation Act.
See COBRA.

Coordination of bene?ts 21, 121
Cosmetic surgery 55
Cost Plan. See lvledicare Cost Plans.

Costs (copayments, coinsurance, deductibles, and


Comparison of plan costs 122?123

Extra Help paying for Part 93?95

Help with PartA and Part costs 95?96

Medicare Advantage Plans 66

Original lvledicare 

PartA and Part 22-25, 26?55

Part late enrollment penalty 35?3?
Coverage determination (Part D) 102?1 O3
Coverage gap 84, 93
Covered services (Part A and Part B) 25?55
Creditable prescription drug coverage 31?32, 123
Custodial care 29, 56, 124

Topics 11

 

 

Note: The page numbers shown in bold provide the most detailed information.

 

 



De?brillator (implantable automatic) 3?
De?nitions 123?126

Demonstrationsr?pilot programs 1'4, 124
Dental care and dentures 1'5
DepartmentofDefense 121

Department of Health and Human Services. See Of?ce
for Civil Rights.

Department ofMeteransAffairs 91, 121
Depression 31,46

Diabetes 35, 38-39, 45

Dialysis (kidney dialysis) 16, 51, 64, 65?61', FD
Disability 4, 15-18, 20, 96

Disenroll 81

DNAtesting 36

Donut hole. See Coverage gap.

Drug plan

Costs 82?86

Enrollment 80?81

Types of plans 19?80
What'scovered 81?88

Drugs {outpatient) 48

Dual eligibles 96

Durable medical equipment (like walkers) 4, 30,
39-40, 128


EHR. See Electronic Health Record.
EKGIECG 41, 52
Electrocardiogram. See EKGIECG.
Electronic handbook 113, 115, 122
Electronic Health Record (EHR) 118
Electronic Medicare Summary 59, 115
Electronic prescribing 119
Emergency department services 41
Employer group health plan coverage
Costs for Part A may be different 26

Medicare Advantage Plan (Part C) 66
Medigap Open Enrollment 
Prescription drug coverage 80, 85, 9D
See Electronic Medicare Summary 
End?Stage Renal Disease 44, 64?66, 1'0
Enroll
Part4 15?18
Part 15?21
PartC 64?65
Part 80?81
ESRD. See End?Stage Renal Disease.
Exception (Part D) 81', 88, 102

Extra Help (help paying Medicare drug costs) 1'2,
93?96, 120, 124

Eyeglasses 41


Fecal occult blood test 36

Federal Employee Health Bene?ts (FEHB) Program 91,
122

Federally Quali?ed Health Center services 41, 51
FEHB. See Federal Employee Health Bene?ts Program.
Flexible sigmoidoscopy 36

Flu shot 41

Foot exam 42

Form 1095-8 21

Formulary 82, 102, 124

Fraud 81110-112



Gap (coverage). See Coverage Gap.
General Enrollment Period 18, 23, 1'1, 80
Glaucomatest 42



Health Insurance Marketplace 18?19

Health Maintenance Organization (HMD) 6?
Health riskassessment 54

12 Topics

 

 

Note: The page numbers shown in bold provide the most detailed information.

 

 

Hearing aids 42, 55, 1'5

HepatitisBshot 42

43

Hll.l screening 43

HMO. See Health Maintenance Organization.
Home health care 4, 25?26, 44, 103, 123
Hospice care 4, 25, 26, 62, 103

Hospital care (inpatient coverage) 22?23

I

Identitytheft 110

Indian Health Service 92

Initial Enrollment Period 21, 80
Inpatient 22?23

Institution 124



Join
Medicare drug plan 30?31
Medicare health plan 64?65



Kidney dialysis 16, 44, 51, 64, 65?62, 1'0, 114
Kidney disease education services 44

Kidney transplant 16, 45, 52-53, 65?66



laboratory services 45, 52

late enrollment penalty. See Penalty.
lifetime reserve days 23, 124

limited income 93?93

long?term care 55, 56, 125

lovv?Income Subsidy (US). See Extra Help.
lung cancer screening 45


Mammogram 33

Marketplace. See Health Insurance Marketplace.

Medicaid 56, 1'2, 31
Medical equipment. See Durable medical equipment.
Medical nutrition therapy 45
Medical Savings Account (MSA) Plans 64
Medicare
PartA 
Part 4
PartC 4
Part0 4, 29?90
Medicare Administrative Contractor 101
Medicare Advantage Plan {like an HMO or FPO)
How they vvorkvvith other coverage 65
local plan listings 122?123
Plan types 62?20
Star ratings 1'2
Medicare Authorization to Disclose Personal Health
Information 113
Medicare Bene?ciary 0mbudsman 112
Medicare Cost Plans 23, 1'9, 32
Medicare Drug Integrity Contractor 111
Medicare.gov 114
Medicare?Medicaid Plans 9?
Medicare plans 122?123

Medicare prescription drug coverage. See Prescription
drug coverage (Part 0).

Medicare Savings Programs 95?96

Medicare Summary Notice (MSN) 101, 110, 115

Medicare Supplement Insurance (Medigap) 53, 65,
25?23, 90

Medication Therapy Management Program 39

Medigap. See Medicare Supplement Insurance.

Mental health care 46

MSA. See Medical Savings Account Plans.

MSN. See Medicare Summary Notice.

MyMedicare.gov 59, 111, 115

Topics 13

 

 

Note: The page numbers shown in bold provide the most detailed information.

 

 



Notices 59, 101, 103?104, 110, 115
Nurse practitioner 39

Nursing home 31, 94, 124

Nutrition therapy services. See Medical nutrition
therapy.

0

Obesity screening and counseling 46
Occupationaltherapy 46

Of?ce for Civil Rights 101r

Of?ce of Personnel Management 23, 122
Ombudsman 112

Open Enrollment 63, 30, 100

OPM. See Of?ce of Personnel Management.
Original Medicare 26,29

Orthotic items 49

Outpatient hospital services 22?23, 42
Oxygen 39



PACE. See Programs of All?inclusive Care for the Elderly.

Payment options (premium) 23?24
Pelvic exam 34
Penalty (late enrollment)

PartA 22

Part3 23

PartD 35?31r
PEES. See Private Fee?for?Service Plans.
Pharmaceutical Assistance Programs 93
Physical therapy 4?
Physician assistant 39
Pilotldemonstration programs 124
Pneumococcal shots 43
PPO. See Preferred Provider Organization.
Preferred Provider Organization (PPO) Plan 63
Prescription drug coverage (Part D)

Appeals 100?103
Coverage under Part A 26?23
Coverage under Part3 43
Join, switch, or drop 30?31
Medicare Advantage Plans 64
Overview 29?90
Preventive services 31?55, 126
Primary care doctor 34, 42, 45, 46, 53, 62?20, 126
Privacynotice 106?101r
Private Fee?for?Service (PEFS) Plans 69

Programs of All?inclusive Care forthe Elderly (PACE) 74,
93

Prostate screening (PSA test) 49
Publications 120

Puerto Rico 1920, 100, 102
Pulmonary rehabilitation 49


Quality of care 1'4, 99


Railroad Retirement Board 15?16, 19, 59, 32, 33,
122
Referral
Considervvhen choosing a plan 2
De?nition 126
Medicare Advantage Plans 62?30
Original Medicare 53
Part B?covered services 41, 49, 52
Religious non?medical health care institution 25, 29
Respite care 2?
Retiree health insurance (coverage) 90?91
RRB. See Railroad Retirement Board.
Rural Health Clinic 49, 51

5
Second surgical opinions 50
Senior Medicare Patrol (SMP) Program 111

14 Topics

 

 

Note: The page numbers shown in bold provide the most detailed information.

 

Service area 63, 126

Sexually transmitted infections screening and
counseling 50

SHIP. See State Health Insurance Assistance Program.

Shots (vaccinations) 41, 43, 50, 54, 126

Sigmoidoscopv 36

Skilled nursing care 4, 25, 22?29, 1'6, 103,
104, 126

Smoking cessation {tobacco?use cessation) 51
SNF. See Skilled nursing facility (SHE) care.
SNP. See Special Needs Plans.
Social Securitv

Change address on MSN 59

Extra Help paving Part costs 93

Get questions answered 120

PartA and Part premiums 22?25

Part premium 32?33

Sign up for PartA and Part 16?11r

Supplemental Securitv Income (SSI) bene?ts 93
SPAP See State Pharmacv Assistance Program.
Special Enrollment Period

PartA and Part 

Part (Medicare Advantage Plans) 22?23

Part (Medicare Prescription Drug Plans) 31
Special Needs Plans 20
Speech?language pathologv 51
SSI. See Supplemental Securitv Income.
State Medical Assistance (Medicaid) of?ce 91r
State Pharmacv Assistance Program (SPAP) 91r
Supplemental policv (Medigap)

Drug coverage 90

Medicare Advantage Plans 1'9

Open Enrollment 

Original Medicare 53
Supplemental Security Income (SSI) 98
Supplies (medical) 29, 44, 41?; 49, 51, 53

Surgical dressing services 41', 51


Taxforms 21

Telehealth 51

Tel etvpewriter. See 

Tiers (drug formularv) 32, 102
Tobacco?use cessation counseling 51
Transitional Care Management Services 52
Transplant services 33, 45, 52?53, 66?62
Travel 53, 1'6

TRICARE 19,92,121

113



Union
Costs for PartA may be different 26
Enrolling in Part A and Part 13
Medicare Advantage Plan 65
Medigap Open Enrollment 30
Prescription drug coverage 30

Urgentlv needed care 54

1!
MA. See ?v'eterans' bene?ts.
Vaccinations. See Shots.

'v'eterans' bene?ts (MA) 35, 91, 121
Vision (eve care) 41,55



Walkers 39, 123

"Wel come to Medicare" preventive visit 41, 54
Wellnessvisit 54?55

Wheelchairs 39?40


X?rav 28, 41', 52

 

 

 

If you live in
Puerte Rice,
you don?t
automatically
get Part B. You
must sign up
far it. See page
20 for more
information.

 

 

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

15

Section 1:
Signing up for Medicare
Part A 81 Part 

Some people get Part A and Part 
automatically

 

If you?re already getting bene?ts from Social Security or the
Railroad Retirement Board (RRB), you?ll automatically get Part A
and Part starting the ?rst day of the month you turn 65. (If your
birthday is on the ?rst day of the month, Part A and Part will start
the ?rst day of the prior month.)

If you?re under 65 and disabled, you?ll automatically get Part A and
Part after you get disability bene?ts from Social Security or certain
disability bene?ts from the RRB for 24 months.

If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou
Gehrig?s disease), you?ll get Part A and Part automatically the
month your Social Security disability bene?ts begin.

If you?re automatically enrolled, you?ll get your red, white, and blue
Medicare card in the mail 3 months before your 65th birthday or 25th
month of disability bene?ts. If you do nothing, you?ll keep Part and
will pay Part premiums. You can chooSE not to keep Part B, but if
you decide you want Part later, you may have to wait to enroll and
pay a penalty fur as long as you have Part B. See page 27.

Note: If you don?t get your card in the mail, call Social Security

at 1?800?772?1213 and let them know. TTY users can call
1?800?325?0773. Ifyou get RRB bene?ts, call 1?877?772?5772. TTY
users can call 1?312?751?4701.

16 Section 1: Signing up for Medicare Part A 8: Part 

 

 

Nd matter haw
yau in
Medicare, yau?ll
need ta decide
hawta get
yaur Medicare
caverage.

See pages
4?3fdr mare
infermatien.

 

 

 

Some people have to sign up for Part A and/or

Part 

If you?re close to 65, but not getting Social Security or Railroad
Retirement Board (RRB) bene?ts, you?ll need te sign up fer Medicare.
Contact Social Security 3 months before you turn 65. You can also
apply fer Part A and Part at secialsecurity.gew? retirement. If yen
werked fer a railread, centact the RRB. In most cases, if you don?t
sign up fer Part when you?re ?rst eligible, you may have a delay in
getting Medicare coverage in the future, and yen may have to pay a
late enrellment penalty fer as long as yen have Part B.

 

If yen have End-Stage Renal Disease
(ESRD) and yen want Medicare, you?ll need
te sign up. Centact Secial Security to ?nd out
when and hew te sign up fer Part A and

Part B. Fer mere infermatien, visit
to View the
beeklet ?Medicare Coverage ef Kidney
Dialysis 3: Kidney Transplant Services.?

If you live in Puerte Rice and get bene?ts from Social Security or
the RRB, yen?ll antematically get Part A the ?rst day of the menth yen
turn 65 er after yen get disability bene?ts fer 24 menths. However,

if you want Part B, you?ll need to sign up fer it by completing an
?Application fer Enrollment in Part Form? If yen
don?t sign up for Part when you?re ?rst eligible, you may have

to pay a late enrellment penalty fer as long as you have Part B.

Visit 
cms017339.html to get Perm in English or Spanish. Contact
yenr lecal Secial Security ef?ce er RRB fer mere infermatien.

Where can I get more information?

Call Social Security at for more information about
yenr Medicare eligibility and te sign up fer Part A andfer Part B.
TTY users can call If yen werked fer a railread or
get RRB bene?ts, call the RRB at 1?877?5?72?5772. TTY users can call
1?312?751?4701.

Yen can alse get free persenalized health insurance cennseling frem
yenr State Health Insurance Assistance Pregram (SHIP). See the back
cover for the phone number.

Section 1: Signing upfor Medicare Part A 8: Part 17

If I'm not automatically enrolled, when can I

 

sign up?

If you?re not automatically enrolled in free Part A, you can sign

up for Part A once your Initial Enrollment Period starts. Your

Part A coverage will start 6 months back from the date you apply for
Medicare (or Social Securityr?RRB bene?ts), but no earlier than the
?rst month you were eligible for Medicare. However, you can only
sign up for Part (or Part A if you have to buy it) during the times
listed below. Remember, in most cases, if you don?t sign up for
Part A (if you have to buy it) and Part when you?re ?rst eligible,

you may have to pay a late enrollment penalty.

Initial Enrollment Period

You can ?rst sign up for Part A andfor Part during the 7?month
period that begins 3 months before the month you turn 65, includes
the month you turn 65, and ends 3 months after the month you
turn 65.

If you sign up for Part A andx?or Part during the ?rst 3 months of
your Initial Enrollment Period, in most cases, your coverage starts
the ?rst day of your birthday month. However, if your birthday is on
the ?rst day of the month, your coverage will start the ?rst day of the
prior month.

If you enroll in Part A andz?or Part the month you turn 65 or during
the last 3 months of your Initial Enrollment Period, the start date for
your Medicare coverage will be delayed.

Special Enrollment Period

After your Initial Enrollment Period is over, you may have a chance to
sign up for Medicare during a Special Enrollment Period. If you didn?t
sign up for Part (or Part A if you have to buy it) when you were

?rst eligible because you?re covered under a group health plan based
on current employment (your own, a spouse?s, or if you?re disabled, a
family member?s), you can sign up for Part A ands?or Part B:

- Anytime you?re still covered by the group health plan

- During the 8?month period that begins the month after the
employment ends or the coverage ends, whichever happens ?rst

18 Section 1: Signing up for Medicare Part A 8: Part 

Usually, you don?t pay a late enrollment penalty if you sign up
during a Special Enrollment Period. This Special Enrollment Period
doesn?t apply to people who are eligible for Medicare based on End?
Stage Renal Disease (ESRD).

Note: If you?re disabled, and the group health plan coverage is
based on the current employment of a family member, the employer
offering the group health plan must have 100 or more employees to
get a Special Enrollment Period.

COBRA (Consolidated Omnibus Budget Reconciliation Act)
coverage, retiree health plans, and individual health coverage

(like through the Health Insurance Marketplace) aren?t
considered coverage based on current employment. You aren?t
eligible for a Special Enrollment Period when that coverage
ends. To avoid paying a higher premium, make sure you sign
up for Medicare when you?re ?rst eligible. See page 94 for more
information about COBRA coverage.

To learn more about enrollment periods, visit Medicaregov, or
call (1?800?633?4227). TTY users can call
1?877?486?2048.

General Enrollment Period

If you didn?t sign up for Part A (if you have to buy it) andr?or Part 
(for which you must pay premiums) during your Initial Enrollment
Period, and you don?t qualify for a Special Enrollment Period, you
can sign up between January 1?March 31 each year. Your coverage
won?t start until July 1 of that year, and you may have to pay a
higher Part A. andfor Part premium for late enrollment. See
pages 26?27.

Should I get Part 

This information can help you decide if you should get Part B:

Employer or union coverage?If you or your spouse (or family
member if you?re disabled) is still working and you have health
coverage through that employer or union, contact your employer or
union bene?ts administrator to ?nd out how your coverage works
with Medicare. This includes federal or state employment, coverage
through the Health Insurance Marketplace Small Business Health
Options Program (SHOP), and active?duty military service. It
might be to your advantage to delay Part enrollment.

 

 

If you have
CHAMPVA
coverageynu
must enroll in
Parts and Part
to keep it. Call
1?300?133?3331
for more
information

about CHAMPVA.

 

 

Section 1: Signing upfor Medicare Part A 8: Part 19

Note: Remember, coverage based on current employment doesn?t
include:

- COBRA
- Retiree coverage
- VA coverage

- Individual health coverage (like through the Health Insurance
Marketplace)

you have TRICARE (health care program for active?duty
and retired service members and their families), you generally must
enroll in Part A and Part when you?re ?rst eligible to keep your
TRICARE coverage. However, if you?re an active?duty service member
or an active?duty family member, you don?t have to enroll in Part

to keep your TRICARE coverage. For more information, contact

TRICARE. See page 18.

Health Insurance Marketplace?If you have coverage through an
individual Marketplace plan (not through an employer), you may want
to end your Marketplace coverage and enroll in Medicare during your
Initial Enrollment Period to avoid the risk of a delay in future Medicare
coverage and the possibility of a Medicare late enrollment penalty.
Once you?re considered eligible for Part A, you won?t qualify for help
paying your Marketplace plan premiums or other medical costs. If you
continue to get help paying your Marketplace plan premium after you
have Medicare, you might have to pay back the help you got when you
?le your taxes. Visit HealthCare.gov to connect to the Marketplace in
your state and learn more. You can also ?nd out how to terminate your
Marketplace plan when your Medicare enrollment begins.

Health savings accounts can?t contribute to your HSA
once your Medicare coverage begins. However, you may use money
that?s already in your HSA after you enroll in Medicare to help pay for
deductibles, premiums, copayments, or coinsurance. If you contribute
to your HSA after your Medicare coverage starts, you may have to pay
a tas: penalty. If you?d like to continue contributing to your HSA, you
shouldn?t apply for Medicare, Social Security, or Railroad Retirement
Board (RRB) bene?ts.

20 Sectien 1: Signing up fer Medicare Part A Part 

Remember, premium?free Part A ceyerage begins 6 menths back frem
the date yeu apply fer Medicare (er Secial SecurityI'RRB bene?ts), but

ne earlier than the ?rst menth yeu were eligible fer Medicare. Te ayeid a
tax penalty, yeu sheuld step centributing te yeur HSA at least 6 menths
befere yeu apply fer Medicare.

 

How does my other insurance work with Medicare?

When yeu have ether insurance and Medicare, there are rules fer
whether Medicare er yeur ether insurance pays ?rst.

 

If yeu have retiree insurance (insurance Medicare pays ?rst.
frem yeur er yeur speuse?s fermer
empleyment). . .

 

If yeu?re 65 er elder, have greup health plan Yeur greup health plan pays ?rst.
ceyerage based en yeur er yeur speuse?s
current empleyment, and the empleyer has
20 er mere empleyees. ..

 

If yeu?re 65 er elder, have greup health plan Medicare pays ?rst.
ceyerage based en yeur er yeur speuse?s
current empleyment, and the empleyer has
fewer than 20 empleyees. ..

 

If yeu?re under 65 and disabled, have Yeur greup health plan pays ?rst.
greup health plan ceyerage based en yeur,
a speuse?s, er a family member?s current
empleyment, and the empleyer has 100 er
mere empleyees. ..

 

If yeu?re under 65 and disabled, have greup Medicare pays ?rst.
health plan ceyerage based en yeur er a
family member?s current empleyment,
and the empleyer has fewer than 100
empleyees. . .

 

If yeu have Medicare because ef End?Stage Yeur greup health plan will pay
Renal Disease (ESRD). .. ?rst fer the ?rst 30 menths after
yeu beceme eligible te enrell in
Medicare. Medicare will pay ?rst
after this 30?menth peried.

 

 

Section 1: Signing upfor Medicare Part A 8: Part 21

Note: In some cases, your employer may join with other employers or
unions to form or sponsor a multiple?employer plan. If this happens, the
size of the largest employer! union determines whether Medicare pays
?rst or second.

Here are some important facts to remember:

- The insurance that pays ?rst (primary payer) pays up to the limits of its
coverage.

- The insurance that pays second (secondary payer) only pays if there are
costs the primary insurer didn?t cover.

- The secondary payer (which may be Medicare) might not pay all of the
uncovered costs.

- If your employer insurance is the secondary payer, you might need to
enroll in Part before your insurance will pay.

- Medicaid pays after Medicare.

For more information, visit Medicaregovf publications to view the
booklet ?Medicare 8: Other Health Bene?ts: Your Guide to Who Pays

First.?

If you have other insurance or changes to your insurance, you need
to let Medicare know by calling Medicare?s Bene?ts Coordination
3: Recovery Center (BCRC) at 1?855 398?2621 TTY users can call
1?855?797?2627.

If you have Medicare Part A (including coverage in a Medicare
Advantage Plan), you meet the requirement for having health
coverage. You?ll have to report this on your federal income tax
return, and you won?t have to pay a penalty for not having health
coverage.

If you have Part A, you may get a Health Coverage form (IRS
Form 1095?13) from Medicare by early 2019. This form veri?es
that you had health coverage in 2018. Keep the form for your
records. Not everyone will get this form. If you don?t get Form
1095?3, don?t worry, you don?t need to have it to ?le your taxes.

22 Section 1: Signing up for Medicare Part A 8: Part 

How much does Part A coverage cost?

You usually don?t pay a premium for Part A coverage if you or
your spouse paid Medicare taxes while working for a certain amount
of time. This is sometimes called premium?free Part A. If you aren?t
eligible for premium?free Part A, you may be able to buy Part A.

In most cases, if you choose to buy Part A, you must also have Part 
and pay premiums for both.

The 2019 Part A premium amounts weren?t available at the time of
printing. To get the most up?to?date cost information, visit
Medicaregov later this fall.

What's the Part A late enrollment penalty?

If you aren?t eligible ?Jr premium?free Part A, and you don?t buy it when
you?re ?rst eligible, your premium may go up 10%. You?ll have
to pay the higher premium for twice the number of years you could?ve
had Part A, but didn?t sign up.

Example: If you were eligible for Part A for 2 years but didn?t
sign up, you?ll have to pay a 10% higher premium for 4 years.

 

How much does Part coverage cost?

The standard Part premium amount for 2018 is $134. However, some
people who get Social Security bene?ts will pay less than this amount
($130 on average). Social Security will tell you the exact amount you?ll
pay for Part in 2018. You?ll pay the standard premium amount (or

higher) if:

- You enroll in Part for the ?rst time in 2018.

- You don?t get Social Security bene?ts.

- You?re directly billed for your Part premiums.

- You have Medicare and Medicaid, and Medicaid pays your premiums.
(Your state will pay the standard premium amount of $134 in 2018.)

- Your modi?ed adjusted gross income as reported on your IRS tax
return from 2 years ago is above a certain amount. If so, you?ll pay
the standard premium amount and an Income Related 
Adjustment Amount, also known as IRMAA. IRMAA is an extra

charge added to your premium.

