Medicare for Dummies

Weave your way through the tangled web of Medicare
Medicare for Dummies, 3^rd Edition will help you navigate the complicated, often confusing maze of the Medicare system. In simple language, with clear step-by-step instructions, the book helps you determine how and when to enroll, avoid costly mistakes, and find a plan that is right for you and your family.

Written byPatricia Barry, a nationally recognized authority on Medicare and Medicare Part D prescription drug coverage, this invaluable resource offers:

•    Tips on reducing out-of-pocket expenses

•    Guidance for knowing your rights and protections

•     Ways to choose the best policy for you

With this definitive guide, you’ll get answers to the most common and not so common questions about Medicare, to get the most out of your coverage.

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

Introduction 1

About This Book 2

Foolish Assumptions 3

Icons Used in This Book 4

Beyond the Book 4

Where to Go from Here 5

Part 1: Getting Started with Medicare 7

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

Addressing Some Upfront Questions 10

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

Part A 13

Part B 14

Part C 15

Part D 15

Recognizing That You Have Choices and Must Make Timely Decisions 16

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

Understanding What Part A and Part B Cover 20

Necessary medical care 20

Preventive care 21

Specialized care in certain circumstances 24

Medical supplies and equipment 28

Knowing What Part D Covers 30

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

Finding out about formularies 32

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

The Gaps: Discovering What Medicare Doesn’t Cover 35

Routine hearing, vision, dental, and foot care 35

Home safety items 36

Nursing home care 37

Medical services abroad 37

Services that may be nice but aren’t necessary 38

Distinguishing When Coverage Comes with Limits 39

Limits on hospital stays 39

Limits on skilled nursing facility stays 40

Limits on mental health benefits 41

Limits on therapy services 42

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

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

Part A costs 45

Part B costs 47

Part D costs 48

Medicare Advantage costs 49

Paying Higher-Income Premiums 50

Understanding who’s liable for the surcharges 51

Figuring out what the surcharges cost you 53

Getting the surcharges waived 54

Paying Different Premiums than Other People in Certain Years 57

Paying Medicare Taxes While Receiving Medicare Benefits 58

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

Purchasing Medigap Insurance 60

Examining Medigap policies 61

Choosing and buying a Medigap policy 65

Qualifying for Help from Your State 66

Medicaid 66

Medicaid medical spend-down programs 68

Medicare Savings Programs 68

PACE plans 69

State Pharmacy Assistance Programs 71

Examining Whether Extra Help Can Lower Your Drug Costs 71

Qualifying for Extra Help 72

Applying for Extra Help 74

Choosing a drug plan with Extra Help 80

Considering Other Ways to Cut Costs 83

Taking income tax deductions for Medicare costs 83

Lowering drug costs without Extra Help 84

Part 2: The Hows and Whens of Medicare 89

Chapter 5: Qualifying for Medicare 91

Hitting the Milestone of Age 65 92

Debunking some qualification myths 92

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

Qualifying for Part A on your own work record 94

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

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

Receiving disability payments 98

Suffering from permanent kidney failure (ESRD) 101

Living with Lou Gehrig’s disease (ALS) 101

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

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

Paying for COBRA temporary insurance 103

Purchasing individual insurance through the online Marketplace 103

Buying health insurance outside of the Obamacare Marketplace 105

Getting health care without insurance 106

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

At a Glance: Surveying Situations That Affect Enrollment Timing 108

Understanding Your Initial Enrollment Period 110

Using your IEP at age 65 110

Taking advantage of your IEP when you have disabilities 111

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

Being able to delay Part B without penalty 113

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

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

Using the special enrollment period 118

Enrolling in Other Specific Situations 119

You’re a legal permanent resident 119

You live outside the United States 120

You’re in a nontraditional marriage or domestic partnership 123

You’re incarcerated 124

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

Assessing drug coverage you have from elsewhere 125

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

Figuring the best time to enroll in Part D 128

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

Missing your deadline for Part B 131

Passing your deadline for Part A 134

Neglecting your deadline for Part D 136

Figuring out whether you can get a late penalty revoked 138

Chapter 7: Discovering How to Sign Up for Medicare 141

Being Automatically Enrolled in Medicare Parts A and B 142

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

Signing up from inside the United States 144

Enrolling while you’re living abroad 147

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

Declining Part A 150

Opting out of Part B 151

Disenrolling from Part B 153

Knowing When Your Coverage Begins 154

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

When you sign up during IEP months four through seven 156

When you are awarded Medicare coverage retroactively 157

Transitioning from Obamacare to Medicare 158

Figuring out whether you need to make the switch 158

Knowing how and when to switch from Marketplace to Medicare 161

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

Understanding Medicare’s Coordination of Benefits System 166

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

Keeping Medicare informed if your coverage changes 168

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

Working with insurance from a current employer 169

Having insurance from a former employer 172

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

The Federal Employees Health Benefits Program 176

TRICARE and TRICARE For Life 178

The Veterans Affairs health system 182

The Indian Health Service 183

The Black Lung Program 184

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

When you first make a claim 185

If the claim isn’t settled promptly 186

When the claim has been settled 187

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

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

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

Understanding the consequences of your choice of system 192

Weighing the two systems 195

Recognizing when you may not have a choice 198

