Large Print Edition
Centers for Medicare & Medicaid Services
Medicare & You
2024
This is the ocial U.S. government
Medicare handbook.
2
What’s new & important?
Medicare strives to improve access to aordable
treatments to keep you healthy. Check out what’s new this
year to help you manage your health.
Saving money on your prescription drugs
If you have Medicare drug coverage (Part D) and your
drug costs are high enough to reach the catastrophic
coverage phase, you don’t have to pay a copayment or
coinsurance. Extra Help—a program that helps cover your
Part D drug costs—expanded to cover more drug costs
for certain people with limited resources and income. Go
to pages 201 and 227.
Coinsurance amounts for some Part B-covered drugs may
be less if a prescription drug’s price increased higher than
the rate of ination. Go to pages 87 – 88.
3
—
What’s new & important?
Lower costs for insulin and vaccines
Your Medicare drug plan can’t charge you more than
$35 for a one-month supply of each insulin product Part D
covers, and you don’t have to pay a deductible for it. Go
to pages 214 – 215.
If you take insulin through a traditional pump that’s
covered under Medicare’s durable medical equipment
benet, that insulin is covered under Medicare Part B. You
won’t pay more than $35 for a month’s supply and the
Medicare deductible no longer applies. Go to pages 84
and 215.
Recommended adult vaccines are also now available at
no cost to you. Go to page 115.
Changes to telehealth coverage
You can still get telehealth services at any location in the
U.S., including your home, until the end of 2024. After
that, you must be in an oce or medical facility located
in a rural area to get most telehealth services. There are
some exceptions, like for mental health services. Go to
pages 117 – 118.
4
—
What’s new & important?
Managing and treating chronic pain
Medicare now covers monthly services to treat chronic
pain if you’ve been living with it for more than 3 months.
Go to page 73.
Better mental health care
Medicare now covers intensive outpatient program
services provided by hospitals, community mental health
centers, and other locations if you need mental health
care. Go to page 106.
More times to sign up for Medicare
If you recently lost (or will soon lose) Medicaid, you may
be able to sign up for Medicare or change your current
Medicare coverage. There are other special situations that
allow you to sign up for Medicare. Go to page 30.
COVID-19 care
Medicare continues to cover the COVID-19 vaccine, and
several tests and treatments to keep you and others safe.
Go to pages 79 – 81.
5
Contents
What’s new & important? ˍ ̲ 2
What are the parts of Medicare? ˍ ̲ 7
Your Medicare options ˍ ̲ 9
At a glance: Original Medicare vs.
Medicare Advantage ˍ ̲ 11
Get started with Medicare ˍ ̲ 17
Get help nding the right coverage for you ˍ ̲ 19
Section 1: Signing up for Medicare ˍ ̲ 21
Section 2: Find out what Medicare covers ˍ ̲ 47
Section 3: Original Medicare ˍ ̲ 133
Section 4: Medicare Advantage Plans &
other options ˍ ̲ 143
Section 5: Medicare Supplement Insurance
(Medigap) ˍ ̲ 179
Section 6: Medicare drug coverage (Part D) ˍ ̲ 191
Section 7: Get help paying your health &
drug costs ˍ ̲ 223
7
What are the parts of Medicare?
Part A (Hospital Insurance)
Helps cover:
•
Inpatient care in hospitals
•
Skilled nursing care facility
•
Hospice care
•
Home health care
Go to pages 48 – 57.
Part B (Medical Insurance)
Helps cover:
•
Services from doctors and other health care providers
•
Outpatient care
•
Home health care
•
Durable medical equipment (like wheelchairs, walkers,
hospital beds, and other equipment)
•
Many preventive services (like screenings, shots or
vaccines, and yearly “Wellness” visits)
Go to pages 58 – 128.
8
—
What are the parts of Medicare?
Part D (Drug coverage)
Helps cover the cost of prescription drugs (including many
recommended shots or vaccines).
Plans that oer Medicare drug coverage (Part D) are run
by private insurance companies that follow rules set by
Medicare.
Go to pages 191 – 222.
•
End of Page
9
Your Medicare options
When you rst sign up for Medicare, and during certain
times of the year, you can choose how you get your
Medicare coverage. There are 2 main ways to get
Medicare:
Original Medicare
•
Original Medicare includes Medicare Part A (Hospital
Insurance) and Part B (Medical Insurance).
•
You can join a separate Medicare drug plan to get
Medicare drug coverage (Part D).
•
You can use any doctor or hospital that takes
Medicare, anywhere in the U.S.
•
To help pay your out-of-pocket costs in Original
Medicare (like your 20% coinsurance), you can also
shop for and buy supplemental coverage.
•
This includes Medicare Supplement
Insurance (Medigap). Go to Section 5
(starting on page 179) to learn more about
Medigap. Or, you can use coverage from a current
or former employer or union, or Medicaid.
Go to Section 3 (starting on page 133) to learn more
about Original Medicare.
10
—
Your Medicare options
Medicare Advantage (also known as Part C)
•
Medicare Advantage is a Medicare-approved plan
from a private company that offers an alternative to
Original Medicare for your health and drug coverage.
These “bundled” plans include Part A, Part B, and
usually Part D.
•
In many cases, you can only use doctors who are in
the plan’s network.
•
In many cases, you may need to get approval from
your plan before it covers certain drugs or services.
•
Plans may have lower or higher out-of-pocket costs
than Original Medicare. You may also have an
additional premium.
•
Plans may offer some extra benefits that Original
Medicare doesn’t cover—like certain vision, hearing,
and dental services.
Go to Section 4 (starting on page 143) to learn more
about Medicare Advantage.
11
At a glance: Original Medicare vs.
Medicare Advantage
Doctor & hospital choice
Original Medicare
•
You can use any doctor or hospital that takes
Medicare, anywhere in the U.S.
•
In most cases, you don’t need a referral to use a
specialist.
Medicare Advantage (Part C)
•
In many cases, you can only use doctors and other
providers who are in the plan’s network and
service area (for non-emergency care). Some plans
offer non-emergency coverage out of network, but
typically at a higher cost.
•
You may need to get a referral to use a specialist.
12
—
Original Medicare vs. Medicare Advantage
Cost
Original Medicare
•
For Part B-covered services, you usually pay 20% of
the Medicare-approved amount after you meet your
deductible. This amount is called your coinsurance.
•
You pay a premium (monthly payment) for Part B.
If you choose to join a Medicare drug plan, you’ll pay
a separate premium for your Medicare drug coverage
(Part D).
•
There’s no yearly limit on what you pay out of
pocket, unless you have supplemental coverage—like
Medicare Supplement Insurance (Medigap).
•
You can choose to buy Medigap to help pay
your remaining out-of-pocket costs (like your 20%
coinsurance). Go to page 184. Or, you can use
coverage from a current or former employer or union,
or Medicaid.
13
—
Original Medicare vs. Medicare Advantage
Medicare Advantage (Part C)
•
Out-of-pocket costs vary—plans may have lower or
higher out-of-pocket costs for certain services.
•
You pay the monthly Part B premium and may also
have to pay the plan’s premium. Some plans may
have a $0 premium and may help pay all or part of
your Part B premium. Most plans include Medicare
drug coverage (Part D).
•
Plans have a yearly limit on what you pay out of
pocket for services Medicare Part A and Part B cover.
Once you reach your plan’s limit, you’ll pay nothing
for services Part A and Part B cover for the rest of the
year.
•
You can’t buy Medigap.
•
End of Page
14
—
Original Medicare vs. Medicare Advantage
Coverage
Original Medicare
•
Original Medicare covers most medically necessary
services and supplies in hospitals, doctors’ offices,
and other health care facilities. Original Medicare
doesn’t cover some benefits like eye exams, most
dental care, and routine exams. Go to page 129.
•
You can join a separate Medicare drug plan to get
Medicare drug coverage (Part D).
•
In most cases, you don’t need approval for Original
Medicare to cover your services or supplies.
Medicare Advantage (Part C)
•
Plans must cover all medically necessary services
that Original Medicare covers. Plans may also offer
some extra benefits that Original Medicare doesn’t
cover—like certain vision, hearing, and dental services.
•
Medicare drug coverage (Part D) is
included in most plans. In most types of
Medicare Advantage Plans, you can’t join a separate
Medicare drug plan.
•
In many cases, you may need to get approval from
your plan before it covers certain services or supplies.
15
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Original Medicare vs. Medicare Advantage
Foreign travel
Original Medicare
•
Original Medicare generally doesn’t cover medical
care outside the U.S. You may be able to buy a
Medicare Supplement Insurance (Medigap) policy that
covers emergency care outside the U.S.
Medicare Advantage (Part C)
•
Plans generally don’t cover medical care outside the
U.S. Some plans may offer a supplemental benefit that
covers emergency and urgently needed services when
traveling outside the U.S.
•
End of Page
16
—
Original Medicare vs. Medicare Advantage
This handbook explains these topics in more detail:
•
Original Medicare: Go to Section 3 (starting on
page 133).
•
Medicare Advantage: Go to Section 4 (starting on
page 143).
•
Medicare Supplement Insurance (Medigap): Go to
Section 5 (starting on page 179).
•
Medicare drug coverage (Part D): Go to Section 6
(starting on page 191).
17
Get started with Medicare
It’s important for you to:
•
Understand your Medicare coverage options. There
are 2 main ways to get your Medicare coverage—
Original Medicare (Part A and Part B) and Medicare
Advantage. Go to pages 9 – 16 to learn more.
•
Find out how and when you can sign up. If
you don’t have Medicare Part A or Part B, go to
Section 1 (starting on page 21). If you have other health
insurance, go to pages 31 – 39 to nd out how your
other insurance works with Medicare.
Important!
If you don’t have Medicare drug coverage (Part D),
go to Section 6 (starting on page 191). There may
be penalties if you don’t sign up when you’re rst
eligible.
•
Mark your calendar with these important dates!
These may be the only times you have each year to
change your coverage.
•
January 1, 2024: New coverage begins if you
made a change. If you kept your existing coverage
and your plan’s costs or benefits changed, those
changes also start on this date.
18
—
Get started with Medicare
•
January 1 to March 31, 2024: If you’re in a
Medicare Advantage Plan, you can change to
a different Medicare Advantage Plan or switch to
Original Medicare (and join a separate Medicare
drug plan) once during this time. Any changes
you make will be effective the first day of the
month after the plan gets your request. Go to
pages 150 – 153.
•
October 1, 2024: Start comparing your current
coverage with other options. You may be
able to save money or get extra benefits. Visit
Medicare.gov/plan-compare.
•
October 15 to December 7, 2024: Change your
Medicare health or drug coverage for 2024,
if you decide to. You can join, switch or drop a
Medicare Advantage Plan or Medicare drug plan,
or switch to Original Medicare during this Open
Enrollment Period each year.
Each year, it’s important to review your Medicare
health and drug coverage to make sure it still meets
your needs, and decide if you want to make a change.
You don’t need to sign up for Medicare each year, but
you should still review your options.
19
Get help nding the right coverage
for you
Explore your coverage options
•
Find and compare health and drug plans at
Medicare.gov/plan-compare.
•
Call 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
•
Get free, personalized health insurance counseling
from your State Health Insurance Assistance Program
(SHIP). Go to pages 280 – 287 for the phone number of
your local SHIP. A trusted agent or broker may also be
able to help.
Get the most value out of your health care
We want to make sure you have the information you
need to make the best decisions about your health care.
Look for the “Cost & coverage” highlights throughout this
handbook to learn about costs and coverage for services.
Learn about preventive services
Medicare covers many preventive services at no cost
to you. Ask your doctor or other health care provider
which preventive services (like screenings, shots or
vaccines, and yearly “Wellness” visits) you need. Go to
pages 60 – 128 to learn more about which preventive
services Medicare covers.
20
—
Get help nding the right coverage for you
Get help paying for health care
There are multiple programs available to help with costs.
Many people with Medicare qualify. For more on these
programs, go to pages 223 – 236.
Review this handbook online
Help Medicare save money by switching to the electronic
version of your handbook. Log into (or create) your
secure Medicare account at Medicare.gov to switch
to the electronic handbook. We’ll email you a link to a
PDF version instead of sending a paper copy in the mail
each fall.
Need information in an accessible format or
another language?
You can get the “Medicare & You” handbook in
an accessible format at no cost to you. Go to
pages 297 – 298. To get free help in a language other than
English, go to pages 320 – 323.
Have questions or comments about this
handbook?
Email us at medicareandyou@cms.hhs.gov.
21
Section 1: Signing
up for Medicare
Will I get Part A and Part B automatically?
If you’re already getting benets from Social Security
or the Railroad Retirement Board (RRB), you’ll
automatically get Part A and Part B 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 B starts the rst day of the
prior month.)
If you’re under 65 and have a disability, you’ll
automatically get Part A and Part B after getting
24 months of disability benets, either from Social
Security or certain disability benets from the RRB.
If you live in Puerto Rico, you don’t automatically get
Part B. You must sign up for it. Go to page 24.
If you have ALS (amyotrophic lateral sclerosis, also
called Lou Gehrig’s disease), you’ll get Part A and
Part B automatically the month your Social Security
disability benets begin.
Underlined words are dened on pages 289 – 296.
22
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Section 1: Signing up for Medicare
If you automatically get Medicare, you’ll get your red,
white, and blue Medicare card in the mail 3 months
before your 65th birthday or 25th month of disability
benets, and you don’t need to pay a premium for
Part A (sometimes called “premium-free Part A”). Most
people choose to keep Part B. If you don’t want Part B, let
us know before the coverage start date on your Medicare
card. If you do nothing, you’ll keep Part B and pay Part B
premiums through your Social Security or RRB benets.
If you have other coverage and need help deciding if you
should keep Part B, go to pages 31 – 39. If you choose
not to keep Part B but decide you want it later, you
may have a delay in getting Medicare Part B coverage
because you can only sign up at certain times. You
may also have to pay a late enrollment penalty for as
long as you have Part B. Go to pages 41 – 42.
23
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Section 1: Signing up for Medicare
Will I have to sign up for Part A and/or
Part B?
If you’re close to 65, but NOT getting Social Security
or RRB benets, you’ll need to sign up for Medicare. Visit
SSA.gov/medicare to apply for Part A and Part B. You
can also contact Social Security 3 months before you turn
65 to set up an appointment. If you worked for a railroad,
contact the RRB.
In most cases, if you don’t sign up for Part B when you’re
rst eligible, you may have a delay in getting Medicare
Part B coverage in the future because you can only sign
up at certain times. You may also have to pay a late
enrollment penalty for as long as you have Part B. Go
to pages 41 – 42.
If you have End-Stage Renal Disease (ESRD) and
want Medicare, you’ll need to sign up for it. Contact
Social Security to nd out when and how to sign
up for Part A and Part B. For more information, visit
Medicare.gov/publications to review the booklet,
“Medicare Coverage of Kidney Dialysis & Kidney
Transplant Services.”
24
—
Section 1: Signing up for Medicare
Important!
If you live in Puerto Rico and get benets from Social
Security or the RRB, you’ll automatically get Part A the
rst day of the month you turn 65 or after you get disability
benets for 24 months. However, if you want Part B, you’ll
need to sign up for it by completing an “Application for
Enrollment in Part B Form” (CMS-40B). To get this form in
English and Spanish, visit: Medicare.gov/basics/forms-
publications-mailings/forms/enrollment. If you don’t
sign up for Part B when you’re rst eligible, you may have
a delay in getting Part B coverage in the future because
you can only sign up at certain times. You may also have
to pay a late enrollment penalty for as long as you
have Part B. Go to page 42.
Where can I get more information?
Call Social Security at 1 800 772 - 1213 for more
information about your Medicare eligibility and to
sign up for Part A and/or Part B. TTY users can call
1 800 325 - 0778. If you worked for a railroad or get RRB
benets, call the RRB at 1 877 772 - 5772. TTY users can
call 1 312 751 - 4701.
25
—
Section 1: Signing up for Medicare
You can also get free, personalized health insurance
counseling from your State Health Insurance Assistance
Program (SHIP). Go to pages 280 – 287 for the phone
number of your local SHIP.
After you’ve signed up for Medicare Part A and/or
Part B, it’s time to look at your coverage options.
People get Medicare coverage in dierent ways. To
get the most out of your coverage, review all of your
options and decide what best meets your needs. Go to
pages 11 – 18 for more details.
If I didn’t get Part A and Part B
automatically, when can I sign up?
If you didn’t automatically get premium-free Part A (for
example, because you’re still working and not yet getting
Social Security or Railroad Retirement Board (RRB)
benets), you can sign up for it any time after you’re
rst eligible for Medicare. Go to pages 39 – 40 for more
information.
26
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Section 1: Signing up for Medicare
In this example, your Part A coverage will go back
(retroactively) 6 months from when you sign up for
Part A or apply for Social Security or RRB benets, but
no earlier than the rst month you’re eligible for Medicare.
Depending on how you become eligible for Part A, the
retroactive period may be dierent.
You can only sign up for Part B during the enrollment
periods listed on the next page.
Important!
Remember, in most cases, if you don’t sign up for
Part A (if you have to buy it) and Part B when you’re
rst eligible, your enrollment may be delayed and
you may have to pay a late enrollment penalty. Go to
pages 40 – 42.
What are the Part A and Part B enrollment
periods?
You can only sign up for Part B (and/or Part A if you have
to buy it) during these enrollment periods.
27
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Section 1: Signing up for Medicare
Initial Enrollment Period
Generally, you can rst sign up for Part A and/or Part B
during the 7-month period that begins 3 months before
the month you turn 65 and ends 3 months after the month
you turn 65. If your birthday is on the rst of the month,
your 7-month period starts 4 months before the month
you turn 65 and ends 2 months after the month you
turn 65.
Example: If you turn 65 on June 2, your 7-month period
would begin in March and end in September. If you
turn 65 on June 1, your 7-month period would begin in
February and end in August.
If you sign up for Part A and/or Part B during the rst
3 months of your Initial Enrollment Period, in most cases,
your coverage begins the rst day of your birthday month.
However, if your birthday is on the rst day of the month,
your coverage starts the rst day of the prior month.
If you sign up the month you turn 65 or during the last
3 months of your Initial Enrollment Period, your coverage
starts the rst day of the month after you sign up.
28
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Section 1: Signing up for Medicare
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. For example, if you didn’t sign up for
Part B (or Part A if you have to buy it) when you were rst
eligible because you have group health plan coverage
based on current employment (your own, a spouse’s, or
a family member’s if you have a disability), you can sign up
for Part A and/or Part B:
•
Any time 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 first
Your coverage starts the rst day of the month after you
sign up. Usually, you won’t have to pay a late enrollment
penalty if you sign up during a Special Enrollment Period.
This period doesn’t apply if you’re eligible for Medicare
based on End-Stage Renal Disease (ESRD), or you’re still
in your Initial Enrollment Period.
To sign up for Part A and/or B, contact Social
Security at 1 800 772 - 1213. TTY users should call
1 800 325 - 0778.
29
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Section 1: Signing up for Medicare
Important!
COBRA (Consolidated Omnibus Budget Reconciliation
Act) coverage, retiree health plans, VA coverage, and
individual health insurance coverage (like coverage
through the Health Insurance Marketplace
®
) aren’t
considered coverage based on current employment
and don’t count as employer coverage for a Special
Enrollment Period. There may be reasons why you
should take Part B instead of, or in addition to, COBRA
coverage. You have 8 months after your coverage based
on current employment ends to sign up for Part B
without a penalty, whether or not you choose COBRA.
However, if you have COBRA and you’re eligible for
Medicare, COBRA may only pay a small portion of
your medical costs. You generally aren’t eligible for a
Special Enrollment Period to sign up for Medicare when
that COBRA coverage ends. Go to page 217 for more
information about COBRA coverage. To avoid paying a
penalty, make sure you sign up for Medicare when you’re
rst eligible. If you have retiree coverage, it may not pay
for your health services if you don’t have both Part A and
Part B.
30
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Section 1: Signing up for Medicare
Exceptional situations for a Special Enrollment
Period
There are other circumstances where you may be able to
sign up for Medicare during a Special Enrollment Period.
You may be eligible for a Special Enrollment Period
if you miss an enrollment period because of certain
exceptional circumstances, like being impacted by a
natural disaster or an emergency, incarceration, employer
or health plan error, losing Medicaid coverage, or other
circumstances outside of your control that Medicare
determines to be exceptional. For more information, visit
Medicare.gov or call 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
Important!
If you recently lost Medicaid and you now qualify for
Medicare, but didn’t sign up for Medicare when you
rst became eligible, you may be able to sign up for
Part A and Part B without paying a late enrollment
penalty. If you already have Medicare but lost Medicaid,
you also have coverage options. For more information,
check out the “Losing Medicaid?” fact sheet at
go.Medicare.gov/losingmedicaid.
31
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Section 1: Signing up for Medicare
General Enrollment Period
If you have to pay for Part A but don’t sign up for it
and/or don’t sign up for Part B (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 during the General Enrollment Period from
January 1 – March 31 each year. You may have to
pay a higher Part A and/or Part B premium for late
enrollment. Go to pages 40 – 42.
When you sign up during the General Enrollment Period,
your coverage starts the rst day of the month after you
sign up.
Not sure if you qualify for an enrollment period? Visit
Medicare.gov, or call 1 800 633 - 4227. TTY users can
call 1 877 486 - 2048.
I have other health coverage. Should I get
Part B?
This information can help you decide if you should get
Part B based on the type of health coverage you may have.
32
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Section 1: Signing up for Medicare
Employer or union coverage
If you or your spouse (or family member if you have a
disability) are still working and you have health coverage
through that employer or union, go to pages 36 – 37 to
nd out how your coverage works with Medicare. You can
also contact the employer or union benets administrator
for information. This includes federal or state employment
and active-duty military service. It might be to your
advantage to delay Part B enrollment while you still have
health coverage based on your or your spouse’s current
employment.
Coverage based on current employment doesn’t
include:
•
COBRA (or similar continuation coverage after
employment ends)
•
Retiree coverage
•
VA coverage
•
Individual health insurance coverage (like through the
Health Insurance Marketplace
®
)
33
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Section 1: Signing up for Medicare
TRICARE
If you have TRICARE (health care program for active-duty
and retired service members and their families), you
generally must sign up for Part A and Part B 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 sign up
for Part B to keep your TRICARE coverage. For more
information, contact your TRICARE contractor. Go to
page 221.
