Introduction xiii
1. Understanding The Basics of Enrollment in and Entitlement to Medicare's Programs 1
1. What is Medicare? 1
2. Medicare's Fundamental Programs 1
3. Entitlement 3
3.1 Entitlement based on a retirement account 3
3.2 Entitlement based on a survivor's account 5
3.3 Entitlement based on a disability account 6
3.4 Entitlement based on end-stage renal disease 7
3.5 Retroactive Part A entitlement 9
4. Buying into Medicare: Premium Part A 9
5. Enrollment Periods 11
5.1 Individual enrollment periods 12
5.2 General enrollment periods 12
5.3 Employer and union group health special enrollment period 13
5.4 Foreign situations 13
5.5 International volunteers 14
6. How Part B Coordinates with Your Other Health Insurance 14
7. Noncoverage outside the US 15
CONTENTS
iv Managing your Medicare
8. Getting Help Paying Your Part B Premium 16
8.1 The Social Security savings clause 16
8.2 Medicaid 16
8.3 Medicare Savings Program 16
8.4 Payment by employer, union, or other organization 17
8.5 Reimbursement programs 17
8.6 Your Medicare Advantage Part C health plan 19
9. Part B: High-Income Premium Surcharges 19
9.1 Modifi ed Adjusted Gross Income (MAGI) 20
9.2 Requesting a change in premium surcharge 20
9.3 Paying your premium amounts 23
10. Information about Your Medicare Number and Card 23
2 Part A 25
1. Hospital Inpatient Stays 25
1.1 Benefi t period for inpatient stays 26
1.2 Medicare hospital benefi ts 26
1.3 Special notes on Medicare hospital coverage 27
2. Skilled Nursing Facility (SNF) Care 28
2.1 Qualifying for a stay 28
2.2 What Medicare covers in a Skilled Nursing Facility 29
2.3 Benefi t period for a Skilled Nursing Facility 30
3. Home Health Care 33
3.1 Home health-care benefi ts 34
3.2 Additional home health-care benefi ts 35
4. Hospice Care 37
4.1 What hospice care covers 37
4.2 Other hospice issues 40
3 Part B: The Basics 41
1. Part B Providers 41
2. Assignment 42
3. Filing Claims 46
4. Waiver of Liability: Advanced Benefi ciary Notice 46
4 Part B: Details of Coverage 49
1. The Most Commonly Covered Part B Services 49
1.1 Doctors' services 50
1.2 Radiology procedures 50
1.3 Diagnostic tests 50
1.4 Lab tests 51
1.5 Hospital outpatient departments and clinics 51
Contents v
1.6 Emergency rooms 51
1.7 Home health visits 51
1.8 Therapy 52
1.9 Ambulance 53
1.10 Pathology 53
1.11 Comprehensive Outpatient Rehabilitation Facilities (CORF) 53
1.12 Mental health services 54
1.13 Ambulatory surgical centers 55
2. Information about Coverage for Other Services 55
2.1 Abdominal aortic screening 55
2.2 Abortion 56
2.3 Acupuncture 56
2.4 Alcoholism 56
2.5 Anesthesia 56
2.6 Artifi cial hearts 56
2.7 Blood 56
2.8 Bone mass measurement 56
2.9 Cardiac rehabilitation programs 57
2.10 Cardiovascular disease screening 57
2.11 Chemotherapy 57
2.12 Chiropractic 57
2.13 Clinical trials and research studies 57
2.14 Colorectal cancer screening 58
2.15 Community Mental Health Centers (CMHCs) 60
2.16 Cosmetic procedures 60
2.17 Dentistry 60
2.18 Diabetes screenings 60
2.19 Dialysis 62
2.20 Drug abuse and chemical dependency treatment 62
2.21 Drugs and biologicals 62
2.22 Eye coverage 63
2.23 Federally Qualifi ed Health Clinics (FQHCs) 64
2.24 Flu vaccine 64
2.25 Foot care 64
2.26 Hearing aids and hearing exams 65
2.27 Hepatitis B vaccines 65
2.28 Inpatient ancillaries 65
2.29 Mammograms 65
2.30 Nutrition therapy 66
vi Managing your Medicare
2.31 Pap smear, pelvic exam, and breast exam 66
2.32 Partial hospitalization 66
2.33 Pathology 67
2.34 Pneumonia or pneumococcal vaccine 67
2.35 Portable X-rays and diagnostic X-rays 67
2.36 Prostate cancer screening 67
2.37 Radiation therapy 67
2.38 Rural health clinic (RHC) 67
2.39 Physician second and third opinions 68
2.40 Smoking cessation counseling 68
2.41 Telemedicine 68
2.42 Transplants 68
2.43 Transportation 68
2.44 Vaccinations 69
2.45 Welcome to Medicarea Physical Exam 69
5 Part B: Durable Medical Equipment 71
1. Coverage of Durable Medical Equipment 72
2. Equipment Must Be Supplied to Your Home 78
3. Payment Methods for Durable Medical Equipment 78
3.1 Low-cost or frequently purchased items 78
3.2 Always rentals 79
3.3 Capped rental items 79
4. Extra Documentation on Durable Medical Equipment 80
5. Advanced Determination of Medical Coverage 80