 

 

If you need help
paying ypur Part
premium, see
pages 99?100.

 

 

Section 1: Signing upfor Medicare Part A 8: Part 23

The 2019 Part premium amount wasn?t available at the time of
printing. To get the most up?to?date cost information, visit
Medicare.gov later this fall.

What's the Part late enrollment penalty?

If you don?t sign up for Part when you?re ?rst eligible, you may have
to pay a late enrollment penalty for as long as you have Part B. Your
premium for Part may go up 10% for each full 12?month
period that you could?ve had Part B, but didn?t sign up for it. If you?re
allowed to sign up for Part during a Special Enrollment Period, you
usually don?t pay a late enrollment penalty. See pages 21?22.

Example: Mr. Smith?s Initial Enrollment Period ended

September 30, 2017. He waited to sign up for Part until

March 2019 during the General Enrollment Period. His Part 
premium penalty is 20%, and he?ll have to pay this penalty for as
long as he has Part B. (Even though Mr. Smith waited a total of
30 months to sign up, this included only 2 full 12?month periods.)

How can I pay my Part premium?

If you get Social Security or Railroad Retirement Board (RRB) bene?ts,
your Medicare Part (Medical Insurance) premium will be deducted
from your bene?t payment.

If you?re a federal retiree with an annuity from 0PM and not entitled
to or SSA bene?ts, you may request to have your Medicare Part 
premiums deducted from your annuity. Call 
(1?800?633?4223?) to make your request. TTY users can call
1?877?486?2048.

If you don?t get these bene?t payments, you?ll get a bill. If you choose to
buy Part A, you?ll always get a bill for your premium. There are 4 ways
to pay these bills:

1. Pay by check or money order. Write your Medicare Number on your
payment, and mail it with your payment coupon to:
Medicare Premium Collection Center
PO. Box 79 0355
St. Louis, MO 63179?0355

24 Section 1: Signing up for Medicare Part A 8: Part 

2. Pay by credit! debit card. To do this, complete the bottom portion of
the payment coup on on your Medicare Premium Bill, and mail it to
the address above. Payments submitted without the bottom portion
of the payment coupon may not be processed.

3. Sign up for Medicare Easy Pay. This is a free service that
automatically deducts your premium payments from your savings
or checking account each month. Visit Medicare.gov or call
(1?800?633?4223 to learn more and to ?nd out
how to sign up. TTY users can call 1?877?486?2048.

4. Make an online bill payment. This is a more secure and faster way
to make your payment without sending your personal information in
the mail. Ask your ?nancial institution if it allows customers to pay
bills online. Not all ?nancial institutions offer this service and some
may charge a fee. You?ll need to give your ?nancial institution this
information:

- Account number: This is your Medicare Number. It?s important
that you use the exact number on your red, white, and blue
Medicare card, but without the dashes.

- Biller name: CMS Medicare Insurance

- Remittance address:
Medicare Premium Collection Center
PO. BOX 790355
St. Louis, MO 63179?0355

Note to Annu itants: If you get a bill from the RRB, mail your
premium payments to:

RRB Medicare Premium Payments

P.O. Box 9?9024

St. Louis, MO 631919000.

If you have questions about your premiums or need to change your
address on your bill, call Social Security at 1?800?37?72?1213. TTY
users can call 1?800?325?0778. If your bills are from the call
1?877?7?2?57?2. TTY users can call 1?312?751?4701.

If you?d like more information about paying your Medicare premiums,
visit Medicare.gov to view the brochure ?Understanding the Medicare
Premium Bill Form 

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

25

Section 2:
Find out if Medicare covers
your test, service, or item

 

What services does Medicare cover?

Medicare covers certain medical services and supplies in hoSpitals,
doctors? of?ces, and other health care settings. Services are either
covered under Part A or Part B.

If you have both Part A and Part B, you can get all of the
Medicare?covered services listed in this section, whether you have
Original Medicare or a Medicare health plan.

To get Medicare?covered Part A andi'or Part services, you must be a
U.S. citizen or be lawfully present in the U.S.

What does Pa rt A cover?

Part A (HoSpital Insurance) helps cover:

- Inpatient care in a hoSpital

- Inpatient care in a skilled nursing facility (not custodial or long?term
care)

- HoSpice care

- Horne health care

- Inpatient care in a religious nonrnedical health care institution

You can ?nd out if you have Part A by looking at your red, white, and
blue Medicare card. If you have it, it will be listed as and
will have an effective date. If you have Original Medicare, you?ll use
this card to get your Medicare?covered services. If you join a Medicare
health plan, in most cases, you must use the card from the plan to get
your Medicare?covered services.

26 Section 2: Find out if Medicare covers your test, service, or item

 

Original
Medicare will
caverynur
hospice care,
even if you?re
in a Me dicare

 

Advantage Plan.

 

 

What do I pay for Part A-covered services?

Copayments, coinsurance, or deductibles may apply for each

service listed on the following pages. Visit Medicaregov, or call
(1?800?633?4227) to get speci?c cost information.
TTY users can call 1?877?486?2048.

If you?re in a Medicare Advantage Plan or have other insurance (like
a Medicare Supplement Insurance (Medigap) policy, or employer or
union coverage), your copayments, coinsurance, or deductibles may
be different. Contact the plans you?re interested in to ?nd out about the
costs, or visit the Medicare Plan Finder at Medicaregovl?nd-a-plan.

Part A-covered services

Blood

If the hospital gets blood from a blood bank at no charge, 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 ?rst 3 units of blood you get in
a calendar year or have the blood donated by you or someone else.

Home health services

You can use your home health bene?ts under Part A andi'or Part B. See
page 48 for more information about home health bene?ts.

Hospice care

To qualify for hospice care, a hospice doctor and your doctor (if you
have one) must certify that you?re terminally ill, meaning you have a life
expectancy of 6 months or less. Coverage includes:

- All items and services needed for pain relief and 
management

- Medical, nursing, and social services
- Drugs

- Certain durable medical equipment
- Aide and homemaker services

- Other covered services, as well as services Medicare usually doesn?t
cover, like spiritual and grief counseling

Section 2: Find out if Medicare covers your test, service, or item 2?

A Medicare?approved hospice usually gives hospice care in your home
or other facility where you live, like a nursing home.

Hospice care doesn?t pay for your stay in a facility (room and board)
unless the hospice medical team determines that you need short?term
inpatient stays for pain and management that can?t be
addressed at home. These stays must be in a Medicare?approved facility,
like a hospice facility, hospital, or skilled nursing facility that contracts
with the hospice. Medicare also covers inpatient respite care, which is
care you get in a Medicare?approved facility so that your usual caregiver
(family member or friend) 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 or related

conditions. You can continue to get hospice care as long as the hospice

medical director or hospice doctor recerti?es that you?re terminally ill.

- You pay nothing for hospice care.

- You pay a copayrnent of up to $5 per prescription for outpatient
prescription drugs for pain and management. In the rare
case your drug isn?t covered by the hospice bene?t, your hospice
provider should contact your Medicare drug plan to see if it?s covered
under Part D.

- You pay 5% of the Medicare?approved amount for inpatient respite
care.

Hospital care (inpatient care)

Medicare covers semi?private rooms, meals, general nursing, and
drugs as part of your inpatient treatment, and other hospital services
and supplies. This includes care you get in acute care hospitals, critical
access hospitals, inpatient rehabilitation facilities, long?term care
hospitals, inpatient care as part of a qualifying clinical research study,
and inpatient mental health care given in a hospital or other
hospital. This doesn?t include private?duty nursing, a television or phone
in your room (if there?s a separate charge for these items), or personal
care items, like razors or slipper socks. It also doesn?t include a private
room, unless medically necessary. If you have Part B, it generally covers
80% of the Medicare?approved amount for doctors services you get
while you?re in a hospital.
- You pay a deductible and no coinsurance for days 1? 60 of each bene?t
period.

28 Section 2: Find out if Medicare covers your test, service, or item

- You pay coinsurance per day for days 61? 90 of each bene?t period.

- You pay coinsurance per ?lifetime reserve day? after day 90 of each
bene?t period (up to 60 days over your lifetime).

- You pay all costs for each day after you use all the lifetime reserve days.

- Inpatient care in a freestanding hospital is
limited to 190 days in a lifetime.

Am I an inpatient or outpatient?

Staying overnight in a hospital doesn?t always mean you?re an inpatient.
You only become an inpatient when a hospital formally admits you as

an inpatient, after a doctor orders it. You?re still an outpatient if you
haven?t been formally admitted as an inpatient, even if you?re getting
emergency department services, observation services, outpatient
surgery, lab tests, or X?rays. You or a family member should always ask
if you?re an inpatient or an outpatient each day during your stay, since
it affects what you pay and can affect whether you?ll qualify for Part A
coverage in a skilled nursing facility.

A Medicare Outpatient Observation Notice (MOON) is a document
that lets you know you?re an outpatient in a hospital or critical access
hospital. You must receive this notice if you?re getting observation
services as an outpatient for more than 24 hours. The MOON will tell
you why you?re an outpatient receiving observation services, rather than
an inpatient. It will also let you know how this may affect what you pay
while in the hospital, and for care you get after leaving the hospital.

 

 

Medicare
advantage
Plans can?t
charge more
than Original
Medicare for
skilled nursing
facility care
services.

 

 

Section 2: Find out if Medicare covers your test, service, or item 29

Religious non-medical health ca re institution

[in patient care)

In these facilities, religious beliefs prohibit conventional and
unconventional medical care. If you qualify for hospital or skilled
nursing facility care, Medicare will only cover the inpatient,
non?religious, non?medical items and services. Examples are room
and board, or any items and services that don?t require a doctor?s order
or prescription, like unmedicated wound dressings or use of a simple
walker.

Skilled nursing facility care

Medicare covers semi?private rooms, meals, skilled nursing and
rehabilitative services, and other medically necessary services and
supplies after a 3?day minimum, medically necessary, inpatient hospital
stay for a related illness or injury. An inpatient hospital stay begins the
day the hospital formally admits you as an inpatient based on a doctor?s
order and doesn?t include the day you?re discharged. You may get skilled
nursing care or skilled therapy care if it?s necessary to help improve or
maintain your current condition.

To qualify for care this setting, your doctor must certify that you need
daily skilled care (like intravenous injections or physical therapy) which,
as a practical matter, can only be provided in a skilled nursing facility.

You pay:

- Nothing for the ?rst 20 days of each bene?t period

- Coinsurance per day for days 21?100 of each bene?t period
- All costs for each day after day 100 in a bene?t period

Visit Medicaregov later this fall to ?nd out what you?ll pay for inpatient
hospital stays and skilled nursing facility care in 2019.

Note: Medicare doesn?t cover long?term care or custodial care.

30

 

See page FD
tn?nd nut
what affects
ynur Medicare
advantage Plan


 

 

 

Medicare
Advantage Plans
have a yearly
limit an ynur
nut?nf?pncket
costs for medical
services. See
page 

 

 

Section 2: Find out if Medicare covers your test, service, or item

What does Part cover?

Medicare Part (Medical Insurance) helps cover medically necessary
doctors? services, outpatient care, home health services, durable
medical equipment, mental health services, and other medical
services. Part also covers many preventive services. You can ?nd out
if you have Part by looking at your red, white, and blue Medicare
card. If you have it, it will be listed as and will have an
effective date. See pages 35?59 for a list of common Part B?covered
services and general descriptions. Medicare may cover some services
and tests more often than the timeframes listed if needed to diagnose
or treat a condition. To ?nd out if Medicare covers a service not on
this list, visit Medicaregovfcoverage, or call 
(1?800?633?4223?) TTY users can call 1?871-486?2048. For more details
about Medicare covered services, visit Medicaregovfpublications to
view the booklet ?Your Medicare Bene?ts.? Call to
?nd out ifa copy can be mailed to you.

What do I pay for Pa rt B-covered services?

The alphabetical list on the following pages gives general information
about what you pay if you have Original Medicare and see doctors or
other health care providers who accept assignment. See page 64. You?ll
pay more if you see doctors or providers who don?t accept assignment.
If you?re in a Medicare health plan or have other insurance, your
costs may be different. Contact your plan or bene?ts administrator
directly to ?nd out about the costs.

Under Original Medicare, if the Part deductible ($183 in 2018)
applies, you must pay all costs (up to the Medicare?approved amount)
until you meet the yearly Part deductible. After your deductible is
met, Medicare begins to pay its share and you typically pay 20% of the
Medicare?approved amount of the service, if the doctor or other health
care provider accepts assignment. There?s no yearly limit for what you
pay out?of?poclcet. Visit Medicaregov, or call 1?80 to
get speci?c cost information.

You pay nothing for most covered preventive services if you get

the services from a doctor or other quali?ed health care provider
who accepts assignment. However, for some preventive services,
you may have to pay a deductible, coinsurance, or both. These costs
may also apply if you get a preventive service in the same visit as a
non?preventive service.

Section 2: Find out if Medicare covers your test, service, or item 31

Part B-covered services

 

\f You?ll see this apple next to the preventive services
a on pages 31?55.

 

 

 

 

 

Visit the
Eldercare [orator
at eldertare.

gov to get help
with advance
directives.

 

 

Abdominal aortic aneurysm screening

Medicare covers a one-time abdominal aortic aneurysm screening ultrasound
for people at risk. You must get a referral from your doctor or other
practitioner. You pay nothing for the screening if the health care provider
accepts assignment.

Note: If you have a family history of abdominal aortic or you?re a
man 65??5 and you?ve smoked at least 100 cigarettes in your lifetime, you?re
considered at rislc.

Advance care planning

Medicare covers voluntary advance care planning as part of the yearly
?Wellness? visit. This is planning for care you would want to get if you
become unable to spealc for yourself. You can tallc about an advance
directive with your health care professional, and he or she can help you
?ll out the forms, if you want to. An advance directive is an important
legal document that records your wishes about medical treatment at a
future time, if you?re not able to malce decisions about your care. You
pay nothing if the health care provider accepts assignment.

Note: Medicare may also cover this service as part of your medical
treatment. When advance care planning isn?t part of your yearly
?Wellness? visit, the Part deductible and coinsurance apply.

Alcohol misuse screening and counseling

Medicare covers one alcohol misuse screening per year for adults with
Medicare (including pregnant women) who use alcohol, but don?t meet

the medical criteria for alcohol dependency. If your health care provider
determines you?re misusing alcoholbrief face-to-

face counseling sessions per year [ifyou?re competent and alert during
counseling). You must get counseling in a primary care setting (like a doctor?s
of?ce]. You pay nothing if the doctor or other quali?ed health care provider
accepts assignment.

32 Section 2: Find out if Medicare covers your test, service, or item

Ambulance services

Medicare covers ground ambulance transportation when you need to

be transported to a hospital, critical access hospital, or skilled nursing
facility for medically necessaryr services, and transportation in any other
vehicle could endanger your health. Medicare may pay for emergency
ambulance transportation in an airplane or helicopter to a hospital if
you need immediate and rapid ambulance transportation that ground
transportation can?t provide.

In some cases, Medicare may pay for limited, medically necessary,
non?emergency ambulance transportation if you have a written order
from your doctor stating that ambulance transportation is medically
necessary. An example may be a medically necessary ambulance
transport to a dialysis facility for someone with End?Stage Renal Disease

(ESRD).

Medicare will only cover ambulance services to the nearest appropriate
medical facility that?s able to give you the care you need.

You pay 20% of the Med icare?approved amount, and the Part 
deductible applies.

Ambulatory surgical centers

Medicare covers the facility service fees related to approved surgical
procedures provided in an ambulatory surgical center (facility where
surgical procedures are performed, and the patient is expected to be
released within 24 hours). Except for certain preventive services (for
which you pay nothing if the doctor or other health care provider
accepts assignment), you pay 20% of the Medicare?approved amount to
both the ambulatory surgical center and the doctor who treats you, and
the Part deductible applies. You pay all of the facility service fees for
procedures Medicare doesn?t cover in ambulatory surgical centers.

Blood

If the provider gets blood from a blood bank at no charge, you won?t
have to pay for it or replace it. However, you?ll pay a copayment for the
blood processing and handling services for each unit of blood you get,
and the Part deductible applies. If the provider has to buy blood for
you, you must either pay the provider costs for the ?rst 3 units of blood
you get in a calendar year, or have the blood donated by you or
someone else.

Section 2: Find out if Medicare covers your test, service, or item 33

Bone mass measurement (bone density)

This test helps to see if you?re at risk for broken bones. It?s covered

once every 24 months (more often if medically necessary) for people
who have certain medical conditions or meet certain criteria. You pay
nothing for this test if the doctor or other quali?ed health care provider
accepts assignment.

Breast cancer screening (mammograms)

Medicare covers screening mammograms to check for breast cancer
once every 12 months for all women with Medicare who are 40 and
older. Medicare covers one baseline mammogram for women between
35 ?39. You pay nothing for the test if the doctor or other quali?ed
health care provider accepts assignment.

Note: Part also covers diagnostic mammograms more frequently
than once a year when medically necessary. You pay 20% of the
Med icare?approved amount for diagnostic mammograms, and the Part

deductible applies.

Cardiac rehabilitation

Medicare covers comprehensive programs that include exercise,
education, and counseling for patients who meet at least one of these
conditions:

- A heart attack in the last 12 months

- Coronary artery bypass surgery

- Current stable angina pectoris (chest pain)
- A heart valve repair or replacement

- A coronary angioplasty (a medical procedure used to open a blocked
artery) or coronary stenting (a procedure used to lceep an artery open)

- A heart or heart?lung transplant
- Stable, chronic heart failure (for regular cardiac rehabilitation only)

Medicare also covers intensive cardiac rehabilitation programs that
are typically more rigorous or more intense than regular cardiac
rehabilitation programs. Services are covered in a doctor?s o?ice or
hospital outpatient setting. You pay 20% of the Medicare?approved
amount if you get the services in a doctor?s of?ce. In a hospital
outpatient setting, you also pay the hospital a copayment. The Part 
deductible applies.

34 Section 2: Find out if Medicare covers your test, service, or item

\f Cardiovascular disease (behavioral therapy)

a Medicare will cover one visit per year with a primary care doctor
in a primary care setting (like a doctor?s o?ice) to help lower your
risk for cardiovascular disease. During this visit, the doctor may
discuss aspirin use (if appropriate), check your blood pressure,
and give you tips to make sure you eat well. You pay nothing if the
doctor or other quali?ed health care provider accepts assigm'neut.

\f Cardiovascular disease screenings
These screenings include blood tests that help detect conditions

that may lead to a heart attack or stroke. Medicare covers these
screening tests once every 5 years to test your cholesterol, lipid,
lipoprotein, and triglyceride levels. You pay nothing for the tests
if the doctor or other quali?ed health care provider accepts
assignment.

\f Cervical and vaginal cancer screenings

Part covers Pap tests and pelvic exams to check for cervical and
vaginal cancers. As part of the pelvic exam, Medicare also covers
a clinical breast exam to check for breast cancer. Medicare covers
these screening tests once every 24 months. Medicare covers these
screening tests once every 12 months if you?re at high risk for
cervical or vaginal cancer, or if you?re of child?bearing age and had
an abnormal Pap test in the past 36 months.

Part also covers Human Papillomavirus (HPV) tests (when
received with a Pap test) once every 5 years if you?re age 30? 65
without 

You pay nothing for the lab Pap test or for the lab HP?iir with Pap
test if your doctor or other quali?ed health care provider accepts
assignment. You also pay nothing for the Pap test specimen
collection and pelvic and breast exams if the doctor or other
quali?ed health care provider accepts assignment.

Section 2: Find out if Medicare covers your test, service, or item 35

Chemotherapy

Medicare covers chemotherapy in a doctor?s of?ce, freestanding
clinic, or hospital outpatient setting for people with cancer. You pay a
copayment for chemotherapy in a hospital outpatient setting.

For chemotherapy given in a doctor?s of?ce or freestanding clinic, you
pay 20% of the Medicare?approved amount, and the Part deductible
applies.

For chemotherapy in a hospital inpatient setting covered under Part A,
see Hospital care (inpatient care) on pages 31?32.

Chiropractic services (limited coverage)

Medicare covers manipulation of the spine if medically necessary to
correct a subluxation (when one or more of the bones of your spine
move out of position) when provided by a chiropractor or other
quali?ed provider. You pay 20% of the Medicare?approved amount,
and the Part deductible applies.

Note: Medicare doesn?t cover other services or tests ordered by a
chiropractor, including K?rays, massage therapy, and acupuncture.
If you think your chiropractor is billing Medicare for services

that aren?t covered, you can report suspected Medicare fraud by
calling (1?800?633?4223. TTY users can call
1?877?486?2048.

Chronic care management services

If you have 2 or more serious, chronic conditions (like arthritis,
asthma, diabetes, hypertension, heart disease, osteoporosis, and other
conditions) that are expected to last at least a year, Medicare may pay
for a health care providers help to manage those conditions. This
includes a comprehensive care plan that lists your health problems and
goals, other health care providers, medications, community services
you have and need, and other information about your health. It also
explains the care you need and how your care will be coordinated.
Your health care provider will ask you to sign an agreement to provide
this service. If you agree, he or she will prepare the care plan, help

you with medication management, provide 241'? access for urgent care
needs, give you support when you go from one health care setting to
another, review your medicines and how you take them, and help you
with other chronic care needs. You pay a fee, and the Part 
deductible and coinsurance apply.

36 Section 2: Find out if Medicare covers your test, service, or item

Clinical research studies

Clinical research studies test how well different types of medical care work
and ifthey?re safe. Medicare covers some costs, lilce of?ce visits and tests,
in qualifying clinical research studies. You may pay 20% ofthe Medicare?
approved amount, and the Part deductible may apply.

Note: If you?re in a Medicare Advantage Plan (like an HMO or PPO), some
costs may be covered by Original Medicare and some may be covered by your
Medicare Advantage Plan.

\f Colorectal cancer screenings

a Medicare covers these screenings to help ?nd precancerous growths or ?nd
cancer early, when treatment is most effective. One or more of these tests may
be covered:

I Multi?target stool DNA test?This lab test is generally covered once every 3
years ifyou meet all of these conditions:

Are between ages 50?85.

Show no signs or of colorectal disease including, but not
limited to, lower gastrointestinal pain, blood in stool, positive guaiac
fecal occult blood test or fecal immunochemical test.

At average risk for developing colorectal cancer, meaning:

Have no personal history of adenomatous polyps, colorectal
cancer, in?ammatory bowel disease, including Crohn?s Disease
and ulcerative colitis.

Have no family history of colorectal cancer or adenomatous
polyps, familial adenomatous polyposis, or hereditary
nonpolyposis colorectal cancer.

You pay nothing for the test if the doctor or other quali?ed health care
provider accepts assignment.

- Screening fecal occult blood test?This test is covered once every 12
months if you?re 50 or older. You pay nothing for the test if the doctor or
other quali?ed health care provider accepts assignment.

- Screening ?exible sigmoidoscopy?Th is test is generally covered once every
48 months if you?re 50 or older, or 120 months after a previous screening
colonoscopy for those not at high risk. You pay nothing for the test if the
doctor or other quali?ed health care provider accepts assignment.

- Screening colonoscopy?This test is generally covered once every 120
months (high rislc every 24 months) or 48 months after a previous flexible
sigmoidoscopy. There?s no minimum age. You pay nothing for the test if the
doctor or other quali?ed health care provider accepts assignment.

Section 2: Find out if Medicare covers your test, service, or item 3?

Note: If a polyp or other tissue is found and removed during the
colonoscopy, you may have to pay 20% of the Medicareapproved amount
for the doctor?s services and a copayment in a hospital outpatient setting.
The Part deductible doesn?t apply.