If you have CHAMPVA coverage, you must sign up for
Part A and Part B to keep it. Call 1 800 733 - 8387 for
more information about CHAMPVA.
Medicaid
If you have Medicaid and don’t have Part B, Medicaid may
help you sign up for it. Medicare will pay rst, and Medicaid
will pay second. Medicaid may be able to help pay your
Medicare out-of-pocket costs (like premiums, deductibles,
coinsurance, and copayments).
Call your State Medical Assistance (Medicaid) oce for more
information and to nd out if you qualify. Visit Medicaid.gov/
about-us/beneciary-resources/index.html#statemenu,
or call 1 800 633 - 4227 to get the phone number for your
state’s Medicaid oce. TTY users can call 1 877 486 - 2048.
34
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Section 1: Signing up for Medicare
Health Insurance Marketplace
®
Even if you have Marketplace coverage (or other individual
health coverage that isn’t based on current employment),
you should generally sign up for Medicare when you’re
rst eligible to avoid the risk of a delay in Medicare
coverage and the possibility of a Medicare late enrollment
penalty.
Here are some important points to consider if you have
Marketplace coverage:
•
You need to end your Marketplace coverage in a timely
manner when you become eligible for Medicare to
avoid an overlap in coverage.
•
Once you’re considered eligible for premium-free
Part A, or already have Part A with a premium, you
won’t qualify for help from the Marketplace to pay your
Marketplace plan premiums or other medical costs. If
you continue to get help paying for your Marketplace
plan premiums after that point, you may have to pay
back some or all of the help you got when you file your
federal income taxes.
35
—
Section 1: Signing up for Medicare
Visit HealthCare.gov to connect to the Marketplace
in your state and learn more. To nd out how to end
your Marketplace plan or Marketplace savings when
your Medicare coverage begins, visit HealthCare.gov/
medicare/changing-from-marketplace-to-medicare.
You can also call the Marketplace Call Center at
1 800 318 - 2596. TTY users can call 1 855 889 - 4325.
Health Savings Account (HSA)
You aren’t eligible to make contributions to an HSA after
you have Medicare. To avoid a tax penalty, you should
make your last HSA contribution the month before your
Part A coverage begins. Premium-free Part A coverage
will go back (retroactively) 6 months from when you sign
up for Part A or apply for benets from Social Security or
the Railroad Retirement Board (RRB), but no earlier than
the rst month you’re eligible for Medicare. Depending on
how you become eligible for Part A, the retroactive period
may be dierent. Review the information below to help
decide when it’s best to stop your HSA contributions.
•
If you sign up for Medicare during your Initial
Enrollment Period OR 2 months after your Initial
Enrollment Period ends: You can avoid a tax penalty
by making your last HSA contribution the month before
you turn 65.
36
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Section 1: Signing up for Medicare
•
If you wait to sign up for Medicare less
than 6 months after you turn 65: You can avoid a
tax penalty by stopping HSA contributions the month
before you turn 65.
•
If you wait to sign up for Medicare 6 or more
months after you turn 65: You can avoid a tax
penalty by stopping HSA contributions 6 months
before the month you apply for Medicare.
Note: A Medicare Medical Savings Account (MSA) Plan is
similar to an HSA. Go to pages 160 – 161.
How does my other insurance work with
Medicare?
When you have other insurance (like group health plan,
retiree health, or Medicaid coverage) and Medicare, there
are rules for whether Medicare or your other coverage
pays rst.
•
If you have retiree health coverage (like insurance from
your or your spouse’s former employment)... Medicare
pays first.
•
If you’re 65 or older, have group health plan coverage
based on your or your spouse’s current employment,
and the employer has 20 or more employees… Your
group health plan pays first.
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Section 1: Signing up for Medicare
•
If you’re 65 or older, have group health plan coverage
based on your or your spouse’s current employment,
and the employer has fewer than 20 employees…
Medicare pays first.
•
If you’re under 65 and have a disability, have group
health plan coverage based on your or a family
member’s current employment, and the employer has
100 or more employees… Your group health plan
pays first.
•
If you’re under 65 and have a disability, have group
health plan coverage based on your or a family
member’s current employment, and the employer has
fewer than 100 employees… Medicare pays first.
•
If you have group health plan coverage based on
your or a family member’s employment or former
employment, and you’re eligible for Medicare because
of End-Stage Renal Disease (ESRD)… Your group
health plan pays first for the first 30 months after you
become eligible for Medicare. Medicare pays first after
this 30-month period.
•
If you have TRICARE... Medicare pays first, unless
you’re on active duty, or get items or services from a
military hospital or clinic, or other federal health care
provider.
•
If you have Medicaid... Medicare pays first.
38
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Section 1: Signing up for Medicare
Important!
If you’re still working and have employer coverage
through work, contact your employer to nd out how your
employer’s coverage works with Medicare.
Here are some important facts to remember about how
other insurance works with Medicare-covered services:
•
The insurance that pays first (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 payer didn’t cover.
•
The secondary payer (which may be Medicare) might
not pay all of the uncovered costs.
•
If your group health plan or retiree health coverage is
the secondary payer, you’ll likely need to sign up for
Part B before your insurance will pay.
Visit Medicare.gov/publications to review the booklet,
“Medicare and Other Health Benets: Your Guide to Who
Pays First.” You can also call 1 800 633 - 4227 for more
information. TTY users can call 1 877 486 - 2048.
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Section 1: Signing up for Medicare
Important!
If you have other insurance or changes to your
insurance, you need to let Medicare know by calling
Medicare’s Benets Coordination & Recovery Center at
1 855 798 - 2627. TTY users can call 1 855 797 - 2627.
If you have Part A, you may get a “Health Coverage” form
(IRS Form 1095-B) from Medicare. This form veries that
you had health coverage in the past year. Keep the form
for your records. Not everyone will get this form. If you
don’t get Form 1095-B, don’t worry. You don’t need it to
le your taxes.
Do I have to pay for Part A?
You usually don’t pay a monthly 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 it. For more
information on how to pay your Part A premium, go to
pages 43 – 45.
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—
Section 1: Signing up for Medicare
If you buy Part A, you’ll pay a premium of either $278 or
up to $505 each month in 2024 depending on how long
you or your spouse worked and paid Medicare taxes.
If you need help paying your Part A premium, go to
pages 229 – 236. If you have questions about paying for
Part A, visit Medicare.gov
or call 1 800 633 - 4227. TTY
users can call 1 877 486 - 2048.
In most cases, if you choose to buy Part A, you must
also have Part B and pay monthly premiums for both. If
you choose NOT to buy Part A, you can still buy Part B if
you’re eligible.
What’s the Part A late enrollment penalty?
If you aren’t eligible for premium-free Part A, and you
don’t buy it when you’re rst eligible, your monthly
premium may go up 10%. You’ll have to pay the higher
premium for twice the number of years you could have
had Part A but didn’t sign up. For 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.
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Section 1: Signing up for Medicare
How much does Part B coverage cost?
The standard Part B premium amount in 2024 is $174.70.
Most people pay the standard Part B premium amount
every month.
If your modied adjusted gross income is above a certain
amount (in 2024: $103,000 if you le individually or
$206,000 if you’re married and le jointly), you may pay
an Income Related Monthly Adjustment Amount (IRMAA).
IRMAA is an extra charge added to your premium.
To determine if you’ll pay the IRMAA, Medicare uses the
modied adjusted gross income reported on your IRS
tax return from 2 years ago. Visit Medicare.gov to learn
more about IRMAA.
Note: You may also pay an extra amount for your
Medicare drug coverage (Part D) premium if your modied
adjusted gross income is above a certain amount. Go to
pages 199 – 200.
If you have to pay an extra amount and you disagree (for
example, your income is lower due to a life event), visit
SSA.gov
or call Social Security at 1 800 772 - 1213. TTY
users can call 1 800 325 - 0778.
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—
Section 1: Signing up for Medicare
What’s the Part B late enrollment penalty?
Important!
If you don’t sign up for Part B when you’re rst
eligible, you may have to pay a late enrollment penalty
for as long as you have Part B. Your monthly Part B
premium may go up 10% for each full 12 months in the
period that you could’ve had Part B, but didn’t sign up.
If you’re allowed to sign up for Part B during a Special
Enrollment Period, you usually don’t pay a late enrollment
penalty. Go to pages 26 – 30.
Example: Mr. Smith’s Initial Enrollment Period ended
December 2020. He waited until March 2023 (during the
General Enrollment Period) to sign up for Part B. His
Part B premium penalty is 20%, and he’ll have to pay this
penalty in addition to his standard Part B premium for as
long as he has Part B. (Even though Mr. Smith didn’t have
Part B for 27 months, this included only 2 full 12-month
periods.)
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Section 1: Signing up for Medicare
Cost & coverage:
To learn how to get help with Medicare costs, go to
Section 7 (starting on page 223).
How can I pay my Part B premium?
If you get Social Security or Railroad Retirement Board
(RRB) benets, your Part B premium will be deducted
from your monthly benet payment.
Note: If you get a bill from the RRB, mail your premium
payments to:
RRB Medicare Premium Payments
PO Box 979024
St. Louis, MO 63197-9000
If you have questions about bills you get from the RRB,
call 1 877 772 - 5772. TTY users can call 1 312 751 - 4701.
If you’re a federal retiree with an annuity from the
Oce of Personnel Management and you aren’t
entitled to Social Security or RRB benets, you can
ask to have your Part B premiums deducted from your
annuity. Call 1 800 633 - 4227 to make your request. TTY
users can call 1 877 486 - 2048.
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—
Section 1: Signing up for Medicare
If you don’t get these benet payments, you’ll get a bill
for your Part B premium. Typically, Part B premiums are
billed quarterly (every 3 months). If you also pay for Part A
or Part D IRMAA, or use Medicare Easy Pay to pay your
premiums, you’ll get a monthly bill (go to pages 39 – 40
and pages 198 – 199). There are 4 ways to pay your
premium bill:
1. Pay online by credit card, debit card, savings or
checking account. To do this, log into (or create) your
secure Medicare account at Medicare.gov. Paying
online is a faster and more secure way to make your
payment without sending your personal information in
the mail. You’ll get a confirmation number when you
make your payment.
2. Pay directly from your savings or checking account
through your bank’s online bill payment services.
Ask your bank if it allows customers to pay bills
online—not all banks offer this service and some may
charge a fee. Your bank will need this information:
•
Your Medicare number: It’s important that you
use the exact number on your red, white, and blue
Medicare card, but without the dashes.
•
Payee name: CMS Medicare Insurance
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—
Section 1: Signing up for Medicare
•
Payee address:
Medicare Premium Collection Center
PO Box 790355
St. Louis, MO 63179-0355
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/medicare-easy-pay, or call
1 800 633 - 4227 to find out how to sign up. TTY users
can call 1 877 486 - 2048.
4. Mail your payment to Medicare. You can pay by
check, money order, credit card, or debit card. Write
your Medicare number on your payment, and fill
out your payment coupon. Mail your payment and
coupon to:
Medicare Premium Collection Center
PO Box 790355
St. Louis, MO 63179-0355
If you have questions about your premiums, call
1 800 633 - 4227 or visit Medicare.gov.
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—
Section 1: Signing up for Medicare
If you need to change your address on your bill, call
Social Security at 1 800 772 - 1213. TTY users can call
1 800 325 - 0778.
You may be able to get help from your state to pay your
Part A and Part B premiums through a Medicare Savings
Program. Go to pages 223 – 226.
•
End of Page
47
What services does Medicare cover?
In this section, you’ll nd information about the items,
tests, and services that Original Medicare (Part A and
Part B) covers in hospitals, doctors’ oces, and other
health care facilities. You may be eligible for the Medicare-
covered services in this section if you have both Part A
and Part B.
If you have Original Medicare, you’ll use your red, white,
and blue Medicare card to get your Medicare-covered
services. Your Medicare card shows whether you have
Part A (listed as HOSPITAL), Part B (listed as MEDICAL),
or both, and the date your coverage begins.
Important!
If you join a Medicare Advantage Plan or other
Medicare health plan, in most cases, you’ll use your
plan’s card to get your Medicare-covered services.
Section 2: Find
out what Medicare
covers
Underlined words are dened on pages 289 – 296.
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Section 2: Find out what Medicare covers
Note: If you’re not lawfully present in the U.S., Medicare
won’t pay for your Part A and Part B claims, and you can’t
join a Medicare Advantage Plan or a Medicare drug
plan.
What does Part A cover?
Part A (Hospital Insurance) helps cover:
•
Inpatient care in a hospital
•
Skilled nursing facility
•
Hospice care
•
Home health care
•
Inpatient care in a religious non-medical health care
institution
Go to pages 50 – 57 for a list of common services Part A
covers and general descriptions.
For more information on Part A-covered services, visit
Medicare.gov/coverage.
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Section 2: Find out what Medicare covers
Cost & coverage:
Find out what’s covered using your mobile device.
To get Medicare coverage information, download
Medicare’s free “What’s covered” mobile app on your
smartphone or tablet. “What’s covered” is available in the
App Store and on Google Play.
What do I pay for Part A-covered
services?
Copayments, coinsurance, or deductibles may apply
for each service listed on the following pages.
If you’re in a Medicare Advantage Plan or have
other insurance (like Medigap, Medicaid, employer,
retiree, or union coverage), your copayments,
coinsurance, or deductibles may be dierent. For
more information about costs, contact your plan or visit
Medicare.gov/plan-compare.
You can also call 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
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Section 2: Find out what Medicare covers
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 you or someone else can donate the blood.
Home health services
Part A and/or Part B covers home health benets. Go to
pages 98 – 99.
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. When you agree to hospice care, you’re agreeing
to comfort care (palliative care) instead of care to cure
your terminal illness. You also must sign a statement
choosing hospice care instead of other Medicare-covered
treatments for your terminal illness and related conditions.
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Section 2: Find out what Medicare covers
Coverage includes:
•
All items and services needed for pain relief and
symptom management
•
Medical, nursing, and social services
•
Drugs for pain and symptom management
•
Durable medical equipment for pain relief and
symptom management
•
Aide and homemaker services
•
Other covered services you need to manage your pain
and other symptoms, as well as spiritual and grief
counseling for you and your family
Medicare-certied hospice care is usually given in your
home or other facility where you live, like a nursing home.
Original Medicare will still pay for covered benets for any
health problems that aren’t part of your terminal illness
and related conditions, but hospice should cover most of
your care.
Medicare won’t pay room and board for your care in
a facility, unless the hospice medical team decides
you need short-term inpatient care to manage
pain and other symptoms. This care must be in a
Medicare-approved facility, like a hospice facility, hospital,
or skilled nursing facility that contracts with the hospice.
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Section 2: Find out what Medicare covers
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.
After 6 months, you can continue to get hospice care as
long as the hospice medical director or hospice doctor
recerties (at a face-to-face meeting) that you’re still
terminally ill.
You pay:
•
Nothing for hospice care.
•
A copayment of up to $5 per prescription for
outpatient drugs for pain and symptom management.
•
Five percent of the Medicare-approved amount for
inpatient respite care.
Original Medicare will be billed for your hospice care,
even if you’re in a Medicare Advantage Plan. When
you get hospice care, your Medicare Advantage
Plan can still cover services that aren’t part of your
terminal illness or any conditions related to your
terminal illness. For more on hospice care and to nd
Medicare-approved providers, contact your plan or visit
Medicare.gov/care-compare.
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Section 2: Find out what Medicare covers
Inpatient hospital care
Medicare covers semi-private rooms, meals, general
nursing, drugs (including methadone to treat an opioid
use disorder), and other hospital services and supplies as
part of your inpatient treatment. This includes care you
get in acute care hospitals, critical access hospitals,
inpatient rehabilitation facilities, long-term care
hospitals, psychiatric care in inpatient psychiatric
facilities, and inpatient care for a qualifying clinical
research study. This doesn’t include private-duty
nursing, a television or phone in your room (if there’s a
separate charge for these items), personal care items
(razors or slipper socks), or a private room, unless
medically necessary.
If you also have Part B, it generally covers 80% of the
Medicare-approved amount for doctors’ services you
get while you’re in a hospital.
In each benefit period, you pay:
•
Days 1–60 (of each benefit period): $0 after you meet
your Part A deductible.
•
Days 61–90 (of each benefit period): A $408
coinsurance amount each day.
•
After day 90 (of each benefit period): An $816
coinsurance amount each day while using your
60 lifetime reserve days.
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Section 2: Find out what Medicare covers
After you use all of your lifetime reserve days, you pay
all costs.
Part A only pays for up to 190 days of inpatient psychiatric
hospital care provided in a freestanding psychiatric
hospital during your lifetime.
Note: Hospitals are now required to include the
standard charges for all of their items and services
(including the standard charges negotiated by
Medicare Advantage Plans) on a public website to help
you make more informed decisions about your care.
Am I an inpatient or outpatient?
Whether you’re an inpatient or an outpatient aects how
much you pay for hospital services and if you qualify for
Part A skilled nursing facility care.
•
You’re an inpatient when the hospital formally admits
you with a doctor’s order.
•
You’re an outpatient if you’re getting emergency or
observation services (which may include an overnight
stay in the hospital or services in an outpatient
clinic), lab tests, or X-rays, without a formal inpatient
admission (even if you spend the night in the hospital).
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Section 2: Find out what Medicare covers
Each day you have to stay, you or your caregiver
should always ask the hospital and/or your doctor, or
a hospital social worker or patient advocate, if you’re
an inpatient or outpatient.
Important!
Sometimes doctors will keep you as an outpatient for
observation services while they decide whether to admit
you as an inpatient or release (discharge) you. If you’re
under observation more than 24 hours, you must get a
“Medicare Outpatient Observation Notice” (also called
“MOON”). This notice tells you why you’re an outpatient (in
a hospital or critical access hospital) getting observation
services, and how it aects what you pay in the hospital
and for care after you leave.
Religious non-medical health care institution
(inpatient care)
If you qualify for inpatient hospital or skilled nursing
facility care in these facilities, Medicare will only cover
inpatient, non-religious, non-medical items and services,
like room and board, and items or services that don’t need
a doctor’s order or prescription (like unmedicated wound
dressings or use of a simple walker). Medicare doesn’t
cover the religious portion of this type of care.
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Section 2: Find out what Medicare covers
Skilled nursing facility care
Medicare only covers skilled nursing facility care
after a 3-day minimum medically necessary inpatient
hospital stay* (not including the day you leave the
hospital) for an illness or injury related to the hospital
stay. Medicare covers semi-private rooms, meals, skilled
nursing and therapy services, and other medically
necessary services and supplies in a skilled nursing
facility.
To qualify for skilled nursing facility care, your doctor must
certify that you need daily skilled care (like intravenous
uids/medications or physical therapy) which, as a
practical matter, you can only get as a skilled nursing
facility inpatient. Medicare doesn’t cover non-medical
long-term care. Go to pages 130 – 131.
You may get skilled nursing care or therapy if it’s
necessary to improve or maintain your current condition.
If you disagree with your discharge, you can appeal. For
example, if you’re discharged only because you aren’t
improving, but you still require skilled nursing or therapy
care to keep your condition from getting worse, you can
appeal.
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Section 2: Find out what Medicare covers
In each benefit period, you pay:
•
Days 1–20: $0 copayment. Note: If you’re in a
Medicare Advantage Plan, you may be charged
copayments during the rst 20 days.
•
Days 21–100: $204 copayment each day.
•
Days 101 and beyond: You pay all costs.
*Note: You may not need a 3-day minimum inpatient
hospital stay if your doctor participates in an
Accountable Care Organization (ACO), or an entity
participating in another type of Medicare initiative
approved for a Skilled Nursing Facility 3-Day Rule Waiver.
If your provider participates in an ACO (pages 271 – 274),
check with them to nd out what benets may be
available. Medicare Advantage Plans may also waive the
3-day minimum. Contact your plan for more information.
•
End of Page
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Section 2: Find out what Medicare covers
What does Part B cover?
Medicare Part B (Medical Insurance) helps cover
medically necessary doctor’s services, outpatient care,
home health services, durable medical equipment, mental
health services, and other medical services. Part B also
covers many preventive services. Go to pages 60 – 128
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 that isn’t on this list or for more on Part B-
covered services, visit Medicare.gov/coverage. Or, call
1 800 633 - 4227. TTY users can call 1 877 486 - 2048.
What do I pay for services Part B covers?
The list of covered services (in alphabetical order on the
following pages) gives general information about what
you pay if you have Original Medicare and use doctors
or other health care providers who accept assignment
(go to pages 139 – 140). You’ll pay more if you use
doctors or providers who don’t accept assignment. If
you’re in a Medicare Advantage Plan or have other
insurance (like Medigap, Medicaid, employer, retiree,
or union coverage), your copayments, coinsurance, or
deductibles may be dierent. Contact your plan for more
information.
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Section 2: Find out what Medicare covers
Under Original Medicare, if the Part B deductible
applies, you must pay all costs (up to the
Medicare-approved amount) until you meet the yearly
Part B deductible. After you meet your deductible,
Medicare will pay its share and you typically pay 20% of
the Medicare-approved amount (if the doctor or other
health care provider accepts assignment). There’s no
yearly limit on what you pay out of pocket if you have
Original Medicare. There may be limits on expenses you
pay through supplemental coverage you may have, like
Medigap, Medicaid, employer, retiree, or union coverage.
You pay nothing for most covered preventive services
if you get the services from a doctor or other qualied
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.
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Section 2: Find out what Medicare covers
Part B-covered services
Preventive service
Abdominal aortic aneurysm screenings
Medicare covers an abdominal aortic aneurysm screening
ultrasound once if you’re at risk (only with a referral
from your doctor or other qualied health care provider).
You’re considered at risk if you have a family history of
abdominal aortic aneurysms, or you’re a man 65 – 75
and have smoked at least 100 cigarettes in your lifetime.
You pay nothing for the screening if your doctor or other
qualied health care provider accepts assignment.