6. If You Leave Original Medicare and Go to Medicare Advantage 81
6 Part D: The Prescription Drug Benefi t 83
1. The Part D Structure 83
1.1 Deductible 84
1.2 Basic benefi t 84
1.3 Coverage gap 85
1.4 Catastrophic coverage 85
1.5 Tiered payments 85
1.6 Calculating your true out-of-pocket costs 85
2. Enrollment Periods and Penalties 86
2.1 Individual initial enrollment period 87
2.2 Annual coordinated enrollment period 88
2.3 Special enrollment periods 89
2.4 Penalties 92
2.5 Premium payments 93
Contents vii
3. Pharmacy Networks 93
4. Mail Order 94
5. Utilization Controls 94
6. Medication Therapy Management Programs 94
7. Part D: Details of Coverage 95
7.1 How Part D works with Part A and Part B 95
7.2 If you have Medicaid 96
7 Part D: Extra Help with Your Prescription Drug Benefi t 99
1. What Extra Help Covers 99
2. Automatic Qualifi cation 101
3. Applying for Extra Help 101
4. Income and Resources for Extra Help Purposes 102
4.1 Income 103
4.2 Resources and assets 105
5. Special Family Situations 106
6. Special Circumstances in Qualifying for Extra Help 106
7. Premium Limits for Extra Help Benefi ciaries 106
8. Changes and Redeterminations to Your Extra Help Status 108
8.1 Subsidy changing events 109
8.2 Redeterminations 109
8.3 Extra Help notices 109
9. Appealing an Extra Help Decision 110
8 Part C: Medicare Advantage Plans and Enrollment Requirements 113
1. Types of Medicare Advantage Plans 113
1.1 Point-of-Service (POS) option 113
1.2 Religious Fraternal Benefi t plans 114
1.3 Health Maintenance Organizations (HMO) 114
1.4 Provider Sponsored Organizations (PSO) 114
1.5 Preferred Provider Organizations (PPO) 114
1.6 Special Needs Plans (SNP) 115
1.7 Private Fee-for-Service (PFFS) plans 116
1.8 Medical Savings Accounts (MSA) 117
1.9 Cost plans 118
1.10 Demonstration plans 118
1.11 PACE plans 119
2. Enrolling in or Disenrolling from a Medicare Advantage Plan 119
2.1 Initial coverage election period 119
2.2 General enrollment period 120
2.3 Open enrollment for newly eligible individuals 120
viii Managing your Medicare
2.4 Annual election period 121
2.5 Open enrollment period 121
2.6 Special enrollment periods 122
3. End-Stage Renal Disease and Medicare Advantage 127
4. The Grandfather Clause 128
9 Part C: Researching and Managing Medicare Advantage Plans 129
1. Researching Plans 129
2. Common Marketing Scams 130
2.1 Marketing restrictions on Medicare Advantage Plans 131
3. Important Plan Communications 132
3.1 Evidence of Coveragea booklet 132
3.2 Annual Notice of Change 133
3.3 Physician or health provider leaves the plan 134
4. Special Care Situations 134
4.1 Emergency and urgently needed care 134
4.2 Direct access to care situations 136
4.3 Hospice care and Medicare Advantage 136
5. Your Special Rights and Protections in a Medicare Advantage Plan 136
5.1 Change primary care physician 136
5.2 Choose health-care providers 136
5.3 Noninterference 137
5.4 Compensation arrangements 137
5.5 Second opinion 137
5.6 Cultural competence 137
5.7 Treatment plan 137
5.8 Advance directives 138
10. Medigap: Medicare Supplement Insurance 139
1. Medigap SELECT Policies 139
2. Medigap Structure and Benefi ts 140
2.1 Basic benefi ts 140
2.2 Part A inpatient deductible 142
2.3 Skilled Nursing Facility 142
2.4 Part B deductible 142
2.5 Part B excess charges 142
2.6 At-home recovery 142
2.7 Foreign travel emergency 142
2.8 Preventive care 143
2.9 High deductible policies 143
2.10 Catastrophic policies 143
Contents ix
3. Medigap Structure for Massachusetts, Minnesota, and Wisconsin 145
4. Variations in Policy Pricing 145
5. Information gathering 148
5.1 Finding the policy that works for you 149
6. Discounts 150
7. Underwriting 150
7.1 Preexisting conditions 150
8. Medigap Rights and Protections 151
8.1 Your Medigap open enrollment period 151
8.2 Your special guaranteed issue rights 151
8.3 Disabled benefi ciary's special suspension right 154
8.4 Medicaid benefi ciary's special suspension right 155
8.5 Special Medigap consumer rights and protections 155
9. If You Kept a Medigap Policy with Drug Coverage 156
10. Contacting Companies 157
11. Major Medigap Changes in June, 2010 157
12. Medical Bill Tracking 157
11. Medicare and Private Health Insurance: Coordinating Your Benefi ts 159
1. Coordination of Benefi ts 159
2. Employer and Union Group Health Insurance 160