- Screening barium enema?This test is generally covered once every
48 months if you?re 50 or older (high rislc every 24 months) when used
instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare-
approved amount for the doctor services. In a hospital outpatient setting,
you also pay the hospital a copayment. The Part deductible doesn?t apply.

Continuous Positive Airway Pressure (CPAP) therapy

Medicare covers a 3-month trial of CPAP therapy if you?ve been diagnosed
with obstructive sleep apnea. Medicare may cover it longer if you meet

in person with your doctor, and your doctor documents in your medical
record that the CPAP therapy is helping you.

You pay 20% of the Medicare-approved amount for rental of the machine
and purchase of related supplies [like maslcs and tubing), and the Part 
deductible applies. Medicare pays the supplier to rent the machine for 13
months if you?ve been using it without interruption. After you?ve rented the
machine for 13 months, you own it.

Note: If you had a CPAP machine before you got Medicare, Medicare may
cover rental or a replacement CPAP machine and! or CPAP accessories if
you meet certain requirements.

De?brillator (implantable automatic)

Medicare covers these devices for some people diagnosed with heart failure.
Ifthe surgery takes place in an outpatient setting, you pay 20% ofthe

Med icare?approved amount for the doctor?s services. If you get the device
as a hospital outpatient, you also pay the hospital a copayment. In most
cases, the copayment amount can?t be more than the Part A hospital stay
deductible. The Part deductible applies. Part A covers surgeries to implant
de?brillators in a hospital inpatient setting. See Hospital care (inpatient
care) on pages 31?32.

Depression screening

Medicare covers one depression screening per year. The screening must

be done in a primary care setting (like a doctor?s of?ce) that can provide
follow-up treatment and referrals. You pay nothing for this screening if the
doctor or other quali?ed health care provider accepts assignment.

38 Section 2: Find out if Medicare covers your test, service, or item

\f Diabetes screenings

a Medicare covers these screenings if your doctor determines you?re at
risk for diabetes or diagnosed with prediabetes. You may be eligible for
up to 2 diabetes screenings each year. You pay nothing for the test if
your doctor or ether quali?ed health care provider accepts assignment.

 

 

Medicare Diabetes Prevention Preg ram

Prediabetes is a serious health condition where blood sugar levels
are higher than normal, but not high enough yet to be diagnosed as
type 2 diabetes. Fortunately, type 2 diabetes can usually be delayed
or prevented with health behavior changes. If you have prediabetes,
losing a small amount of weight if you?re overweight and getting
regular exercise can lower your risk for developing type 2 diabetes.

If you have Medicare Part and have prediabetes, Medicare covers
a proven lifestyle change program to help you prevent diabetes.

The program begins with at least 16 core sessions over a 6?month
period that are offered in a group setting. After the core sessions,
less intensive follow?up sessions help you maintain healthy

habits.

In these sessions, you?ll get:

- Training to make realistic, lasting lifestyle changes

- Tips on how to get more exercise

- Strategies for controlling your weight

- A lifestyle coach, specially trained to help keep you motivated
- Support from people with similar goals and challenges

If you think you?re at risk, ask your doctor to be tested for
prediabetes to ?nd out if you qualify for the program. If you qualify,
you can join a program at no out?of?pocket cost and without a
doctor referral.

 

 

 

Section 2: Find out if Medicare covers your test, service, or item 39

Diabetes self-management training

Medicare covers diabetes outpatient self?management training to teach
you to cope with and manage your diabetes. The program may include
tips for eating healthy, being active, monitoring blood sugar, taking
medication, and reducing risks. You must have diabetes and a written
order from your doctor or other health care provider. You pay 20% of
the Medicare?approved amount, and the Part deductible applies.

Diabetes supplies

Medicare covers blood sugar testing monitors, blood sugar test
strips, lancet devices and lancets, blood sugar control solutions,
and therapeutic shoes (in some cases). Medicare only covers insulin
if it?s medically necessary and you use an external insulin pump

to administer the insulin. You pay 20% of the Med icare?approved
amount, and the Part deductible applies.

Note: Medicare prescription drug coverage (Part D) may cover insulin,
certain medical supplies used to inject insulin (like syringes), and
some oral diabetes drugs. Check with your plan for more information.

Doctor and other health care provider services

Medicare covers medically necessary doctor services (including
outpatient services and some doctor services you get when you?re a
hospital inpatient) and covered preventive services. Medicare also
covers services provided by other health care providers, like physician
assistants, nurse practitioners, social workers, physical therapists, and
Except for certain preventive services (for which you
may pay nothing), you pay 20% of the Medicare?approved amount,
and the Part deductible applies.

40 Section 2: Find out if Medicare covers your test, service, or item

Durable medical equipment (DME)

Medicare covers items like oxygen equipment and supplies, wheelchairs,
walkers, and hospital beds ordered by a doctor or other health care
provider enrolled in Medicare for use in the home. Some items must be
rented. You pay 20% of the Medicare?approved amount, and the Part 
deductible applies.

Make sure your doctors and DME suppliers are enrolled in Medicare.
Doctors and suppliers have to meet strict standards to enroll and stay
enrolled in Medicare. If your doctors or suppliers aren?t enrolled,
Medicare won?t pay the claims they submit. It?s also important to ask
your suppliers if they participate in Medicare before you get DME.

If suppliers are participating suppliers, they must accept assignment
(that is, they?re limited to charging you only coinsurance and the Part
deductible for the Medica re?approved amount). If suppliers aren?t
participating and don?t accept assignment, there?s no limit on the
amount they can charge you. To ?nd suppliers who accept assignment,
visit Medicare.govisupplierdirectory or call 
(1?800?633?4223. TTY users can call 1?877?486?2048. You can also call
if you?re having problems with your DME supplier,
or you need to ?le a complaint.

For more information, visit Medicaregovf publications to view the
booklet ?Medicare Coverage of Durable Medical Equipment and Other
Devices.?

EKG or ECG (electrocardiogram) screening

Medicare covers a one?time screening ECG if referred by your
doctor or other health care provider as part of your one?time ?Welcome
to Medicare? preventive visit. See page 58. You pay 20% of the

Med icare?approved amount, and the Part deductible applies. An 
ECG is also covered as a diagnostic test. See page 56. If you have the

test at a hospital or a hospital?owned clinic, you also pay the hospital a
copayment.

Section 2: Find out if Medicare covers your test, service, or item 41

Emergency department services

These services are covered when you have an injury, a sudden illness,
or an illness that quickly gets much worse. You pay a speci?ed
copayment for the hospital emergency department visit, and you pay
20% of the Medicare?approved amount for the doctor?s or other health
care provider?s services. The Part deductible applies. However, your
costs may be di?erent if you?re admitted to the hospital as an inpatient.

Eyeglasses (after cataract surgery)

Medicare covers 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 
deductible applies.

Note: Medicare will only pay for contact lenses or eyeglasses provided
by a supplier enrolled in Medicare, no matter who submits the claim
(you or your provider).

Federally Quali?ed Health Center (FQHC) services

provide many outpatient primary care and preventive health
services. There?s no deductible, and generally, you?re responsible for
paying 20% of the charges or 20% of the Medicare?approved amount.
You pay nothing for most preventive services. All offer
discounts if your income is limited. To ?nd a FQHC near you, visit
?ndahealthcenter.hrsa.gov.

Flu shots
Medicare normally covers one ?u shot per flu season. You pay nothing

for the ?u shot if the doctor or other quali?ed health care provider
accepts assignment for giving the shot.

Foot exams and treatment

Medicare covers foot exams and treatment if you have diabetes?related
nerve damage andfor meet certain conditions. You pay 20% of the
Med icare-approved amount, and the Part deductible applies. In a
hospital outpatient setting, you also pay the hospital a copayment.

42 Section 2: Find out if Medicare covers your test, service, or item

Glaucoma tests

These tests are covered once every 12 months for people at high risk
for the disease glaucoma. You?re at high risk if you have diabetes, a
family history of glaucoma, are African American and 50 or older, or
are Hispanic and 65 or older. An doctor who?s legally allowed by the
state must do the tests. You pay 20% of the Medicare?approved amount,
and the Part deductible applies. In a hospital outpatient setting, you
also pay the hospital a copayment.

Hearing and balance exams

Medicare covers these exams if your doctor or other health care
provider orders them to see if you need medical treatment. You pay 20%
of the Medicare?approved amount, and the Part deductible applies. In
a hospital outpatient setting, you also pay the hospital a copayment.

Note: Original Medicare doesn?t cover hearing aids or exams for ?tting
hearing aids.

\f Hepatitis shots

a Medicare covers these shots for people at medium or high risk for
Hepatitis B. Some risk factors include hemophilia, End?Stage Renal
Disease (ESRD), diabetes, if you live with someone who has Hepatitis B,
or if you?re a health care worker and have frequent contact with blood or
body ?uids. Check with your doctor to see if you?re at medium or high
risk for Hepatitis B. You pay nothing for the shot if the doctor or other
quali?ed health care provider accepts assigm?neut.

Section 2: Find out if Medicare covers your test, service, or item 43

Hepatitis Virus (HBV) infection screening

Medicare covers HBV infection screenings if you meet one of these
conditions:
- You?re at high risk for HBV infection.

- You?re pregnant.

Medicare will only cover HBV infection screenings if they?re ordered
by a primary care provider.

HBV infection screenings are covered:

- Annually only for those with continued high risk who don?t get a
Hepatitis vaccination.

- For pregnant women: At the ?rst prenatal visit for each pregnancy.

- At the time of delivery for those with new or continued risk factors.

- At the ?rst prenatal visit for future pregnancies, even if you
previously got the Hepatitis shot or had negative HBV screening
results.

You pay nothing for the screening test if the doctor or other quali?ed
health care provider accepts assignment.

Hepatitis screening test

Medicare covers one Hepatitis screening test if you meet one of these

conditions:

- You?re at high risk because you have a current or past history of illicit
injection drug use.

- You had a blood transfusion before 1992.

- You were born between 1945?1965.

Medicare also covers yearly repeat screenings for certain people at

high risk.

Medicare will only cover Hepatitis screening tests if they?re ordered
by your health care provider. You pay nothing for the screening test if
the doctor or other quali?ed health care provider accepts assignment.

44 Section 2: Find out if Medicare covers your test, service, or item

\f HIV screening
a Medicare covers HIV (Human Immunode?ciency Virus) screenings
once every 12 months for:

- People between the ages of 15?65.
- People younger than 15 and older than 65, who are at increased risk.

Note: Medicare also covers this test up to 3 times during a pregnancy.

You pay nothing for the HIV screening if the doctor or other quali?ed
health care provider accepts assignment.

Home health services

You can use your home health bene?ts under Part A andfor Part B.
Medicare covers medically necessary part?time or intermittent skilled
nursing care, andfor physical therapy, speech?language pathology
services, andfor services if you have a continuing need for occupational
therapy. A doctor, or certain health care professionals who work with

a doctor, must see you face?to?face before a doctor can certify that

you need home health services. A doctor must order your care, and a
Medicare?certi?ed 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 any of these is true:

- You have trouble leaving your home without help (like using a cane,
wheelchair, walker, or crutches; special transportation; or help from
another person) because of an illness or injury

- Leaving your home isn?t recommended because of your condition.

- You?re normally unable to leave your home because it?s a major e?cort.

You pay nothing for covered home health services. You pay 20% of

the Medica re?approved amount, and the Part deductible applies, for
Medicare?covered medical equipment.

Section 2: Find out if Medicare covers your test, service, or item 45

Kidney dialysis services and supplies

Generally, Medicare covers 3 dialysis treatments per week if you have
End?Stage Renal Disease (ESRD). This includes all ESRD ?related
drugs and biologicals, laboratory tests, home dialysis training, support
services, equipment, and supplies. The dialysis facility is responsible
for coordinating your dialysis services (at home or in a facility). You
pay 20% of the Medicare?approved amount, and the Part deductible
applies.

Kidney disease education services

Medicare covers up to 6 sessions of kidney disease education services
if you have Stage IV chronic kidney disease, and your doctor or other
health care provider refers you for the service. You pay 20% of the
Med icare?approved amount, and the Part deductible applies.

La boratory services

Medicare covers laboratory services including certain blood tests,
urinalysis, certain tests on tissue specimens, and some screening tests.
You generally pay nothing for these services.

Lung cancer screening

Medicare covers a lung cancer screening with Low Dose Computed
Tomography (LDCT) once per year if you meet all of these conditions:

- You?re 55?77.

- You?re (you don?t have signs or of lung
cancer).

- You?re either a current smoker or have quit smoking within the last
15 years.

- You have a tobacco smoking history of at least 30 ?pack years? (an
average of one pack a day for 30 years).

- You get a written order from a doctor or other quali?ed health care
provider.

You generally pay nothing for this service if the health care provider
accepts assignment.

Note: Before your ?rst lung cancer screening, you?ll need to schedule
an appointment with your doctor to discuss the bene?ts and risks of
lung cancer screening. You and your doctor can decide whether lung
cancer screening is right for you.

46 Section 2: Find out if Medicare covers your test, service, or item

\f Medical nutrition therapy services

Medicare may cover medical nutrition therapy and certain related
services if you have diabetes or kidney disease, or you have had a kidney
transplant in the last 36 months, and your doctor or other health care
provider refers you for the service. You pay nothing for these services if
the doctor or other quali?ed health care provider accepts assignment.

Mental health care (outpatient)

Medicare covers mental health care services to help with conditions like
depression or anxiety. Coverage includes services generally provided

in an outpatient setting (like a doctor?s or other health care provider?s
o?ice, hospital outpatient department, or community mental health
center), including visits with a or other doctor, clinical
nurse practitioner, physician assistant, clinical nurse
specialist, or clinical social worker. Laboratory tests are also covered.
Certain limits and conditions may apply.

Generally, you pay 20% of the Medica re-approved amount and the
Part deductible applies for mental health care services.

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

\f Obesity screening and counseling

a If you have a body mass index (BMI) of 3D or more, Medicare covers
face?to?face individual behavioral therapy sessions to help you lose
weight. This counseling may be covered if you get it in a primary care
setting (like a doctor?s of?ce), where it can be coordinated with your
other care and a personalized prevention plan. You pay nothing for
this service if the doctor or other quali?ed health care provider accepts
assignment.

Occupational therapy

Medicare covers evaluation and treatment to help you perform activities
of daily living (like dressing or bathing) when your doctor or other
health care provider certi?es you need it. There may be a limit on the
amount Medicare will pay for these services in a single year, and there
may be certain exceptions to these limits. You pay 20% of the Medicare?
approved amount, and the Part deductible applies.

Section 2: Find out if Medicare covers your test, service, or item 4?

Out patient hospital services

Medicare covers many diagnostic and treatment services in

hospital outpatient departments. Generally, you pay 20% of the

Med icare?approved amount for the doctor?s or other health care
provider?s services. You may pay more for services you get in a hospital
outpatient setting than you?ll pay for the same care in a doctor?s of?ce.
In addition to the amount you pay the doctor, you?ll also usually

pay the hospital a copayment for each service you get in a hospital
outpatient setting, except for certain preventive services that don?t have
a copayment. In most cases, the copayment can?t be more than the
Part A hospital stay deductible for each service. The Part deductible
applies, except for certain preventive services. If you get hospital
outpatient services in a critical access hospital, your copayment may be
higher and may exceed the Part A hospital stay deductible.

Outpatient medical and surgical services
and supplies

Medicare covers approved procedures like X?rays, casts, stitches, or
outpatient surgeries. You pay 20% of the Medicare?approved amount
for the doctor?s or other health care provider?s services. You generally
pay the hospital a copayment for each service you get in a hospital
outpatient setting. In most cases, for each service provided, the
copayment can?t be more than the Part A hospital stay deductible. The
Part deductible applies, and you pay all costs for items or services
that Medicare doesn?t cover.

Physical therapy

Medicare covers evaluation and treatment for injuries and diseases
that change your ability to function when your doctor or other health
care provider certi?es your need for it. There may be a limit on the
amount Medicare will pay for these services in a single year, and
there may be certain exceptions to these limits. You pay 20% of the
Medicare?approved amount, and the Part deductible applies.

48 Section 2: Find out if Medicare covers your test, service, or item

\f Pneumococcal shots

Medicare covers pneumococcal shots to help prevent pneumococcal
infections (like certain types of pneumonia). The two shots protect
against different strains of the bacteria. Medicare covers the ?rst shot
at any time, and also covers a different second shot if it?s given one year
(or later) after the ?rst shot. Talk with your doctor or other health care
provider to see if you need one or both of the pneumococcal shots. You
pay nothing for these shots if the doctor or other quali?ed health care
provider accepts assignment for giving the shots.

Prescription drugs (limited)

Medicare covers a limited number of drugs like injections you get

in a doctor?s o?ice, certain oral anti?cancer drugs, drugs used with
some types of durable medical equipment (like a nebulizer or external
infusion pump), immunosuppressant drugs (see pages 56?57), and,
under very limited circumstances, certain drugs you get in a hospital
outpatient setting. You pay 20% of the Medicare-approved amount for
these covered drugs, and the Part deductible applies.

If the covered drugs you get in a hospital outpatient setting are part of
your outpatient services, you pay a copayment for the services. However,
other types of drugs in a hospital outpatient setting (sometimes called
?self?administered drugs? or drugs you?d normally take on your own)
aren?t covered by Part B. What you pay depends on whether you have
Part or other prescription drug coverage, whether your drug plan
covers the drug, and whether the hospital?s pharmacy is in your drug
plan?s network Contact your prescription drug plan to ?nd out what
you pay for drugs you get in a hospital outpatient setting that aren?t
covered under Part B.

Other than the examples above, you pay 100% for most prescription
drugs, unless you have Part or other drug coverage. See pages 83?96
for more information about Part D.

Section 2: Find out if Medicare covers your test, service, or item 49

Prostate cancer screenings

Medicare covers a Prostate Speci?c Antigen (PSA) test and a digital
rectal exam once every 12 months for men over 50 (beginning the day
after your 50th birthday). You pay nothing for the PSA test. For the
digital rectal exam, you pay 20% of the Medicare-approved amount,
and the Part deductible applies. In a hospital outpatient setting, you
also pay the hospital a copayment.

Prosthetic/orthotic items

Medicare covers arm, leg, back, and neck braces; arti?cial eyes;
arti?cial 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 ordered by a
doctor or other health care provider enrolled in Medicare.

For Medicare to cover your prosthetic or orthotic, you must go
to a supplier that?s enrolled in Medicare. You pay 20% of the
Medicare?approved amount, and the Part deductible applies.

Pulmonary rehabilitation

Medicare covers a comprehensive pulmonary rehabilitation program
if you have moderate to very severe chronic obstructive pulmonary
disease (COPD) and have a referral from the doctor treating this
chronic respiratory disease. You pay 20% of the Medicare?approved
amount if you get the service in a doctor?s of?ce. You also pay the
hospital a copayment per session if you get the service in a hospital
outpatient setting. The Part deductible applies.

Rural Health Clinic (RHC) services

RHCs furnish many outpatient primary care and preventive health
services. RHCs are located in rural and underserved areas. Generally,
you?re responsible for paying 20% of the charges, and the Part 
deductible applies. You pay nothing for most preventive services.

Second surgical opinions

Medicare covers second surgical opinions for surgery that isn?t an
emergency. In some cases, Medicare covers third surgical opinions.
You pay 20% of the Med icare-approved amount, and the Part 
deductible applies.

50 Section 2: Find out if Medicare covers your test, service, or item

\f Sexually transmitted infection (STI) screening and

counseling

Medicare covers STI screenings for chlamydia, gonorrhea, syphilis,

and Hepatitis B. These screenings are covered if you?re pregnant or at
increased risk for an STI when the tests are ordered by a primary care
provider. Medicare covers these tests once every 12 months or at certain
times during pregnancy.

Medicare also covers up to 2 individual, 20?30 minute, face?to?face,
high?intensity behavioral counseling sessions each year for sexually
active adults at increased risk for STIs. Medicare will only cover these
counseling sessions if they?re provided by a primary care doctor or other
primary care practitioner and take place in a primary care setting (like
a doctor?s of?ce). Counseling conducted in an inpatient setting, like a
skilled nursing facility, won?t be covered as a preventive service.

You pay nothing for these services if the primary care doctor or other
quali?ed health care provider accepts assignment.

Shots

Part covers:

- Flu shots. See page 46.

- Hepatitis shots. See page 

- Pneumococcal shots. See page 52.

Note about the shingles shot:

The shingles shot isn?t covered by Part A or Part B. Generally, Medicare
prescription drug plans (Part D) cover the shingles shot, as well as all
commercially available vaccines needed to prevent illness. Contact your
Medicare drug plan for more information about coverage.

\f Smoking and tobacco-use cessation (counseling to
stop smoking or using tobacco products)
Medicare covers up to 8 face?to?face visits in a 12?month period. All
people with Medicare who use tobacco are covered. You pay nothing
for the counseling sessions if the doctor or other quali?ed health care
provider accepts assignment.

Section 2: Find out if Medicare covers your test, service, or item 51

Speech-language pathology services

Medicare covers evaluation and treatment to regain and strengthen
speech and language skills, including cognitive and swallowing skills,
when your doctor or other health care provider certi?es you need

it. There may be a limit on the amount Medicare will pay for these
services in a single year, and there may be certain exceptions to these
limits. You pay 20% of the Med icare?approved amount, and the Part 
deductible applies.

Surgical dressing services

Medicare covers medically necessary treatment of a surgical or
surgically treated wound. You pay 20% of the Medicare?approved
amount for the doctor?s or other health care provider?s services. You
pay a ?xed copayment for these services when you get them in a
hospital outpatient setting. The Part deductible applies. You pay
nothing for the supplies.

Telehealth

Medicare covers services like of?ce visits, 
consultations, and certain other medical or health services provided
using an interactive, two?way telecommunications system (like
real?time audio and video) by an eligible provider who isn?t at your
location. These services are available in rural areas, under certain
conditions, but only if you?re located at: a doctor?s of?ce, hospital,
critical access hospital, Rural Health Clinic, Federally Quali?ed Health
Center, hospital?based dialysis facility, skilled nursing facility, or
community mental health center. For most of these services, you?ll pay
the same amount that you would if you got the services in person.

Tests (other than lab tests)

Medicare covers X?rays, MRIs, scans, and some other
diagnostic tests. You pay 20% of the Medicare?approved amount, and
the Part deductible applies. If you get the test at a hospital as an
outpatient, you also pay the hospital a copayment that may be more
than 20% of the Medicare?approved amount, but, in most cases, this
amount can?t be more than the Part A hospital stay deductible. See
Laboratory services on page 49 for other Part B?covered tests.

52 Section 2: Find out if Medicare covers your test, service, or item

Transitional care management services

Medicare may cover this service if you?re returning to your community
after a stay at certain facilities, like a hospital or skilled nursing facility.
The health care provider who?s managing your transition back into the
community will work to coordinate and manage your care for the ?rst
30 days after you return home. He or she will work with you and your
family and caregiver(s), as appropriate, and with your other health care
providers. You?ll also be able to get an in?person of?ce visit within 2
weeks of your return home. The health care provider may also review
information on the care you received in the facility, provide information
to help you transition back to living at home, work with other care
providers, help you with referrals or arrangements for follow?up care or
community resources, assist you with scheduling, and help you manage
your medications. The Part deductible and coinsurance apply.

Transplants and immunosuppressive drugs

Medicare covers doctor services for heart, lung, kidney, pancreas,
intestine, and liver transplants under certain conditions but only in
Medicare?certi?ed facilities. Medicare also covers bone marrow and
cornea transplants under certain conditions.