Acupuncture
Medicare only covers acupuncture (including dry needling)
for chronic low back pain. Medicare covers up to 12
acupuncture visits in 90 days for chronic low back pain
dened as:
•
Lasting 12 weeks or longer
•
Not having an identifiable cause (for example, not an
identifiable disease like cancer that has spread, or an
infectious or inflammatory disease)
•
Pain that isn’t associated with surgery or pregnancy
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Section 2: Find out what Medicare covers
Medicare covers an additional 8 sessions if you
show improvement. You can get a maximum of 20
acupuncture treatments in a 12-month period. The Part B
deductible and coinsurance apply. If you aren’t showing
improvement, Medicare won’t cover the 8 additional
treatments.
Not all providers can give acupuncture, and Medicare
can’t pay licensed acupuncturists directly for their
services.
Advance care planning
Medicare covers voluntary advance care planning as part
of your yearly “Wellness” visit (go to pages 126 – 128).
This is planning for care you would get when you need
help making decisions for yourself. As part of advance
care planning, you may choose to complete an advance
directive. This is an important legal document that records
your wishes about medical treatment in the future, if you
aren’t able to make decisions about your care. You can
talk about an advance directive with your health care
provider, and they can help you ll out the forms, if you
prefer.
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Section 2: Find out what Medicare covers
Consider carefully who you want to speak for you and
what directions you want to give. You have the right to
carry out your plans as you choose without discrimination
based on your age or disability. You can update your
advance directive at any time. You pay nothing if it’s given
as part of the yearly “Wellness” visit, and your doctor or
other qualied health care provider accepts assignment.
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 B deductible and
coinsurance apply.
Need help with your advance directive? Visit the
Eldercare Locator at eldercare.acl.gov to nd help in
your community.
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Section 2: Find out what Medicare covers
Preventive service
Alcohol misuse screenings & counseling
Medicare covers an alcohol misuse screening for adults
(including pregnant individuals) who use alcohol, but
don’t meet the medical criteria for alcohol dependency. If
your primary care doctor or other health care provider
determines you’re misusing alcohol, you can get up to 4
brief, face-to-face counseling sessions per year (if you’re
competent and alert during counseling). You must get
counseling in a primary care setting, like a doctor’s oce.
You pay nothing if your primary care doctor or other
health care provider accepts assignment.
Ambulance services
Medicare covers ground ambulance transportation to
a hospital, critical access hospital, rural emergency
hospital, or skilled nursing facility for medically
necessary services when traveling in any other vehicle
could endanger your health. Medicare may pay for
emergency ambulance transportation in an airplane or
helicopter if you need immediate and rapid ambulance
transport that ground transportation can’t provide.
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Section 2: Find out what Medicare covers
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. For example, someone with End-Stage
Renal Disease (ESRD) may need a medically necessary
ambulance transport to a facility that furnishes provides
dialysis.
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
Medicare-approved amount. The
Part B deductible applies.
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Section 2: Find out what Medicare covers
Ambulatory surgical centers
Medicare covers the facility service fees related to
approved surgical procedures done in an ambulatory
surgical center (outpatient facility that performs surgical
procedures, and the patient is expected to be released
within 24 hours). Except for certain preventive services
(for which you pay nothing if your 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. The Part B
deductible applies. You pay all of the facility service fees
for procedures Medicare doesn’t cover in ambulatory
surgical centers.
Cost & coverage:
To get cost estimates for ambulatory
surgical center outpatient procedures, visit
Medicare.gov/procedure-price-lookup.
Bariatric surgery
Medicare covers some bariatric surgical procedures,
like gastric bypass surgery and laparoscopic
banding surgery, when you meet certain conditions
related to morbid obesity. For cost information, visit
Medicare.gov/coverage/bariatric-surgery.
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Section 2: Find out what Medicare covers
Behavioral health integration services
If you have a behavioral health condition (like depression,
anxiety, or another mental health condition), Medicare
may pay your provider to help manage that condition.
Some providers that manage behavioral health conditions
may oer integrated care services, like the Psychiatric
Collaborative Care Model. This model is a set of integrated
behavioral health services, including care management
support that may include:
•
Care planning for behavioral health conditions
•
Ongoing assessment of your condition
•
Medication support
•
Counseling
•
Other treatment your provider recommends
Your health care provider will ask you to sign an
agreement for you to get these services on a monthly
basis. Your Part B deductible and coinsurance will apply
to the monthly service fee.
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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. The Part B
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 you or
someone else can donate the blood.
Preventive service
Bone mass measurements
This test helps to see if you’re at risk for broken bones.
Medicare covers it 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 your doctor or other qualied health
care provider accepts assignment.
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Cardiac rehabilitation
Medicare covers comprehensive programs that include
exercise, education, and counseling if you’ve had 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 keep an artery open)
•
A heart or heart-lung transplant
•
Stable chronic heart failure
Medicare covers regular and intensive cardiac
rehabilitation programs. Medicare covers services in a
doctor’s oce or hospital outpatient setting. You pay
20% of the
Medicare-approved amount if you get
the services in a doctor’s oce, and a copayment in a
hospital outpatient setting. The Part B deductible applies.
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Preventive service
Cardiovascular behavioral therapy
Medicare covers a cardiovascular behavioral therapy
visit one time each year with your primary care doctor
or other qualied primary care practitioner in a primary
care setting (like a doctor’s oce) to help lower your risk
for cardiovascular disease. During this visit, your doctor
may discuss aspirin use (if appropriate), check your
blood pressure, and give you tips on eating well. You pay
nothing if your primary care doctor or other health care
provider accepts assignment.
Preventive service
Cardiovascular disease screenings
These screenings include blood tests for cholesterol,
lipid, and triglyceride levels that help detect conditions
that may lead to a heart attack or stroke. Medicare covers
these screening blood tests once every 5 years. You pay
nothing for the tests if the doctor or other qualied health
care provider accepts assignment.
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Preventive service
Cervical & vaginal cancer screenings
Medicare 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 in most cases. 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.
Medicare also covers Human Papillomavirus (HPV) tests
(as part of a Pap test) once every 5 years if you’re 30 – 65
without HPV symptoms.
You pay nothing for the lab Pap test, the lab HPV with the
Pap test, the Pap test specimen collection, and pelvic and
breast exams if your doctor or other qualied health care
provider accepts assignment.
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Chemotherapy
Medicare covers chemotherapy in a doctor’s oce,
freestanding clinic, or hospital outpatient setting if you
have cancer. You pay a copayment for chemotherapy in a
hospital outpatient setting.
You pay 20% of the Medicare-approved amount for
chemotherapy in a doctor’s oce or freestanding clinic.
The Part B deductible applies.
For chemotherapy in an inpatient hospital setting
covered under Part A, go to inpatient hospital care on
pages 53 – 55.
Chiropractic services
The only service ordered by a chiropractor that
Medicare covers is manipulation of the spine to correct a
subluxation (when the spinal joints fail to move properly,
but the contact between the joints remains intact). You
pay 20% of the Medicare-approved amount. The Part B
deductible applies.
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Chronic care management services
If you have 2 or more serious chronic conditions (like
arthritis and diabetes) that you expect to last at least a
year, Medicare may pay for a health care provider’s help to
manage those conditions. This includes a comprehensive
care plan that lists your health problems and goals, other
providers, medications, community services you have and
need, and other health information. It also explains the
care you need and how it will be coordinated.
If you agree to get this service, your provider will prepare
the care plan for you or your caregiver, help you with
medication management, provide 24/7 access for urgent
care management needs, give you support when you go
from one health care setting to another, and help you with
other chronic care needs.
You pay a monthly fee, and the Part B deductible and
coinsurance apply. If you have supplemental insurance,
including Medicaid, it may help cover the monthly fee.
Contact your plan for details.
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New!
Chronic pain management and treatment
services
Medicare covers monthly services for people living with
chronic pain (persistent or recurring pain lasting longer
than 3 months). Services may include pain assessment,
medication management, and care coordination and
planning. The Part B deductible and coinsurance apply.
Clinical research studies
Clinical research studies test how well dierent types
of medical care work and if they’re safe, like how
well a cancer drug works. Medicare covers some
costs, like oce visits and tests in certain qualifying
clinical research studies. You may pay 20% of the
Medicare-approved amount, depending on the
treatment you get. The Part B deductible may apply.
Note: If you’re in a Medicare Advantage Plan, Original
Medicare may cover some costs along with your Medicare
Advantage Plan.
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Section 2: Find out what Medicare covers
Cognitive assessment & care plan services
When you visit your provider (including your yearly
“Wellness” visit), they may perform a cognitive
assessment to look for signs of dementia, including
Alzheimer’s disease. Signs of cognitive impairment include
trouble remembering, learning new things, concentrating,
managing nances, or making decisions about your
everyday life. Conditions like depression, anxiety, and
delirium can also cause confusion, so it’s important to
understand why you may be having symptoms.
Medicare covers a separate visit with a doctor or health
care practitioner to do a full review of your cognitive
function, establish or conrm a diagnosis like dementia
or Alzheimer’s disease, and develop a care plan. You
can bring someone with you, like a spouse, friend,
or caregiver, to help provide information and answer
questions.
During this visit, the doctor or health care practitioner
may:
•
Perform an exam, talk with you about your medical
history, and review your medications.
•
Identify your social supports including care that your
usual caregiver can provide.
•
Create a care plan to help address and manage your
symptoms.
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Section 2: Find out what Medicare covers
•
Help you develop or update your advance care plan.
Go to pages 61 – 62.
•
Refer you to a specialist, if needed.
•
Help you understand more about community
resources, like rehabilitation services, adult day health
programs, and support groups.
The Part B deductible and coinsurance apply.
Preventive service
Colorectal cancer screenings
Medicare covers these screenings to help nd
precancerous growths or nd cancer early, when
treatment is most eective. Medicare may cover one or
more of these screening tests:
•
Barium enema: Medicare covers this test once every
48 months if you’re 45 or older (or every 24 months if
you’re high risk) when your doctor uses it instead of
a flexible sigmoidoscopy or screening colonoscopy.
You pay 20% of the Medicare-approved amount for
your doctors’ services. In a hospital outpatient setting,
you also pay the hospital a copayment. The Part B
deductible doesn’t apply.
Visit Medicare.gov/coverage/barium-enemas for
more information.
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•
Screening Colonoscopies: Medicare covers this
screening test once every 120 months (or every 24
months if you’re high risk) or 48 months after a previous
flexible sigmoidoscopy. There’s no minimum age
requirement. If you initially have a non-invasive stool-
based screening test (fecal occult blood tests or multi-
target stool DNA test) and receive a positive result,
Medicare also covers a follow-up colonoscopy as a
screening test. You pay nothing for the screening test(s)
if your doctor or other qualified health care practitioner
accepts assignment.
•
Flexible sigmoidoscopies: Medicare covers this
test once every 48 months if you’re 45 or older, or
120 months after a previous screening colonoscopy if
you aren’t at high risk. You pay nothing for the test if
your doctor or other qualified health care practitioner
accepts assignment.
If your doctor nds and removes a polyp or other tissue
during the colonoscopy or exible sigmoidoscopy, you
pay 15% of the Medicare-approved amount for your
doctors’ services. In a hospital outpatient setting, you
also pay the hospital a 15% coinsurance. The Part B
deductible doesn’t apply.
•
Fecal occult blood tests: Medicare covers this
screening test once every 12 months if you’re 45
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or older. You pay nothing for the test if your doctor
or other qualified health care practitioner accepts
assignment.
•
Multi-target stool DNA & blood-based biomarker
tests: Medicare covers these screening tests once
every 3 years if you meet all of these conditions:
•
You’re between 45 – 85.
•
You show no symptoms of colorectal disease
including, but not limited to, lower gastrointestinal
pain, blood in stool, a positive guaiac fecal occult
blood test or fecal immunochemical test.
•
You’re at average risk for developing colorectal
cancer, meaning:
•
You have no personal history of adenomatous
polyps, colorectal cancer, or inflammatory bowel
disease, including Crohn’s Disease and ulcerative
colitis.
•
You have no family history of colorectal cancer
or adenomatous polyps, familial adenomatous
polyposis, or hereditary nonpolyposis colorectal
cancer.
Multi-target stool DNA tests are at-home lab tests.
Blood-based biomarker tests are conducted in a lab.
You pay nothing for these tests if your doctor or other
qualied health care practitioner accepts assignment.
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Continuous Positive Airway Pressure (CPAP)
devices, accessories, & therapy
Medicare may cover a 3-month trial of CPAP therapy
(including devices and accessories) if you’ve been
diagnosed with obstructive sleep apnea. After the trial
period, Medicare may continue to cover CPAP therapy,
devices and accessories if you meet with your doctor
in person, and your doctor documents in your medical
record that you meet certain conditions and the therapy is
helping you.
You pay 20% of the Medicare-approved amount for
the machine rental and purchase of related supplies
(like masks and tubing). The Part B 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: Medicare may cover a rental or replacement CPAP
machine and/or CPAP accessories if you had a CPAP
machine before you got Medicare, and you meet certain
requirements.
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Section 2: Find out what Medicare covers
Preventive service
Counseling to prevent tobacco use & tobacco-
caused disease
Medicare covers up to 8 face-to-face visits in a 12-month
period if you use tobacco. You pay nothing for the
counseling sessions if your doctor or other qualied
health care practitioner accepts assignment.
COVID-19 (Coronavirus disease 2019)
Many people with Medicare are at higher risk for serious
COVID-19 illness, so it’s important to take the necessary
steps to keep yourself and others safe.
Medicare covers several tests, items, and services related
to COVID-19. Talk with your doctor or health care provider
to nd out which are right for you:
Preventive service
COVID-19 Vaccines:
•
FDA-approved and FDA-authorized vaccines help
reduce the risk of illness from COVID-19 by working
with the body’s natural defenses to safely develop
immunity (protection) against the virus.
•
You pay nothing for the COVID-19 vaccine.
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•
Be sure to bring your red, white, and blue Medicare
card with you when you get the vaccine so your health
care provider or pharmacy can bill Medicare. If you’re
in a Medicare Advantage Plan, you must use the card
from your plan to get your Medicare-covered services
and, like other covered services, your plan may require
that you get the vaccine from an in-network provider. If
you’re in a Medicare Advantage Plan, you pay nothing
when you get the vaccine from an in-network provider.
Diagnostic laboratory tests:
•
These FDA-authorized tests check to see if you have
COVID-19.
•
You pay nothing when a health care provider orders
this test and the test is performed by a laboratory
(including at a pharmacy, clinic or doctor’s office), or
hospital that takes Medicare. If you’re in a Medicare
Advantage Plan, you pay nothing when you get this
test from an in-network provider.
Monoclonal antibody treatments and products:
•
These FDA-authorized treatments can help fight the
disease and keep you out of the hospital, if you test
positive for COVID-19 and have mild to moderate
symptoms.
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•
You pay nothing for this treatment when you get
it from a Medicare provider or supplier. You must
meet certain conditions to qualify. If you’re in a
Medicare Advantage Plan, you pay nothing when you
get these treatments from an in-network provider.
•
Original Medicare will cover monoclonal antibody
treatments if you have COVID-19 symptoms.
Note: Certain monoclonal antibody products can
protect you before you’re exposed to COVID-19. If
you have Part B and your doctor decides this type
of product could work for you (like if you have a
weakened immune system), you pay nothing for the
product when you get it from a Medicare provider or
supplier.
Get more information
•
Learn more about these covered services at
Medicare.gov/medicare-coronavirus.
•
For more on COVID-19, visit CDC.gov/coronavirus.
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Debrillators
Medicare may cover an implantable automatic debrillator
if you’ve been diagnosed with heart failure. If the surgery
takes place in an outpatient setting, you pay 20% of
the Medicare-approved amount for your doctors’
services. You also pay a copayment. In most cases, the
copayment can’t be more than the Part A hospital stay
deductible. The Part B deductible applies. Part A covers
surgeries to implant debrillators in an inpatient hospital
setting. Go to inpatient hospital care on pages 53 – 55.
Preventive service
Depression screening
Medicare covers one depression screening per year. The
screening must be done in a primary care setting (like a
doctor’s oce) that can provide follow-up treatment and/
or referrals. You pay nothing for this screening if your
doctor accepts assignment.
If you or someone you know is struggling or in crisis
and would like to talk to a trained crisis counselor,
call or text 988, the free and condential Suicide & Crisis
Lifeline. You can also connect with a counselor through
web chat at 988lifeline.org.
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Preventive service
Diabetes screenings
Medicare covers up to 2 blood glucose (blood
sugar) laboratory test screenings (with and without
a carbohydrate challenge) each year if your doctor
determines you’re at risk for developing diabetes. You pay
nothing for the test if your doctor or other qualied health
care practitioner accepts assignment.
Preventive service
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 glucose (blood sugar),
taking prescription drugs, and reducing risks. You must
have been diagnosed with diabetes and have a written
order from your doctor or other health care provider.
Some patients may also be eligible for medical nutrition
therapy services (go to page 104). You pay 20% of the
Medicare-approved amount. The Part B deductible
applies.
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Diabetes equipment, supplies, & therapeutic
shoes
Medicare covers meters and continuous glucose monitors
that measure blood glucose (blood sugar) and related
supplies, including test strips, lancets, lancet holders,
sensors, and control solutions. Medicare also covers
tubing, insertion sets, and insulin for patients using insulin
pumps, sensors, transmitters, and receivers for patients
using continuous glucose monitors. In addition, Medicare
covers one pair of extra-depth or custom shoes and
inserts per year for people with specic diabetes-related
foot problems.
You pay 20% of the
Medicare-approved amount if your
supplier accepts assignment. The Part B deductible
applies.
Important!
Medicare drug coverage (Part D) may cover insulin, certain
medical supplies used to inject insulin (like syringes),
disposable pumps, and some oral diabetes drugs.
Check with your plan for more information. The cost of
a one-month supply of each covered insulin product is
capped at $35. Go to pages 214 – 215. (Similar caps on
costs apply for traditional insulin used in insulin pumps
covered under Part B).
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Section 2: Find out what Medicare covers
Doctor & other health care provider services
Medicare covers medically necessary doctor services
(including outpatient services and some inpatient hospital
doctor services) and most preventive services. Medicare
also covers services you get from other health care
providers, like physician assistants, nurse practitioners,
clinical nurse specialists, clinical social workers, physical
therapists, occupational therapists, speech-language
pathologists, and clinical psychologists. Except for certain
preventive services (for which you may pay nothing if
your doctor or other provider accepts assignment), you
pay 20% of the
Medicare-approved amount for most
services. The Part B deductible applies.
Important!
If you haven’t received services from your doctor or group
practice in the last 3 years, they may consider you a new
patient. Check with the doctor or group practice to nd
out if they’re accepting new patients.
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Section 2: Find out what Medicare covers
Drugs
Part B covers a limited number of outpatient prescription
drugs, like:
•
Injections you get in a doctor’s office
•
Certain oral anti-cancer drugs
•
Drugs used with some types of durable medical
equipment (like a nebulizer or external infusion pump)
•
Intravenous Immune Globulin for use in the home
•
Certain drugs you get in a hospital outpatient setting
(under very limited circumstances)
Note: Other than the examples above, you pay 100% for
most drugs, unless you have Medicare drug coverage
(Part D) or other drug coverage. Go to pages 191 – 222 for
more information about Medicare drug coverage.
For some drugs used with an external infusion pump,
and for Intravenous Immune Globulin for use in the
home, Medicare may also cover services (like nursing
visits) under the home infusion therapy benet and the
Intravenous Immune Globulin benet (go to page 100).
Part B also covers some injectable or implantable drugs to
treat substance use disorder when a provider administers
it in a doctor’s oce or a hospital as an outpatient.
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You pay 20% of the Medicare-approved amount for
these drugs. The Part B deductible applies. You won’t
have to pay any copayments for these services if you get
them from a Medicare-enrolled opioid treatment program
(go to pages 108 –109).
Doctors and pharmacies must accept assignment for
Part B-covered drugs, so you should never be asked to
pay more than the coinsurance or copayment for the
Part B drug itself.
Important!
Your coinsurance can change depending on your
prescription drug’s price. You might pay a lower
coinsurance for certain drugs and biologicals covered by
Part B that you get in a doctor’s oce or pharmacy, or in
a hospital outpatient setting, if their prices have increased
higher than the rate of ination. The specic drugs and
potential savings change every quarter.
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If the Part B-covered drugs you get in a hospital
outpatient setting are part of your outpatient services, you
pay a copayment for the services. Part B doesn’t cover
“self-administered drugs” in a hospital outpatient setting.
“Self-administered drugs” are drugs you’d normally take
on your own.
What you pay for self-administered drugs in an outpatient
hospital setting depends on whether you have Medicare
drug coverage (Part D) or other drug coverage, and
whether the hospital’s pharmacy is in your drug plan’s
network. If you have other drug coverage, your drug plan
may cover drugs that Part B may not cover. Contact your
drug plan to nd out what you pay for drugs you get in a
hospital outpatient setting that Part B doesn’t cover.
Durable medical equipment (DME)
Medicare covers medically necessary items like
oxygen and oxygen equipment, wheelchairs, walkers,
and hospital beds when a Medicare-enrolled doctor or
other health care provider orders for use in the home.
You must rent most items, but you can also buy them.
Some items become your property after you’ve made
a number of rental payments. You pay 20% of the
Medicare-approved amount. The Part B deductible
applies.
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Make sure your doctors and DME suppliers are
enrolled in Medicare. It’s important to ask your
suppliers if they participate in Medicare before you get
DME. If suppliers are participating suppliers, they must
accept assignment (which means, they can charge you
only the coinsurance and Part B deductible for the
Medicare-approved amount). If DME suppliers aren’t
participating and don’t accept assignment, there’s no limit
on the amount they can charge you.
Electrocardiogram (EKG or ECG) screenings
Medicare covers a routine EKG/ECG screening if you get
a referral from your doctor or other health care provider
during your one-time “Welcome to Medicare” visit (go to
pages 125 – 126). After you meet the Part B deductible,
you pay 20% of the Medicare-approved amount. Medicare
also covers EKGs or ECGs as diagnostic tests (go to
page 119). You also pay a copayment if you have the test
at a hospital or a hospital-owned clinic.
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Emergency department services
Medicare covers these services when you have an injury, a
sudden illness, or an illness that quickly gets much worse.