2.1 Retirement employer and union group health insurance 161
2.2 Working employer and union group health insurance 162
2.3 Consolidated Omnibus Budget Reconciliation Act (COBRA) 164
3. Workers' Compensation 168
3.1 Conditional payment 168
3.2 Set-aside arrangements 169
4. No-Fault and Liability Insurance 170
12. Coordinating Medicare with Government-Sponsored Health Programs 171
1. Federal Black Lung Benefi ts Program 171
2. Veterans Benefi ts 172
2.1 Coordination of Veterans Benefi ts with Part B and Part D 172
3. Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) 173
3.1 Coordination of CHAMPVA with Part A, Part B, and Part D 174
4. TRICARE For Life (TFL) 175
4.1 Coordination of TRICARE For Life and Part A, Part B, and Part D 176
5. Federal Employee Health Benefi ts (FEHB) 177
5.1 Federal Employee Health Benefi ts (FEHB) and Part B 178
5.2 Federal Employee Health Benefi ts (FEHB) and Part D 179
x Managing your Medicare
5.3 Primary payer rules 179
5.4 Special rule for retirees who do not have Medicare 179
6. Medicaid 180
6.1 Medicaid and Part D 180
13. Specifi c Diseases and How Medicare Can Help 181
1. Diabetes 181
2. Heart attack 182
3. Alzheimer's Disease 183
4. End-stage renal disease 184
4.1 If you have Medicare and then get end-stage renal disease 184
4.2 A special note on delaying your fi ling for Medicare 185
4.3 End-stage renal disease benefi ciaries and Medicare Advantage 186
4.4 Termination of Medicare for end-stage renal disease benefi ciaries 187
4.5 Treatments and options 187
4.6 End-stage renal disease networks 190
14. Medicare Appeals 193
1. Some Helpful Guidelines for Medicare Appeals 193
1.1 Amount in controversy 193
1.2 Federal rules govern 194
1.3 Forms 194
1.4 Other entities appealing 194
1.5 Representation 194
1.6 Escalation 194
2. Original Medicare Appeals 194
2.1 Resubmittals 195
2.2 Redeterminations 195
2.3 Reconsiderations 195
2.4 Administrative Law Judge hearings 196
2.5 Medicare Appeals Council reviews 197
2.6 US Federal District Court suits 197
2.7 Your right to receive notice of and to appeal the termination of four specifi c services 197
2.8 Appeals of local and national coverage determinations 199
3. Medicare Managed Care Rights 200
3.1 Right to a determination 201
3.2 Your basic right to a decision on a claim and how to appeal it 204
3.3 Right to fi le a grievance 205
3.4 Right to express dissatisfaction about quality of care 206
Contents xi
4. Part D: Rights, Determinations, and Appeals 206
4.1 Your special rights under Part D 207
4.2 How to make a standard or normal time determination 208
4.3 Expedited procedures 209
4.4 Second level appeals: Reconsiderations 211
4.5 Subsequent appeals 212
15. Your Rights as a Medicare Benefi ciary: Know Them and Use Them! 213
1. Entitlement and Enrollment Rights for Medicare Applicants and Benefi ciaries 213
1.1 Be protected against discrimination 213
1.2 Receive services in a culturally competent way 214
1.3 Get information from Medicare 214
1.4 Participate in your health care decisions 214
1.5 Advance notice for proposed medical care or treatment that is part
of a research experiment 214
1.6 Use advance directives 214
1.7 File a complaint about the quality of your care 214
2. Your Benefi ciary Rights in Original Medicare 216
2.1 Free choice by patient and provider 216
2.2 Obtain an itemized statement 216
3. Your Rights to Privacy Protections 216
4. Your Responsibilities 217
TABLES
1 Resource Limits for all Medicare Savings Programs 18
2 Monthly Income Limits for Qualifi ed Disabled Working Individuals 18
3 Monthly Income Limits for Qualifi ed Medicare Benefi ciaries 18
4 Monthly Income Limits for Specifi ed Low-income Medicare Benefi ciaries 18
5 Monthly Income Limits for Qualifi ed Individuals 18
6 For Single Persons and Married Couples Filing Jointly 19
7 For Married Persons Filing Separately 19
8 Part B Payments 44
9 Colorectal Screening Tests 59
10 Simplifi ed Extra Help for 2009 (For lower 48 states only) 100
11 100 Percent of the Federal Poverty Limit (2009) 103
12 150 Percent of the Federal Poverty Limit (2009) 103
13 Extra Help Premium Benchmark Information 107
14 Open Enrollment Period Dos and Don'ts 122
15 Medigap Standard Policies 141
16 How Plans K and L Differ from the Standard Medigap Plans 144