Note: The transplant surgery may be covered as a hospital inpatient
service under Part A. See pages 31?32 for more information.

Medicare covers immunosuppressive drugs if the transplant was
covered by Medicare or an employer or union group health plan was
required to pay before Medicare paid for the transplant. You must have
Part A at the time of the covered transplant, and you must have Part

at the time you get immunosuppressive drugs. You pay 20% of the
Medicare?approved amount for the drugs, and the Part deductible
applies.

If you?re thinking about joining a Medicare Advantage Plan (like an
HMO or PPO) 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, other health care providers, 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 if they aren?t covered by Original Medicare.

Section 2: Find out if Medicare covers your test, service, or item 53

Travel (health care needed when traveling outside
the U5.)

Medicare generally doesn?t cover health care while you?re traveling
outside the U.S. (The includes the 50 states, the District

of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the
Northern Mariana Islands, and American Samoa.) There are

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

- You?re in the U.S. when an emergency occurs, and the foreign
hospital is closer than the nearest U.S. hospital that can treat your
medical condition.

- You?re traveling through Canada without unreasonable delay by
the most direct route between Alaska and another U.S. state when
a medical emergency occurs, and the Canadian hospital is closer
than the nearest U.S. hospital that can treat the emergency.

- 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.

Medicare may cover medically necessary ambulance transportation
to a foreign hospital only with admission for medically

necessary covered inpatient hospital services. You pay 20% of the
Med icare?approved amount, and the Part deductible applies.

Urgently needed care

Medicare covers urgently needed care to treat a sudden illness

or injury that isn?t a medical emergency. You pay 20% of the

Med icare?approved amount for the doctor?s or other health care
provider?s services, and the Part deductible applies. In a hospital
outpatient setting, you also pay the hospital a copayment.

54 Section 2: Find out if Medicare covers your test, service, or item

\f "Welcome to Medicare" preventive visit

0 During the ?rst 12 months that you have Part B, you can get
a ?Welcome to Medicare? preventive visit. This visit includes
a review of your medical and social history related to your
health, and education and counseling about preventive services,
including certain screenings, ?u and pneumococcal shots,
and referrals for other care, if needed. When you make your
appointment, let your doctor?s of?ce know that you?d like to
schedule your ?Welcome to Medicare? preventive visit. You pay
nothing for the ?Welcome to Medicare? preventive visit if the
doctor or other quali?ed health care provider accepts assignment.

If your doctor or other health care provider performs additional
tests or services during the same visit that aren?t covered under
this preventive bene?t, you may have to pay coinsurance, and the
Part deductible may apply.

\f Yearly "Wellness" visit

a If you?ve had Part for longer than 12 months, you can get a
yearly ?Wellness? visit to develop or update a personalized plan to
prevent disease or disability based on your current health and risk
factors. This visit is covered once every 12 months.

Your provider will ask you to ?ll out a questionnaire, called a
?Health Risk Assessment,? as part of this visit. Answering these
questions can help you and your provider develop a personalized
prevention plan to help you stay healthy and get the most out of
your visit. When you make your appointment, let your doctor?s
of?ce know that you?d like to schedule your yearly ?Wellness?
visit.

Note: Your ?rst yearly ?Wellness? visit can?t take place within
12 months of your enrollment in Part or your ?Welcome to
Medicare? preventive visit. However, you don?t need to have had
a ?Welcome to Medicare? preventive visit to qualify for a yearly
?Wellness? visit.

You pay nothing for the yearly ?Wellness? visit if the doctor or
other quali?ed health care provider accepts assignment.

 

 

Same Medicare
Advantage Plans
may cheese

to cover these
services. See
page 65.

 

 

Section 2: Find out if Medicare covers your test, service, or item 55

If your doctor or other health care provider performs additional
tests or services during the same visit that aren?t covered under this
preventive bene?t, you may have to pay coinsurance, and the Part 
deductible may apply.

 

What's NOT covered by Part A and Pa rt 

Original Medicare doesn?t cover everything. If you need certain
services that aren?t covered under Medicare Part A or Part B, you?ll
have to pay for them yourself unless:

- You have other coverage (including Medicaid) to cover the costs.

- You?re in a Medicare Advantage Plan that covers these services.

Some of the items and services that Original Medicare doesn?t
cover include:

Most dental care.

examinations related to prescribing glasses.
Dentures.

Cosmetic surgery.

Massage therapy.

Acupuncture.

Hearing aids and exams for ?tting them.



Long?term care. See next page for more information about
paying for long?term care.



Concierge care (also called concierge medicine, retainer?based
medicine, boutique medicine, platinum practice, or direct care).

56 Section 2: Find out if Medicare covers your test, service, or item

 

Special Needs
Plans are a type
of Medicare
Advantage Plan
that may caver
long?term care
if you have
Medicare and
Medicaid. See
page F4.

 

 

 

Paying for long-term care

Long?term care includes non?medical care for people who have a
chronic illness or disability. This includes non?skilled personal care
assistance, like help with everyday activities, including dressing,
bathing, and using the bathroom. Medicare and most health
insurance plans, including Medicare Supplement Insurance
(Medigap) policies, don?t pay for this type of care, sometimes
called ?custodial care.? You may be eligible for this type of care
through Medicaid, or you can choose to buy private long-term
care insurance. Long?term care can be provided at home, in the
community, in an assisted living facility, or in a nursing home. It?s
important to start planning for long?term care now to maintain
your independence and to malce sure you get the care you may
need, in the setting you want, in the future.

Long-term care resources
Use these resources to get more information about long?term care:

- Visit longtermcare.gov to learn more about planning for
long?term care.

- Call your State Insurance Department to get information about
long?term care insurance. Visit Medicaregovfcontacts, or call
(1?800?633?4227) to get the phone number.
TTY users can call 1?877?486?2048.

- Call the National Association of Insurance Commissioners at
1?866?470?6242 to get a copy of Shopper?s Guide to Long?Term
Care Insurance.?

- Call your State Health Insurance Assistance Program (SHIP). See
the baclc cover for the phone number.

- Visit the Eldercare Locator, a public service of the U.S.
Administration on Aging, at eldercare.gov to ?nd help in your
community.

5?

Section 3:
Original Medicare

 

How does Original Medicare work?

Original Medicare is one of your health coverage choices as part of
Medicare. You?ll have Original Medicare unless you cheese a Medicare
Advantage Plan or other type of Medicare health plan.

Original Medicare is coverage managed by the
federal government. You generally have to pay
a portion of the cost for each service covered
by Original Medicare. See the next page for the
general rules about how it works.

 

 

 

De?nitions
of blue 
are on pages
123?126.

 

 

58

Section 3: Original Medicare

Original Medicare

 

Can I get my health
care from any doctor,
other health care
provider, or hospital?

In most cases, yes. You can go to any doctor, other
health care provider, hospital, or other facility
that?s enrolled in Medicare and accepting Medicare
patients. Visit Medicaregov to search for and
compare health care providers, hospitals, and
facilities in your area.

 

Are prescription
drugs covered?

No, with a few exceptions (see pages 31, 52, and 56),
most prescriptions aren?t covered. You can add drug
coverage by joining a Medicare Prescription Drug
Plan (Part D). See pages 83?96.

 

Do I need to choose a
primary care doctor?

No.

 

Do have to get a
referral to see a
specialist?

In most cases, no, but the specialist must be
enrolled in Medicare.

 

Should I get a
supplemental policy?

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 Medicare Supplement
Insurance (Medigap) policy if you?re eligible. See
pages 79?82.

 

What else do I need
to know about
Original Medicare?

 

- You generally pay a set amount for your health
care (deductible) before Medicare pays its share.
Then, Medicare pays its share, and you pay your
share (coinsurance I'copaymeut) for covered
services and supplies. There?s no yearly limit for
what you pay out?of?pocket.

- You usually pay a premium for Part B.
See pages 99?100 for information about help
paying your Part premium.

- You generally don?t need to ?le Medicare claims.
The law requires providers (like doctors, hospitals,
skilled nursing facilities, and home health
agencies) and suppliers to ?le your claims for the
covered services and supplies you get.

 

 

Section 3: Original Medicare 59

What do I pay?

Your out?of?poclcet costs in Original Medicare depend on:
- Whether you have Part A andfor Part B. Most people have both.

- Whether your doctor, other health care provider, or supplier accepts
?assignment.?

- 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 costs unless you have other insurance that covers them.

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

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

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

- Whether you and your doctor or other health care provider sign a private
contract. See page 64.

How do I know what Medicare paid?

If you have Original Medicare, you?ll get a ?Medicare Summary Notice?
(MSN) in the mail every 3 months that lists all the services billed to
Medicare. The MSN shows what Medicare paid and what you may owe the
provider. The MSN isn?t a bill. Review your MSNs to be sure you got all the
services, supplies, or equipment listed.

If you need to change your address on your MSN, call Social Security at
1?800?37?72?1213. TTY users can call If you get Railroad
Retirement Board (RRB) bene?ts, call the RRB at 1?87??772?5772. TTY
users can call 1?312?751?4701.

Your MSN will tell you if you?re enrolled in the Quali?ed Medicare
Bene?ciary Program (QMB). If you have QMB, Medicare providers

aren?t allowed to bill you ?or Medicare Part A andr'or Part deductibles,
coinsurance, or copayments. For more information about QMB and steps to
take if you get billed for these costs, see page 99.

Get your Medicare Summary Notices electronically

Go paperless and get your ?Medicare Summary Notices? electronically (also
called You can sign up by visiting MyMedicare.gov. If you sign
up for we?ll send you an email each month when they?re available in
your MyMedicare.gov account. The contain the same information as
paper MSNs. You won?t get printed copies of your MSNs in the mail if you
choose 

60

 

 

Tn ?nd nut if
someone accepts
assignment or
participates in
Medicare, visit
Medicaregevf
physician or
Medicaregnvf
supplier. Or,

you can call


(1?300?633?422?).

users can call


 

 

 

 

To ?nd doctors
in your area who
have npted?nut
of Medicare,

visit Medicare.

Or, you can call


(1?300-633?4223.

TW users can call


 

 

Section 3: Original Medicare

What's assignment?

Assignment means that your doctor, provider, or supplier agrees (or
is required by law) to accept the Medica re?approved amount as full
payment for covered services.

If your doctor, provider, or supplier accepts assignment:

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

- They agree to charge you only the Medicare deductible and
coinsurance amount and usually wait for Medicare to pay its share
before asking you to pay your share.

- They have to submit your claim directly to Medicare and can?t charge
you for submitting the claim.

Non?participating providers haven?t signed an agreement to accept
assignment for all Medicare?covered services, but they can still choose
to accept assignment for individual services. These providers are called
?non?participating.? Here?s what happens if your doctor, provider, or
supplier doesn?t accept assignment:

- You might have to pay the entire charge at the time of service.
Your doctor, provider, or supplier is supposed to submit a claim to
Medicare for any Medicare?covered services they provide to you.
If they don?t submit the Medicare claim once you ask them to, call


- They can charge you more than the Medicare?approved amount, but
there?s a limit called ?the limiting charge.?

Certain doctors and other health care providers who don?t want to
enroll in the Medicare program may ?opt?out? of Medicare. You can still
see these providers, but they must enter into a private contract with you
(unless you?re in need of emergency or urgently needed care). Medicare
won?t pay for any services you get under a private contract. However,
private contracts give you and your provider the flexibility to set up your
own payment terms that work best for you.

You can contact your State Health Insurance Assistance Program
(SHIP) to get free help with these topics. See the back cover for the
phone number.

 

 

You don?t need a
referral to see a
specialist if you
have Original
Medicare. See
page 62.

 

 

61

Section 4:

Learn about Medicare
Advantage Plans 8: other
projects

What are Medicare Advantage Plans?

 

A Medicare Advantage Plan (like an HMO or PPO) is another way to
get your Medicare coverage. Medicare Advantage Plans, sometimes
called ?Part or Plans,? are offered by Medicare-approved
private companies that must follow rules set by Medicare. If you join a
Medicare Advantage Plan, you?ll still have Medicare but you?ll get your
Medicare Part A (HoSpital Insurance) and Medicare Part (Medical
Insurance) coverage from the Medicare Advantage Plan, not Original
Medicare. You may need to use health care providers who participate
in the plan?s network. Some plans offer out-of-networlc coverage.
Remember, in most cases, you must use the card from your Medicare
Advantage Plan to get your Medicare-covered services. Keep your
Medicare card in a safe place because you?ll need it if you ever switch
back to Original Medicare.

What are the different types of Medicare

 

Advantage Plans?

Health Maintenance Organization (HMO) plans: See page 71.
Preferred Provider Organization (PPO) plans: See page 72.
Private Fee?for?Service (PFFS) plans: See page 73.

Special Needs Plans (SNPs): See page 74.

HMO Point?of?Service (HMOPOS) plans: These are HMO plans
that may allow you to get some services out-of-networlc for a higher
copayntent or coinsurance.

62 Section 4: Learn about Medicare Advantage Plans 8: other options

 

In mast cases,
you can?t get a
preautharizatian
for services ar
supplies if you
have Original
Medicare.

 

 

 

Medical Savings Account (MSA) plans: These plans combine a high?
deductible health plan with a bank account. Medicare deposits money
into the account (usually less than the deductible). You can use the
money to pay for your health care services during the year. MSA plans
don?t offer Medicare drug coverage. If you want drug coverage, you have
to join a Medicare Prescription Drug Plan.

Medicare Advantage Plans cover all Medicare
Pa rt A and Part services

In all types of Medicare Advantage Plans, you?re always covered for
emergency and urgent care. Medicare Advantage Plans must cover all
of the services that Original Medicare covers. However, if you?re in a
Medicare Advantage Plan, Original Medicare will still cover the cost for
hospice care, some new Medicare bene?ts, and some costs for clinical
research studies.

Most Medicare Advantage Plans o?cer coverage for things that aren?t
covered by Original Medicare, like vision, hearing, dental, and other
health and wellness programs. Most include Medicare prescription
drug coverage (Part D). In addition to your Part premium, you might
have to pay a premium for the Medicare Advantage Planitem or service will be
covered in advance

You [or a provider acting on your behalf) always have the right to request
a preauthorization to see if an item or service will be covered by the plan.
This is called an ?organization determination.? If your plan denies your
preauthorization, the plan must tell you in writing.

You don?t have to pay more than the applicable cost-sharing for a service or
supply if a network provider didn?t get a preauthorization [or ?organization
determination?) and either of these is true:

I The provider furnished or referred you for services or Supplies that you
reasonably thought would be covered.

I The provider referred you to an out-of?network provider for plan-covered
services.

Contact your plan for more information.

 

 

 

Section 4: Learn about Medicare Advantage Plans 8: other options 63

Medicare Advantage Plans must follow
Medica re's rules

Medicare pays a ?xed amount for your coverage each month to the
companies offering Medicare Advantage Plans. These companies must
follow rules set by Medicare. However, each Medicare Advantage Plan
can charge different out?of?pocket costs and have different rules for
how you get services (like whether you need a referral to see a specialist
or if you have to go to doctors, facilities, or suppliers that belong to the
plan?s network for non?emergency or non?urgent care). These rules can
change each year. The plan must notify you about any changes before
the start of the next enrollment year. Remember, you have the option
each year to keep your current plan, choose a different plan, or switch
to Original Medicare. See page 75.

Read the information you get from your plan

If you?re in a Medicare Advantage Plan, review the ?Evidence of
Coverage? (EOC) 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, provider networks, service area, and more that will
be effective in January. If you don?t get these important documents
before the start of Open Enrollment, contact your plan.

What else should I know about Medicare Advantage
Plans?

- You have Medicare rights and protections, including the right to
appeal. See pages 104?101

- You must follow plan rules. It?s important to check with the plan for
information about your rights and responsibilitiesdoctor, other health care provider, facility, or supplier
that doesn?t belong to the plan?s network for non?emergency or non?
urgent care services, your services may not be covered, or your costs

could be higher. In most cases, this applies to Medicare Advantage
HMOs and PPOs.

- Providers can join or leave a plan?s provider network anytime during
the year. Your plan can also change the providers in the network
anytime during the year. If this happens, you may need to choose a
new provider. You generally can?t change plans during the year if this

happens.

64 Section 4: Learn about Medicare Advantage Plans 8: other options

 

A Medicare
Advantage

Plan with drug
coverage can be
a good option if
you're interested
in enrolling in
Part but can?t
afford a separate
premium. See
page 33.

 

 

 

- Plans may include ?tness and wellness bene?ts.

- Medicare Advantage Plans can?t charge more than Original Medicare
for certain services, like chemotherapy, dialysis, and skilled nursing
facility care.

- Medicare Advantage Plans have a yearly limit on your out?of?pocket
costs for medical services. Once you reach this limit, you?ll pay
nothing for covered services. Each plan can have a di?ferent limit,
and the limit can change each year. You should consider this when
choosing a plan.

Joining and leaving

- You can join a Medicare Advantage Plan even if you have a
pre?eXisting condition, except for End?Stage Renal Disease (ESRD), for
which there are special rules. See page 69.

- You can only join or leave a Medicare Advantage Plan at certain
times during the year. See pages 

- Each year, Medicare Advantage Plans can choose to leave Medicare or
make changes to the services they cover and what you pay. If the plan
decides to stop participating in Medicare, you?ll have to join another
Medicare Advantage Plan or return to Original Medicare. See page
104.

- Medicare Advantage Plans must follow certain rules when giving
you information about how to join their plan. See page 115 for more
information about these rules and how to protect your personal
information.

Prescription drug cove rage

You usually get prescription drug coverage (Part D) through the
Medicare Advantage Plan. In certain types of plans that can?t offer drug
coverage (like MSA plans) or choose not to offer (like some plans)
drug coverage, you can join a separate Medicare Prescription Drug
Plan. If you?re in a Medicare Advantage HMO or PPO, and you join a
separate Medicare Prescription Drug Plan, you?ll be disenrolled from
your Medicare Advantage Plan and returned to Original Medicare.

Section 4: Learn about Medicare Advantage Plans 8: other options 65

Who can join?

You must meet these conditions to join a Medicare Advantage Plan:
- You have Part A and Part B.

- You live in the plan?s service area.

- You don?t have End?Stage Renal Disease (ESRD), except as explained
on page 69.
- You?re a U.S. citizen or lawfully present in the United States.

What if I have other coverage?

Talk to your employer, union, or other bene?ts administrator about
their rules before you join a Medicare Advantage Plan. In some cases,
joining a Medicare Advantage Plan might cause you to lose your
employer or union coverage. If you lose coverage for yoursel? you may
also lose coverage for your spouse and dependents. 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 Medicare Advantage Plan
you join. Remember, if you lose your employer or union coverage,
you may not be able to get it back.

What ifl have a Medicare Supplement Insurance

(Medigap) Policy?

You can?t enroll in (and don?t need) a Medicare Supplement Insurance
(Medigap) policy while you?re in a Medicare Advantage Plan. You
can?t use it to pay for any expenses (copayments, deductibles, and
premiums) you have under a Medicare Advantage Plan. If you
already have a Medigap policy and join a Medicare Advantage Plan,
you?ll probably want to drop your Medigap policy. If you drop your
Medigap policy, you may not be able to get it back. See page 81.

What ifl have End-Stage Renal Disease 

If you have End?Stage Renal Disease (ESRD), you can only join a

Medicare Advantage Plan in certain situations:

- If you?re already in a Medicare Advantage Plan when you develop
ESRD, you can stay in your plan or you may be able to join another
Medicare Advantage Plan offered by the same company.

- If you?re 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.

66 Section 4: Learn about Medicare Advantage Plans 8: other options

- If you have an employer or union health plan or other health coverage
through a company that o?cers one or more Medicare Advantage Plan(s), you
may be able to join one of that company?s Medicare Advantage Plans.

- If you?ve had a successful kidney transplant, you may be able to join a
Medicare Advantage Plan.

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

For more information, visit Medicaregovi" publications to view the booklet
?Medicare Coverage of Kidney Dialysis 3: Kidney Transplant Services.?

Note: If you have ESRD and Original Medicare, you may join a Medicare
Prescription Drug Plan.

What do I pay?
Your out?of?pocket costs in a Medicare Advantage Plan depend on:

- Whether the plan charges a premium. You pay this in addition to
the Part premium. In 2018, the average Medicare Advantage Plan
premium was $30.

- Whether the plan pays any of your Medicare premiums. As an
added bene?t, some Medicare Advantage Plans will help pay all or part of
your Part premium. This bene?t is sometimes called a ?Medicare Part 
premium reduction.?

- Whether the plan has a yearly deductible or any additional deductibles for
certain services.

- How much you pay for each visit or service (copayrnents or coinsurance).

- The type of health care services you need and how often you get them.

- Whether you go to a doctor or supplier who accepts assignment (if you?re in
a Preferred Provider Organization, Private Pee?for?Service Plan, or Medical
Savings Account Plan and you go out?of?network). See page 64 for more
information about assignment.

- Whether you get services from a network provider or a provider that doesn?t
contract with the plan.

- Whether you need extra bene?ts and if the plan charges for them.

- The plan?s yearly limit on your out?of?pocket costs for all medical services.
Once you reach this limit, you?ll pay nothing for covered services.

- Whether you have Medicaid or get help from your state.

To learn more about your costs in speci?c Medicare Advantage Plans, see
Section 11, which starts on page 129, then contact the plans you?re interested in
for more details. Or, you can visit 

 0

Section 4: Learn about Medicare Advantage Plans 8: other options I 6?

Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) plan

Can I get my health care from any doctor, other health care
provider, or hospital?

No. You generally must get your care and services from doctors,

other health care providers, 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. This is called an HMO with a point?of?service
(P03) option.

Are prescription drugs covered?
In most cases, yes. If you want Medicare drug coverage, you must join
an HMO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?
In most cases, yes.

Do I have to get a referral to see a specialist?
In most cases, yes. Certain services, like yearly screening
mammograms, don?t require a referral.

What else do I need to know about this type of plan?

- If your doctor or other health care provider leaves the plan?s network,
your plan will notify you. You may choose another doctor in the
plan?s network.

- 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.

- If you need more information than what?s listed on this page, check
with the plan.

68 I Section 4: Learn about Medicare Advantage Plans 8: other options

0
n.
a.

Preferred Provider Organization (PPO) plan

Can I get my health care from any doctor, other health care
provider, or hospital?

In most cases, yes. PPOs have network doctors, other health care
providers, and hospitals, but you can also use out?of?network providers
for covered services, usually for a higher cost.

Are prescription drugs covered?
In most cases, yes. If you want Medicare drug coverage, you must join a
PPO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?
No.

Do I have to get a referral to see a specialist?
In most cases, no.

What else do I need to know about this type of plan?

- PPO plans aren?t the same as Original Medicare or Medigap.

- Medicare PPO plans usually o??er more bene?ts than Original
Medicare, but you may have to pay extra for these bene?ts.

- If you need more information than what?s listed on this page, check
with the plan.

PFFS

Section 4: Learn about Medicare Advantage Plans 8: other options 69

Private Fee-for-Service (PFFS) plan

Can I get my health care from any doctor, other health care
provider, or hospital?

You can go to any Medicare?approved doctor, other health care
provider, or hospital that accepts the plan?s payment terms and agrees
to treat you. If you join a PFFS plan that has a network, you can also
see any of the network providers who?ve agreed to always treat plan
members. You can also choose an out?of?network doctor, hospital, or
other provider, who accepts the plan?s terms, but you may pay more.

Are prescription drugs covered?
Sometimes. If your PFFS plan doesn?t offer drug coverage, you can join
a Medicare Prescription Drug Plan to get coverage.

Do I need to choose a primary care doctor?
No.

Do have to get a referral to see a specialist?
No.