You pay a copayment for each emergency department
visit and 20% of the
Medicare-approved amount for
doctors’ services. The Part B deductible applies. If your
doctor admits you to the same hospital as an inpatient,
your costs may be dierent.
E-visits
Medicare covers E-visits to allow you to talk with your
provider using an online patient portal without going
to the provider’s oce. Providers who can give these
services include doctors, nurse practitioners, clinical
nurse specialists, physician assistants, physical therapists,
occupational therapists, speech-language pathologists,
licensed clinical social workers (in specic circumstances),
and clinical psychologists (in specic circumstances).
To get an E-visit, you must request one with your doctor
or other provider. You pay 20% of the Medicare-approved
amount for your doctor’s or other provider’s services. The
Part B deductible applies.
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Eyeglasses
Medicare covers one pair of eyeglasses with standard
frames (or one set of contact lenses) after each cataract
surgery that implants an intraocular lens. Medicare will
only pay for contact lenses or eyeglasses from a supplier
enrolled in Medicare, no matter if you or your provider
submits the claim. After you meet the Part B deductible,
you pay 20% of the Medicare-approved amount for
corrective lenses after cataract surgery with an intraocular
lens.
Federally Qualied Health Center services
Federally Qualied Health Centers provide many
outpatient primary care and preventive health services.
There’s no deductible, and you usually pay 20% of the
charges or the Medicare-approved amount. You pay
nothing for most preventive services. All Federally
Qualied Health Centers may oer discounts if your
income is limited. Visit ndahealthcenter.hrsa.gov to nd
a health center near you.
Note: You can get covered telehealth services at Federally
Qualied Health Centers through December 31, 2024. Go
to page 117.
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Section 2: Find out what Medicare covers
Preventive service
Flu shots
Medicare covers the seasonal u shot (or vaccine). You
pay nothing (and the Part B deductible doesn’t apply)
for the u shot if the doctor or other qualied health care
provider accepts assignment for giving the shot.
Foot care
Medicare covers yearly foot exams or treatment if
you have diabetes-related lower leg nerve damage
that can increase the risk of limb loss or need
medically necessary treatment for foot injuries or
diseases, like hammer toe, bunion deformities, and heel
spurs. You pay 20% of the Medicare-approved amount
for medically necessary treatment your doctor approves.
The Part B deductible applies. You also pay a copayment
for medically necessary treatment in a hospital outpatient
setting.
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Preventive service
Glaucoma screenings
Medicare covers this screening once every 12 months if
you’re at high risk for the eye 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 eye doctor who’s legally
allowed to do glaucoma screenings in your state must
do or supervise the screening. You pay 20% of the
Medicare-approved amount. The Part B deductible
applies. You also pay a copayment in a hospital
outpatient setting.
Hearing & balance exams
Medicare covers these diagnostic exams if your doctor
or health care provider orders them to see if you need
medical treatment.
You can visit an audiologist once every 12 months without
an order from a doctor or other health care provider, but
only for non-acute hearing conditions (like hearing loss
that occurs over many years) and for diagnostic services
related to hearing loss that’s treated with surgically
implanted hearing devices.
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You pay 20% of the Medicare-approved amount. The
Part B deductible applies. You also pay a copayment in
a hospital outpatient setting.
Note: Medicare doesn’t cover hearing aids or exams for
tting hearing aids.
Preventive service
Hepatitis B shots
Medicare covers these shots (or vaccines) if you’re 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 nd
out if you’re at medium or high risk for Hepatitis B. You
pay nothing for the shot if the doctor or other qualied
health care provider accepts assignment.
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Preventive service
Hepatitis B Virus infection screenings
Medicare covers Hepatitis B Virus infection screenings
only if your doctor orders it. Medicare also covers the
screenings:
•
Yearly, only if you’re at continued high risk and don’t
get a Hepatitis B shot.
•
If you’re pregnant:
•
At the first prenatal visit for each pregnancy
•
At the time of delivery for those with new or
continued risk factors
•
At the first prenatal visit for future pregnancies,
even if you previously got the Hepatitis B shot or
had negative Hepatitis B Virus screening results
You pay nothing for the screening test if the doctor or
health care practitioner accepts assignment.
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Preventive service
Hepatitis C screenings
Medicare covers one Hepatitis C screening test if you
meet one of these conditions:
•
You’re at high risk because you use or have used illicit
injection drugs.
•
You had a blood transfusion before 1992.
•
You were born between 1945 – 1965.
Medicare also covers yearly repeat screenings if you’re at
high risk.
Medicare will only cover a Hepatitis C screening test if
your health care provider orders one. You pay nothing for
the screening test if your primary care doctor or other
qualied health care provider accepts assignment.
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Preventive service
HIV (Human Immunodeciency Virus) screenings
Medicare covers HIV screenings once every 12 months if
you’re:
•
Between 15 – 65.
•
Younger than 15 or older than 65, and at increased
risk.
Medicare also covers this test up to 3 times during a
pregnancy.
You pay nothing for the HIV screening if your doctor or
other qualied health care provider accepts assignment.
•
End of Page
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Section 2: Find out what Medicare covers
Home health services
Medicare covers home health services under Part A
and/or Part B. Medicare covers medically necessary
part-time or intermittent skilled nursing care, physical
therapy, speech-language pathology services, or
continued occupational therapy services. 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. “Part-time or intermittent” means you may
be able to get skilled nursing care and home health aide
services if they are provided less than 8 hours each day
or less than 28 hours each week (or up to 35 hours a
week in some limited situations). A doctor, or other health
care provider (like a nurse practitioner), must assess you
face-to-face before certifying that you need home health
services. A doctor or health care provider must order your
care, and a Medicare-certied home health agency must
provide it.
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Section 2: Find out what Medicare covers
Medicare covers home health services as long as you
need part-time or intermittent skilled services and as long
as you’re “homebound,” which means:
•
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 effort.
You pay nothing for covered home health services.
However, for Medicare-covered durable medical
equipment, you pay 20% of the
Medicare-approved
amount. The Part B deductible applies.
•
End of Page
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Section 2: Find out what Medicare covers
Home infusion therapy services & supplies
Medicare covers equipment and supplies (like pumps,
IV poles, tubing, and catheters) for home infusion
therapy to administer certain IV infusion drugs, like
Intravenous Immune Globulin, at home. Medicare
covers certain equipment and supplies (like the
infusion pump) and the infusion drug under Durable
Medical Equipment benet (go to page 88). Medicare
also covers services (like nursing visits), training for
caregivers, and patient monitoring. You pay 20% of the
Medicare-approved amount for these services and for
the equipment and supplies you use in your home.
Kidney (renal) dialysis services & supplies
Generally, Medicare covers 3 dialysis treatments (or
equivalent continuous ambulatory peritoneal dialysis) per
week if you have End-Stage Renal Disease (ESRD). This
includes most renal dialysis drugs and biological
products, and all 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. The Part B deductible
applies.
101
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Section 2: Find out what Medicare covers
Kidney disease education
Medicare covers up to 6 sessions of kidney disease
education services if you have Stage IV chronic kidney
disease that will usually require dialysis or a kidney
transplant, and your doctor or other health care
provider refers you for the service. You pay 20% of the
Medicare-approved amount per session if you get
the service from a doctor or other qualied health care
provider. The Part B deductible applies.
Laboratory tests
Medicare covers medically necessary clinical diagnostic
laboratory tests when your doctor or provider orders
them. These tests may include certain blood tests,
urinalysis, certain tests on tissue specimens, and some
screening tests. You generally pay nothing for these tests.
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Section 2: Find out what Medicare covers
Preventive service
Lung cancer screenings
Medicare covers lung cancer screenings with low dose
computed tomography once per year if you meet these
conditions:
•
You’re 50 – 77.
•
You don’t have signs or symptoms of lung cancer
(you’re asymptomatic).
•
You’re either a current smoker or you quit smoking
within the last 15 years.
•
You have a tobacco smoking history of at least 20
“pack years” (an average of one pack—20 cigarettes—
per day for 20 years).
•
You get an order from your doctor.
You pay nothing for this service if your doctor accepts
assignment.
Before your rst lung cancer screening, you’ll need to
schedule an appointment with a health care provider to
discuss the benets and risks of lung cancer screening to
decide if the screening is right for you.
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Section 2: Find out what Medicare covers
New!
Lymphedema compression treatment items
If you’ve been diagnosed with lymphedema, Medicare will
cover your prescribed gradient compression garments
(standard and custom tted). You pay 20% of the
Medicare-approved amount. The Part B deductible
applies.
Preventive service
Mammograms
Medicare covers a mammogram screening to check for
breast cancer once every 12 months if you’re a woman
40 or older. Medicare covers one baseline mammogram
if you’re a woman between 35 – 39. You pay nothing for
the test if the doctor or other qualied health care provider
accepts assignment.
Part B also covers diagnostic mammograms more
frequently than once a year when medically necessary.
You pay 20% of the
Medicare-approved amount for
diagnostic mammograms. The Part B deductible applies.
Note: Medicare covers medically necessary breast
ultrasounds only when your doctor or provider orders
them.
104
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Section 2: Find out what Medicare covers
Preventive service
Medical nutrition therapy services
Medicare covers medical nutrition therapy services if
you have diabetes or kidney disease, or if you’ve had
a kidney transplant in the last 36 months and a doctor
refers you for services. Only a Registered Dietitian or
nutrition professional who meets certain requirements
can provide medical nutrition therapy services. If you
have diabetes, you may also be eligible for diabetes self-
management training (go to page 83). You pay nothing for
medical nutrition therapy preventive services because the
deductible and coinsurance don’t apply.
Preventive service
Medicare Diabetes Prevention Program
Medicare covers a once-per-lifetime health behavior
change program to help you prevent type 2 diabetes. The
program begins with weekly core sessions oered in a
group setting over a 6-month period. Once you complete
the core sessions, you’ll get 6 monthly follow-up sessions
to help you maintain healthy habits. If you started the
Medicare Diabetes Prevention Program in 2021 or earlier,
you’ll get an additional 12 monthly sessions if you meet
certain weight loss goals.
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Section 2: Find out what Medicare covers
You can get these services from an approved Medicare
Diabetes Prevention Program supplier. These suppliers
may be traditional health care providers or organizations
like community centers or faith-based organizations.
To nd a supplier or learn more about the program,
visit Medicare.gov/coverage/medicare-diabetes-
prevention-program.
If you’re in a Medicare Advantage Plan, contact your
plan to nd out where to get these services.
Mental health care (outpatient)
Medicare covers mental health care services to help
with conditions like depression and anxiety. These visits
are often called counseling or psychotherapy, and can
be done individually, in group psychotherapy or family
settings, and in crisis situations. Coverage includes
services generally provided in an outpatient setting (like a
doctor’s or other health care provider’s oce, or hospital
outpatient department), including visits with a psychiatrist
or other doctor, clinical psychologist, clinical nurse
specialist, clinical social worker, nurse practitioner, or
physician assistant.
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New!
Medicare covers mental health care services provided by
marriage & family therapists and mental health counselors.
Covered mental health care includes partial hospitalization
services given by a community mental health center or
by a hospital to outpatients. Partial hospitalization is a
structured day program that oers outpatient psychiatric
services as an alternative to inpatient psychiatric care.
New!
Medicare covers intensive outpatient program services
provided by hospitals, community mental health centers,
federally qualied health centers, and Rural Health Clinics.
Partial hospitalization and intensive outpatient services
are more rigorous than care you’d get in a doctor’s or
therapist’s oce. Visit Medicare.gov/coverage/mental-
health-care-partial-hospitalization to learn more.
Generally, you pay 20% of the Medicare-approved
amount and the Part B deductible applies for mental
health care services.
Part A covers inpatient mental health care services you
get in a hospital (go to page 53).
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Section 2: Find out what Medicare covers
Preventive service
Obesity behavioral therapy
If you have a body mass index (BMI) of 30 or more,
Medicare covers obesity screenings and behavioral
counseling to help you lose weight by focusing on diet
and exercise. Medicare covers this counseling if your
primary care doctor or other primary care practitioner
gives the counseling in a primary care setting (like
a doctor’s oce), where they can coordinate your
personalized prevention plan with your other care. You pay
nothing for this service if your primary care doctor or other
provider accepts assignment.
Occupational therapy services
Medicare covers medically necessary therapy to help
you perform activities of daily living (like dressing or
bathing). This therapy helps to improve or maintain current
capabilities or slow decline when your doctor or other
health care provider certies you need it. You pay 20% of
the Medicare-approved amount. The Part B deductible
applies.
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Section 2: Find out what Medicare covers
Opioid use disorder treatment services
Medicare covers opioid use disorder treatment services
in opioid treatment programs. The services include
medication (like methadone, buprenorphine, naltrexone,
and naloxone), substance use counseling, drug testing,
individual and group therapy, intake activities, and periodic
assessments. Medicare covers counseling, therapy
services, and periodic assessments both in-person and,
in certain circumstances, by virtual delivery (using audio
and video communication technology, like your phone or
a computer). Medicare also covers services given through
opioid treatment program mobile units.
Medicare pays doctors and other providers for
oce-based opioid use disorder treatment, including
management, care coordination, psychotherapy, and
counseling activities.
Under Original Medicare, you won’t have to pay any
copayments for these services if you get them from
an opioid treatment program provider that’s enrolled in
Medicare and meets other requirements. However, the
Part B deductible still applies. Talk to your doctor or other
health care provider to nd out where to go for these
services. You can also visit Medicare.gov/coverage/
opioid-use-disorder-treatment-services to nd a
program near you.
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Medicare Advantage Plans must also cover opioid
treatment program services, but may require you see an
in-network opioid treatment program. Since Medicare
Advantage Plans can apply copayments to opioid
treatment program services, check with your plan to nd
out if you have to pay a copayment.
Outpatient hospital services
Medicare covers many diagnostic and treatment
services you get as an outpatient from a Medicare-
participating hospital. Generally, you pay 20% of the
Medicare-approved amount for your doctors’ or other
health care providers’ 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 oce. 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 B 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.
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Cost & coverage:
To get cost estimates for hospital outpatient procedures
done in hospital outpatient departments, visit
Medicare.gov/procedure-price-lookup.
Outpatient medical & surgical services &
supplies
Medicare covers approved procedures, like X-rays, casts,
stitches, or outpatient surgeries. You pay 20% of the
Medicare-approved amount for doctor or other health
care provider services. You generally pay a copayment
for each service you get in a hospital outpatient setting. In
most cases, the copayment can’t be more than the Part A
hospital stay deductible for each service you get. The
Part B deductible applies, and you pay all costs for items
or services that Medicare doesn’t cover.
Physical therapy services
Medicare covers evaluation and treatment for injuries and
diseases that change your ability to function, or to improve
or maintain current function or slow decline, when your
doctor or other health care provider, including a nurse
practitioner, clinical nurse specialist or physician
assistant certies you need it. You pay 20% of the
Medicare-approved amount. The Part B deductible
applies.
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Section 2: Find out what Medicare covers
Preventive service
Pneumococcal shots
Medicare covers pneumococcal shots (or vaccines) to
help prevent pneumococcal infections (like certain types
of pneumonia). Talk with your doctor or other health care
provider about this vaccine. You pay nothing for these
shots if the provider accepts assignment for giving the
shots.
Principal care management services
Medicare covers disease-specic services to help you
manage a single, complex chronic condition that puts you
at risk of hospitalization, physical or cognitive decline, or
death. If you have one chronic high-risk condition that
you expect to last at least 3 months (like cancer and you
aren’t being treated for any other complex conditions),
Medicare may pay for a health care provider’s help to
manage it. Your provider will create a disease-specic
care plan and continuously monitor and adjust it, including
the medicines you take. The Part B deductible and
coinsurance apply.
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Section 2: Find out what Medicare covers
Preventive service
Prostate cancer screenings
Medicare covers digital rectal exams and prostate
specic antigen (PSA) tests once every 12 months for
men over 50 (starting the day after your 50th birthday).
For the digital rectal exam, you pay 20% of the
Medicare-approved amount. The Part B deductible
applies. You also pay a copayment in a hospital
outpatient setting. You pay nothing for the PSA test.
Prosthetic/orthotic items
Medicare covers these prosthetics/orthotics when a
Medicare-enrolled doctor or other health care provider
orders them: arm, leg, back, and neck braces; articial
eyes; articial limbs (and their replacement parts); and
prosthetic devices needed to replace an internal body
organ or function of the organ (including ostomy supplies,
parenteral and enteral nutrition therapy, and some types of
breast prostheses after a mastectomy).
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. The Part B
deductible applies.
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Pulmonary rehabilitation programs
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
who’s treating it.
•
Had confirmed or suspected COVID-19 and experience
persistent symptoms that include respiratory
dysfunction for at least 4 weeks.
You pay 20% of the Medicare-approved amount if
you get the service in a doctor’s oce. You also pay a
copayment per session if you get the service in a hospital
outpatient setting. The Part B deductible applies.
Rural Health Clinic services
Rural Health Clinics provide many outpatient primary
care and preventive services in rural and underserved
areas. Generally, you pay 20% of the charges. The Part B
deductible applies. You pay nothing for most preventive
services.
Note: You can get covered telehealth services at Rural
Health Clinics through December 31, 2024. Go to
page 117.
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Section 2: Find out what Medicare covers
Second surgical opinions
Medicare covers a second surgical opinion in some cases
for medically necessary surgery that isn’t an emergency.
In some cases, Medicare covers third surgical opinions.
You pay 20% of the Medicare-approved amount. The
Part B deductible applies.
Preventive service
Sexually transmitted infection (STI) screenings &
counseling
Medicare covers STI screenings for chlamydia, gonorrhea,
syphilis, and/or Hepatitis B. Medicare covers these
screenings if you’re pregnant or at increased risk for an
STI when your primary care doctor or other health care
provider orders the tests. 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 if you’re a sexually active adult at increased
risk for STIs. Medicare will only cover these counseling
sessions with a primary care doctor or health care
practitioner in a primary care setting (like a doctor’s oce).
Medicare won’t cover counseling as a preventive service
in an inpatient setting, like a skilled nursing facility.
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You pay nothing for these services if your
primary care doctor or practitioner accepts assignment.
Shots (or vaccines)
Part B covers:
•
Flu shots. Go to page 92.
•
Hepatitis B shots. Go to page 94.
•
Pneumococcal shots. Go to page 111.
•
Coronavirus disease 2019 (COVID-19) vaccine. Go to
page 79.
Important!
Medicare drug coverage (Part D) generally covers all other
recommended adult immunizations to prevent illness (like
shingles, tetanus, diphteria, pertussis, and respiratory
syncytial virus (RSV)) at no cost to you. If the shot isn’t
on your plan’s drug list yet, you can ask for a coverage
exception or get reimbursed. Contact your plan for details,
and talk to your doctor or other health care provider about
which vaccines are right for you. To learn more about
other covered vaccines, visit Medicare.gov/coverage.
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Speech-language pathology services
Medicare covers medically necessary evaluation
and treatment to regain and strengthen speech and
language skills. This includes cognitive and swallowing
skills, or to improve or maintain current function or
slow decline, when your doctor or other health care
provider certies you need it. You pay 20% of the
Medicare-approved amount. The Part B deductible
applies.
Surgical dressing services
Medicare covers medically necessary treatment of a
surgical or surgically treated wound. You pay nothing for
the
supplies and 20% of the Medicare-approved amount
for your doctor or other health care provider services.
You pay a set copayment for these services when you
get them in a hospital outpatient setting. The Part B
deductible applies.
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Section 2: Find out what Medicare covers
Telehealth
Medicare covers certain telehealth services provided by
a doctor or other heath care practitioner who’s located
elsewhere using audio and video communication
technology (or audio-only telehealth services in some
cases), like your phone or a computer. Telehealth can
provide many services that generally occur in-person,
including oce visits, psychotherapy, consultations, and
certain other medical or health services.
New!
Through December 31, 2024, you can get telehealth
services at any location in the U.S., including your home.
After this period, you must be in an oce or medical
facility located in a rural area for most telehealth services.
However, you’ll still be able to get certain Medicare
telehealth services without being in a rural health care
setting. They include:
•
Monthly End-Stage Renal Disease (ESRD) visits for
home dialysis.
•
Services for diagnosis, evaluation, or treatment of
symptoms of an acute stroke wherever you are,
including in a mobile stroke unit.
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•
Services to treat a substance use disorder or a
co-occurring mental health disorder (sometimes called
a “dual disorder”) or for the diagnosis, evaluation, or
treatment of a mental health disorder, including in your
home.
•
Behavioral health services, including in your home.
•
Diabetes self-management training
•
Medical nutrition therapy
You pay 20% of the Medicare-approved amount for
your doctor or other health care provider or practitioner’s
services. The Part B deductible applies. For most of
these services, you’ll pay the same amount you would if
you got the services in person.
Compare:
Medicare Advantage Plans and some providers, like
ones who are part of certain Medicare Accountable Care
Organizations (ACOs), may oer more telehealth benets
than Original Medicare. For example, you may be able to
get some services from home, no matter where you live.
Check with your plan to nd out what benets they oer. If
your provider participates in an ACO, check with them to
nd out what telehealth benets may be available. Go to
pages 271 – 274.
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Section 2: Find out what Medicare covers
Tests (Non-laboratory)
Medicare covers X-rays, MRIs, CT scans, EKG/ECGs,
and some other diagnostic tests. You pay 20% of the
Medicare-approved amount. The Part B 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. In most cases,
this amount can’t be more than the Part A hospital stay
deductible. Go to “Laboratory tests” on page 101 for other
Part B-covered tests.
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 with you and your caregiver to coordinate and
manage your care for the rst 30 days after you return
home. The Part B deductible and coinsurance apply.
Visit Medicare.gov/coverage/transitional-care-
management-services to learn more.
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Transplants & immunosuppressive drugs
Medicare covers doctor services for heart, lung, kidney,
pancreas, intestine, and liver transplants under certain
conditions, but only in Medicare-certied facilities.
Medicare also covers bone marrow and cornea transplants
under certain conditions.
Medicare covers immunosuppressive drugs if Medicare
paid for the transplant. You must have Part A at the time
of the covered transplant, and you must have Part B at
the time you get immunosuppressive drugs (or qualify for
the immunosuppressive drug benet described below).