Being on your guard against “auto-enrollment” 199

Digging into the Details of Traditional Medicare versus Medicare Advantage 200

Opting for traditional Medicare 201

Looking at Medicare Advantage plans 202

Checking out three other types of Medicare health plans 206

Discovering How Medigap Policies Differ from Medicare Advantage Plans 207

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

Understanding the Need to Compare Part D Plans Carefully 212

Knowing what not to do 212

Defining “the best plan” 213

Recognizing that comparing plans is worth the effort 214

Seeing how comparing plans can save big bucks 215

Getting organized with two crucial lists 217

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

Assessing the plan finder’s reliability 220

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

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

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

Choosing a Medigap policy 231

Buying a Medigap policy at the right time 232

Buying Medigap if you’re under 65 235

Suspending a Medigap policy 236

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

Comparing Medicare Advantage Plans 240

Comparing plans’ medical benefits 241

Adding prescription drug coverage 246

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

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

Enrolling in a Medicare Advantage plan 250

Taking action if you change your mind 250

Chapter 12: Getting Help in Making Medicare Choices 253

One on One: Getting Personal Help on Medicare Issues 254

Asking family and friends 254

Contacting State Health Insurance Assistance Programs 255

Calling Medicare’s help line 256

Seeking advice from other sources 258

Buyer Beware! Avoiding Scams and Hard-Sell Marketing 259

Steering clear of outright scams 260

Resisting hard-sell marketing tactics 262

Part 4: Navigating Medicare from the Inside 267

Chapter 13: Starting Out as a New Medicare Beneficiary 269

Playing Your Cards Right 270

Understanding when to use each card 270

Protecting your cards from loss or theft 273

Replacing your cards 274

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

Managing Premiums 276

Discovering different ways to pay Medicare premiums 276

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

Keeping Track of Your Expenses 283

Understanding Medicare Summary Notices 283

Maintaining hard-copy records you can rely on 285

Tracking information online 287

Dealing with Doctors 287

Finding doctors who accept Medicare patients 288

Understanding what doctors can charge you 288

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

When does my coverage begin? 291

Which kind of pharmacy can I use? 292

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

How do I prove I have Part D coverage? 295

How can I ensure I get my meds? 296

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

Taking a Closer Look at Part A 300

Understanding hospital benefit periods 300

Taking note of the three-day rule 302

Defining observation status 303

Being aware of the improvement standard 305

Fighting premature hospital discharge 306

Proceeding if the hospital makes a mistake 307

Knowing your rights in a skilled nursing facility 308

Zooming In on Part B 311

Checking on whether Medicare will cover your treatment 311

Receiving a notice saying that Medicare may not pay 312

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

Maximizing your chances for coverage 315

Recognizing your right to second opinions 316

Filing a claim directly to Medicare 317

Delving into Part D 318

Understanding how a plan may restrict your drug coverage 318

Grappling with the tier system of co-pays 321

Navigating the doughnut hole 323

Using Part D to get the shingles vaccine 325

Taking advantage of free Medication Therapy Management benefits 326

Chapter 15: Changing Your Medicare and Medigap Coverage 327

Switching Coverage during Open Enrollment or Disenrollment 328

The open enrollment period 328

The disenrollment period 329

Taking Advantage of Special Enrollment Periods 330

Recognizing when you can use SEPs to change plans 331

Making sure your records and prescriptions are transferred 335

Dropping a Plan (Or Being Dropped) 336

Leaving a plan on your own 337

Getting the boot from your plan 338

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

Reading your Annual Notice of Change to understand plan alterations 340

Comparing plans (yes, all over again!) 341

Looking at extra factors influencing your decision 342

Changing to Another Medigap Policy 344

Knowing the consequences of switching Medigap policies 345

Exploring a change of Medigap coverage 345

Exercising your right to a 30-day free look 346

Chapter 16: Knowing Your Rights 347

Understanding Your Right to Accurate Information 347

Knowing whom to call 348

Seeking a second opinion 349

Asking for an Investigation 350

Requesting equitable relief 350

Contacting an ombudsman 351

Reaching out to your Quality Improvement Organization 351

Getting ahold of your plan 352

Filing a grievance 352

Taking Steps toward an Appeal 353

Obtaining a formal denial 354

Requesting a coverage determination 354

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

Filing a Formal Appeal 357

Walking through the five levels of appeal 357

Getting help in making an appeal 361

Part 5: The Part of Tens 363

Chapter 17: Top Ten Medicare Mistakes 365

Thinking You Must Reach Full Retirement Age before Signing Up 366

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

Failing to Enroll in Part B When You Should 367

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

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

Picking a Part D Drug Plan for the Wrong Reasons 368

Misunderstanding Enrollment Periods 369

Being Too Late to Buy Medigap with Full Protections 369

Failing to Read Your Annual Notice of Change 370

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

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

Taking Action to Avoid Falls 373

Exercising Regularly 375

Quitting Smoking 375

Eating Healthfully 376

Cutting Out Soft Drinks and Extra Sugar 377

Keeping an Eye on Prescription Drugs 377

Continuing to Work or Stay Active 378

Staying Connected and Engaged 378

Keeping Your Brain in Shape 379

Addressing Tough Choices before They’re Necessary 379

Part 6: Appendixes 381

Appendix A: Sources of Help and Information 383

Government Help Lines and Websites 383

The Centers for Medicare & Medicaid Services 383

The Social Security Administration 384

State Health Insurance Assistance Programs 384

The Eldercare Locator 389

Independent Sources of Direct Help 389

The Medicare Rights Center 389

The National Alliance for Hispanic Health 390

The National Asian Pacific Center on Aging 390

Resources for Saving Money 391

Consumer Information and Advocacy Organizations 392

Sources for Updates on Medicare 393

Appendix B: Glossary 395

Index 401

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