What else do I need to know about this type of plan?
- PFFS plans aren?t the same as Original Medicare or Medigap.

- The plan decides how much you must pay for services.

- Some PFFS plans contract with a network of providers who agree to
always treat you, even if you?ve never seen them before.

- Out?of?network doctors, hospitals, and other providers may decide
not to treat you, even if you?ve seen them before.

- For each service you get, make sure to show your plan member card
before you get treated.

- In a medical emergency, doctors, hospitals, and other providers must
treat you.

- If you need more information than what?s listed on this page, check
with the plan.

10 I Section 4: Learn about Medicare Advantage Plans 8: other options

0.


V)

Special Needs Plan (SNP)

Can I get my health care from any doctor, other health care
provider, or hospital?

You generally must get your care and services from doctors, other health
care providers, or hospitals in the plan?s network (except emergency
care, out?of?area urgent care, or out?of?area dialysis).

Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage.

Do I need to choose a primary care doctor?
Generally, yes.

Do have to get a referral to see a specialist?
In most cases, yes. Certain services, like yearly screening mammograms,
don?t require a referral.

What else do I need to know about this type of plan?

- A plan must limit membership to these groups: 1) people who live in
certain institutions (like nursing homes) or who require nursing care
at home, or 2) people who are eligible for both Medicare and Medicaid,
or 3) people who have speci?c chronic or disabling conditions (like

diabetes, End?Stage Renal Disease, HIWAIDS, chronic heart failure, or
dementia). Plans may further limit membership.

- Plans will coordinate the services and providers you need to help you
stay healthy and follow doctors? or other health care providers? orders.

- See Section 11, which starts on page 129, or visit
Medicaregow??nd-a-plan to see if there are SNPs available in your
area.

- If you need more information than what?s listed on this page, check
with the plan.

 

Section 4: Learn about Medicare Advantage Plans 8: other options 3'1

When can ljoin, switch, or drop a Medicare Advantage
Plan?

- When you ?rst become eligible for Medicare, you can sign up during
your Initial Enrollment Period. See page 21.

- If you have Part A coverage and you get Part for the ?rst time
during the General Enrollment Period, you can also join a Medicare
Advantage Plan. Your coverage may not start until July 1. See page 22.

- Between October 15?December 7, anyone with Medicare can join,
switch, or drop a Medicare Advantage Plan. Your coverage will begin
on Ianuary 1, as long as the plan gets your request by December T.

Can I make changes to my coverage after December 
Between January 1?March 31 each year, you can make these changes
during the Medicare Advantage Open Enrollment Period:

- If you?re in a Medicare Advantage Plan (with or without drug coverage),
you can switch to another Medicare Advantage Plan (with or without
drug coverage).

- You can disenroll from your plan and return to Original Medicare. If
so, you?ll be able to join a Medicare Prescription Drug Plan.

- If you enrolled in a Medicare Advantage Plan during your Initial
Enrollment Period, you can change to another Medicare Advantage
Plan (with or without drug coverage) or go back to Original Medicare
(with or without drug coverage).

During this period, you can?t:
- Switch from Original Medicare to a Medicare Advantage Plan.

- Ioin a Medicare Prescription Drug Plan if you?re in Original Medicare.

- Switch from one Medicare Prescription Drug Plan to another if you?re
in Original Medicare.

Any changes you make during this period will be effective the ?rst of the
month after the request is received by plan.

 

Thinking about joining a Medicare Advantage Plan, but aren?t
sure? The Medicare Advantage Open Enrollment Period gives you
an opportunity to try out a Medicare Advantage Plan. It also lets
you switch back to Original Medicare depending on which coverage
works better for you.

 

 

 

12 Section 4: Learn about Medicare Advantage Plans 8: other options

Special Enrollment Periods

In most cases, you must stay enrolled for the 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 during a Special
Enrollment Period. Some examples are:

- You move out of your plan?s service area.
- You have Medicaid.
- You qualify for Extra Help. See pages 9??98.

- You live in an institution (like a nursing home).

5-star Special Enrollment Period

You can switch to a Medicare Advantage Plan or Medicare Cost Plan
(see page 77) that has 5 stars for its overall star rating from December
8, 2018?November 30, 2019. You can only use this Special Enrollment
Period once during this timeframe. The overall star ratings are available
at Medicaregovf?nd-a-plan. See page 120 for more information.

You may lose your prescription drug coverage if you move from a

Medicare Advantage Plan that has drug coverage to a 5?star Medicare
Advantage Plan that doesn?t. You?ll have to wait until your next
enrollment opportunity to get drug coverage, and you may have to pay a
Part late enrollment penalty. See pages 84?85.

How do I switch?

Follow these steps if you?re already in a Medicare Advantage Plan and

want to switch:

- To switch to a new Medicare Advantage Plan, simply join the plan
you choose during one of the enrollment periods explained on pages
75?76. You?ll 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?633?4227). TTY users can call
1?877?486?2048. If you don?t have drug coverage, you should consider
joining a Medicare Prescription Drug Plan to avoid paying a penalty
if you decide to join later. You may also want to consider joining a
Medicare Supplement Insurance (Medigap) policy if you?re eligible. See
page 79 for more information about buying a Medigap policy.

For more information on joining, dropping, and switching plans, visit
Medicaregov or call 

Section 4: Learn about Medicare Advantage Plans 8: other options 3'3

Are there other types of Medicare health plans

 

and projects?

Some types of Medicare health plans that provide health care
coverage aren?t Medicare Advantage Plans but are still part of
Medicare. Some of these plans provide Medicare Part A (Hospital
Insurance) and Medicare Part (Medical Insurance) coverage, while
others provide only Part coverage. In addition, some also provide
Part prescription drug coverage. These plans have some of the same
rules as Medicare Advantage Plans. However, each type of plan has
special rules and exceptions, so you should contact any plans you?re
interested in to get more details.

Medicare Cost Plans

Medicare Cost Plans are a type of Medicare health plan available

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 have Part A and Part and go to a non?network provider, the
services are covered under Original Medicare. You?ll pay the Part A
and Part coinsurance and deductibles.

- You can join anytime the Cost 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 Cost Plan (if offered), or you can join a Medicare Prescription
Drug Plan. Even if the Cost Plan o?cers prescription drug coverage,
you can choose to get drug coverage from a di??erent plan.

Note: You can add or drop Medicare prescription drug coverage
only at certain times. See pages 84?85.

For more information about Medicare Cost Plans, visit the Medicare
Plan Finder at Medicaregovl?nd-a-plan. Your State Health Insurance
Assistance Program (SHIP) can also give you more information. See
the back cover for the phone number.

14 Section 4: Learn about Medicare Advantage Plans 8: other options

 

De?nitions
of blue words
are on pages
125?128.

 

 

 

Programs of All-inclusive Care for the Elderly (PACE)
PACE is a Medicare and Medicaid program offered in many states
that allows people who otherwise need a nursing home?level of care to
remain in the community. To qualify for PACE, you must meet these
conditions:

- You?re 55 or older.
- You live in the service area of a PACE organization.
- You?re certi?ed by your state as needing a nursing home?level of care.

- At the time you join, you?re able to live safely in the community with

the help of PACE services.

PACE provides coverage for many services, including prescription
drugs, doctor or other health care provider visits, transportation, home
care, hospital visits, and even nursing home stays whenever necessary.

If you have Medicaid, you won?t have to pay a premium for

the long?term care portion of the PACE bene?t. If you have Medicare
but not Medicaid, you?ll be charged a premium to cover

the lorig?tern'i ca re portion of the PACE bene?t and a premium for
Medicare Part drugs. However, in PACE, there?s never a deductible or
copaymerit for any drug, service, or care approved by the PACE team of
health care professionals.

See Section 11, which starts on page 129, to see if there?s a PACE
organization that serves your community.

Medicare Innovation Projects

Medicare develops innovative models, demonstrations, and pilot
projects to test and measure the effect of potential changes in Medicare.
These projects help to ?nd new ways to improve health care quality and
reduce costs. Usually, they operate only a limited time for a speci?c
group of people author are o?cered only in speci?c areas. Examples of
current models, demonstrations, and pilot projects include innovations
in primary care, care related to speci?c procedures (such as hip and
knee replacements), cancer care, and care for people with End?stage
Renal Disease. To learn more about the current Medicare models,
demonstrations, and pilot projects, visit innovation.cms.gov. You can
also call (1?800?633?4227). TTY users can call
1?877?486?2048.

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

.75

Section 5:
Medicare Supplement
Insurance (Medigap) Policies

 

Original Medicare pays for much, but not all, of the cost for health
care services and supplies. Medicare Supplement Insurance policies,
sold by private companies, can help pay some of the remaining health
care costs, like copayments, coinsurance, and deductibles. Medicare
Supplement Insurance policies are also called Medigap policies.

Some Medigap policies also offer coverage for services that Original
Medicare doesn?t cover, like medical care when you travel outside the
U.S. Generally, Medigap policies don?t cover long?term care (like care
in a nursing home), vision or dental care, hearing aids, eyeglasses, or
private?duty nursing.

Medigap policies are standardized

Every Medigap policy must follow federal and state laws designed

to protect you, and they must be clearly identi?ed as ?Medicare
Supplement Insurance.? Insurance companies can sell you only a
?standardized? policy identi?ed in most states by letters A through
D, through G, and through N. All policies offer the same basic
bene?ts, but some o??er additional bene?ts so you can choose which
one meets your needs. In Massachusetts, Minnesota, and Wisconsin,
Medigap policies are standardized in a different way.

Medigap plans that cover the Medicare Part deductible

(Plans and in most states) will no longer be sold to most
people who turn 65 or who ?rst become eligible for Medicare after
Ianuary l, 2020. If you buy a Medigap Plan or before

January 1, 2020, you can keep that plan and your bene?ts

won?t change.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16 Section 5: Medicare Supplement Insurance [Medigap} Policies

How do I compare Medigap policies?

The chart belovv shovvs basic information about the different bene?ts

that Medigap policies cover. If a percentage appears, the Medigap plan

covers that percentage of the bene?t, and you?re responsible for the rest.
Bene?ts A F"r 
Medicare Part A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
coinsurance and hospital
costs (up to an additional
365 days after Medicare
bene?ts are used)
Medicare Part 100% 100% 100% 100% 100% 100% 50% 75% 100% 100%
0r 1*
Blood [?rst 3 pints] 100% 100% 100% 100% 100% 100% 50% 25% 100% 100%
Part A hospice care 100% 100% 100% 100% 100% 100% 50% 25% 100% 100%
coinsurance or copayment
Skilled nursing facility care 100% 100% 100% 100% 50% 25% 100% 100%
coinsurance
Part A deductible 100% 100% 100% 100% 100% 50% 75% 50% 100%
Part deductible 100% 100%
Part excess charges 100% 100%
Foreign travel emergency 80plan limits]

Out-of-
pocket limit
in 2018
$5,240 $2,620

 

 

 

 

 

Plan also offers a high?deductible plan in some states. If you choose this option,
this means you must pay for Medicare?covered costs (coinsurance, copayments, and
deductibles) up to the deductible amount of $2,240 in 2018 before your policy pays

anything.

Plan pays 100% of the Part coinsurance, except for a copayment of up to $20 for
some o?ice visits and up to a $50 copayment for emergency room visits that don?t result
in an inpatient admission.

Section 5: Medicare Supplement Insurance (Medigap) Policies 

What else should I know about Medicare Supplement
Insurance (Medigap)?

Important facts
- You must have Part A and Part B.

- You pay the private insurance company a premium for your
Medigap policy in addition to your Part premium that you
pay to Medicare. Also, if you join a Medigap policy and a Medicare
drug plan offered by the same company, you may need to make 2
separate premium payments for your coverage. Contact the company
to ?nd out how to pay your premiums.

- A Medigap policy only covers one person. Spouses must buy separate
policies.

- You can?t have prescription drug coverage in both your Medigap policy
and a Medicare drug plan. See page 94. The same insurance company
may o?cer Medigap policies and Medicare Prescription Drug Plans.

- It?s important to compare Medigap policies since the costs can vary
between insurance companies for exactly the same coverage, and may
go up as you get older. Some states limit Medigap premium costs.

- In some states, you may be able to buy another type of Medigap policy
called Medicare SELECT. If you buy a Medicare SELECT policy, you
have rights to change your mind within 12 months and switch to a
standard Medigap policy.

When to buy

- The best time to buy a Medigap policy is during your Medigap Open
Enrollment Period. This 6?month period begins on the ?rst day of
the month in which you?re 65 or older and enrolled in Part B. (Some
states have additional Open Enrollment Periods.) After this enrollment
period, you may not be able to buy a Medigap policy. If you?re able to
buy one, it may cost more.

- If you delay enrolling in Part because you have group health coverage
based on your (or your spouse?s) current employment, your Medigap
Open Enrollment Period won?t start until you sign up for Part B.

- Federal law generally doesn?t require insurance companies to sell
Medigap policies to people under 65. If you?re under 65, you might not
be able to buy the Medigap policy you want, or any Medigap policy,
until you turn 65. However, some states require Medigap insurance
companies to sell Medigap policies to people under 65. If you?re able to
buy one, it may cost more.

78

Section 5: Medicare Supplement Insurance (Medigap) Policies

How does Medigap work with Medicare

Advantage Plans?

- If you have a Medicare Advantage Plari (like an HMO or PPO), it?s
illegal for anyone to sell you a Medigap policy unless you?re switching
back to Original Medicare. If you?re not planning to leave your
Medicare Advantage Plan, and someone tries to sell you a Medigap
policy, report it to your State Insurance Department.

- If you have a Medigap policy and join a Medicare Advantage Plan, you
may want to drop your Medigap policy. Your Medigap policy can?t be
used to pay your Medicare Advantage Plan copaymerits, deductibles,
and premiums. If you want to cancel your Medigap policy, contact
your insurance company. In most cases, if you drop your Medigap
policy to join a Medicare Advantage Plan, you won?t be able to get it
back.

- If you join a Medicare Advantage Plan for the ?rst time, and you aren?t
happy with the plan, you?ll have special rights under federal law 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 policy back if the company still sells it. If it isn?t
available, you can buy another Medigap policy.

If you joined a Medicare Advantage Plan when you were ?rst
eligible for Medicare, you can choose from any Medigap policy
within the ?rst year of joining.

You may be able to join a Medicare Prescription Drug Plan.

Some states provide additional special rights.

Where can I get more information?

- Visit Medicaregov to ?nd policies in your area.

- Visit Medicare.govfpublicatious to view the booklet ?Choosing
a Medigap Policy: A Guide to Health Insurance for People with
Medicare.?

- Call your State Insurance Department. Visit Medicaregovr'corrtacts,
or call (1?800?633?4222?) to get the phone number.
TTY users can call 1?877?486?2048.

- Call your State Health Insurance Assistance Program (SHIP). See the
back cover for the phone number.

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

3'9

Section 6:
Medicare prescription drug
coverage (Part D)

How does Medicare prescription drug
coverage (Pa rt D) work?

 

Medicare prescription drug coverage is an optional bene?t. Medicare
o?ers drug coverage to everyone with Medicare. Even if you don?t

take preScriptions now, you should consider joining a Medicare drug
plan. If you decide not to join a Medicare drug plan when you?re ?rst
eligible, and you don?t have other creditable prescription drug coverage
or get Extra Help, you?ll likely pay a late enrollment penalty if you

join a plan later. Generally, you?ll pay this penalty for as long as you
have Medicare prescription drug coverage. See pages 89?91. To get
Medicare prescription drug coverage, you must join a plan approved
by Medicare that offers Medicare drug coverage. Each plan can vary
in cost and speci?c drugs covered. See Section 11, which starts on page
129, for more information about plans in your area.

There are 2 ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. These plans (sometimes called
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. You must
have Part A and/or Part to join a Medicare Prescription Drug
Plan.

2. Medicare Advantage Plans (like HMOs or PPOs) or other
Medicare health plans that offer Medicare prescription drug
coverage. You get all of your Part A, Part B, and prescription drug
coverage (Part D), through theSe plans. Medicare Advantage Plans
with prescription drug coverage are sometimes called 
Remember, you must have Part A and Part to join a Medicare
Advantage Plan, and not all of these plans offer drug coverage.

80 Section 6: Medicare prescription drug coverage (Part D)

In either case, you must live in the service area of the Medicare drug
plan you want to join. Both types of plans are called ?Medicare drug
plans? in this handbook.

If you have employer or union coverage

Call your bene?ts administrator before you make any changes, or
sign up for any other coverage. Signing up for other coverage could
cause you to lose your employer or union health and drug coverage for
you and your dependents. If you lose your employer or union coverage,
you may not be able to get it back. If you want to know how Medicare
prescription drug coverage works with other drug coverage you may
have, see pages 94?96.

When can I join, switch, or drop a Medicare

 

drug plan?

- When you ?rst become eligible for Medicare, you can join during your
Initial Enrollment Period. See page 21.

- If you get Part for the ?rst time during the General Enrollment
Period, you can also join a Medicare drug plan from
April 1 June 30. Your coverage will start on Iuly 1. See page 22.

- You can join, switch, or drop between October lS?December each
year. Your changes will take effect on Ianuary 1 of the following year,
as long as the plan gets your request during Open Enrollment.

- If you?re enrolled in a Medicare Advantage Plan, you can join,
switch, or drop during the Medicare Advantage Open Enrollment
period, between Ianuary 1?March 31 each year. See page 75 for more
information.

- If you qualify for a Special Enrollment Period. See the next page.

Section 6: Medicare prescription drug coverage (Part D) 81

Special Enrollment Periods

You generally must stay enrolled for the calendar year. However, in
certain situations, you may be able to join, switch, or drop Medicare
drug plans at other times. Some examples are if you:

- Move out of your plans service area.

- Lose other creditable prescription drug coverage.
- Live in an institution (like a nursing home).

- Have Medicaid.

- Qualify for Extra Help. See pages 97?98.

5-star Special Enrollment Period

You can switch to a Medicare Prescription Drug Plan that has 5 stars
for its overall star rating from December 8, 2018 ?November 30, 2019.
You can only use this Special Enrollment Period once during

this timeframe. The overall star ratings are available at
Medicaregovf?nd-a-plan.

lfyou have a Medicare Advantage Plan

If you?re in a Medicare Advantage HMO or PPO, and you join a
separate Medicare Prescription Drug Plan, you?ll be disenrolled from
your Medicare Advantage Plan and returned to Original Medicare.

How do I switch?

You can switch to a new Medicare drug plan simply by joining another
drug plan during one of the times listed on pages 84?85. You don?t
need to cancel your old Medicare drug plan. Your old Medicare drug
plan coverage will end when your new drug plan coverage begins. You
should get a letter from your new Medicare drug plan telling you when
your coverage with the new plan begins.

How do I drop a Medicare drug plan?

If you want to drop your Medicare drug plan and don?t want to join a
new plan, you can only do so during certain times. See pages 84?85.
You can disenroll by calling (1?800?633?4223?)
TTY users can call 1?877?486?2048. You can also send a letter to the
plan to tell them you want to disenroll. If you drop your plan and
want to join another Medicare drug plan later, you have to wait for an
enrollment period. You may have to pay a late enrollment penalty if
you don?t have creditable prescription drug coverage. See pages 89 ?91.

82 Section 6: Medicare prescription drug coverage (Pa rt D)

 

De?nitions
of blue words
are on pages
125?128.

 

 

 

Read the information you get from your plan

Review the ?Evidence of Coverage? (EOC) 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, provider networks,
service area, and more that will be effective in January. If you don?t get
these important documents in the early fall, contact your plan.

How much do I pay?

Below and continued on the next page are descriptions of what you pay
in your Medicare drug plan. Your actual drug plan costs will vary
depending on:

- Your prescriptions and whether they?re on your plan?s ?ormulary (list
of covered drugs) and depending on what ?tier? the drug is in. See
page 91.

- Which phase of your drug bene?t that you?re in (some examples
include whether or not you met your deductible, are you in the
coverage gap, etc.)

- The plan you choose. Remember, plan costs can change each year.

- Which pharmacy you use (whether it offers preferred or standard cost
sharing, is out?of?network, or is mail order).

- Whether you get Extra Help paying your Part costs. See pages 97?
98.

premium

Most drug plans charge a fee that varies by plan. In 2018, the
average drug plan premium was around $33. You pay this in
addition to the Part premium. If you?re in a Medicare Advantage Plan
(like an HMO or FPO) or a Medicare Cost Plan that includes Medicare
prescription drug coverage, the premium may include an
amount for prescription drug coverage.

Note: Contact your drug plan (not Social Security or the Railroad
Retirement Board if you want your premium deducted from
your Social Security or RRB payment. If you want to stop
premium deductions and get billed directly, contact your drug plan.

Section 6: Medicare prescription drug coverage (Part D) 83

If you have a higher income, you might pay more for your Part 

coverage. If your income is above a certain limit (385,0 00 if you ?le
individually or $170,0 00 if you?re married and ?le jointly), you?ll pay
an extra amount in addition to your plan premium (sometimes called
?Part This doesn?t affect everyone, so most people won?t
have to pay a higher amount.

Usually, the extra amount will be deducted from your Social Security
check. If you get bene?ts from the Railroad Retirement Board (RRB),
the extra amount will be deducted from your RRB check. If you?re
billed the amount by Medicare or the RRB, you must pay the extra
amount to Medicare or the RRB and not your plan. If you don?t pay
the extra amount, you could lose your Part coverage. You may not
be able to enroll in another plan right away, and you may have to pay a
late enrollment penalty for as long as you have Part D.

If you have to pay an extra amount and you disagree (for example,
you have a life event that lowers your income), visit socialsecurity.gov
or call Social Security at users can call
1?800?325?0778.

Yearly deductible

This is the amount you must pay before your drug plan begins to
pay its share of your covered drugs. Some drug plans don?t have a

deductible.

Copayments or coinsurance

These are the amounts you pay for your covered prescriptions after the
deductible (if the plan has one). You pay your share and your drug plan
pays its share for covered drugs. The amounts may vary based on the
cost of the drugs, and the amounts could change throughout the year.

84 Section 6: Medicare prescription drug coverage (Part D)

Coverage ga 

Most Medicare drug plans have a coverage gap (also called the ?donut
hole?). The coverage gap begins after you and your drug plan together
have spent a certain amount for covered drugs. In 2019, once you enter
the coverage gap, you pay 25% of the plan?s cost for covered brand?name
drugs and 37% of the plan?s cost for covered generic drugs until you
reach the end of the coverage gap. Not everyone will enter the coverage
gap because their drug costs won?t be high enough.

These costs (sometimes called true out?of?pocket, or costs) all
count toward you getting out of the coverage gap:

- Your yearly deductible, coinsurance, and copayments

- The discount you get on covered brand?name drugs in the
coverage gap

- What you pay in the coverage gap

The drug plan premium and what you pay for drugs that aren?t covered
don?t count toward getting you out of the coverage gap.

Some plans o?cer additional cost sharing reductions in the gap beyond
the standard bene?ts and discounts on brand?name and generic drugs,
but they may charge a higher premium. Check with the plan
?rst to see if your drugs would have additional cost?sharing reductions
while you?re in the gap.

Catastrophic coverage

Once you have met the cost requirements of the coverage gap, you
automatically get ?catastrophic coverage.? With catastrophic coverage,
you only pay a reduced coinsurance amount or copayment for covered
drugs for the rest of the year.

Note: If you get Extra Help, you won?t have some of these costs. See
pages 

Look for speci?c Medicare drug plan costs in Section 11, which starts

on page 129, and call the plans you?re interested in to get more details.
For help comparing plan costs, contact your State Health Insurance
Assistance Program (SHIP). See the back cover for the phone number.