You pay 20% of the
Medicare-approved amount
for the drugs. The Part B deductible applies. Keep
in mind, Medicare drug coverage (Part D) covers
immunosuppressive drugs if Part B doesn’t cover them.
If you’re thinking about joining a Medicare Advantage
Plan and are on a transplant waiting list or think 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. Ask for information
about covered drugs and their costs. Also, check the
plan’s coverage rules for prior authorization and coverage
for your living donors.
Note: Medicare may cover transplant surgery as a hospital
inpatient service under Part A. Go to pages 53 – 55.
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Section 2: Find out what Medicare covers
Medicare pays the full cost of care for your kidney donor.
You and your donor won’t have to pay a deductible,
coinsurance, or any other costs for their hospital stay.
Immunosuppressive drug benet
If you only have Medicare because of End-Stage Renal
Disease (ESRD), your Medicare coverage (including
immunosuppressive drug coverage) ends 36 months after
a successful kidney transplant. Medicare oers a benet
that helps you pay for your immunosuppressive drugs
beyond 36 months if you don’t have certain types of
other health coverage (like a group health plan, TRICARE,
or Medicaid that covers immunosuppressive drugs). This
benet only covers your immunosuppressive drugs
and no other items or services. It isn’t a substitute for
full health coverage. You can sign up for this benet
any time after your Medicare Part A coverage ends,
as long as you had Medicare because of ESRD at
the time of your kidney transplant. To sign up, call
Social Security at 1 877 465 - 0355. TTY users can
call 1 800 325 - 0788.
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You’ll pay a monthly premium of $103 (or higher
based on your income) and $240 deductible for this
immunosuppressive drug benet in 2024. Once you’ve met
the deductible, you’ll pay 20% of the Medicare-approved
amount for immunosuppressive drugs. If you have limited
income and resources, you may be able to get help from
your state to pay for this benet. Go to page 231, or visit
Medicare.gov/basics/end-stage-renal-disease to learn
more.
Travel
Medicare generally doesn’t cover health care while you’re
traveling outside the U.S. (the “U.S.” 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 limited exceptions.
Visit Medicare.gov/coverage/travel-outside-the-u.s. to
learn more.
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 Medicare-approved amount. The
Part B deductible applies.
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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
Medicare-approved amount for your doctor or
other health care provider services, and a copayment in a
hospital outpatient setting. The Part B deductible applies.
Virtual check-ins
Medicare covers virtual check-ins (also called “brief
communication technology-based services”) with your
doctor or certain other providers, like nurse practitioners,
clinical nurse specialists, or physician assistants. Virtual
check-ins use audio and video communication technology,
like your phone or a computer, without you going to the
doctor’s oce. Your doctor can also conduct remote
assessments using photo or video images you send for
review to determine whether you need to go to the doctor’s
oce.
Your doctor or other provider can respond to you by phone,
virtual delivery, secure text message, email, or patient
portal.
You can use these services if you have met these
conditions:
•
You talked to your doctor or other provider about
starting these types of visits.
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Section 2: Find out what Medicare covers
•
The virtual check-in doesn’t relate to a medical visit
you’ve had within the past 7 days and doesn’t lead
to the medical visit within the next 24 hours (or the
soonest appointment available).
•
You verbally consent to the virtual check-in, and
your doctor documents your consent in your medical
record. Your doctor may get one consent for a year’s
worth of these services.
Compare:
You pay 20% of the Medicare-approved amount for
your doctor or other health care provider services. The
Part B deductible applies. Medicare Advantage Plans
may oer more virtual check-in services than Original
Medicare. Check with your plan to nd out what they oer.
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Section 2: Find out what Medicare covers
Preventive service
“Welcome to Medicare” preventive visit
During the rst 12 months that you have Part B, you
can get a “Welcome to Medicare” preventive visit. The
visit includes a review of your medical and social history
related to your health. It also includes education and
counseling about preventive services, including certain
screenings, shots or vaccines (like u, pneumococcal, and
other recommended shots or vaccines), and referrals for
other care, if needed.
When you make your appointment, let your doctor’s oce
know that you would like to schedule your “Welcome
to Medicare” preventive visit. You pay nothing for the
“Welcome to Medicare” preventive visit if the doctor or
other qualied health care provider accepts assignment.
If you have a current prescription for opioids, your
provider will review your potential risk factors for opioid
use disorder, evaluate your severity of pain and current
treatment plan, provide information on non-opioid
treatment options, and may refer you to a specialist, if
appropriate. Your provider will also review your potential
risk factors for substance use disorder, like alcohol and
tobacco use, and refer you for treatment, if needed.
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Important!
If your doctor or other health care provider performs
additional tests or services during the same visit that
Medicare doesn’t cover under this preventive benet, you
may have to pay coinsurance, and the Part B deductible
may apply. If Medicare doesn’t cover the additional tests
or services (like a routine physical exam), you may have to
pay the full amount.
Preventive service
Yearly “Wellness” visit
If you’ve had Part B for longer than 12 months, you can
get a yearly “Wellness” visit to develop or update your
personalized plan to prevent disease or disability based
on your current health and risk factors. The yearly
“Wellness” visit isn’t a physical exam. Medicare covers
this visit once every 12 months.
Your doctor or health care practitioner 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 doctor develop a personalized prevention
plan to help you stay healthy and get the most out of your
visit. Your visit may include: routine measurements, health
advice, a review of your medical and family history, your
current prescriptions, advance care planning and more.
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Your doctor or health care practitioner will also perform
a cognitive assessment to look for signs of dementia,
including Alzheimer’s disease. Signs of cognitive
impairment include trouble remembering, learning new
things, concentrating, managing nances, and making
decisions about your everyday life. If your doctor or
health care practitioner thinks you may have cognitive
impairment, Medicare covers a separate visit to do a more
thorough review of your cognitive function and check for
conditions like dementia, depression, anxiety, or delirium
and design a care plan. Go to pages 74 – 75.
Your doctor or health care practitioner will also evaluate
your potential risk factors for a substance use disorder
and refer you for treatment, if needed. If you use opioid
medication, your provider will review your pain treatment
plan, share information about non-opioid treatment
options, and refer you to a specialist, as appropriate.
Note: Your rst yearly “Wellness” visit can’t take place
within 12 months of your Part B enrollment 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 health care practitioner accepts assignment.
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Important!
If your doctor or health care practitioner performs
additional tests or services during your “Wellness” visit
that Medicare doesn’t cover under this preventive benet,
you may have to pay a coinsurance, and the Part B
deductible may apply. If Medicare doesn’t cover the
additional tests or services (like a routine physical exam),
you may have to pay the full amount.
What ISN’T covered by Part A and Part B?
Medicare doesn’t cover everything. If you need certain
services Part A or Part B doesn’t cover, 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 or Medicare
Cost Plan that covers these services. Medicare
Advantage Plans and Medicare Cost Plans may cover
some extra benefits, like fitness programs and vision,
hearing, and dental services.
129
—
Section 2: Find out what Medicare covers
Some of the items and services that Original Medicare
doesn’t cover include:
•
Eye exams (for prescription eyeglasses)
•
Long-term care
•
Cosmetic surgery
•
Massage therapy
•
Routine physical exams
•
Hearing aids and exams for fitting them
•
Concierge care (also called concierge medicine,
retainer-based medicine, boutique medicine, platinum
practice, or direct care)
•
Covered items or services you get from an opt-out
doctor (go to page 141) or other provider (except in the
case of an emergency or urgent need)
•
Most dental care: In most cases, Original Medicare
doesn’t cover dental services like routine cleanings,
llings, tooth extractions, or items like dentures.
However, in some cases, Original Medicare may pay
for some dental services related to specic medical
procedures like:
•
A heart valve repair or replacement
•
An organ transplant
•
Cancer-related treatments
130
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Section 2: Find out what Medicare covers
Paying for long-term care
Medicare and most health insurance, including
Medicare Supplement Insurance (Medigap), don’t pay
for long-term care. This type of care (sometimes called
“long-term services and supports”) includes medical and
non-medical care for people who have a chronic illness
or disability. This includes personal care assistance, like
help with everyday activities, including dressing, bathing
and using the bathroom. Long-term care may also include
home-delivered meals, adult day health care, home and
community-based services and others. You may be
eligible for this care through Medicaid, or you can choose
to buy private long-term care insurance.
You can get long-term care 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 make sure you get the
care you may need, in the setting you want, now and in
the future.
131
—
Section 2: Find out what Medicare covers
Long-term care resources
Use these resources to get more information about
long-term care:
•
Visit longtermcare.acl.gov to learn more about
planning for long-term care.
•
Call your State Insurance Department to get
information about long-term care insurance. Call
1 800 633 - 4227 to get the phone number. TTY users
can call 1 877 486 - 2048.
•
Call your State Medical Assistance (Medicaid) office
or visit Medicaid.gov and ask for information about
long-term care coverage.
•
Get a copy of “A Shopper’s Guide to Long-Term Care
Insurance” from the National Association of Insurance
Commissioners at content.naic.org/sites/default/
files/publication-ltc-lp-shoppers-guide-long-term.
pdf.
•
Visit the Eldercare Locator at eldercare.acl.gov, or
call 1 800 677 - 1116 to find help in your community.
•
Call your State Health Insurance Assistance Program
(SHIP). Go to pages 280 – 287 for the phone number of
your local SHIP.
132
Notes
133
How does Original Medicare work?
Original Medicare is one of your Medicare health coverage
choices. You’ll have Original Medicare unless you
choose a Medicare Advantage Plan or other type of
Medicare health plan. Original Medicare includes two
parts: Part A (Hospital Insurance) and Part B (Medical
Insurance).
You generally have to pay a portion of the cost for each
service Original Medicare covers. There’s no limit to what
you’ll pay out of pocket in a year unless you have other
coverage (like Medigap, Medicaid, employer, retiree,
or union coverage) or join a Medicare Advantage Plan
instead of Original Medicare.
Section 3: Original
Medicare
Underlined words are dened on pages 289 – 296.
134
—
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 Medicare-enrolled
doctor, other health care provider, hospital, or other facility
that accepts Medicare patients anywhere in the U.S.
Visit Medicare.gov/care-compare to nd and compare
providers, hospitals, and facilities in your area.
Does it cover prescription drugs?
No, with a few exceptions (go to pages 49 – 54, 100, 108,
and 120), Original Medicare doesn’t cover most drugs.
You can add Medicare drug coverage (Part D) by joining a
separate Medicare drug plan. Go to pages 191 – 222.
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to use a specialist?
In most cases, no.
135
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Section 3: Original Medicare
Should I get a supplemental policy?
You may already have Medicaid, or employer, retiree,
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.
Go to pages 179 – 189. You can also check with your
State Medical Assistance (Medicaid) oce to see if you’re
eligible for Medicaid.
What else do I need to know about Original Medicare?
•
You generally pay a set amount for your health care
(deductible) before Medicare begins to pay its share.
Once Medicare pays its share, you pay a coinsurance
or copayment for covered services and supplies.
There’s no yearly limit for what you pay out of
pocket unless you have other insurance (like Medigap,
Medicaid, or employer, retiree, or union coverage).
•
You usually pay a monthly premium for Part B, which
may change each year.
•
You generally don’t need to file Medicare claims.
Providers and suppliers must file your claims for the
covered services and supplies you get.
136
—
Section 3: Original Medicare
What do I pay?
Your out-of-pocket costs in Original Medicare depend on:
•
Whether you have Part A and/or Part B. Most people
have both.
•
Whether your doctor, other health care provider, or
supplier accepts “assignment.” Go to page 139.
•
The type of health care you need and how often you
need it.
•
If you choose to get services or supplies Medicare
doesn’t cover. If so, you pay all costs unless you have
other insurance that covers them.
•
Whether you have other health insurance that works
with Medicare. Go to pages 36 – 38.
•
Whether you have full Medicaid or get help from your
state to pay your Medicare costs through a Medicare
Savings Program. Go to pages 223 – 226.
•
Whether you have Medicare Supplement Insurance
(Medigap).
•
Whether you and your doctor or other health care
provider sign a private contract. Go to page 141.
137
—
Section 3: Original Medicare
How do I know what Medicare paid?
If you have Original Medicare, you’ll get a “Medicare
Summary Notice” (MSN) that lists all the services billed to
Medicare. You can sign up to get this Notice electronically
every month (review below) or a Medicare contractor will
mail it to you every 3 months. It’s not a bill. The MSN
shows what Medicare paid and what you may owe the
provider. Review your MSNs to be sure you got all the
services, supplies, or equipment listed. If you disagree
with Medicare’s decision not to pay for (cover) a service,
the MSN will tell you how to appeal. Go to page 241 for
information on how to le an appeal.
If you need to change your address on your MSN, call
Social Security at 1 800 772 - 1213. TTY users can call
1 800 325 - 0778. If you get Railroad Retirement Board
(RRB) benets, call the RRB at 1 877 772 - 5772. TTY
users can call 1 312 751 - 4701.
Your MSN will tell you if you’re enrolled in the Qualied
Medicare Beneciary (QMB) program. If you’re in the QMB
program, Medicare providers aren’t allowed to bill you for
Medicare Part A and/or Part B deductibles, coinsurance,
or copayments. In some cases, you may be billed a small
copayment through Medicaid, if one applies. For more
information about QMB and steps to take if a provider bills
you for these costs, go to page 223.
138
—
Section 3: Original Medicare
Important!
Get your Medicare Summary Notices electronically
Sign up to get your “Medicare Summary Notices,” (also
called “eMSNs”) electronically. Visit Medicare.gov to log
into (or create) your secure Medicare account. If you sign
up for eMSNs, we’ll send you an email each month when
they’re available in your Medicare account. The eMSNs
have the same information as paper MSNs. You won’t
get printed copies in the mail if you choose eMSNs, but
you can choose to print them yourself at home. As of
mid-2023, people who signed up for eMSNs helped save
the Medicare Program close to $30 million.
You have options in how you get your Medicare claims
information. You can access your claims in your account
on Medicare.gov and share this information with
doctors, pharmacies, and others using a Blue Button
®
app of your choice. A growing number of computer and
mobile apps are connected to Medicare through Blue
Button 2.0
®
. If you agree to share your information with
one of these apps, it can show you the details of the
claims that Medicare has paid on your behalf. Go to
pages 268 – 269 for more information.
139
—
Section 3: Original Medicare
What’s assignment?
Assignment means that your doctor, provider, or
supplier agrees (or is required by law) to accept the
Medicare-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.
•
End of Page
140
—
Section 3: Original Medicare
Some providers haven’t agreed and aren’t required by
law to accept assignment for all Medicare-covered
services, but they can still choose to accept assignment
for individual services. The providers who haven’t agreed
to accept assignment for all services are called “non-
participating.” You might have to pay more for their
services if they don’t accept assignment for the care
they provide to you. 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 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
•
They can charge you more than the Medicare-
approved amount. In many cases, the charge
can’t be more than an amount called “the limiting
charge.”
If you have Original Medicare, you can use any provider
you want that takes Medicare, anywhere in the U.S.
141
—
Section 3: Original Medicare
Compare:
If you’re in a Medicare Advantage Plan, in most cases,
you’ll need to use doctors and other providers who are in
the plan’s network.
To nd out if someone accepts assignment or
participates in Medicare, visit Medicare.gov/care-
compare.
To nd out if a medical equipment supplier accepts
assignment, visit Medicare.gov/medical-equipment-
suppliers.
You can also call your State Health Insurance Assistance
Program (SHIP) to get free help with these topics. Go to
pages 280 – 287 for the phone number of your local SHIP.
What if I want to use a provider who opts out of
Medicare?
Certain doctors and other health care providers who don’t
want to work with the Medicare Program may “opt out” of
Medicare. Medicare doesn’t pay for any covered items or
services you get from an opt-out doctor or other provider,
except in the case of an emergency or urgent need. If you
still want to use an opt-out provider, you and your provider
can set up payment terms that you both agree to through a
private contract.
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—
Section 3: Original Medicare
A doctor or other provider who chooses to opt out must
do so for 2 years, which automatically renews every
2 years unless the provider requests not to renew their
opt-out status. You can still get care from these providers,
but they must enter into a private contract with you (unless
you’re in need of emergency or urgently needed care).
If you’re unsure if a provider has opted out of Medicare,
check with them so you’ll know ahead of time if you’ll
need to pay out of pocket for your care.
Go to pages 9 – 20 for an overview of your Medicare
options.
143
What are Medicare Advantage Plans?
A Medicare Advantage Plan is another way to get
your Medicare Part A and Part B coverage. Medicare
Advantage Plans, sometimes called “Part C” or “MA
Plans,” are Medicare-approved plans oered by private
companies that must follow rules set by Medicare. Most
Medicare Advantage Plans include drug coverage (Part D).
In many cases, you’ll need to use health care providers
who participate in the plan’s network. These plans set a
limit on what you’ll have to pay out-of-pocket each year
for covered services. Some plans oer non-emergency
coverage out of network, but typically at a higher cost. In
many cases, you may need to get approval, also called
prior authorization, from your plan before it covers certain
drugs or services.
Section 4: Medicare
Advantage Plans &
other options
Underlined words are dened on pages 289 – 296.
144
—
Section 4: Medicare Advantage Plans &
other options
Remember, you must use the card from your
Medicare Advantage Plan to get your Medicare-covered
services. Keep your red, white, and blue Medicare card in
a safe place because you might need it later.
If you join a Medicare Advantage Plan, you’ll still have
Medicare but you’ll get most of your Part A and Part B
coverage from your Medicare Advantage Plan, not Original
Medicare.
What are the dierent types of Medicare
Advantage Plans?
•
Health Maintenance Organization (HMO) Plan: Go
to page 158.
•
HMO Point-of-Service (HMOPOS) Plan: This HMO
plan may allow you to get some services out of
network for a higher copayment or coinsurance. Go
to page 158.
•
Medical Savings Account (MSA) Plans: Go to
page 160.
•
Preferred Provider Organization (PPO) Plan: Go to
page 162.
•
Private Fee-for-Service (PFFS) Plan: Go to page 164.
•
Special Needs Plan (SNP): Go to page 166.
144
—
Section 4: Medicare Advantage Plans &
other options
145
—
Section 4: Medicare Advantage Plans &
other options
What do Medicare Advantage Plans cover?
Medicare Advantage Plans provide all of your Part A and
Part B benets, except for certain costs of clinical trials
(clinical research studies), hospice care, the cost of getting
a kidney transplant (like expenses for a living kidney
donor), and, for a temporary time, some new benets that
come from legislation or national coverage determinations.
Contact your plan if you have questions about covered
services.
Plans may oer some extra benets
With a Medicare Advantage Plan, you may have coverage
for things Original Medicare doesn’t cover, like tness
programs (gym memberships or discounts) and some
vision, hearing, and dental services (like routine check
ups or cleanings). Plans can also choose to cover even
more benets. For example, some plans may oer
coverage for services like transportation to doctor visits,
over-the-counter drugs that Part D doesn’t cover, and
other health care services. Check with the plan before you
join to nd out what benets it oers, and if there are any
limitations.
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—
Section 4: Medicare Advantage Plans &
other options
Plans can also tailor their benet packages to oer
additional benets to certain chronically-ill enrollees.
These packages will provide benets customized to
treat specic conditions. Although you can check with a
Medicare Advantage Plan before you join to nd out if
they oer these benet packages, you’ll need to wait until
you join the plan to nd out if you qualify.
Get the most out of your dental benets
If you’re in a Medicare Advantage Plan, take charge
of your oral health, and contact your plan to learn
more about dental services that it may cover and what
limitations may apply.
•
End of Page
146
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Section 4: Medicare Advantage Plans &
other options
147
—
Section 4: Medicare Advantage Plans &
other options
Medicare Advantage Plans must follow
Medicare’s rules
Medicare pays a xed amount for your
coverage each month to the companies oering
Medicare Advantage Plans. These companies must
follow rules set by Medicare. However, each Medicare
Advantage Plan can charge dierent out-of-pocket costs
and have dierent rules for how you get services (like
whether you need a referral to use 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 dierent plan, or switch to
Original Medicare. Go to page 169.
Providers can join or leave a plan’s provider network
any time during the year. Your plan can also change the
providers in the network any time during the year. If this
happens, you usually won’t be able to change plans
but you can choose a new provider. You generally can’t
change plans during the year.
148
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Section 4: Medicare Advantage Plans &
other options
New!
Even though the network of providers may change during
the year, the plan must still give you access to qualied
doctors and specialists. Your plan will notify you that
your provider is leaving your plan so you have time to
choose a new one. You’ll get this notice if it’s a primary
care or behavioral health provider and you have gone to
that provider in the past three years. If any of your other
providers leave your plan, you’ll get this notice in certain
situations. Your plan will also:
•
Help you choose a new provider to continue managing
your health care needs.
•
Help you continue needed care that’s already in
progress.
•
Notify you about the different enrollment periods
available to you and options you may have for
changing plans.
Read your notices carefully so you’re aware of any
changes and can change plans if you aren’t satised,
either during Open Enrollment or a Special Enrollment
Period, if you qualify.
148
—
Section 4: Medicare Advantage Plans &
other options
149
—
Section 4: Medicare Advantage Plans &
other options
When an in-network provider or benet isn’t available or
can’t meet your medical needs, most plans will help you
get any medically necessary care outside the provider
network (at the in-network cost sharing).
Compare:
If you have Original Medicare, you don’t need a referral
to use a specialist in most cases (go to page 134). You
can also use any provider you want that takes Medicare,
anywhere in the U.S.
Important!
Read the information you get from your plan
If you’re in a Medicare Advantage Plan, review the
“Annual Notice of Change” and “Evidence of Coverage”
from your plan each year:
•
Annual Notice of Change: Includes any changes
in coverage, costs, and more that will be effective
starting in January. Your plan will send you a printed
copy by September 30.
150
—
Section 4: Medicare Advantage Plans &
other options
•
Evidence of Coverage: Gives you details about what
the plan covers, how much you pay, and more in the
next year. Your plan will send you a notice (or printed
copy) by October 15, which will include information on
how to access the Evidence of Coverage electronically
or request a printed copy.