Section 6: Medicare prescription drug coverage (Part D) 85

What's the Part late enrollment penalty?

The late enrollment penalty is an amount that?s added to your Part

premium. You may owe a late enrollment penalty if at any time
after your Initial Enrollment Period is over, there?s a period of 63 or
more days in a row when you don?t have Part or other creditable
prescription drug coverage. You?ll generally have to pay the penalty for
as long as you have Part coverage.

Note: If you get Extra Help, you don?t pay a late enrollment penalty.

3 ways to avoid paying a penalty:

1 . Join a Medicare drug plan when you?re ?rst eligible. Even if
you don?t take prescriptions now, you should consider joining a
Medicare drug plan or a Medicare Advantage Plan that offers drug
coverage to avoid a penalty. You may be able to ?nd a plan that
meets your needs with little to no premiums. See pages
4?6 to learn more about your choices.

2. Enroll in a Medicare drug plan if you lose other creditable
coverage. Creditable prescription drug coverage could include drug
coverage from a current or former employer or union, TRICARE,
Indian Health Service, the Department of Veterans Affairs, or
individual health insurance coverage. Your plan must tell you each
year if your drug coverage is creditable coverage. If you go 63 days
or more in a row without a Medicare drug plan or other creditable
coverage, you may have to pay a penalty if you join later.

3. Tell your plan about any drug coverage you had if they ask about
it. If you don?t tell the plan about your creditable prescription drug
coverage, you may have to pay a penalty for as long as you have
Part coverage.

86 Section 6: Medicare prescription drug coverage (Part D)

How much more will I pay?

The cost of the late enrollment penalty depends on how long you

didn?t have creditable pres criptiori drug coverage. Currently, the late
enrollment penalty is calculated by multiplying 1% of the ?national base
bene?ciary premium? ($35.02 in 2018) by the number of full, uncovered
months that you were eligible but didn?t join a Medicare drug plan and
went without other creditable prescription drug coverage. The ?nal
amount is rounded to the nearest $.10 and added to your 
premium. Since the ?national base bene?ciary premium? may increase
each year, the penalty amount may also increase each year. After you
join a Medicare drug plan, the plan will tell you if you owe a penalty and
what your premium will be.

Example:

Mrs. Martin didn?t join when she was ?rst eligible?by June 2015.
She doesn?t have prescription drug coverage from any other source.
She joined a Medicare drug plan during the 201'? Open Enrollment
Period, and her coverage began on Ianuary 1, 2018.

Since Mrs. Martin was without creditable prescription drug coverage
from July 2015?December 2017, her penalty in 2018 is 30% 

for each of the 30 months) of $35.02 (the national base bene?ciary
premium for 2018), which is $10.50. She?ll be charged $10.50 each
month in addition to her plan?s premium in 2018. She?ll
continue to pay a penalty for as long as she has Part coverage, and
the amount may go up each year.

Here?s the math:
.30 (30% penalty) $35.02 (2018 base bene?ciary premium) 2 $10.50
$10.50 Mrs. Martin?s late enrollment penalty for 2018

Section 7?Get Information about Prescription Drug Coverage [Part 8?

What if I don?t agree with the penalty?

If you disagree with your penalty, you can ask for a review or
reconsideration. Generally, you must request this review within

60 days from the date on the ?rst letter you get stating you have to
pay a late enrollment penalty. You?ll need to ?ll out a reconsideration
request form (that your Medicare drug plan will send you) by the date
listed in the letter. You can provide proof that supports your case, like
information about previous creditable prescription drug coverage.

If you need help, call your plan.

Which drugs are covered?

Information about a plan?s list of covered drugs (called a ?tbrn1ulary?)
isn?t included in this handbook because each plan has its own
formulary. Many Medicare drug plans place drugs into different
?tiers? on their forrnularies. Drugs in each tier have a different cost.
For example, a drug in a lower tier will generally cost you less than a
drug in a higher tier. In some cases, if your drug is in a higher tier and
your prescriber (your doctor or other health care provider who?s legally
allowed to write prescriptions) thinks you need that drug instead of a
similar drug in a lower tier, you or your prescriber can ask your plan
for an exception to get a lower copayment for the drug in the higher
tier. See page 106 for more information on exceptions.

Contact the plan for its current formulary, or visit the plan?s
website. You can also visit the Medicare Plan Finder at
Medicaregovf?nd-a-plan, or call 

(1?800?633?4223?) TTY users can call 1?877?486?2048. Your
plan will notify you of any formulary changes.

Each month that you ?ll a prescription, your drug plan mails you

an ?Explanation of Bene?ts? (BOB) notice. Review your notice and
check it for mistakes. Contact your plan if you have questions or
?nd mistakes. If you suspect fraud, call the Medicare Drug Integrity
Contractor (MEDIC) at See page
115 for more information about the MEDIC.

88 Section 6: Medicare prescription drug coverage (Part D)

Plans may have these coverage rules:

- Prior authorization?You andz?or your prescriber must contact the
drug plan before you can ?ll certain prescriptions. Your prescriber
may need to show that the drug is medically necessary for 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.

Before your prescriptions are ?lled, your Medicare drug plan will also
perform additional safety checks, such as checking for unsafe amounts
of opioid pain medications.

If you or your prescriber believe that one of these coverage rules
should be waived, you can ask for an exception. See page 106.

Do you get automatic prescription re?lls in
the mail?

Some people with Medicare get their prescription
drugs by using an ?automatic re?ll? service that
automatically delivers prescription drugs when
they?re about to run out. To malce sure you still
need a prescription before they send you a re?ll,
prescription drug plans should get your approval
to deliver a new or re?lled prescription before each
delivery, except when you ask for the re?ll or new
prescription. If you get a prescription automatically
by mail that you don?t want, and you weren?t
contacted to see if you wanted it before it shipped,

you may be eligible for a refund.

 

Section 6: Medicare prescription drug coverage (Part D) 89

Medication Therapy Management (MTM) Program
Medicare drug plans offer additional Medication Therapy Management
(MTM) services to plan members who meet certain requirements.
Members who qualify can get these MTM services to help them
understand how to manage their medications and use them safely.
The MTM services offered may vary in some plans. MTM services are
free and usually include a discussion with a pharmacist or health care
provider to review your medications. The pharmacist or health care
provider may talk with you about:

- How well your medications are working

- Whether your medications have side effects

- If there might be interactions between the drugs you?re taking

- Whether your costs can be lowered

- Other problems you?re having

Visit Medicaregovf?rrd-a-plarr to get general information about
program eligibility for your Medicare drug plan or for other plans that
interest you. Contact each drug plan for speci?c details.

Drug Management Programs

Medicare drug plans may also have a Drug Management Program

to monitor the safe use of prescription drugs that may be abused. If
you use opioid medications from several doctors andfor pharmacies,
your plan may communicate with the doctors who prescribed these
medications to make sure this use is appropriate and medically
necessary. Your plan will give you a letter in advance if coverage of your
opioid or benzodiazepine medications will be limited, or if you will

be required to get your opioid or benzodiazepine prescriptions from
certain doctors or pharmacies. If you believe a mistake has been made,
you and your prescriber have the right to appeal the determination that
you are an at?risk bene?ciary by contacting your plan. Also, you may
be exempt from a Drug Management Program if, for example, you have
cancer and/or you?re in hospice or long?term care facility.

90 Section 6: Medicare prescription drug coverage (Part D)

How do other insurance and programs work with
Part 

The charts on this page and the next 2 pages provide in?lrmation about
how other 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 spouses, 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 prescription
drug coverage is creditable. Keep the information you get. Call your
bene?ts administrator for more information before making any changes
to your coverage.

Note: If you join a Medicare drug plan, you, your spouse, or your
dependents may lose your employer or union health coverage.

COBRA

This is 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 pages
22?23, there may be reasons why you should take Part instead of, or
in addition to, COBRA coverage. However, if you take COBRA and it
includes creditable prescription drug coverage, you?ll have a Special
Enrollment Period to join a Medicare drug 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 the back cover for the phone number.

Medicare Supplement Insurance (Medigap) policy with
prescription drug coverage

You may choose to join a Medicare drug plan because most Medigap
drug coverage isn?t creditable, and you may pay more if you join a
drug plan later. See pages 89?91. 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. If you join a Medicare
drug plan, tell your Medigap insurance company so they can remove
the prescription drug coverage under your Medigap policy and adjust
your pren?1iurns. Call your Medigap insurance company for more
information.

Section 6: Medicare prescription drug coverage (Part D) 91

Note: Keep any creditable prescription drug 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 or certi?cates to
Medicare.

How does other government insurance work
with Part 

These types of insurance are all considered creditable prescription
drug coverage, and in most cases, it will be to your advantage to keep
this coverage if you have it.

Federal Employee Health Bene?ts (FEHB) Program

This is health coverage for current and retired federal employees and
covered family members. FEHB plans usually include prescription
drug coverage, so you don?t need to join a Medicare drug plan.
However, if you decide to join a Medicare drug plan, you can keep
your FEHB plan, and in most cases, the Medicare plan will pay

?rst. For more information for retirees, visit opm.govihealthcare-
insurance/healthcare, or call the Of?ce of Personnel Management at
1?888?767?6738. TTY users can call If you?re an active
federal employee, contact your Bene?ts Of?cer. Visit apps.opm.gov!
abo for a list of Bene?ts Of?cers. You can also call your plan if you
have questions.

Vetera ns?r bene?ts

This is 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 at the same time. For more
information, visit va.gov, or call the VA at 1?800?827?1000. TTY users
can call 1?800?829?4833.

92 Section 6: Medicare prescription drug coverage (Part D)

TRICARE (military health bene?ts}

This is a health care plan for active?duty service members, military
retirees, and their families. Most people with TRICARE who are
entitled to Part A must have Part to keep TRICARE prescription
drug bene?ts. If you have TRICARE, you don?t need to join a Medicare
Prescription Drug Plan. However, if you do, your Medicare drug plan

pays ?rst, and TRICARE pays second.

If you join a Medicare Advantage Plan (like an HMO or PPO) with
prescription drug coverage, your Medicare Advantage Plan and
TRICARE may coordinate their bene?ts if your Medicare Advantage
Plan network pharmacy is also a TRICARE network pharmacy.
Otherwise, you can ?le your own claim to get paid back for your out?
of?pocket expenses. For more information, visit tricare.mil, or call the
TRICARE Pharmacy Program at 1?87??363?1303. TTY users can call
1?877?540?6261.

Indian Health Service 

The IHS is the primary health care provider to the American Indian!
Alaska Native (AIIAN) Medicare population. The Indian health care
system, consisting of tribal, urban, and federally operated IHS health
programs, delivers a spectrum of clinical and preventive health services
through a network of hospitals, clinics, and other entities. Many Indian
health facilities participate in the Medicare prescription drug program.
If you get prescription drugs through an Indian health facility, you?ll
continue to get drugs at no cost to you, and your coverage won?t be
interrupted. Joining a Medicare drug plan may help your Indian health
facility because the drug plan pays the Indian health facility for the
cost of your prescriptions. Talk to your local Indian health bene?ts
coordinator who can help you choose a plan that meets your needs and
tell you how Medicare works with the Indian health care system.

Note: If you?re getting care through an IHS or tribal health facility or
program without being charged, you can continue to do so for some
or all of your care. Getting Medicare doesn?t a?cect your ability to get
services through the IHS and tribal health facilities.

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

93

Section 7:
Get help paying your health
8: prescription drug costs

What ifl need help paying my Medicare
prescription drug costs?

 

If you have limited income and resources, you may qualify for help to
pay for some health care and prescription drug costs.

Note: Extra Help isn?t available in Puerto Rico, the U.S. Virgin Islands,
Guam, the Northern Mariana Islands, or American Samoa. See page
102 for information about programs that are available in those areas.

Extra Help is a Medicare program to help people with limited

income and resources pay Medicare prescription drug costs. You

may qualify for Extra Help if your yearly income and resources are

below these limits in 2018:

- Single person?income less than $18,090 and resources less than
$14,100 per year

- Married person living with a spouse and no other dependents?
income less than $24,360 and resources less than $28,150 per year

These amounts may change in 2019. You may qualify even if you
have a higher income (like if you still work, live in Alaska or Hawaii,
or have dependents living with you). Resources include money in

a checking or savings account, stocks, bonds, mutual funds, and
Individual Retirement Accounts (IRAs). 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?ll:
I Get help paying your Medicare drug plan?s costs.

- Have no coverage gap.

- Have no late enrollment penalty.

- Have additional chances to switch plans. Any change you make will
take effect the ?rst day of the following month.

94 Section Tr?: Get help paying your health 8: prescription drug costs

You automatically qualify for Extra Help if you have Medicare and meet
any of these conditions:

- You have full Medicaid coverage.

- You get help from your state Medicaid program paying your Part 
premiums (in a Medicare Savings Program). See pages 99?100.

- You get Supplemental Security Income (SSI) bene?ts.

To let you know you automatically qualify for Extra Help, Medicare will
mail you a purple letter that you should keep for your records. You don?t
need to apply for Extra Help if you get this letter.

- If you aren?t already in a Medicare drug plan, you must join one to use

this Extra Help.

- If you don?t join a Medicare drug plan, Medicare may enroll you in one
so that you?ll be able to use the Extra Help. If Medicare enrolls you in
a plan, you?ll get a yellow or green letter letting you know when your
coverage begins.

- Different plans cover different drugs. Check to see if the plan you?re
enrolled in covers the drugs you use and if you can go to the pharmacies
you want. Visit Medicaregovl?nd-a-plan, or call 
(1?800?633?4223 to compare with other plans in your area. TTY users
can call 1?877?486?2048.

- If you have Medicaid and live in certain institutions (like a nursing
home) or get home? and community?based services, you pay nothing for
your covered prescription drugs.

If you don?t want to join a Medicare drug plan (for example, because

you want only your employer or union coverage), call the plan listed in
your letter, or call Tell them you don?t want to be in a
Medicare drug plan (you want to ?opt out?). If you continue to qualify for
Extra Help or if your employer or union coverage is creditable prescription
drug coverage, you won?t have to pay a penalty if you join later.

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

plan, you may lose your employer or union coverage (for you and your
dependents) even if you qualify for Extra Help. Call your employer?s

bene?ts administrator before you join a Medicare drug plan.

If you didn?t automatically qualify for Extra Help, you can apply



I Visit socialsecuritygovfil?Z? to apply online.

- Call Social Security at 1?800?772?1213. TTY users can call
1?800?325?02778.

Section 7: Get help paying your health 8: prescription drug costs 95

Drug costs in 2019 for people who qualify will be no more than $3.40 for
each generic drug and $8.50 for each brand?name drug. Look on the Extra
Help letters you get, or contact your plan to ?nd out your exact costs.

To get answers to your questions about Extra Help and help choosing

a drug plan, call your State Health Insurance Assistance Program

(SHIP). See the back cover for the phone number. You can also call
(1?800?633?4227). TTY users can call 1?877?486?2048.

What ifl need help paying my Medicare health

ca re costs?

 

Medicare Savings Programs

If you have limited income and resources, you may be able to get help
from your state to pay your Medicare costs if you meet certain conditions.

There are 4 kinds of Medicare Savings Programs:

1. Quali?ed Medicare Bene?ciary (QMB) Program?If you?re eligible,
the QMB Program helps pay for Part A andfor Part premiums. In
addition, Medicare providers aren?t allowed to bill you for Medicare
deductibles, coinsurance, and copayments when you get services
and items Medicare covers, except outpatient prescription drugs.
Pharmacists may charge you up to a limited amount (no more than
$3.80 in 2019) for prescription drugs covered by Medicare Part D. (If
you have QMB, you automatically get Extra Help. See page 97.)

To make sure your provider knows you have QMB, show both your
Medicare and Medicaid or QMB card each time you get care. If you
get a bill for medical care Medicare covers, call your provider about
the charges. If you have Original Medicare, show your provider
your Medicare Summary Notice (see page 63). It will show you
have QMB and that you shouldn?t be billed. Tell them that you have
QMB and can?t be charged for Medicare deductibles, coinsurance,
and copayments. If this doesn?t resolve the billing problem, call
Medicare will ask the provider to stop improper
billing, and refund any incorrect payments you made. If you?re in a
Medicare Advantage Plan, call your plan.

96 Section Tr?: Get help paying your health 8: prescription drug costs

2. Speci?ed Low-Income Medicare Bene?ciary (SLMB) Program?
Helps pay Part premiums only.

3. Qualifying Individual (QI) Program?Helps pay Part premiums
only. You must apply each year for QI bene?ts and the applications

are granted on a ?rst?come, ?rst?served basis.

4. Quali?ed Disabled and Working Individuals (QDWI) Program?
Helps pay Part A premiums only. You may qualify for this program if

you have a disability and are working.

The names of these programs and how they work may vary by state.

Medicare Savings Programs aren?t available in Puerto Rico and the U.S.
Virgin Islands.

How do I qualify?
In most cases, to qualify for a Medicare Savings Program, you must
have income and resources below a certain limit.

Many states ?gure your income and resources differently, so you should
check with your state to see if you qualify.

For more information

- Call or visit your Medicaid o?ice, and ask for information about
Medicare Savings Programs. To get the phone number for your state,
visit Medicaregovfcontacts. You can also call 
(1?800?633?4227). TTY users can call 1?871-486?2048.

- Contact your State Health Insurance Assistance Program (SHIP). See
the back cover for the phone number.

Medicaid

Medicaid is a joint federal and state program that helps pay medical
costs if you have limited income andi'or resources and meet other
requirements. Some people qualify for both Medicare and Medicaid.

What does Medicaid cover?

- If you have Medicare and full Medicaid coverage, most of your health
care costs are covered. You can get your Medicare coverage through
Original Medicare or a Medicare Advantage Plan (like an HMO or
FPO).

- If you have Medicare andr'or full Medicaid coverage, Medicare covers
your Part prescription drugs. Medicaid may still cover some drugs
and other care that Medicare doesn?t cover.

Section 7: Get help paying your health 8: prescription drug costs 9?

- People with Medicaid may get coverage for services that Medicare
may not or may partially cover, like nursing home care, personal
care, and home? and community?based services.

How do I qualify?
- Medicaid programs vary from state to state. They may also have
di?cerent names, like ?Medical Assistance? or ?Medi?Cal.?

- Each state has different income and resource requirements.

- In some states, you may need to be enrolled in Medicare, if eligible,
to get Medicaid.

- Call your Medicaid o?ice (State Medical Assistance Of?ce) for more
information and to see if you qualify. Visit Medicaregovlcontacts, or
call (1?800?633?4223. TTY users can call
1?877?486?2048.

Demonstration plans for people who have both Medicare

and Medicaid

Medicare is working with some states and health plans to offer
demonstration plans for certain people who have both Medicare and
Medicaid, called Medicare?Medicaid Plans. If you?re interested in
joining a Medicare?Medicaid Plan, visit Medicaregovf?rrd-a-plarr
to see if one is available in your area and if you qualify. Call your
Medicaid o?ice for more information.

State Pharmacy Assistance Programs (SPAPs)

Many states have SPAPs that help certain people pay for prescription
drugs based on ?nancial need, age, or medical condition. To ?nd out if
there?s an SPAP in your state and how it works, call your State Health
Insurance Assistance Program (SHIP). See the back cover for the
phone number.

98 Section Tr?: Get help paying your health 8: prescription drug costs

Pharmaceutical Assistance Programs [also called
Patient Assistance Programs)

Many major drug manufacturers offer assistance programs for people
with Medicare drug coverage who meet certain requirements. Visit
to learn more about
Pharmaceutical Assistance Programs.

Programs of All-inclusive Care for the

Elderly (PACE)

PACE is a Medicare and Medicaid program offered in many states that
allows people who need a nursing home?level of care to remain in the
community. See page T8 for more information.

Supplemental Security Income bene?ts

SSI is a cash bene?t paid by Social Security to people with limited
income and resources who are disabled, blind, or 65 or older. SSI
bene?ts aren?t the same as Social Security retirement bene?ts.

You can visit bene?tsgovfssa, and use the ?Bene?t Eligibility Screening
Tool? to ?nd out if you?re eligible for SSI or other bene?ts. lCall Social
Security at 1?800?37?72?1213 or contact your local Social Security of?ce
for more information. TTY users can call 

Note: People who live in Puerto Rico, the U.S. Virgin Islands, Guam, or
American Samoa can?t get SSI.

Programs for people who live in the U.S. territories
There are programs in Puerto Rico, the U.S. Virgin Islands, Guam,
the Northern Mariana Islands, and American Samoa to help

people with limited income and resources pay their Medicare costs.
Programs vary in these areas. Call your Medicaid of?ce (State Medical
Assistance Of?ce) to learn more. Visit Medicaregovfcorrtacts, or call
(1?800?633?4227) to get the phone number. TTY
users can call 133?486?2048.

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

99

Section 8:
Know your rights 8: protect
yourself from fraud

What are my Medicare rights?

 

No matter how you get your Medicare, you have certain rights and
protections. All people with Medicare have the right to:

- Be treated with dignity and respect at all times

- Be protected from diScrimination

- Have personal and health information kept private

I Get information in a way they understand from Medicare, health
care providers, and Medicare contractors

- Have questions about Medicare answered

- Have access to doctors, other health care providers, Specialists, and
hoSpitals

- Learn about their treatment choices in clear language that they can
understand, and participate in treatment decisions

I Get Medicare?covered services in an emergency

- Get a decision about health care payment, coverage of services, or
prescription drug coverage

- Request a review (appeal) of certain decisions about health care
payment, coverage of services, or prescription drug coverage

- File complaints (sometimes called i?grievances?), including
complaints about the quality of their care

1 00 Section 8: Know your rights 8: protect yourself from fraud

What are my rights if my plan stops participating

in Medicare?

 

Medicare health and prescription drug plans can decide not to
participate in Medicare for the coming year. In these cases, your
coverage under the plan will end after December 31. Your plan will send
you a letter about your options before Open Enrollment. If this happens:

- You can choose another plan during Medicare Open Enrollment
between October lS?December 7. Your coverage will begin
January 1.

- You?ll also have a special right to join another Medicare plan until
February 28, 2019.

- You?ll have the right to buy certain Medigap policies within 63 days
after your plan coverage ends.

 

What's an appeal?

An appeal is the action you can take if you disagree with a coverage or

payment decision by Medicare or your Medicare plan. For example, you

can appeal if Medicare or your plan denies:

- A request for a health care service, supply, item, or prescription drug
that you think should be covered by Medicare.

- A request for payment of a health care service, supply, item, or
preScription drug you already got.

- A request to change the amount you must pay for a health care service,
Supply, item, or prescription drug.

You can also appeal if Medicare or your plan stops
providing or paying for all or part of a health care
service, Supply, item, or preScription drug you think
you still need.

If you decide to ?le an appeal, you can ask your
doctor, supplier, or other health care provider for any
information that may help your case. Keep a copy

of everything related to your appeal, including what
you send to Medicare or your plan.

 

Section 8: Know your rights 8: protect yourself from fraud 101

How do I ?le an appeal?

How you ?le an appeal depends on the type of Medicare coverage you
have:

If you have Original Medicare
1. Get the ?Medicare Summary Notice? (MSN) that shows the item or
service you?re appealing. See page 63.

2. Circle the item(s) on the MSN you disagree with. Write an
explanation of why you disagree with the decision. You can write

on the MSN or on a separate piece of paper and attach it to the
MSN.

3. Include your name, phone number, and Medicare number on the
MSN, and sign it. Keep a copy for your records.

4. Send the MSN, or a copy, to the company that handles bills for
Medicare (Medicare Administrative Contractor or NIAC) listed on
the MSN. You can include any other additional information you
have about your appeal. Or, you can use CMS Form 20027. To view
or print this form, visit 
pdf, or call (1?800?633?4122?) to have a copy
mailed to you. TTY users can call 1?877?486?2048.