If you decide to join a Medicare Advantage Plan,
consider signing up for an electronic version of the
Medicare & You handbook at Medicare.gov/go-digital.
You’ll get cost and coverage information from your plan.
If you don't get these important documents, contact
your plan.
What should I know about Medicare Advantage
Plans?
Who can join?
To join a Medicare Advantage Plan you must:
•
Have Part A and Part B.
•
Live in the plan’s service area.
•
Be a U.S. citizen or lawfully present in the U.S.
150
—
Section 4: Medicare Advantage Plans &
other options
151
—
Section 4: Medicare Advantage Plans &
other options
Joining and leaving
•
You can join a Medicare Advantage Plan even if you
have a pre-existing condition.
•
You can join or drop a Medicare Advantage
Plan only at certain times during the year. Go to
pages 169 – 174.
•
Each year, Medicare Advantage Plans can choose
to leave Medicare or make changes in coverage,
costs, service area, and more. If the plan decides
to stop participating in Medicare, you’ll have to join
another Medicare Advantage Plan or return to Original
Medicare. Go to page 240.
•
Medicare Advantage Plans must follow certain rules
when giving you information about how to join their
plan. Go to pages 257 – 260 for more information
about these rules and how to protect your personal
information.
152
—
Section 4: Medicare Advantage Plans &
other options
What if I have End-Stage Renal Disease (ESRD)?
If you have ESRD, you can choose either Original
Medicare or a Medicare Advantage Plan when deciding
how to get Medicare coverage. If you’re only eligible
for Medicare because you have ESRD and you get
a kidney transplant, your Medicare benets will end
36 months after the transplant. Go to pages 121 – 122 for
more information about continuing coverage for
immunosuppressive drugs.
Medicare drug coverage (Part D)
Most Medicare Advantage Plans include Medicare drug
coverage (Part D). In certain types of plans that don’t
include Medicare drug coverage (like Medical Savings
Account (MSA) Plans and some Private-Fee-for-Service
(PFFS) Plans), you can join a separate Medicare drug plan.
However, if you join a Health Maintenance Organization
Plan or Preferred Provider Organization Plan which
doesn’t cover drugs, you can’t join a separate Medicare
drug plan.
152
—
Section 4: Medicare Advantage Plans &
other options
153
—
Section 4: Medicare Advantage Plans &
other options
In this case, you’ll either need to use other prescription
drug coverage you have (like employer or retiree
coverage), or go without drug coverage. If you
decide not to get Medicare drug coverage when
you’re rst eligible and your other drug coverage isn’t
creditable prescription drug coverage, you may have
to pay a late enrollment penalty (go to pages 202 – 206) if
you join a Part D plan later.
What if I have other coverage?
Talk to your employer, union, or other benets
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 for yourself, your spouse, and
your dependents, and you may not be able to get it back.
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. Your
employer or union may also oer a Medicare Advantage
retiree health plan that they sponsor. You can only be in
one Medicare Advantage Plan at a time.
154
—
Section 4: Medicare Advantage Plans &
other options
What if I have Medicare Supplement Insurance
(Medigap)?
You can’t buy Medigap while you’re in a
Medicare Advantage Plan. You can’t use Medigap to pay
for any costs (copayments, deductibles, and premiums)
you have with a Medicare Advantage Plan.
Important!
If you already have Medigap and join a Medicare
Advantage Plan, you may want to drop Medigap. Keep
in mind, if you drop Medigap to join a Medicare
Advantage Plan, you may not be able to get it back
depending on your state’s Medigap enrollment rules
and your situation. Go to pages 186 – 188.
What do I pay?
Your out-of-pocket costs in a Medicare Advantage Plan
depend on:
•
Whether the plan charges a monthly premium. Some
Medicare Advantage Plans have a $0 premium (but
you still may pay the Part B premium). If you join a plan
that does charge a premium, you pay this in addition
to the Part B premium (and the Part A premium if you
don’t have premium-free Part A).
154
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Section 4: Medicare Advantage Plans &
other options
155
—
Section 4: Medicare Advantage Plans &
other options
•
Whether the plan pays any of your monthly Part B
premiums. Some Medicare Advantage Plans will
help pay all or part of your Part B premium. This
is sometimes called a “Medicare Part B 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
(copayments or coinsurance). Medicare Advantage
Plans can’t charge more than Original Medicare for
certain services, like chemotherapy, dialysis, and
skilled nursing facility care.
•
The type of health care services you need and how
often you get them.
•
Whether you get services from a network provider or
a provider that doesn’t contract with the plan. If you
go to a doctor, 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 plan
may not cover your services, or your costs could be
higher.
156
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Section 4: Medicare Advantage Plans &
other options
•
Whether you go to a doctor or supplier who accepts
assignment (if you’re in a Preferred Provider
Organization Plan, Private Fee-for-Service Plan, or
Medical Savings Account (MSA) Plan and you go out
of network). Go to page 139 for more information about
assignment.
•
Whether the plan offers extra benefits (in addition to
Original Medicare benefits) and if you need to pay
extra to get them.
•
The plan’s yearly limit on your out-of-pocket
costs for all Part A and Part B-covered services.
Once you reach this limit, you’ll pay nothing for
Part A and Part B-covered services.
•
Whether you have Medicaid or get help from your
state through a Medicare Savings Program. Go to
pages 223 – 226.
To learn more about your costs in a specic
Medicare Advantage Plan, contact the plan or visit
Medicare.gov/plan-compare.
156
—
Section 4: Medicare Advantage Plans &
other options
157
—
Section 4: Medicare Advantage Plans &
other options
How do I nd out if my plan covers a service, drug, or
supply?
You or your provider can get a decision, either orally or in
writing, from your plan in advance to nd out if it covers
a service, drug, or supply. You can also nd out how
much you’ll have to pay. This is called an “organization
determination.” Sometimes you have to do this as prior
authorization for your plan to cover the service, drug, or
supply. Go to pages 247 – 249.
You, your representative, or your doctor can request this
organization determination. The requested organization
determination can be either oral or written. Based on your
health needs, you, your representative, or your doctor can
ask for a fast decision on your organization determination
request. If your plan denies coverage, the plan must tell
you in writing, and you have the right to appeal. Go to
pages 237 – 247.
If a plan provider refers you for a covered service or
to a provider outside the network, but doesn’t get an
organization determination in advance, this is called
“plan directed care.” In most cases, you won’t have to
pay more than the plan’s usual cost sharing. Check with
your plan for more information about this protection.
158
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Section 4: Medicare Advantage Plans &
other options
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 for emergency care, out-of-area
urgent care, or temporary out-of-area dialysis, which is
covered whether it’s provided in the plan’s network or
outside the plan’s network). However, some HMO plans,
known as HMO Point-of-Service (HMOPOS) plans, oer
an out-of-network benet for some or all covered benets
for a higher copayment or coinsurance.
Do these plans cover prescription drugs?
In most cases, yes. If you’re planning to enroll in an HMO
and you want Medicare drug coverage (Part D), you must
join an HMO plan that oers Medicare drug coverage. If
you join an HMO plan without drug coverage, you can’t
join a separate Medicare drug plan.
Do I need to choose a primary care doctor?
In most cases, yes.
158
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other options
159
—
Section 4: Medicare Advantage Plans &
other options
Do I have to get a referral to use 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 you get non-emergency health care outside the
plan’s network without authorization, 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.
•
Visit Medicare.gov or check with the plan for more
information.
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Medical Savings Account (MSA) Plan
Can I get my health care from any doctor, other health
care provider, or hospital?
Yes. MSA plans usually don’t have a network of doctors,
other health care providers, or hospitals.
Do these plans cover prescription drugs?
No. If you join a Medicare MSA Plan and want Medicare
drug coverage (Part D), you’ll have to join a separate
Medicare drug plan.
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to use a specialist?
No.
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What else do I need to know about this type of plan?
The plan deposits money into a special savings account
for you to use to pay health care expenses. The amount
of the deposit varies by plan. You can use this money to
pay your Medicare-covered costs before you meet the
deductible. Money left in your account at the end of the
year stays there. If you keep your plan the following year,
your plan will add any new deposits to the amount left
over.
•
MSA plans don’t charge a premium, but you must
continue to pay your Part B premium.
•
The plan will only begin to cover your Part A and
Part B costs once you meet a high yearly deductible,
which varies by plan.
•
Some plans may cover some extra benefits, like vision,
hearing, and dental services. You may pay a premium
for this extra coverage.
•
Visit Medicare.gov or check with your plan for more
information.
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Preferred Provider Organization (PPO) Plan
Can I get my health care from any doctor, other health
care provider, or hospital?
Yes. PPO plans have network doctors, specialists,
hospitals, and other health care providers you can use.
You can also use out-of-network providers for covered
services, usually for a higher cost, if the provider agrees to
treat you and hasn’t opted out of Medicare (for Medicare
Part A and Part B items and services). You’re always
covered for emergency and urgent care.
Do these plans cover prescription drugs?
In most cases, yes. If you’re planning to enroll in a PPO
and you want Medicare drug coverage (Part D), you must
join a PPO plan that oers Medicare drug coverage. If you
join a PPO plan without drug coverage, you can’t join a
separate Medicare drug plan.
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Do I need to choose a primary care doctor?
No.
Do I have to get a referral to use a specialist?
In most cases, no. But if you use plan specialists (in
network), your costs for covered services will usually be
lower than if you use non-plan specialists (out of network).
What else do I need to know about this type of plan?
•
Because certain providers are “preferred,” you can
save money by using them.
•
Visit Medicare.gov or check with the plan for more
information.
•
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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, agrees to treat you, and hasn’t opted
out of Medicare (for Medicare Part A and Part B items
and services). If you join a Private Fee-for-Service Plan
that has a network, you can also use any of the network
providers who have agreed to always treat plan members.
If you choose an out-of-network doctor, hospital, or other
provider who accepts the plan’s terms, you may pay more.
Do these plans cover prescription drugs?
Sometimes. If your PFFS Plan doesn’t oer Medicare drug
coverage, you can join a separate Medicare drug plan to
get Medicare drug coverage (Part D).
Do I need to choose a primary care doctor?
No.
Do I have to get a referral to use a specialist?
No.
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What else do I need to know about this type of plan?
•
The plan decides how much you pay for services. The
plan will tell you about your cost sharing in the “Annual
Notice of Change” and “Evidence of Coverage”
documents that it sends each year.
•
Some PFFS Plans contract with a network of providers
who agree to always treat you, even if you’ve never
used them before.
•
Out-of-network doctors, hospitals, and other providers
may decide not to treat you, even if you’ve used them
before.
•
In a medical emergency, doctors, hospitals, and other
providers must treat you.
•
For each service you get, make sure to show your plan
member card before you get treated.
•
Visit Medicare.gov or check with the plan for more
information.
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Special Needs Plan (SNP)
A SNP provides benets and services to people with
specic diseases, certain health care needs, or who also
have Medicaid coverage. SNPs include care coordination
services and tailor their benets, provider choices, and list
of drugs (formularies) to best meet the specic needs of
the groups they serve.
Can I get my health care from any doctor, other health
care provider, or hospital?
Some SNPs cover services out of network and some
don’t. Check with the plan to nd out if they cover
services out of network, and if so, how it aects your
costs.
Do these plans cover prescription drugs?
Yes. All SNPs must provide Medicare drug coverage
(Part D).
Do I need to choose a primary care doctor?
Some SNPs require primary care doctors and some don’t.
Check with the plan to nd out if you need to choose a
primary care doctor.
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Do I have to get a referral to use a specialist?
Some SNPs require referrals and some don’t. Certain
services, like yearly screening mammograms, don’t
require a referral. Check with the plan to nd out if you
need a referral.
What else do I need to know about this type of plan?
•
These groups are eligible to enroll in a SNP:
•
People who live in certain institutions (like nursing
homes) or who live in the community but require
nursing care at home (also called an “Institutional
SNP” or I-SNP).
•
People who are eligible for both Medicare and
Medicaid (also called a “Dual Eligible SNP” or
D-SNP). D-SNPs contract with your state Medicaid
program to help coordinate your Medicare and
Medicaid benefits. Some D-SNPs may provide
Medicaid services in addition to Medicare services.
Call your State Medical Assistance (Medicaid)
office to verify your Medicaid eligibility.
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•
People who have specific severe or disabling
chronic conditions (like diabetes, End-Stage Renal
Disease (ESRD), HIV/AIDS, chronic heart failure, or
dementia) (also called a “Chronic condition SNP”
or C-SNP). Plans may further limit membership
to a single chronic condition or a group of related
chronic conditions.
•
To find and compare SNPs or other Medicare
Advantage Plans, visit Medicare.gov/plan-compare.
Filter your search results by “Special Needs Plans” to
nd out if a SNP is available in your area. Check with
the plan for more information.
•
End of Page
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Section 4: Medicare Advantage Plans &
other options
You can join, switch, drop, or make changes
to your Medicare Advantage Plan
Initial Enrollment Period
Go to page 27.
•
When you first become eligible for Medicare
When you rst become eligible for Medicare, you can join
a Medicare Advantage Plan. If you joined a Medicare
Advantage Plan during your Initial Enrollment Period, you
can switch to another Medicare Advantage Plan (with or
without drug coverage) or go back to Original Medicare
(with or without a separate Medicare drug plan) within the
rst 3 months you have Medicare.
•
End of Page
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General Enrollment Period
Go to page 31.
•
January 1 to March 31
If you have Part A coverage and you get Part B for
the rst time during this period, you can also join a
Medicare Advantage Plan.
Your coverage starts the rst day of the month after you
sign up.
Remember, you must have both Part A and Part B to join
a Medicare Advantage Plan.
Open Enrollment Period
•
October 15 to December 7
You can join, switch, or drop a Medicare Advantage Plan
during the Open Enrollment Period each year.
Your coverage starts on January 1 (as long as the plan
gets your enrollment request by December 7).
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Section 4: Medicare Advantage Plans &
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If you join a Medicare Advantage Plan during this period
but change your mind, you can switch back to Original
Medicare or change to a dierent Medicare Advantage
Plan (depending on which coverage works better for you)
during the Medicare Advantage Open Enrollment Period
(January 1 – March 31) described below.
Medicare Advantage Open Enrollment Period
•
January 1 to March 31
Note: You can only switch plans once during this period.
Coverage starts the rst of the month after the plan gets
your request.
If you’re in a Medicare Advantage Plan (with or without
drug coverage), during this period you can:
•
Switch to another Medicare Advantage Plan (with or
without drug coverage).
•
Drop your Medicare Advantage Plan and return to
Original Medicare. You’ll also be able to join a separate
Medicare drug plan.
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During this period, you can’t:
•
Switch from Original Medicare to a Medicare
Advantage Plan.
•
Join a separate Medicare drug plan if you have Original
Medicare.
•
Switch from one Medicare drug plan to another if you
have Original Medicare.
You can only make one change during this period,
and any changes you make will be eective the rst
of the month after the plan gets your request. If you’re
returning to Original Medicare and joining a separate
Medicare drug plan, you don’t need to contact your
Medicare Advantage Plan to disenroll. The disenrollment
will happen automatically when you join the drug plan.
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Special Enrollment Period
Go to pages 28 – 30.
•
Qualifying Life Event
In most cases, if you join a Medicare Advantage Plan,
you must keep it for the calendar year starting the date
your coverage begins. However, in certain situations,
like if you move or you lose other insurance coverage,
you may be able to join, switch, or drop a Medicare
Advantage Plan during a Special Enrollment Period. Go to
pages 194 – 196.
5-star Special Enrollment Period
•
December 8 to November 30 the following year
Note: You can only switch plans once during this period.
Medicare uses ratings from 1 – 5 stars to help you
compare plans based on quality and performance.
If a Medicare Advantage Plan, Medicare drug plan, or
Medicare Cost Plan with a 5-star quality rating is available
in your area, you can use the 5-star Special Enrollment
Period to switch from your current Medicare plan to a
Medicare plan with a 5-star quality rating.
Visit Medicare.gov for more information.
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Important!
If you drop your Medicare Supplement Insurance
(Medigap) policy to join a Medicare Advantage Plan,
you may not get the same policy back. Also, if you don’t
drop your Medicare Advantage Plan and return to Original
Medicare within 12 months of joining, you may be limited
in your ability to get a Medigap policy when you return to
Original Medicare. Go to page 187 – 188.
Does Medicare oer other types of plans or
programs to get health coverage?
Yes, Medicare may oer some other plans and programs
in your area. Some provide both Part A (Hospital
Insurance) and Part B (Medical Insurance) coverage, while
others provide only Part B coverage. Some also provide
Medicare drug coverage (Part D). They have some (but
not all) of the same rules as Medicare Advantage Plans.
However, each has special rules and exceptions, so you
should contact any plans you’re interested in to get more
details.
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Section 4: Medicare Advantage Plans &
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Cost Plans
Cost Plans are a type of Medicare health plan available in
certain, limited areas of the country.
•
In general, you can join even if you only have Part B.
•
If you have Part A and Part B and go to a non-network
provider, Original Medicare covers the services.
You’ll pay the Part A and Part B coinsurance and
deductibles.
•
You can join any time the Cost Plan is accepting new
members.
•
You can leave any time and return to Original Medicare.
•
You can join a separate Medicare drug plan, or you can
get Medicare drug coverage (Part D) from the Cost Plan
(if offered). You can choose to get a separate Medicare
drug plan even if the Cost Plan offers Medicare drug
coverage. You can only add or drop drug coverage at
certain times (go to pages 193 – 196).
To nd out if there are Cost Plans in your area, visit
Medicare.gov/plan-compare. You can contact the plan
you’re interested in for more information. Your State Health
Insurance Assistance Program (SHIP) can also help you.
Go to pages 280 – 287 for the phone number of your local
SHIP. A trusted agent or broker may also be able to help.
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Program of All-inclusive Care for the Elderly
(PACE)
PACE is a Medicare and Medicaid program oered in
many states that allows people who otherwise need a
nursing home-level of care to remain in the community,
like a home, apartment, or other appropriate setting. 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 certified 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 covers all Medicare- and Medicaid-covered care
and services, and other services that the PACE team
of health care professionals decides are necessary to
improve and maintain your health. This includes drugs,
as well as any other medically necessary care, like
doctor or health care provider visits, transportation, home
care, hospital visits, and even nursing home stays when
necessary.
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Section 4: Medicare Advantage Plans &
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If you have Medicaid, you won’t have to pay a monthly
premium for the long-term care portion of the PACE
benet. If you have Medicare but not Medicaid, you’ll be
charged a monthly premium to cover the long-term care
portion of the PACE benet and a premium for Medicare
drug coverage (Part D). However, in PACE, there’s never a
deductible or copayment for any drug, service, or care
that the PACE team of health care professionals approves.
Visit Medicare.gov/pace to nd out if there’s a PACE
organization that serves your community.
•
End of Page
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Medicare Innovation Projects
Medicare develops innovative models, demonstrations,
and pilot projects to test and measure the eect of
potential changes in Medicare. These projects help to nd
new ways to improve health care quality and reduce costs,
and sometimes oer you extra benets and services.
Usually, they operate only for a limited time and for a
specic group of people and/or are oered only in specic
areas. Examples of current models, demonstrations,
and pilot projects include innovations in primary care,
care related to specic procedures (like hip and knee
replacements), cancer care, skilled nursing facility care
or rehabilitation care, and care for people with chronic
kidney disease and End-Stage Renal Disease (ESRD).
Medicare also explores innovations through
Accountable Care Organizations (ACOs).
Ask your doctor if they participate in these models,
and what it means for your care. To learn more about
the current Medicare models, demonstrations, and
pilot projects, call 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
179
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Section 4: Medicare Advantage Plans &
other options
How does Medigap work?
Original Medicare doesn’t pay all of the cost for covered
health care services and supplies. Medicare Supplement
Insurance (Medigap) policies sold by private insurance
companies can help pay some of the remaining health
care costs for covered services and supplies, like
copayments, coinsurance, and deductibles.
Some Medigap policies also oer coverage for services
that Original Medicare doesn’t cover, like medical care
when you travel outside the U.S. Generally, Medigap
doesn’t cover long-term care (like care in a nursing home),
vision or dental services, hearing aids, eyeglasses, or
private-duty nursing.
Section 5: Medicare
Supplement
Insurance
(Medigap)
Underlined words are dened on pages 289 – 296.
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—
Section 5: Medicare Supplement Insurance
(Medigap)
Medigap plans are standardized
Medigap must follow federal and state laws designed
to protect you, and they must be clearly identied as
“Medicare Supplement Insurance.” Insurance companies
can sell you only a “standardized” plan, identied in most
states as plans A – D, F, G, and K – N. All plans oer the
same basic benets, no matter where you live or which
insurance company you buy the policy from. Some
oer additional benets. Compare the benets of each
lettered plan to help you nd one that meets your needs.
In Massachusetts, Minnesota, and Wisconsin, Medigap
plans are standardized in a dierent way. For more
information or to nd Medigap policies in your area, visit
Medicare.gov/medigap-supplemental-insurance-
plans.
You can also visit Medicare.gov/publications to review
the booklet, “Choosing a Medigap Policy: A Guide to
Health Insurance for People with Medicare.”
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—
Section 5: Medicare Supplement Insurance
(Medigap)
Important!
Medigap plans sold to people who are new to Medicare
on or after January 1, 2020 aren’t allowed to cover the
Part B deductible. Because of this, Plans C and F are
no longer available to people new to Medicare on or
after January 1, 2020. However, if you were eligible for
Medicare before January 1, 2020, but haven’t yet enrolled,
you may be able to buy Plan C or Plan F. People new to
Medicare on or after January 1, 2020 have the right to buy
Plans D and G instead of Plans C and F.
How do I compare Medigap plans?
The text below gives basic information about the dierent
benets that Medicare Supplement Insurance (Medigap)
plans cover for 2024. If a percentage is present, the
Medigap plan covers that percentage of the benet, and
you’re responsible for the rest.
Medigap plans
•
Medicare Part A coinsurance and hospital costs
(up to an additional 365 days after Medicare benets
are used) covers 100% in plans A, B, C, D, F*, G*, K, L,
M, and N.