5. You must ?le the appeal within 120 days of the date you get the
MSN in the mail.

You?ll generally get a decision from the Medicare Administrative
Contractor (WC) within 60 days after they get your request. If
Medicare will cover the item(s) or service(s), it will be listed on your
next MSN.

If you have a Medicare health plan

The time frame for ?ling an appeal may be different than Original
Medicare. Learn more by looking at the materials your plan sends you,
calling your plan, or visiting Medicaregoviappeals.

In some cases, you can ?le a fast appeal. See materials from your plan
and page 107.

102 Section 8: Know your rights 8: protect yourself from fraud

If you have a Medicare Prescription Drug Plan

You have the right to do all of these (even before you buy a certain drug):

- Get a written explanation (called a ?coverage determination?) from
your Medicare drug plan. A coverage determination is the ?rst decision
your Medicare drug plan (not the pharmacy) makes about your
bene?ts. This can be a decision about if your drug is covered, if you met
the plan?s requirements to cover the drug, or how much you pay for the
drug. You?ll also get a coverage determination decision if you ask your
plan to make an exception to its rules to cover your drug.

- Ask for an exception if you or your prescriber (your doctor or other
health care provider who?s legally allowed to write prescriptions)
believes you need a drug that isn?t on your plan?s formula ry.

- Ask for an exception if you or your prescriber believes that a coverage
rule (like prior authorization) should be waived.

- Ask for an exception if you think you should pay less for a higher tier
(more expensive) drug because you or your prescriber believes you can?t
take any of the lower tier (less expensive) drugs for the same conditioncoverage determination or
exception?

You or your prescriber must contact your plan to ask for a coverage
determination or an exception. If your network pharmacy can?t ?ll a
prescription, the pharmacist will give you a notice that explains how to
contact your Medicare drug plan so you can make your request. If the
pharmacist doesn?t give you this notice, ask for a copy.

If you?re asking for prescription drug bene?ts you haven?t gotten yet,

you or your prescriber may make a standard request by phone or in
writing. If you?re asking to get paid back for prescription drugs you
already bought, your plan can require you or your prescriber to make the
standard request in writing.

You or your prescriber can call or write your plan for an expedited

(fast) request. Your request will be expedited if you haven?t gotten the
prescription and your plan determines, or your prescriber tells your plan,
that your life or health may be at risk by waiting.

If you?re requesting an exception, your prescriber must provide a

statement explaining the medical reason why your plan should approve
the exception.

Section 8: Know your rights 8: protect yourself from fraud 103

What are my rights if I think my services are ending
toosoon?

If you?re getting Medicare services from a hospital, skilled nursing
facility, home health agency, comprehensive outpatient rehabilitation
facility, or hospice, and you think your Medicare?covered services are
ending too soon, you can ask for a fast appeal. Your provider will give
you a notice before your services end that will tell you how to ask for a
fast appeal. The notice might call it an ?immediate appeal.? You should
read this notice carefully. If you don?t get this notice, ask your provider
for it. With a fast appeal, an independent reviewer will decide if your
services should continue.

How can I get help ?ling an appeal?

You can appoint a representative to help you. Your representative

can be a family member, friend, advocate, attorney, doctor or
someone else who will act on your behalf. For more information, visit
Medicaregovfappeals. You can also get help ?ling an appeal from
your State Health Insurance Assistance Program (SHIP). See the back
cover for the phone number.

What's an "Advance Bene?ciary Notice of

 

Noncoverage" (AB 

If you have Original Medicare, your doctor, other health care provider,
or supplier may give you a notice called an ?Advance Bene?ciary
Notice of Noncoverage? (ABN). This notice says Medicare probably (or

certainly) won?t pay for some services in certain situations.

What happens ifl get an 

- You?ll be asked to choose Whether to get the items or services listed
on the ABN.

- If you choose to get the items or services listed on the ABN, you?re
agreeing to pay if Medicare doesn?t.

- You?ll be asked to sign the ABN to say that you?ve read and
understood it.

- Doctors, other health care providers, and suppliers don?t have to (but
still may) give you an ABN for services that Medicare never covers.

See page 59.

1 04 Section 8: Know your rights 8: protect yourself from fraud

- An ABN isn?t an of?cial denial of coverage by Medicare. If Medicare
denies payment, you can still ?le an appeal. However, you?ll have
to pay for the items or services if Medicare decides that the items
or services aren?t covered (and no other insurer is responsible for
payment).

Can I get an ABN for other reasons?

- You may get a ?Skilled Nursing Facility when the facility
believes Medicare will no longer cover your stay or other items and
services.

What if I didn't get an 

If your provider was required to give you an ABN but didn?t, in most
cases, your provider must give you a refund for what you paid for the
item or service.

Where can I get more information about appeals and



- Visit Medicaregovlappeals.

- Visit Medicare.gov!publicatiorrs to view the booklet ?Medicare
Appeals.?

- If you?re in a Medicare plan, call your plan to ?nd out if a service or
item will be covered.

Your right to access your personal health

 

information

By law, you or your legal representative generally has the right to view
andfor get copies of your personal health information from health
care providers who treat you, or by health plans that pay for your care,
including Medicare. In most cases, you also have the right to have a
provider or plan send copies of your information to a third party that
you choose, like other providers who treat you, a family member, a
researcher, or a mobile application (or ?app?) you use to manage your
personal health information.

Section 8: Know your rights 8: protect yourself from fraud 105

This includes:

- Claims and billing records

- Information related to your enrollment in health plans, including
Medicare

- Medical and case management records (except notes)

- Any other records that contain information that doctors or health
plans use to make decisions about you

You may have to ?ll out a health information
?request? form, and pay a reasonable, cost?based
fee for copies. Your providers or plans should tell
you about the fee when you make the request. If
they don?t, you should ask The fee can only be for
the labor to make the copies, copying supplies, and
postage (if needed). In most cases, you shouldn?t
be charged for viewing, searching, downloading,
or sending your information through an electronic

portal.

 

Generally, you can get your information on paper or electronically.
If your providers or plans store your information electronically, they
generally must give you electronic copies, if that?s your preference.

You have the right to get your information in a timely manner, but it
may take up to 30 days to ?ll the request.

For more information, visit 


How does Medicare use my personal information?
Medicare protects the privacy of your health information. The next 2
pages describe how your information may be used and given out, and
explain how you can get this information.

106 Section 8: Know your rights 8: protect yourself from fraud

 

Notice of Privacy Practices for Original Medicare

This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it
carefully.

The law requires Medicare to protect the privacy of your personal medical
information. It also requires us to give you this notice so you know how we
may use and share (?disclose?) the personal medical information we have about
you.

We must provide your information to:

I You, to someone you name (?designate?), or someone who has the legal right
to act for you (your personal representative)

I The Secretary ofthe Department of Health and Human Services, ifnecessary
I Anyone else that the law requires to have it

We have the right to use and provide your information to pay for your
health care and to operate Medicare. For example:

I Medicare Administrative Contractors use your information to pay or deny
your claims, collect your premiums, share your bene?t payment with your
other insurer(s), or prepare your ?Medicare Summary Notice.?

I We may use your information to provide you with customer services, resolve
complaints you have, contact you about research studies, and make sure you
get quality care.

We may use or share your information under these limited circumstances:

I To State and other Federal agencies that have the legal right to get Medicare
data (like to make sure Medicare is making proper payments and to help
FederaUState Medicaid programs)

I For public health activities (like reporting disease outbreaks)

I For government health care oversight activities (like investigating fraud and
abuse)

I For judicial and administrative proceedings (like responding to a court order)

I For law enforcement purposes (like providing limited information to ?nd a
missing person)

I For research studies that meet all privacy law requirements [like research to
prevent a disease or disability)

I To avoid a serious and imminent threat to health or safety

I To contact you about new or changed Medicare bene?ts

I To create a collection ofinformation that no one can trace to you

 

 

 

Section 8: Know your rights 8: protect yourself from fraud

 

 

I To practitioners and their contractors for care coordination and quality
improvement purposes, like Accountable Care Organizations (ACO 

We must have your written permission (an ?authorization?) to use or share your
information for any purpose that isn?t described in this notice. We don?t sell or
use and share your information to tell you about health products or services
(?marketing?). You may take back (?revoke?) your written permission at any time,
unless we?ve already shared information because you gave us permission.

You have the right to:
I See and get a copy of the information we have about you.

I Have us change your information if you think it?s wrong or incomplete, and we
agree. If we disagree, you may have a statement of your disagreement added to
your information.

I Get a list of people who get your information from us. The listing won?t
cover information that we gave to you, your personal representative, or law
enforcement, or information that we used to pay for your care or for our
operations.

I Ask us to communicate with you in a different manner or at a different place
(for example, by sending materials to a PD. Box instead of your home address).

I Ask us to limit how we use your information and how we give it out to pay
claims and run Medicare. We may not be able to agree to your request.

I Get a letter that tells you about the likely risk to the privacy of your information
(?breach notification?).

I Get a separate paper copy of this notice.

I Speak to a Customer Service Representative about our privacy notice. Call
LEGO-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

If you believe your privacy rights have been violated, you may ?le a privacy

complaint with:

I The Centers for Medicare 8-: Medicaid Services (CMS). Visit Medicare.gov, or
call LEGO-MEDICARE.

I The U.S. Department of Health and Human Services (HHS), Of?ce for Civil
Rights (0 CR). Visit hhs.gov!hipa af?ling- a? complaint.

Filing a complaint won?t affect your coverage under Medicare.

The law requires us to follow the terms in this notice. We have the right to change
the way we use or share your information. Ifwe make a change, we?ll mail you a
notice within 60 days of the change.

The Notice of Privacy Practices for Original Medicare became e?ective
September 23, 2013.

 

 

107

108

Section 8: Know your rights 8: protect yourself from fraud

 

 

Notice of Accessible Communications

To help ensure people with disabilities have an equal opportunity to
participate in our services, activities, programs, and other bene?ts, we
provide communications in accessible formats. The Centers for Medicare
3: Medicaid Services (CMS) provides auxiliary aids and services to help us
better communicate with people with disabilities. Auxiliary aids include
materials in Braille, audiofdata CD or other accessible formats.

Note: You can get this handbook electronically in standard print, large print,
or as an eBoolc.

For Medicare publications, call us at (1?800?633?4227).
TTY: 

For all other CMS publications and documents, you can contact our
Customer Accessibility Resource Staff:

I Call (1?844?258?3676). TTY: 
- Send a fax to 1?844?530?3636.
- Send an email to altformatrequest@cms.hhs.gov.
- Send a letter to:
Centers for Medicare 3: Medicaid Services
O?ices of Hearings and Inquiries (OHI)
T500 Security Boulevard, Mail Stop 
Baltimore, MD 21244?1850
Attn: Customer Accessibility Resource Staff
You can also contact the Customer Accessibility Resource sta?f:
- To follow up on a previous accessibility request.
- If you have questions about the quality or timeliness of your previous
request.
Note: Your request for a CMS publication or document should include:

- Your name, phone number, and the mailing address where we should send
the publications or documents.

- The publication title and CMS Product No., if known.
- The format you need, like Braille, large print, or datafaudio CD.

Note: If you?re enrolled in a Medicare Advantage or Prescription Drug Plan,
you can contact your plan to request their documents in an accessible format.

 

 

Section 8: Know your rights 8: protect yourself from fraud

 

 

Nondiscrimination Notice

The Centers for Medicare 3: Medicaid Services (CMS) doesn?t exclude, deny
bene?ts to, or otherwise discriminate against any person on the basis of race,
color, national origin, disability, sex, or age in admission to, participation

in, or receipt of the services and bene?ts under any of its programs and
activities, whether carried out by CMS directly or through a contractor or
any other entity with which CMS arranges to carry out its programs and
activities.

How to ?le a complaint

If you believe you?ve been subjected to discrimination in a CMS program
or activity, there are 3 ways to ?le a complaint with the U. S. Department of
Health and Human Services, Of?ce for Civil Rights:

1. Online at:


2. By phone: Call 1?800?368?1019. TDD user can call 

3. In writing: Send information about your complaint to:

O?ice for Civil Rights

US. Department of Health and Human Services
200 Independence Avenue, SW

Room 509E Building

Washington, DC. 20201

 

 

109

1 1 0 Section 8: Know your rights protect yourself from fraud

 

How can I protect myself from identity theft?

Identity theft happens when someone uses your personal information
without your consent to commit fraud or other crimes. Personal
information includes things like your name and your Social Security,
Medicare, credit card, or bank account numbers. Guard your cards
and protect your Medicare and Social Security numbers. Keep this
information safe.

Only give personal information, like your Medicare number, to doctors,
insurers or plans acting on your behalf, or trusted people in the
community who work with Medicare like your State Health Insurance
Assistance Program (SHIP). Don?t share your Medicare number or
other personal information with anyone who contacts you by telephone,
email, or in person. Medicare, or someone representing Medicare, will
only call you in limited situations:

- A Medicare health or drug plan can call you if you?re already a
member of the plan. The agent who helped you join can also call you.

- A customer service representative from can call
you if you?ve called and left a message, or a representative said that
someone would call you back. If you suspect identity theft, or feel
like you gave your personal information to someone you shouldn?t
have, call your local police department and the Federal Trade
Commission?s ID Theft Hotline at 1?377?438?4338. TTY users can call
1?866?653 4261. Visit ftc.govfidtheft to learn more about identity theft.

 

How can I protect myself and Medicare from fraud?

Medicare fraud and abuse can cost taxpayers billions of dollars each
yean

One common form of Medicare fraud is when a provider bills Medicare
for services you never got. When you get health care services, record the
dates on a calendar and save the receipts and statements you get from
providers to check for mistakes. If you think you see an error or are
billed for services you didn?t get, take these steps to ?nd out what was

billed:

- Check your ?Medicare Summary Notice? (MSN) if you have Original
Medicare to see if the service was billed to Medicare. If you?re in a
Medicare health plan, check the statements you get from your plan.

Section 8: Know your rights 8: protect yourself from fraud 111

- If you know the health care provider or supplier, call and ask for an
itemized statement. They should give this to you within 30 days.

- Visit MyMedicare.gov to view your Medicare claims if you have
Original Medicare. Your claims are generally available online within
24 hours after processing. You can also download your claims
information by using Medicare?s Blue Button. See page 120. You can
also call TTY users can call
1?877?486?2048.

If you?ve contacted the provider and you suspect that Medicare is
being charged for a service or supply that you didn?t get, or you
don?t know the provider on the claim, call 1-800-MEDICARE
(1?800?633?4227). TTY users can call 1-877?486-2048.

For more information on protecting yourself from Medicare fraud and
tips for spotting and reporting fraud, visit Medicaregov, or contact your
local Senior Medicare Patrol (SMP) Program. For more information
about the SMP program, visit smpresource. org or call 

You can also visit oig.hhs.gov or call the fraud hotline of the
Department of Health and Human Services Of?ce of the Inspector
General at (1?800?447?8477). TTY users can call
1?800?377?4950.

Plans must follow rules

Medicare plans must follow certain rules when marketing their plans
and getting your enrollment information. They can?t ask you for credit
card or banking information over the phone or via email, unless you?re
already a member of that plan. Medicare plans can?t enroll you into a
plan over the phone unless you call them and ask to enroll, or you?ve
given them permission to contact you.

Call 1-800-MEDICARE to report any plans that:

- Ask for your personal information over the phone or email
- Call to enroll you in a plan

- Use false information to mislead you

You can also call the Medicare Drug Integrity Contractor (MEDIC)

at The MEDIC helps prevent
inappropriate activity and ?ghts fraud, waste, and abuse in Medicare
Advantage (Part C) and Medicare Prescription Drug (Part D) Programs.

1 12 Section 8: Know your rights 8: protect yourself from fraud

Fighting fraud can pay

You may get a reward if you help us ?ght fraud and meet
certain conditions. For more information, visit Medicaregov,
or call (1?800?633?4223. TTY users can call
1?871-486?2048.

Investigating fraud takes time

Every tip counts. Medicare takes all reports of suspected fraud seriously.
?When you report fraud, you may not hear of an outcome right away. It
takes time to investigate your report and build a case, but rest assured
that your information is helping us protect Medicare.

What's the Medicare Bene?ciary Ombudsman?

An ?ombudsman? is a person who reviews complaints and helps
resolve them.

The Ombudsman reviews the concerns raised by people with Medicare
through and through your State Health Insurance
Assistance Program (SHIP).

Visit Medicaregov for information on how the Medicare Bene?ciary
Ombudsman can help you.

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

113

Section 9:
Get more information

 

Where can I get personalized help?

1-800-MEDICARE (1-800-633-4227)
TTY users call 1-877-486-2048
Get information 24 hours a day, including weekends

I Speak clearly and follow the voice prompts to pick the category that
best meets your needs.

- Have your Medicare card in front of you, and be ready to give your
Medicare number.

- When prompted for your Medicare number, speak the numbers and
letters clearly one at a time.

- If you need help in a language other than English or Spanish, or need
to request a Medicare publication in an accessible format (like large
print or Braille), let the customer service representative know.

Do you need someone to be able to call
1-800-MEDICARE on your behalf?

You can ?ll out a ?Medicare Authorization to Disclose Personal
Health Information? form so Medicare can give your personal
health information to someone other than you. You can get a copy
of the form by visiting or by
calling (1?800?633?4227). TTY users can call
1?87??486?2048. You may want to do this now in case you become
unable to do it later.

Did your household get more than one copy of
"Medica re 8: You?"
If you want to get only one copy in the future, call 

If you want to stop getting paper copies in the mail, visit
Medicaregovfgopaperless.

1 14 Section 9: Get more information

What are State Health lnsura nce Assistance

Programs 

SH IPs are state programs that get money from the federal government
to give local health insurance counseling to people with Medicare at

no cost to you. SHIPs aren?t connected to any insurance company or
health plan. SHIP volunteers work hard to help you with these Medicare

questions or concerns:

- Your Medicare rights

- Billing problems

- Complaints about your medical care or treatment
- Plan choices

- How Medicare works with other insurance

- Finding help paying for health care costs

See the back cover for the phone number of your local SHIP. If you
would like to become a volunteer SHIP counselor, contact the SHIP

in your state to learn more. To ?nd a SHIP in another state, visit
shiptacenter.org or call 1-800-MEDICARE.

Where can I ?nd general Medicare information

 

oane?

Visit Medica re.gov

- Get information about the Medicare health and prescription drug
plans in your area, including what they cost and what services they
provide.

- Find doctors or other health care providers and suppliers who
participate in Medicare.

- See what Medicare covers, including preventive services.

- Get Medicare appeals information and forms.

- Get information about the quality of care provided by plans, nursing
homes, hospitals, doctors, home health agencies, dialysis facilities,
hospices, inpatient rehabilitation facilities, and long?term care
hospitals.

- Look up helpful websites and phone numbers.

Section 9: Get more information 115

Where can l?nd personalized Medicare

 

information online?

Register at MyMeclica re.gov

- Manage your personal information (like medical conditions,
allergies, and implanted devices).

I Sign up to get your ?Medicare Summary Noticesu and this
handbook electronically. You won?t get printed copies if you choose
to get them electronically.

- Manage your personal drug list and pharmacy information.

- Search for, add to, and manage a list of your favorite providers and
access quality information about them.

I Select your primary clinician from your list of favorite providers.
Your primary clinician is the practitioner who you want responsible
for coordinating your overall care, regardless of where you choose to
get services. By choosing a primary clinician, your doctor may have
access to more tools or services for your care available to patients
of doctors participating in an Accountable lCare Organization or
certain other Medicare alternative payment models. (This is also
known as ?voluntary alignment?)

- Track Original Medicare claims and your Part deductible status.

- Print an of?cial copy of your new Medicare card once it?s mailed to
you.

116

Section 9: Get more information

 

 

 

MyMedica re.gov's Blue Button

MyMedicaregov?s Blue Button makes it easy for you to download your
personal health information to a ?le. Blue Button is safe, secure, reliable,
and easy to use. You can use Blue Button to:

- Download and save a ?le of your personal health information on your
computer or other device, including your Part A, Part B, and Part 
claims.

- Print or email the information to share with others after you?ve saved
the ?le.

- Import your saved ?le into other computer?based personal health
management tools.

What's Blue Button 2.0?

Medicare?s Blue Button 2.0 lets you connect your Medicare health
information to other services you trust, like:

- Applications (apps)
- Computer?based programs
- Research programs

Blue Button 2.0 gives you a wide range of options to manage and
improve your health. Options might include things like:

- Using an app to keep track of the regular tests and services you need
based on your personal health information. The app can send you
reminders when it?s time to schedule your next appointment.

- Using an app or other computer program to track your health over
long periods of time. This can help you and your doctor make better
decisions about your health.

- Using an app to organize your health information in an easy?to?
read format, like charts and graphs. This can help you keep track of
important information, like your medicines, allergies, or results of lab
tests.

- Connecting your data to research projects. Researchers can use your
data to expand their knowledge about a range of health issues.

Visit MyMedicare.gov to use Blue Button and Blue Button 2.0 today.

 

 

Section 9: Get more information 11?

How do I compare the quality of plans and

 

health care providers?

Medicare collects information about the quality and safety of medical
care and services given by most Medicare plans and health care
providers (and facilities).

Visit and use the Compare tools to
get a snapshot of the quality of care health care providers (and facilities)
give their patients. Some of these tools feature a star rating system to
help you compare quality measures that are important to you. Find out
more about the quality of care by:

- Asking what your health care provider does to ensure and improve
the quality of care. Each health care provider should have someone
you can talk to about quality.

- Asking your doctor or other health care provider what he or she
thinks about the quality of care other providers give. You can also ask
your doctor or other health care provider about the quality of care
information you ?nd on the Medicare.gov Compare tools.

The Medicare Plan Finder at Medicaregovl?nd-a-plan features a star
rating system for Medicare health and drug plans. The Overall Star
Rating gives an overall rating of the plan?s quality and performance for
the types of services each plan offers.

For plans covering health services, this is an overall rating for the
quality of many medical! health care services that fall into 5 categories:

1 . Staying healthy?screening tests and vaccines: Includes whether
members got various screening tests, vaccines, and other check?ups

to help them stay healthy.

2. Managing chronic (long-term) conditions: Includes how often
members with certain conditions got recommended tests and
treatments to help manage their condition.

3. Member experience with the health plan: Includes member ratings
of the plan.

4. Member complaints and changes in the health plan?s
performance: Includes how often Medicare found problems with
the plan and how often members had problems with the plan.
Includes how much the plan?s performance has improved (if at all)
over time.

5. Health plan customer service: Includes how well the plan handles
member appeals.

1 18 Section 9: Get more information

For plans covering drug services, this is an overall rating for the quality
of prescription?related services that fall into 4 categories:

1 . Drug plan customer service: Includes how well the plan handles
member appeals.

2. Member complaints and changes in the drug plan?s performance:
Includes how often Medicare found problems with the plan and how
often members had problems with the plan. Includes how much the
plan?s performance has improved (if at all) over time.

3. Member experience with plan?s drug services: Includes member
ratings of the plan.

4. Drug safety and accuracy of drug pricing: Includes how accurate
the plan?s pricing information is and how often members with certain
medical conditions are prescribed drugs in a way that is safer and
clinically recommended for their condition.

For plans covering both health and drug services, the overall rating for
quality and performance covers all of the topics above.

You can compare the quality of care and services given by health care
providers and Medicare plans nationwide by visiting Medicaregov or
by calling your State Health Insurance Assistance Program (SHIP). See
the back cover for the phone number.