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—
Section 5: Medicare Supplement Insurance
(Medigap)
•
Medicare Part B coinsurance or copayment covers
100% in plans A, B, C, D, F*, G*, M, and N. Covers
50% in plan K and 75% in plan L. Plan N pays 100%***
of the Part B coinsurance, except for a copayment
of up to $20 for some oce visits and up to a $50
copayment for emergency room visits that don’t result
in an inpatient admission.
•
Blood (rst 3 pints) covers 100% in plans A, B, C, D,
F*, G*, M, and N. Covers 50% in plan K and 75% in
plan L.
•
Part A hospice care coinsurance or copayment
covers 100% in plans A, B, C, D, F*, G*, M, and N.
Covers 50% in plan K and 75% in plan L.
•
Skilled nursing facility care coinsurance covers
100% in plans C, D, F*, G*, M, and N. Covers 50% in
plan K and 75% in plan L.
•
Part A deductible covers 100% in plans B, C, D, F*,
G*, and N. Covers 50% in plan K and M and 75% in
plan L.
•
Part B deductible covers 100% in plans C and F*.
•
Part B excess charges covers 100% in plans F*
and G*.
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—
Section 5: Medicare Supplement Insurance
(Medigap)
•
Foreign travel emergency (up to plan limits) covers
80% in plans C, D, F*, G*, M, and N.
•
Out-of-pocket limit for plan K in 2024** is $7,060.
•
Out-of-pocket limit for plan L in 2024** is $3,530.
* Plans F and G also oer a high-deductible plan
in some states. With this option, you must pay for
Medicare-covered costs (coinsurance, copayments,
and deductibles) up to the deductible amount of
$2,800 in 2024 before your policy pays anything. (You
can’t buy Plans C and F if you were new to Medicare
on or after January 1, 2020. Go to page 181 for more
information.)
* * For Plans K and L, after you meet your out-of-pocket
yearly limit and your yearly Part B deductible ($240
in 2024), the Medigap plan pays 100% of covered
services for the rest of the calendar year.
*** Plan N pays 100% of the Part B coinsurance. You
must pay a copayment of up to $20 for some oce
visits and up to a $50 copayment for emergency room
visits that don’t result in an inpatient admission.
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—
Section 5: Medicare Supplement Insurance
(Medigap)
What else should I know about Medigap?
Before you can buy Medicare Supplement Insurance
(Medigap), you must generally have Part A and Part B.
With Medigap, you pay a monthly premium to a private
insurance company in addition to the monthly Part B
premium you pay to Medicare. If you’re thinking about
buying Medigap, be sure to compare plans. The
costs can vary between plans oered by dierent
companies for exactly the same coverage, and may
go up as you get older. Some states limit Medigap
premium costs. A Medigap policy only covers one
person. Spouses must buy separate coverage.
Can I buy Medigap and a separate Medicare drug plan
from the same company?
Yes. But you may need to make 2 separate premium
payments. Contact the company to nd out how to pay
your premiums.
Can I have drug coverage in both Medigap and my
Medicare drug plan?
No. Go to page 218 for more information.
185
—
Section 5: Medicare Supplement Insurance
(Medigap)
Note: In some states, you may be able to buy another
type of Medigap policy called Medicare SELECT.
Medicare SELECT is a type of Medigap policy sold in
some states that requires you to use hospitals and, in
some cases, doctors within its network to be eligible for
full insurance benets (except in an emergency). If you buy
Medicare SELECT, you have rights to change your mind
within 12 months and switch to standard Medigap.
When’s the best time to buy a Medigap policy?
•
The best time to buy a Medigap policy is during your
Medigap Open Enrollment Period. This 6-month period
begins the first month you have Medicare Part B
(Medical Insurance), and you’re 65 or older. (Some
states have additional Open Enrollment Periods.) After
this enrollment period, you may not be able to buy
a Medigap policy or it may cost more. In certain
situations, you may have rights to buy a Medigap
policy (guaranteed issue rights) outside of your
Medigap Open Enrollment Period.
•
If you delay signing up for Part B 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.
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—
Section 5: Medicare Supplement Insurance
(Medigap)
•
Federal law generally doesn’t require insurance
companies to sell Medigap to people under 65. If
you’re under 65, you might not be able to buy the
policy you want, or any 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.
Call your State Health Insurance Assistance Program
(SHIP) (go to pages 280 – 287 for the phone number of
your local SHIP), or your State Insurance Department to
learn more about your rights to buy a Medigap policy.
A trusted agent or broker may also be able to help.
Can I have Medigap and a Medicare Advantage
Plan?
•
If you’re in a Medicare Advantage Plan, it’s illegal
for anyone to sell you a Medigap policy unless you’re
switching back to Original Medicare. If you aren’t
planning to drop your Medicare Advantage Plan, and
someone tries to sell you a Medigap policy, report it to
your State Insurance Department.
•
If you have Medigap and join a Medicare Advantage
Plan, you may want to drop Medigap. You can’t
use Medigap to pay your Medicare Advantage Plan
copayments, deductibles, and premiums.
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Section 5: Medicare Supplement Insurance
(Medigap)
Important!
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 may not be able to get the same policy back, or in
some cases, any Medigap policy unless you leave your
Medicare Advantage Plan during your trial period.
•
If you joined a Medicare Advantage Plan when you
were first eligible for Medicare at 65, you can choose
from any Medigap policy that’s sold by an insurance
company in your state when you switch to Original
Medicare within the first year of joining. You may also
have an opportunity to enroll in a Medicare drug plan
at this time.
•
If you drop a Medigap policy to join a Medicare
Advantage Plan for the first time, you’ll have a single
12-month period (your trial right period) to get your
Medigap policy back if the same insurance company
still sells it once you return to Original Medicare. If
it isn’t available, you can buy a Medigap policy you
qualify for that’s sold by an insurance company in your
state (except for Plans M or N). You may also have an
opportunity to enroll in a Medicare drug plan at this
time.
188
—
Section 5: Medicare Supplement Insurance
(Medigap)
Note: If you don’t drop your Medicare Advantage
Plan and return to Original Medicare within 12 months
of joining, generally, you must keep your Medicare
Advantage Plan for the rest of the year. You can
disenroll or change Medicare Advantage Plans during
the Open Enrollment Period or if you qualify for a
Special Enrollment Period. Depending on the type of
Special Enrollment Period, you may or may not have
the right to buy a Medigap policy.
•
Some states provide additional special rights to buy a
Medigap policy.
•
End of Page
189
—
Section 5: Medicare Supplement Insurance
(Medigap)
Where can I get more information?
•
Call your State Insurance Department. Call
1 800 633 - 4227 to get the phone number. TTY users
can call 1 877 486 - 2048.
•
Visit Medicare.gov/medigap-supplemental-
insurance-plans to find policies and pricing in your
area.
•
Visit Medicare.gov/publications to review the
booklet, “Choosing a Medigap Policy: A Guide to
Health Insurance for People with Medicare.”
•
Call your State Health Insurance Assistance Program
(SHIP). Go to pages 280 – 287 for the phone number of
your local SHIP. A trusted agent or broker in your area
may also be able to help.
Go to pages 9 – 20 for an overview of your Medicare
options.
190
Notes
191
How does Medicare drug coverage work?
Medicare drug coverage (Part D) helps pay for prescription
drugs you need. It’s optional and oered to everyone
with Medicare. Even if you don’t take prescription drugs
now, consider getting Medicare drug coverage. If you
decide not to get it when you’re rst eligible, and you
don’t have other creditable prescription drug coverage
(like drug coverage from an employer or union) 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 drug coverage (go to
pages 202 – 206). To get Medicare drug coverage, you
must join a Medicare-approved plan that oers drug
coverage. Each plan can vary in cost and specic drugs
covered. Visit Medicare.gov/plan-compare to nd and
compare plans in your area.
Section 6: Medicare
drug coverage
(Part D)
Underlined words are dened on pages 289 – 296.
192
—
Section 6: Medicare drug coverage (Part D)
There are 2 ways to get Medicare drug coverage (Part D):
1. Medicare drug plans. These plans add Medicare drug
coverage (Part D) to Original Medicare, some Medicare
Cost Plans, some Medicare Advantage Private
Fee-for-Service Plans, and Medicare Advantage
Medical Savings Account (MSA) Plans. You must have
Part A and/or Part B to join a separate Medicare drug
plan.
2. Medicare Advantage Plans or other
Medicare health plans with drug coverage. You
get your Part A, Part B, and Medicare drug coverage
(Part D) through these plans. Remember, you must
have Part A and Part B to join a Medicare Advantage
Plan, and not all Medicare Advantage Plans offer drug
coverage.
In either case, you must live in the service area of the
plan you want to join and be lawfully present in the U.S.
Medicare drug plans and Medicare health plans with
drug coverage are called “Medicare drug coverage” in
this handbook.
193
—
Section 6: Medicare drug coverage (Part D)
Important!
If you have employer or union coverage
Call your benets administrator before you make any
changes, or sign up for any other coverage. If you
sign up for other coverage, you could lose your employer
or union health and drug coverage for you and your
dependents. If this happens, you may not be able to get
your employer or union coverage back. If you want to
know how Medicare drug coverage (Part D) works with
other drug coverage you may have, go to pages 215 – 222.
When can I join, switch, or drop a plan?
You can join, switch, or drop a Medicare drug plan or a
Medicare Advantage Plan with drug coverage during
these times:
•
Initial Enrollment Period. When you first become
eligible for Medicare, you can join a plan. Go to
pages 26 – 27.
•
Open Enrollment Period. From October 15 –
December 7 each year, you can join, switch, or drop
a plan. Your coverage will begin on January 1 (as long
as the plan gets your request by December 7). Go to
pages 170 – 171.
194
—
Section 6: Medicare drug coverage (Part D)
•
Medicare Advantage Open Enrollment Period
(only if you’re already in a Medicare Advantage
Plan). From January 1 – March 31 each year, if you’re
in a Medicare Advantage Plan, you can switch to a
different Medicare Advantage Plan or switch to Original
Medicare (and join a separate Medicare drug plan)
once during this time. Go to page 171 – 172.
New!
If you have to pay for Part A, and you sign up for Part B
during the General Enrollment Period (January 1 – March
31), you can also join a Medicare drug plan when you sign
up for Part B. You’ll have 2 months after signing up for
Part B to join a drug plan. Your drug coverage will start the
month after the plan gets your request to join.
Special Enrollment Periods
Generally, you must stay in your plan for the entire year.
But when certain events happen in your life, like if you
move or lose other insurance coverage, you may qualify
for a Special Enrollment Period. You may be able make
changes to your plan mid-year if you qualify. Check with
your plan for more information.
195
—
Section 6: Medicare drug coverage (Part D)
New!
If you sign up for Part A or Part B during a Special
Enrollment Period because of an exceptional
condition (go to page 30), you’ll have 2 months to join
a Medicare Advantage Plan (with or without drug
coverage) or a Medicare drug plan (Part D). Your coverage
will start the rst day of the month after the Medicare
Advantage Plan gets your request to join.
Visit Medicare.gov, or check with your plan for more
information. You can also call your State Health
Insurance Assistance Program (SHIP) for help. Go to
pages 280 – 287 for the phone number of your local SHIP.
How do I switch plans?
You can switch to a new Medicare drug plan or Medicare
Advantage Plan with drug coverage simply by joining
another plan during one of the times listed above. Your
old drug coverage will end when your new drug coverage
begins. You should get a letter from your new plan
telling you when your coverage begins, so you don’t
need to cancel your old plan. You can also switch
plans by calling 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
196
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Section 6: Medicare drug coverage (Part D)
How do I drop my plan?
If you want to drop your Medicare drug plan or
Medicare Advantage Plan with drug coverage and don’t
want to join a new plan, you can only do so during certain
times (go to pages 193 – 194). You can disenroll by calling
1 800 633 - 4227. 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 or Medicare health plan with drug
coverage later, you have to wait for an enrollment period.
You may also have to pay a late enrollment penalty if you
don’t have creditable prescription drug coverage. Go
to pages 202 – 206.
Read the information you get from your plan
Review the “Evidence of Coverage” and “Annual Notice of
Change” your plan sends you each year. The Evidence of
Coverage gives you details about what the plan covers,
how much you pay, and more. The Annual Notice of
Change includes any changes in coverage, costs, provider
networks, service area, and more that will be eective
in January. If you don’t get these important documents in
early fall, contact your plan.
197
—
Section 6: Medicare drug coverage (Part D)
How much do I pay?
Your drug costs will vary based on the plan you choose.
Remember, plan coverage and costs can change each
year. You may have to pay a premium, deductible,
copayments, or coinsurance throughout the year. Learn
more about these costs on the next 4 pages.
Your actual drug coverage costs will vary depending
on:
•
Your prescriptions and whether they’re on your plan’s
list of covered drugs (formulary). Go to page 207.
•
What “tier” a drug is in. Go to pages 207 – 208.
•
Which drug benefit phase you’re in (like whether you’ve
met your deductible, or if you’re in the catastrophic
coverage phase). Go to page 201.
•
Which pharmacy you use (whether it offers preferred
or standard cost sharing, is out of network, or is mail
order). Your out-of-pocket drug costs may be less at
a preferred pharmacy because it has agreed with your
plan to charge less.
•
Whether you get Extra Help paying your Medicare
drug costs. Go to page 226 – 228.
198
—
Section 6: Medicare drug coverage (Part D)
Cost & coverage:
Some ways you may be able to lower the cost of your
drugs include choosing generics over brand name
or paying the non-insurance cost of a drug. Ask your
pharmacist—they can tell you if there’s a less expensive
option available. Check with your doctor to make sure the
generic option is best for you.
Monthly premium
Most drug plans charge a monthly fee that varies by plan.
You pay this in addition to the Part B premium. If you’re
in a Medicare Advantage Plan or a Medicare Cost Plan
with drug coverage, the monthly premium may include an
amount for drug coverage.
Note: Contact your plan (not Social Security or the
Railroad Retirement Board (RRB)) if you want your drug
premium deducted from your monthly Social Security or
RRB payment. If you want to stop premium deductions
and get billed directly, contact your plan.
199
—
Section 6: Medicare drug coverage (Part D)
Important!
If you have a higher income, you might pay more
for your Medicare drug coverage (Part D). If your
income is above a certain limit (in 2024: $103,000 if you
le individually or $206,000 if you’re married and le
jointly), you’ll pay an extra amount in addition to your
plan premium (sometimes called “Part D IRMAA”).
You’ll also have to pay this extra amount if you’re in a
Medicare Advantage Plan that includes drug coverage.
This doesn’t aect everyone, so most people won’t have
to pay an extra amount.
Usually, the extra amount will be deducted from your
Social Security or RRB payment. If Medicare or the RRB
bills you for the extra amount instead of deducting it from
your Social Security or RRB payment, then you must pay
the extra amount to Medicare or the RRB, not your plan.
If you don’t pay the extra amount, you could lose your
Medicare drug coverage (Part D). You may not be able
to join another plan right away, and you may have to pay
a late enrollment penalty for as long as you have drug
coverage.
200
—
Section 6: Medicare drug coverage (Part D)
You’ll pay Part D IRMAA payments separately, even if your
employer or another third party (like a retirement system)
pays your plan premiums.
If you have to pay an extra amount and you disagree (for
example, you have one or more life-changing events that
lower your income), visit SSA.gov or call Social Security at
1 800 772 - 1213. TTY users can call 1 800 325 - 0778.
Yearly deductible
This is the amount you must pay before your plan begins
to pay its share of your covered drugs. Some plans
don’t have a deductible. In some plans that do have a
deductible, drugs on some tiers are covered before the
deductible.
Copayments or coinsurance
These are the amounts you pay for your covered drugs
after the deductible (if the plan has one). You pay your
share and your plan pays its share for covered drugs. If
you pay coinsurance, these amounts may vary because
drug plans and manufacturers can change what they
charge at any time throughout the year. The amount you
pay will also depend on the tier level assigned to your
drug. Go to pages 207 – 208.
201
—
Section 6: Medicare drug coverage (Part D)
Once you and your plan spend $5,030 combined on drugs
(including deductible), you’ll generally pay no more than
25% of the cost for prescription drugs until your out-of-
pocket spending is $8,000.
Catastrophic coverage
New!
Once your out-of-pocket spending in 2024 reaches
$8,000, (including certain payments made by other people
or entities, including Medicare’s Extra Help program,
on your behalf), you won’t have to pay a copayment or
coinsurance for covered Part D drugs for the rest of the
calendar year.
Note: If you get Extra Help, you won’t have some of these
costs. Go to pages 226 – 232.
Important!
Visit Medicare.gov/plan-compare to get specic
Medicare drug plan and Medicare Advantage Plan
costs, and call the plans you’re interested in to get more
details. For help comparing plan costs, call your State
Health Insurance Assistance Program (SHIP). Go to
pages 280 – 287 for the phone number of your local SHIP.
A trusted agent or broker may also be able to help.
202
—
Section 6: Medicare drug coverage (Part D)
What’s the Medicare drug coverage (Part D) late
enrollment penalty?
The late enrollment penalty is an amount that’s
permanently added to your Medicare drug coverage
(Part D) premium. You may have to pay a late enrollment
penalty if you enroll at any time after your Initial Enrollment
Period is over and there’s a period of 63 or more days in a
row when you don’t have Medicare drug coverage or other
creditable prescription drug coverage. You’ll generally
have to pay the penalty for as long as you have Medicare
drug coverage.
Note: If you get Extra Help, you don’t pay a late
enrollment penalty.
There are 3 ways to avoid paying a penalty:
1. Get Medicare drug coverage (Part D) when you’re
first eligible for it. Even if you don’t take drugs now,
you should consider joining a separate Medicare
drug plan or a Medicare Advantage Plan with drug
coverage to avoid a penalty. You may be able to find
a plan that meets your needs with little to no monthly
premiums. Go to pages 9 – 20 to learn more about
your choices.
203
—
Section 6: Medicare drug coverage (Part D)
2. Add Medicare drug coverage (Part D) 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 non-Medicare drug
coverage is creditable coverage. If you go 63 days
or more in a row without Medicare drug coverage or
other creditable prescription drug coverage, you may
have to pay a penalty if you sign up for Medicare drug
coverage later.
3. Keep records showing when you had other
creditable prescription drug coverage, and tell your
plan when they ask about it. If you don’t tell your
plan about your previous creditable prescription drug
coverage, you may have to pay a penalty for as long
as you have Medicare drug coverage.
204
—
Section 6: Medicare drug coverage (Part D)
How much more will I pay for a late enrollment
penalty?
The cost of the late enrollment penalty depends on
how long you didn’t have creditable prescription
drug coverage. Currently, the late enrollment penalty
is calculated by multiplying 1% of the “national base
beneciary premium” ($34.70 in 2024) by the number of
full, uncovered months that you were eligible but didn’t
have Medicare drug coverage (Part D) and went without
other creditable prescription drug coverage. The nal
amount is rounded to the nearest $.10 and added to
your monthly premium. The “national base beneciary
premium” may increase or decrease each year. If
that occurs, the penalty amount may also increase or
decrease. After you get Medicare drug coverage, the plan
will tell you if you owe a penalty and what your premium
will be.
Example:
Mrs. Martinez is currently eligible for Medicare, and her
Initial Enrollment Period ended on May 31, 2020. She
doesn’t have prescription drug coverage from any other
source. She didn’t join by May 31, 2020, and instead
joined during the Open Enrollment Period that ended
December 7, 2022. Her drug coverage was eective
January 1, 2023.
205
—
Section 6: Medicare drug coverage (Part D)
2023
Since Mrs. Martinez was without creditable
prescription drug coverage from June 2020 –
December 2022, her penalty in 2023 was 31% (1% for
each of the 31 months) of $32.74 (the national base
beneciary premium for 2023) or $10.14. Since the
monthly penalty is always rounded to the nearest $0.10,
she paid $10.10 each month in addition to her plan’s
monthly premium.
Here’s the math:
.31 (31% penalty) × $32.74 (2023 base beneciary
premium) = $10.14
$10.14 rounded to the nearest $0.10 = $10.10
$10.10 = Mrs. Martinez’s monthly late enrollment
penalty for 2023
2024
In 2024, Medicare recalculated Mrs. Martinez’s penalty
using the 2024 base beneciary premium ($34.70). So,
Mrs. Martinez’s new monthly penalty in 2024 is 31% of
$34.70, or $10.75 each month. Since the monthly penalty
is always rounded to the nearest $0.10, she pays $10.80
each month in addition to her plan’s monthly premium.
206
—
Section 6: Medicare drug coverage (Part D)
Here’s the math:
.31 (31% penalty) × $34.70 (2024 base beneciary
premium) = $10.75
$10.75 rounded to the nearest $0.10 = $10.80
$10.80 = Mrs. Martinez’s monthly late enrollment
penalty for 2024
What if I don’t agree with the late enrollment penalty?
Your Medicare drug plan or Medicare Advantage Plan
with drug coverage will send you a letter stating you
have to pay a late enrollment penalty. If you disagree
with your penalty, you can request a review (generally
within 60 days from the date on the letter). Fill out the
“reconsideration request form” you get with your letter
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.
207
—
Section 6: Medicare drug coverage (Part D)
Which drugs are covered?
All plans must cover a wide range of prescription drugs that
people with Medicare take, including most drugs in certain
“protected classes,” like drugs to treat cancer or HIV/AIDS.
Information about a plan’s list of covered drugs (called a
“formulary”) isn’t included in this handbook because each
plan has its own formulary. A plan can make some changes
to its drug list during the year if it follows guidelines set
by Medicare. For example, your plan may change its
drug list during the year because drug therapies change,
new drugs are released, or new medical information
becomes available. Your plan coinsurance may increase
for a particular brand name drug or generic drug when
the manufacturer raises the price. Your copayment or
coinsurance may increase when a plan starts to oer a
generic form of a brand name drug, but you continue to
take the brand name drug. In some cases, the plan may
cover a drug for one health condition but not another.
Note: Medicare Part B covers a limited number of
outpatient prescription drugs. Go to page 86 for more
information.
Your Medicare drug coverage (Part D) typically places
drugs into dierent levels called “tiers” on their formularies.
Drugs in each tier have a dierent cost. For example, a
drug in a lower tier will generally cost you less than a drug
in a higher tier.