What's Medicare doing to better coordinate

 

my ca re?

Medicare continues to look for ways to better coordinate your care and
to make sure that you get the best health care possible.

Here are examples of how your health care providers can better
coordinate your care:

Electronic Health Records EHRs are records that your doctor,

other health care provider, medical of?ce stall, or hospital keeps on a

computer about your health care or treatments.

- EHRs can help lower the chances of medical errors, eliminate
duplicate tests, and may improve your overall quality of care.

- Your doctor?s EHR may be able to link to a hospital, lab, pharmacy,

or other doctors, so the people who care for you can have a more
complete picture of your health.

Section 9: Get more information 119

Electronic prescribing: This is an electronic way for your prescribers
(your doctor or other health care provider who?s legally allowed to write
prescriptions) to send your prescriptions directly to your pharmacy.
Electronic prescribing can save you money, time, and help keep you safe.

Accountable Care Organizations (ACOs): An ACO is a group of
doctors, hospitals, and other health care providers who agree to work
together with Medicare to give you more coordinated service and care.
If you have Original Medicare and your doctor has decided to
participate in an ACO, you?ll be noti?ed. A poster with information
about your doctor?s participation in an ACO may be displayed at the
of?ce, or your doctor may give you this information in writing.

To help you get better, more coordinated care, Medicare will share
certain health information with ACOs working with your doctors and
other health care providers about the care you get from your doctors
and other providers. Just like Medicare, ACOs must put important
safeguards in place to make sure your health care information is safe.

The poster in your doctor?s of?ce (or written noti?cation) should let you
know whether the doctor or ACO have asked Medicare for access to
your information about the care you get through Medicare. With the
information Medicare shares, the doctors and health care providers in
the ACO can have a complete picture of your health and be better able
to coordinate your care.

You may be asked by your doctor to select him!f her as your primary
clinician on MyMedicare.gov. By making this selection, Medicare will
hold your doctor?s ACO accountable for the quality of your care and
overall medical costs. See page 119 for more information.

You can ask Medicare not to share certain in?eratiorl with the

ACO about the care you got from your doctors and other health care
providers. To do this, call (1?800?633?4227). TTY
users can call and tell us you don?t want us to share
this information. You can also change your data sharing preferences at
any time by calling Even if you ask Medicare not
to share your information, Medicare will still use your information
for some purposes, like assessing the ?nancial and quality of care
performance of providers participating in ACOs. Also, Medicare may
share some of your information with ACOs when measuring the quality
of care given by health care providers participating in those ACOs.

120 Section 9: Get more information

Your Medicare bene?ts, services, costs, and protections won?t change

if your doctor participates in an ACO or if you ask that Medicare not
share your information. You still have the right to visit and get care from
any doctor or hospital that accepts Medicare at any time, the same way
you do now.

For more information about ACOs, visit Medicare.gov, or call



 

Are there other ways to get Medicare information?

Publications

Visit Medicare.govfpublicatious to view, print, or download

copies of publications on different Medicare topics. You can also

call (1?800?633?4227). TTY users can call
Accessible formats are available at no cost. See page 112
for more information.

Social Media

Stay up to date and connect with other people with Medicare by
following us on Facebook (facebook.com!Medicare) and Twitter
(twitter.comeedicareGov).

Videos

Visit to see videos covering different health
care topics on Medicare?s YouTube channel.

Blogs

Visit blog.medicare.gov for up?to?date information on important topics.

Section 9: Get more information I 121

Other helpful contacts

Social Security

Find out if you?re eligible for Part A andz?or Part and how to enroll,
make changes to your Part A audior Part coverage, get a replacement
Social Security card, report a change to your address or name, apply
for Extra Help with Medicare prescription drug costs, ask questions
about Part A and Part premiums, and report a death.

1?800?7?2?1213, TTY: 1?800?325?0?78
socialsecuritygov

Bene?ts Coordination 8: Recovery Center (BCRC)

Contact the BCRC to report changes in your insurance information or
to let Medicare know if you have other insurance.

1?855?798?2627, TTY: 1?855?797?262?

Bene?ciary and Family Centered Care-Quality
Improvement Organization 

Contact a to ask questions or report complaints about the
quality of care for a Medicare?covered service (and you aren?t satis?ed
with the way your provider has responded to your concern). Or, you
can contact the if you think Medicare coverage for your
service is ending too soon (for example, if your hospital says that you
must be discharged and you disagree). Visit or
call (1?800?633?4227) to get the phone number of
your 

Department of Defense
Get information about TRICARE for Life (TFL) and the TRICARE

Pharmacy Program.

TFL Tricare Pharmacy Program
1?866?773?0404 1?877?363?1303

TTY: 1?866?773?0405 TTY: 1?877?540?6261
tricare.milfpharmacy

tricare4u.com express-scripts.comftricare

122

Section 9: Get more information

Department of Veterans Affairs
Contact if you?re a veteran or have served in the U.S. military and you

have questions about VA bene?ts.

1?800?82??1000, TTY: 1?800?829?4833
va.gov

Of?ce of Personnel Management
Get information about the Federal Employee Health Bene?ts (FEHB)
Program for current and retired federal employees.

Retirees: l?888?767?6738, TTY: 
opm.govfhealthcare-insurarrce

Active federal employees: Contact your Bene?ts Of?cer. Visit apps.opm.
govfabo for a list of Bene?ts Of?cers.

Railroad Retirement Board (RRB)

If you get bene?ts from the RRB, call them to change your address or
name, check eligibility, enroll in Medicare, replace your Medicare card,
or report a death.

l?877?7T2?5772, TTY: l?312?751?4701
rrb.gov

123

Section 10:
De?nitions

 

Assignment?An agreement by your doctor, provider, or supplier to
be paid directly by Medicare, to accept the payment amount Medicare
approves for the service, and not to bill you for any more than the
Medicare deductible and coinsurance.

Bene?t period?The way that Original Medicare measures your use
of hospital and skilled nursing facility (SNF) services. A bene?t period
begins the day you?re admitted as an inpatient in a hospital or SNF. The
bene?t period ends when you haven?t received any inpatient hospital
care (or skilled care in a SNF) for 60 days in a row. If you go into a
hospital or a SNF after one bene?t period has ended, a new bene?t
period begins. You must pay the inpatient hospital deductible for each
bene?t period. There?s no limit to the number of bene?t periods.

Coi nsu ra nce?An amount you may be required to pay as your share
of the cost for services after you pay any deductibles. Coinsurance is
usually a percentage (for example, 

Copayment?An amount you may be required to pay as your share
of the cost for a medical service or supply, like a doctor?s visit, hospital
outpatient visit, or prescription drug. A copayment is usually a set
amount, rather than a percentage. For example, you might pay $10 or
$20 for a doctor?s visit or prescription drug.

Creditable prescription drug coverage?Prescription drug
coverage (for example, from an employer or union) that?s expected to
pay, on average, at least as much as Medicare?s standard prescription
drug coverage. People who have this kind of coverage when they
become eligible for Medicare can generally keep that coverage without
paying a penalty, if they decide to enroll in Medicare prescription drug
coverage later.

Critical access hospital?A small facility that provides outpatient
services, as well as inpatient services on a limited basis, to people in
rural areas.

124

Section 10: De?nitions

Custodial ca re ?Non?skilled personal care, like help with activities of
daily living like bathing, dressing, eating, getting chair, moving around, and using the bathroom. It may also include the
kind of health?related care that most people do themselves, like using 
drops. In most cases, Medicare doesn?t pay for custodial care.

Ded ucti hie?The amount you must pay for health care or prescriptions
before Original Medicare, your prescription drug plan, or your other
insurance begins to pay.

Demonstrations?Special projects, sometimes called ?pilot programs?
or ?research studies,? that test improvements in Medicare coverage,
payment, and quality of care. They usually operate only for a limited
time, for a speci?c group of people, andfor in speci?c areas.

Extra Hel p?A Medicare program to help people with limited income
and resources pay Medicare prescription drug program costs, like
premiums, deductibles, and coinsurance.

Form ulary?A list of prescription drugs covered by a prescription drug
plan or another insurance plan offering prescription drug bene?ts. Also
called a drug list.

Inpatient rehabilitation facility?A hospital, or part ofa hospital, that
provides an intensive rehabilitation program to inpatients.

Institution?For the purposes of this publication, an institution is

a facility that provides short?term or long?term care, like a nursing

home, skilled nursing facility (SNF), or rehabilitation hospital. Private
residences, like an assisted living facility or group home, aren?t considered
institutions for this purpose.

Lifetime reserve days?In Original Medicare, these are additional
days that Medicare will pay for when you?re in a hospital for more than
9'0 days. You have a total of 60 reserve days that can be used during your
lifetime. For each lifetime reserve day, Medicare pays all covered costs
except for a daily coinsurance.

Section 10: De?nitions 125

Long-term care hospital?Acute care hospitals that provide treatment
for patients who stay, on average, more than 25 days. Most patients are
transferred from an intensive or critical care unit. Services provided
include comprehensive rehabilitation, respiratory therapy, head trauma
treatment, and pain management.

Medically necessa ry?Health care services or supplies needed to
diagnose or treat an illness, injury, condition, disease, or its 
and that meet accepted standards of medicine.

Medicare Adva ntage Plan (Pa rt type of Medicare health plan
offered by a private company that contracts with Medicare to provide
you with all your Part A and Part bene?ts. Medicare Advantage
Plans include Health Maintenance Organizations, Preferred Provider
Organizations, Private Pee?for?Service Plans, Special Needs Plans,

and Medicare Medical Savings Account Plans. If you?re enrolled in a
Medicare Advantage Plan, most Medicare services are covered through
the plan and aren?t paid for under Original Medicare. Most Medicare
Advantage Plans offer prescription drug coverage.

Medicare-approved amount?In Original Medicare, this is the
amount a doctor or supplier that accepts assignment can be paid. It may
be less than the actual amount a doctor or supplier charges. Medicare
pays part of this amount and you?re responsible for the difference.

Medicare health plan?Generally, a plan offered by a private company
that contracts with Medicare to provide Part A and Part bene?ts to
people with Medicare who enroll in the plan. Medicare health plans
include all Medicare Advantage Plans, Medicare Cost Plans, and
Demonstration;' Pilot Programs. Programs of All? inclusive Care for the
Elderly (PACE) organizations are special types of Medicare health plans.
PACE plans can be offered by public or private entities and provide Part
and other bene?ts in addition to Part A and Part bene?ts.

Medicare pla n?Any way other than Original Medicare that you can
get your Medicare health or prescription drug coverage. This term
includes all Medicare health plans and Medicare Prescription Drug
Plans.

126

Section 10: De?nitions

Premium?The periodic payment to Medicare, an insurance company, or
a health care plan for health or prescription drug coverage.

Preventive services?Health care to prevent illness or detect illness
at an early stage, when treatment is likely to work best (for example,
preventive services include Pap tests, ?u and pneumococcal shots, and
screening mammograms).

Primary ca re doctor?The doctor you see ?rst for most health problems.
He or she makes sure you get the care you need to keep you healthy. He
or she also may talk with other doctors and health care providers about
your care and refer you to them. In many Medicare Advantage Plans, you
must see your primary care doctor before you see any other health care
provider.

Referral?A written order from your primary care doctor for you to see
a specialist or get certain medical services. In many Health Maintenance
Organizations (HMOs), you need to get a referral before you can get
medical care from anyone except your primary care doctor. If you don?t
get a referral ?rst, the plan may not pay for the services.

Service area?A geographic area where a health insurance plan accepts
members if it limits membership based on where people live. For plans
that limit which doctors and hospitals you may use, it?s also generally the
area where you can get routine (non?emergency) services. The plan may
disenroll you if you move out of the plan?s service area.

Skilled nursing facility (SNF) ca re?Skilled nursing care and
rehabilitation services provided on a daily basis in a skilled nursing
facility.

127

Section 11:

Compare health 8:
prescription drug plans
in your area

 

Plan coverage and costs can change each year. If
you already have a Medicare plan, look at your
plans coverage for 2019, and compare it with
other plans. If you?ve compared different plans
and decide to stay with the plan you have, you
don?t have to do anything. Medicare Supplement
Insurance (Medigap) policies aren?t included

in this section. To ?nd out which insurance
companies sell Medigap policies in your state, 
Medicaregov. Remember, you can?t use (and can?t
be sold) a Medigap policy while you?re in a Medicare Advantage Plan.
See pages 79?82 for more information about Medigap.

The information in this section can help you narrow your choices,
but it iSn?t enough for you to select a plan. See page 16 for ways to get

personalized help when choosing a plan.

 

 

 

De?nitions
of blue words
are on pages
123?126.

 

 

128

Section 11:Compare health 8: prescription drug plans in your area

How to read the Medicare health plans chart

Plans and costs are listed by company name on the following pages.
Use these descriptions to help you read the charts. If ?Call plan for
details? appears, Medicare didn?t get the information in time to print it.
Some plans may have an annual deductible that you must meet before
your costs are covered. For more information, call the plans you?re
interested in.

1. Service area?Area where plan is available. You must live in a
plan?s service area to join. Check with the company to see if the
plans you?re interested in are offered in your area.

2. premium?Amount you pay each month for coverage, in
addition to your Part premium.

3. Out-of?pocket lirnits?The ?rst amount shows your limit for
in?network services, and the second amount (if applicable) shows
your limit for out?of?networlc services. Some plans may show
one combined amount which includes both in?networlc and
out?of?network services.

4. Primary care visit?Amounts you pay for an o?ice visit to a
primary care doctor.?P

5. Specialist visit?Amounts you pay for an o?ice visit to a
specialist.?P
6. Chemo drugs?Amounts you pay for chemotherapy?

7. Other Part drugs?Amounts you pay for Part drugs lilce
injectable or infused drugs given as part of a doctor?s visit."P

8. Home health care? Amounts you pay each day for home health
care."rr

9. DME Amounts you pay for durable medical equipment (like
walkers)?i

10. Annual Part deductible Amount you pay for your covered
Part drugs before your plan starts to pay.

*The ?rst amount shows what you pay in?networlc, and the second
amount (if applicable) shows what you pay out?of?networlc. Some plans
may show one combined range for both in?networlc and out?of?networlc
services.

Section 11:Compare health 8: prescription drug plans in your area 129

1 1. Part drugs Range of what you pay for a one?month supply
of covered Part prescription drugs before the coverage gap.
See page 88 for more information about the coverage gap.

1 2. Gap coverage Shows a range of what you pay for a one?month
supply of covered Part drugs during the coverage gap. See
page 88 for more information about the coverage gap.

1 3. Company name and contract number Name of the
organization that contracts with Medicare and its contract
number.

14. Type of Medicare plan Shows whether the plan is a Health
Maintenance Organization (HMO), Private Pee?for?S ervice
(PFFS) plan, Preferred Provider Organization (PPO), Medical
Savings Account (MSA), or Cost Plan. See pages 71??4 and 77.

1 5. Members? Rating of Plan How plan members rated the
plan from the most recent Consumer Assessment of Healthcare
Providers and Systems (CAHPS) survey. If a plan doesn?t have
a rating, you?ll see a note that explains why. This rating is just
one of the many measures Medicare uses to give plans an overall
rating between 1 and 5 stars. Visit Medicaregovf?nd-a-plan for
more information about plan quality, including the overall star
rating that gives you a single summary score to make it easy for
you to compare plans based on quality and performance.

1 6. Plan name and ID number? Shows the di?ferent plans offered
by companies that contract with Medicare.

1 7. Plan phone number Use this number to call the plan for
more information.

1 8. Plan website ?Visit the plan?s website for more information.

1 30 Section 11:Compare health 8: prescription drug plans in your area

Medicare Health
Plans Chart

Section 11:Compare health 8: prescription drug plans in your area 131

Medicare
Special Needs
Plans Chart

1 32 Section 11:Compare health 8: prescription drug plans in your area

MMP
(PLACEHOLDER)

Section 11:Compare health 8: prescription drug plans in your area 133

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

(PLACEHOLDER)

134 Section 11:Compare health 8: prescription drug plans in your area

How to read the Medicare Prescription Drug

Plans (PDPs) chart

On the following pages, you?ll see charts with basic information
about Medicare Prescription Drug Plans available in your area.
Each company that has a contract with Medicare can offer one or
more plans. Remember to check with the company, and aslc if the
plans you?re interested in are offered in your area.

 

Plan coverage and costs usually change each year. If you already
have a Medicare Prescription Drug Plan and it?s still o?fered next
year, look at your plan?s coverage (formula ry) for 2019, and compare
it with other plans. See if there?s a better choice for you. You can
also choose to get your prescription drug coverage through a
Medicare Advantage Plan. See pages 3?6 if you need help deciding.

How do I use the charts?

Plan descriptions and costs are listed by company name on the
following pages. If ?Call plan for details? appears in the charts,
Medicare didn?t get the information in time to print it. All
Medicare drug plans have coverage in the ?gap.? If a plan o?cers
additional cost?sharing reductions in the gap beyond the standard
bene?ts and discounts on brand?name and generic drugs, it will
be noted on the last column of the following charts. See page 88 to
learn more about the coverage gap. For more information, call the
plans you?re interested in.

The Members? Rating of Plan shows how plan members rated the
plan from the most recent Consumer Assessment of Healthcare
Providers and Systems (CAHPS) survey. If a plan doesn?t have a
rating, you?ll see a note that explains why. This rating is just one
of many measures Medicare uses to give plans an overall rating
between 1 and 5 stars.

Visit Medicaregovf?nd-a-plan for more information about plan
quality, including the overall star rating that gives you a single
summary score that malces it easy for you to compare plans based
on quality and performance.

Section 11:Compare health 8: prescription drug plans in your area 135

PDP chart

136

Help in other languages

 

 

If you, or sorneone you?re helping, has questions about Medicare, you hane the right to get help
and information in your language at no cost. To talk to an interpreter, call LEGO-MEDICARE
(1-800-633-4227).

new! Ln; ijmii as; as an. Medicare gages-c, Maui mm was J,i Kasai c115 oi (Arabic) l11.114111
1-800-633-4227 LEGO-MEDICARE Mb. Lia-Si win an email MS: ii a? dine ennui!

hthI??l {Armenian} 131011 r1:111}; Hulti ?21111 11131111119 oq'untl'?u?l utnmgull u?l?q} 111111191111 1111111
Medic are ?11 tiu1u1111, u1u1u1 r11111} 11111311111111.1113 111111113 u?ulaimp 09111113111111 11
U111111111?112r1?111111111 umul'uullni 3111p hullu?iimpulo 111 (1111111: Emuqtfulhzb 1111111 
hu111u111 qu?ithulphp (1 300?633?4227) hhnullunuuihunfulpnq:

5133C [Chinese-Traditional} 

LE a ease-a 
{1?800?633?4221}.

Uca? Le. :gJia?mu?ng?ei adrenal, {FarsiJg-uli
oi?: um Lei 1-: 1-: dun-Mn Late Helen-'1 can: log-JD owl'- ?i-i Lil-ii 4-: gunk! a 4A5 45 4-1.1?
.[1?800?633?4227} 

Frangais (French?i nous, ou quelqu'un que nous etes en train d?aider, a des questions au sujet
de l'assurance?rnaladie Medicare, nous anez le droit d'obtenir de l'aide et de l'inforrnation dans
notre langue a aucun coiit. Pour parlera un interprete, compose: le 
633-4221}

Deutsch {German} Falls Sie oderjernand, dern Sie helfen, Fragen zu Medicare haben, haben Sie
das Recht, kostenlose Hilfe und lnforrnationen in lhrerSprache zu erhalten. Urn rnit einern
Dolmetscher zu sprechen, rufen Sie bitte die Nurnrner EDICARE [1?800?633?422?) an.

Krenol {Haitian Creole) Si ournenrn osnna non rnoun nn ap ede, gen kesnon konsenan Medicare, se
dnna nn pou jnnenn ed ak enfornasnon nan lang ou pale a, san pou pa oene pou sa. Pou pale
anek non entepret, rele nan [1?800?533?4231.

Italiano {Italian}Se noi, una persona che state aiutando, nogliate chiarirne nti a riguardo del
Medicare, anete i  diritto di otte nere assistenza inforrnazioni nella nostra lingua a titolo
gratuito. Per parlare con un interprete, chiarnate i  nurnero [1?800?633?4231.

[Japanese] Medicare [Cgag??g?t? 
LA na? iE?it?i?Ei'i?iEUi? EolcnnE [1?800?633?
422?) an ea<ae Ln

 

 

137

 

 

E'i'o'lmorean} Fig.? HEM new ee 01: 
Biol Ei? 0.101; 92% SEE ERIN
?rl?i?il?l ?c?l?i?i Lia-Aland 

Eii?i?hl?

(Polish) Jeieli Panstwo lub ktos? komu Panstwo pomagaja macie pytania dotyczace
Medicare, maja Panstwo prawo do uzyskania bezpiatnej pomocyi informacji swoim jezyku.
Aby rozmawiac tiumacze m, prosimy dzwonic pod numertelefonu EDICARE {1?800?


Portugu?s (Portuguese) Se yoce (ou alguem due yoce esteja ajudando) tiyer dL?indas sobre a
Medicare, yoce tem direito de obter ajuda informacoes em seu idioma, gratuitamente. Para
falar com um interprete, ligue para (1?800?633?422?).

(Russian) Ecnn eac an nnua, Horopomy nomoraeTe, aoaH mom no noaoay
nporpaMMbJ Meamsap (Medicare), MMEETE npa ao Ha becnnaTHyro nomourb V1 MHdJopmaumo Ha
ea UJEM assure. HTobbJ aocnon baoearbca nepeaoaymsa, no 1?800?
MEDICARE {1?800?633?422?}.

Tagalog (Tagalog) Kong ikaw, ang isang tinutulungan mo, ay may mga katanungan tungkol sa
Medicare, ikaw ay may karapatan na makakuha ng tulong at impormasyon sa iyong lenguwahe
ng walang gastos. Upang makipag?usap sa isang tagasalin ng wika, tumawag sa 
(1?800?633?422?).

Ti?ng Vi?t (Vietnamese) Neu duy hay ngu?oi ma duy y] dang giL?Jb as, co cau boi ye Medicare,
duy y] se co doy?n duoc giL?Jp ya co them thongtin bang ngon ngi?r cCJa minh miEn phi. De noi
cbuy?n qua thong dicb yien, goi so EDICARE (1?800?633?422?).

 

 

The information in ?Medicare 3: You? describes the Medicare program at the
time it was printed. Changes may occur after printing. Visit Medicaregov or
call (1?800?633?4227) to get the most current information.
TTY users can call 

?Medicare 8: You? isn?t a legal document. Of?cial Medicare Program legal
guidance is contained in the relevant statutes, regulations, and rulings.

Paid for by the Department of Health 8: Human Services.

 

us. DEPARTMENT OF sm
HEALTH AND HUMAN SERVICES POSTAGE 8, FEES

PAID CMS

Centers for Medicare Medicaid Serwces PERMIT NO. G-845

7500 Security Blvd.
Baltimore, MD 21244-1850

 

 

 

 

Of?cial Business
Penalty for Private Use, $300

CMS Product No. 10050-01
September 2018

This handbook has special information for 
SHIP for 

 



Moving? Visit socialsecuritycgov, or call Social Security at
TTY users can call 1?800?325?0??8. Ifyou
get RRB bene?ts, contact the RRB at 

TTY users can call 

?Necesita usted una copia de este manual en Espa?ol?
Llame a1 (1?800?633?4122?)
Los usuarios de TTY pueden llamar a1 

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Email us at medicareandyou?? cms.hhs.gov. We can?t

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when writing future handbooks.