208
—
Section 6: Medicare drug coverage (Part D)
What happens if my drug is 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 coinsurance or copayment for the drug in the
higher tier. Go to pages 245 – 247 for more information on
exceptions.
Plans can change their formularies at any time. Your plan
may notify you of any formulary changes that aect drugs
you’re taking.
Contact your plan for its current formulary,
or visit the plan’s website. You can also visit
Medicare.gov/plan-compare
or call 1 800 633 - 4227.
TTY users can call 1 877 486 - 2048.
Important!
Each month you ll a prescription, your plan sends you
an “Explanation of Benets” 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 at 1 877 772 - 3379.
Go to page 263.
209
—
Section 6: Medicare drug coverage (Part D)
Plans may have coverage rules for certain drugs
•
Prior authorization: You and/or your prescriber
must contact your plan before you can fill certain
prescriptions. Your prescriber may need to show
that the drug is medically necessary for the plan to
cover it.
Plans may also use prior authorization when they cover
a drug for only certain medical conditions it’s approved
for, but not others. When this occurs, plans will likely
have alternative drugs on their list of covered drugs
(formulary) for the other medical conditions the drug
is approved to treat.
•
Quantity limits: Limits on how much medicine you
can get at a time.
•
Step therapy: You may need to try one or more
similar, lower-cost drugs before the plan will cover the
prescribed drug.
210
—
Section 6: Medicare drug coverage (Part D)
•
Medication safety checks at the pharmacy: Before
the pharmacy fills your prescriptions, your plan and
pharmacy perform additional safety checks, like
checking for drug interactions and incorrect dosages.
These safety checks also include checking for possible
unsafe amounts of opioid pain medications, limiting
the day’s supply of a rst prescription for opioids, and
use of opioids at the same time as benzodiazepines
(commonly used for anxiety and sleep). Opioid pain
medicine (like oxycodone and hydrocodone) can help
with certain types of pain, but have risks and side
eects (like addiction, overdose, and death). These
can increase when you take opioids with certain other
drugs, like benzodiazepines, anti-seizure medications,
gabapentin, muscle relaxers, certain antidepressants,
and drugs for sleeping problems. Check with your
doctor or pharmacist if you have questions about risks
or side eects.
211
—
Section 6: Medicare drug coverage (Part D)
•
Drug Management Programs: Medicare drug
coverage (Part D) has programs in place to help you use
these opioids and benzodiazepines safely. If your opioid
use could be unsafe (for example due to getting opioid
prescriptions from multiple doctors or pharmacies, or
if you had a recent overdose from opioids), your plan
will contact the doctors who prescribed them for you
to make sure they’re medically necessary and you’re
using them appropriately.
If your plan decides your use of prescription opioids
and benzodiazepines may not be safe, the plan will
send you a letter in advance. This letter will tell you if
the plan will limit coverage of these drugs for you, or
if you’ll be required to get the prescriptions for these
drugs only from one doctor or pharmacy you select.
You and your doctor have the right to appeal these
limitations if you disagree with the plan’s decision (go
to pages 241 – 244). The letter will also tell you how to
contact the plan if you have questions or would like to
appeal.
The opioid safety reviews at the pharmacy and
Drug Management Programs generally don’t apply
if you have cancer or sickle cell disease, are getting
palliative or end-of-life care, are in hospice, or live in a
long-term care facility.
212
—
Section 6: Medicare drug coverage (Part D)
If you or your prescriber believe that your plan should
waive one of these coverage rules, you can ask for an
exception. Go to pages 245 – 246.
Important tips if you’re prescribed opioids:
•
Opioid medications can be an important part of pain
management, but they also can have serious health
risks if misused.
•
Medicare covers naloxone, a drug that your doctor
may prescribe as a safety measure in case you need
to rapidly reverse the effects of an opioid overdose.
Talk with your doctor about having naloxone at home.
•
Talk with your doctor about your dosage and the
length of time you’ll be taking opioids. You and your
doctor may decide later you don’t need to take all of
your prescription.
•
Talk with your doctor about other options that
Medicare covers to treat your pain, like non-
opioid medications and devices, physical therapy,
acupuncture for lower back pain, individual and group
psychotherapy, behavioral health integration services,
and more.
•
Never take more opioids than prescribed. Also, talk
with your doctor about any other pain medicines
you’re taking.
213
—
Section 6: Medicare drug coverage (Part D)
•
Safely store and discard unused prescription opioids
through your community drug take-back program or
your pharmacy mail-back program.
For more information on safe and eective
pain management and opioid use, visit
Medicare.gov/coverage/pain-management or call
1 800 633 - 4227. TTY users can call 1 877 486 - 2048.
Can I get automatic prescription rells in the
mail?
Some people with Medicare get their drugs through
an “automatic rell” service that automatically delivers
prescription drugs before they run out. To make sure you
still need a prescription before they send you a rell, drug
plans may oer a voluntary auto-ship program. Contact
your plan for more information.
Note: Medicare drug coverage (Part D) includes drugs,
like buprenorphine, to treat opioid use disorders. It also
covers drugs, like methadone, when prescribed for pain.
214
—
Section 6: Medicare drug coverage (Part D)
Medication Therapy Management program
Plans with Medicare drug coverage (Part D) must oer
Medication Therapy Management services to help
members if they meet certain requirements or are in
a Drug Management Program. If you qualify, you can
get these services at no cost to help you understand
how to manage your medications and take them safely.
Medication Therapy Management services usually include
a discussion with a pharmacist or health care provider
to review your medications. These services may vary by
plan. Contact your plan for specic details and to nd out
if you’re eligible.
Part D coverage for insulin
Part D covers insulin, including insulin used with either
a disposable or non-traditional insulin pump. It also
covers certain medical supplies used to inject insulin,
like syringes, gauze, and alcohol swabs. Covered insulin
products are included on your plan’s formulary.
Important!
Plans can’t charge you more than $35 for a one-month
supply of each Part D-covered insulin you take, and you
don’t have to pay a deductible for insulin. This applies to
everyone who takes insulin, even if you get Extra Help.
215
—
Section 6: Medicare drug coverage (Part D)
Similar caps on costs apply for traditional insulin
used in insulin pumps (covered under Part B). Visit
Medicare.gov/coverage/insulin to learn more.
How do other insurance and programs work
with Medicare drug coverage (Part D)?
Medicaid
If you have Medicare and full Medicaid coverage,
Medicare covers your prescription drugs. However,
Medicaid may still cover some drugs that Medicare
doesn’t cover.
Note: You automatically qualify for Extra Help if you have
Medicare and Medicaid. Go to pages 226 – 227.
216
—
Section 6: Medicare drug coverage (Part D)
Employer or union coverage
This is health coverage from your, your spouse’s, or
other family member’s current or former employer or
union. When you have employer or union coverage or
other health insurance (like a retiree health plan) and
Medicare, there are rules for whether Medicare or your
other coverage pays rst. Go to pages 36 – 38 for more
information. If you have drug coverage based on your
current or previous employment, your employer or union
will notify you each year to let you know if your drug
coverage is creditable. Keep the information you get.
Call your benets administrator for more information
before making any changes to your coverage.
Important!
If you get Medicare drug coverage, you, your spouse, or
your dependents may lose your employer or union health
coverage.
217
—
Section 6: Medicare drug coverage (Part D)
COBRA
This federal law 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. There may be reasons why you should
take Part B instead of, or in addition to, COBRA coverage
(go to page 29). However, if you take COBRA and you’re
eligible for Medicare, COBRA may only pay a small
portion of your medical costs, and you may have to pay
most of the costs yourself. Contact your COBRA plan and
ask what percent they pay. To avoid unexpected medical
bills, you may need to sign up for Medicare right away.
Talk with your State Health Insurance Assistance Program
(SHIP) for free, personalized help with this decision. Go to
pages 280 – 287 for the phone number of your local SHIP.
If you have COBRA that includes creditable prescription
drug coverage, you’ll have a Special Enrollment Period
to get Medicare drug coverage (Part D) without paying
a penalty when the COBRA coverage ends. If you have
questions about Medicare and COBRA, call the Benets
Coordination & Recovery Center at 1 855 798 - 2627. TTY
users can call 1 855 797 - 2627. A trusted agent
or broker may also be able to help.
218
—
Section 6: Medicare drug coverage (Part D)
Medicare Supplement Insurance (Medigap) with
drug coverage
Medigap policies can no longer be sold with drug
coverage, but if you have an older Medigap policy that
was sold with drug coverage, you can keep it. You may
choose to join a separate Medicare drug plan because most
Medigap drug coverage isn’t creditable, and you may pay
more if you join a drug plan later. Go to page 202.
You can’t have drug coverage in both Medigap and your
Medicare drug plan. If you join a separate Medicare drug
plan, tell your Medigap insurance company so they can
remove the drug coverage and adjust your premiums. Call
your Medigap insurance company for more information.
•
End of Page
219
—
Section 6: Medicare drug coverage (Part D)
How does other government insurance work
with Medicare drug coverage (Part D)?
The types of insurance listed below are all considered
creditable prescription drug coverage. In most cases,
it’s to your advantage to keep this coverage if you have it.
Federal Employee Health Benets Program
(FEHB)
This is health coverage for current and retired federal
employees and covered family members. These plans
usually include creditable prescription drug coverage,
so you don’t need to get Medicare drug coverage
(Part D). However, if you decide to get Medicare drug
coverage, you can keep your FEHB plan, and in most
cases, Medicare will pay rst. For more information, visit
opm.gov/healthcare-insurance/healthcare, or call the
Oce of Personnel Management at 1 888 767 - 6738. TTY
users can call 711. If you’re an active federal employee,
contact your Benets Ocer. Visit apps.opm.gov/abo for
a list of Benets Ocers. You can also call your plan if you
have questions.
220
—
Section 6: Medicare drug coverage (Part D)
Veterans’ benets
This is health coverage for veterans and people who have
served in the U.S. military. You may be able to get drug
coverage through the U.S. Department of Veterans Aairs
(VA) program. You may join a separate Medicare drug
plan, but if you do, you can’t use both types of coverage
for the same drug at the same time. For more information,
visit va.gov
or call the VA at 1 800 827 - 1000. TTY users
can call 711.
CHAMPVA (Civilian Health and Medical Program
of the Department of Veterans Aairs)
This is a comprehensive health care program in which the
Department of Veterans Aairs shares the cost of covered
health care services and supplies with eligible people with
Medicare. You may join a separate Medicare drug plan,
but if you do, you won’t be able to use the Meds by Mail
program which can provide your maintenance drugs at no
charge (no premiums, deductibles, and copayments).
For more information, visit va.gov/communitycare/
programs/dependents/champva or call CHAMPVA at
1 800 733 - 8387.
221
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Section 6: Medicare drug coverage (Part D)
TRICARE (military health benets)
This is a health care program for active-duty service
members, military retirees, and their families. Most
people with TRICARE who are entitled to Part A must
also have Part B to keep their TRICARE drug benets.
If you have TRICARE, you don’t need to join a separate
Medicare drug plan. However, if you do, your Medicare
drug plan pays rst, and TRICARE pays second.
If you join a Medicare Advantage Plan with drug
coverage, your Medicare Advantage Plan and TRICARE
may coordinate benets 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 costs. For more information, visit
tricare.mil, or call the TRICARE Pharmacy Program at
1 877 363 - 1303. TTY users can call 1 877 540 - 6261.
222
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Section 6: Medicare drug coverage (Part D)
Indian Health Service (IHS)
The IHS is the primary health care provider to the
American Indian/Alaska Native Medicare population. The
Indian health care system, consisting of tribal, urban,
and federally operated IHS health programs, delivers
several clinical and preventive health services through
a network of hospitals, clinics, and other entities. Many
Indian health facilities participate in the Medicare drug
coverage (Part D). If you get prescription drugs through an
Indian health facility, you’ll continue to get them at no cost
to you, and your coverage won’t be interrupted. Joining
a Medicare drug plan or Medicare Advantage Plan
with drug coverage may help your Indian health facility
because the plan pays the Indian health facility for the
cost of your prescription drugs. Talk to your local Indian
health benets coordinator who can help you choose a
plan that meets your needs and tell you how Medicare
works with the Indian health care system.
Go to pages 9 – 20 for an overview of your Medicare
options.
223
Medicare Savings Programs (MSPs)
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. Qualified Medicare Beneficiary (QMB) Program: If
you’re eligible, the QMB Program pays for Part A and/
or Part B premiums. In addition, Medicare providers
aren’t allowed to bill you for services and items
Medicare covers, including deductibles, coinsurance,
and copayments. If you get a bill for these charges,
tell your provider or the debt collector that you’re in
the QMB Program and can’t be charged for Medicare
deductibles, coinsurance, and copayments. If you’ve
already made payments on a bill for services and
items Medicare covers, you have the right to a refund.
Section 7: Get help
paying your health
& drug costs
Underlined words are dened on pages 289 – 296.
224
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Section 7: Get help paying your health &
drug costs
If you’re in a Medicare Advantage Plan, you should
also contact the plan to ask them to stop the charges.
In some cases, you may be billed a small copayment
through Medicaid, if one applies.
To make sure your provider knows you’re in the QMB
Program, show both your Medicare and Medicaid or
QMB card each time you get care. If you have Original
Medicare, you can also give your provider a copy of
your “Medicare Summary Notice” (MSN). Your MSN
will show you’re in the QMB Program and shouldn’t
be billed. Log into (or create) your secure Medicare
account at Medicare.gov to sign up to get your MSNs
electronically.
If your provider won’t stop billing you, call
1 800 633 - 4227. TTY users can call 1 877 486 - 2048.
We can also conrm that you’re in the QMB Program.
2. Specified Low-Income Medicare Beneficiary
(SLMB) Program: Pays Part B premiums only.
3. Qualifying Individual (QI) Program: Helps pay
Part B premiums only. You must apply each year for QI
benefits. Apply as soon as possible since applications
are granted on a first-come, first-served basis.
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Section 7: Get help paying your health &
drug costs
4. Qualified Disabled and Working Individuals (QDWI)
Program: Pays Part A premiums only. You may
qualify for this program if you have a disability, you’re
working, and you lost your Social Security disability
benefits and premium-free Part A because you
returned to work.
If you sign up for the immunosuppressive drug benet
(go to page 121) and have limited income and resources,
but don’t have full Medicaid coverage, you may qualify
for help paying the costs through a QMB, SLMB, or QI
Program. Contact your state to apply.
If you qualify for a QMB, SLMB, or QI Program, you
automatically qualify to get Extra Help paying for
Medicare drug coverage (Part D). Go to pages 223 – 228.
Important!
Medicare Savings Programs are available through your
state. The names of these programs and how they work
may vary by state. Programs aren’t available in Puerto
Rico or the U.S. Virgin Islands.
226
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Section 7: Get help paying your health &
drug costs
How do I qualify?
•
In most cases, to qualify for a Medicare Savings
Program, you must have income and resources below
a certain limit.
•
Even if you don’t think you qualify, you should
still apply. Contact your State Medical Assistance
(Medicaid) office to get started.
•
Call 1 800 633 - 4227 or visit Medicaid.gov/about-us/
beneficiary-resources/index.html#statemenu to
get the phone number for your state’s Medicaid office.
TTY users can call 1 877 486 - 2048.
Get Extra Help paying your Medicare
drug costs
If you have limited income and resources, you may qualify
for Extra Help, a program to help pay for some drug
costs.
You may qualify for Extra Help if your yearly income and
resources are below these limits in 2023:
Single person
•
Yearly income: less than $21,870
•
Resources: less than $16,600
227
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Section 7: Get help paying your health &
drug costs
Married person living with a spouse and no other
dependents
•
Yearly income: less than $29,585
•
Resources: less than $33,240
New!
Extra Help has expanded to cover more drug costs for
certain people with limited income and resources.
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).
•
Don’t include your home, car, household items, burial
plot, up to $1,500 for burial expenses (per person), or
life insurance policies.
You can nd 2024 income and resource limits on
Medicare.gov beginning spring 2024.
228
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Section 7: Get help paying your health &
drug costs
If you qualify for Extra Help and join a separate Medicare
drug plan or Medicare Advantage Plan with Medicare
drug coverage (Part D):
•
You’ll get help paying your drug coverage costs.
•
You won’t pay a Part D late enrollment penalty.
Note: Extra Help isn’t available in Puerto Rico, the U.S.
Virgin Islands, Guam, the Northern Mariana Islands, or
American Samoa. But there are other programs available
in these areas to help people with limited income and
resources. Go to page 236 for more information.
Cost & coverage:
Most people with Medicare can only switch plans
at certain times of the year. If you have Medicaid or
get Extra Help, you may be able to change your drug
coverage one time during each of these periods:
•
January – March
•
April – June
•
July – September
If you make a change, it will begin the rst day of the
following month.
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Section 7: Get help paying your health &
drug costs
You automatically qualify for Extra Help if you have
Medicare and meet any of these conditions:
•
You have full Medicaid coverage.
•
You may get help from your state Medicaid program to
pay your Part B premiums and other Medicare costs.
Go to pages 223 – 233.
•
You get Supplemental Security Income (SSI) benefits.
Medicare will mail you a purple letter to let you know you
automatically qualify for Extra Help. Keep this for your
records. You don’t need to apply for Extra Help if you get
this letter.
•
If you don’t already have Medicare drug coverage
(Part D), you must get it to use this Extra Help.
•
If you don’t have drug coverage, Medicare may enroll
you in a separate Medicare drug plan so you’ll be able
to use the Extra Help. If Medicare enrolls you in a plan,
you’ll get a yellow letter letting you know when your
coverage begins, and you’ll have a Special Enrollment
Period to change plans if you want to join a different
plan than the one Medicare enrolled you in.
230
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Section 7: Get help paying your health &
drug costs
•
Different plans cover different drugs. Check to find out
if the plan you’re enrolled in covers the drugs you use
and if you can go to the pharmacies you want. Visit
Medicare.gov/plan-compare or call 1 800 633 - 4227
to compare your plan 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 drugs.
If you don’t want to join a separate Medicare drug
plan (for example, because you want only your employer
or union coverage), call the plan listed in your letter, or
call 1 800 633 - 4227. 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.
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drug costs
Important!
If you have employer or union coverage and you get
Medicare drug coverage (Part D), you may lose your
employer or union coverage (for you and your dependents)
even if you qualify for Extra Help. Call your employer’s
benets administrator before you get Medicare drug
coverage.
New!
Drug costs for people who qualify will generally be no
more than $4.50 for each generic drug and $11.20 for each
brand-name drug. Look at the Extra Help letters you get, or
contact your plan if you have questions about costs.
If you didn’t automatically qualify for Extra Help, you
can apply any time:
•
Visit secure.ssa.gov/i1020/start to apply online.
•
Call Social Security at 1 800 772 - 1213. TTY users can
call 1 800 325 - 0778.
When you apply for Extra Help, you can also begin the
application process for a Medicare Savings Program (MSP).
These state programs provide help with other Medicare
costs. Social Security will send information to your state to
initiate an MSP application, unless you tell them not to on
the Extra Help application.
232
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Section 7: Get help paying your health &
drug costs
To get answers to your questions about Extra Help
and help choosing drug coverage, call your State
Health Insurance Assistance Program (SHIP). Go to
pages 280 – 287 for the phone number of your local SHIP.
You can also call 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
How can I save on my Medicare health care
costs?
Medicaid
Medicaid is a joint federal and state program that helps
pay health care costs if you have limited income and (in
some cases) 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.
233
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Section 7: Get help paying your health &
drug costs
•
If you have Medicare and full Medicaid coverage,
Medicare covers your prescription drugs. You
automatically qualify for Extra Help paying your
Medicare drug costs (go to pages 226 – 232). Medicaid
may still cover some drugs that Medicare doesn’t
cover.
•
People with full Medicaid coverage may get coverage
for services that Medicare doesn’t cover or only
partially covers, like nursing home care, personal
care, transportation to medical services, home and
community-based services, home-delivered meals,
and dental, vision, and hearing services.
How do I qualify?
•
Medicaid programs vary from state to state. They may
also have different names, like “Medical Assistance” or
“Medi-Cal.”
•
Each state has different income and resource
requirements.
•
Call your State Medical Assistance (Medicaid) office
to find out if you qualify. Visit Medicaid.gov/about-
us/beneficiary-resources/index.html#statemenu
or call 1 800 633 - 4227 to get the phone number
for your state’s Medicaid office. TTY users can call
1 877 486 - 2048.
234
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Section 7: Get help paying your health &
drug costs
Medicare-Medicaid Plans
Medicare is working with some states and health plans
to oer demonstration plans for certain people who
have both Medicare and Medicaid and make it easier
for them to get the services they need. They’re called
Medicare-Medicaid Plans. These plans include drug
coverage and are only available in certain states. If
you’re interested in joining a Medicare-Medicaid Plan,
visit Medicare.gov/plan-compare to nd out if one is
available in your area.
State Pharmaceutical Assistance Programs
Many states have State Pharmaceutical Assistance
Programs that help certain people pay for prescription
drugs based on nancial need, age, or medical condition.
To nd out if there’s a State Pharmaceutical Assistance
Program in your state and how it works, call your State
Health Insurance Assistance Program (SHIP). Go to
pages 280 – 287 for the phone number of your local
SHIP. You can also visit Medicare.gov/pharmaceutical-
assistance-program/#state-programs.
235
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Section 7: Get help paying your health &
drug costs
Pharmaceutical Assistance Programs (also called
Patient Assistance Programs)
Many major drug manufacturers oer assistance
programs for people with Medicare drug coverage
(Part D) who meet certain requirements. Visit
Medicare.gov/pharmaceutical-assistance-program to
learn more about Pharmaceutical Assistance Programs.
Program of All-inclusive Care for the Elderly (PACE)
PACE is a Medicare and Medicaid program oered in many
states that allows people who need a nursing home-level of
care to remain in the community. Go to pages 176 – 177.
Supplemental Security Income (SSI) benets
SSI provides monthly payments to adults and children
who are blind or have a disability and have limited income
and resources. SSI payments are also provided to people
65 and older without disabilities who meet the nancial
qualications. These benets aren’t the same as Social
Security retirement benets. You may be able to get both
SSI and Social Security benets at the same time if your
Social Security benet is less than the SSI federal benet
rate. If you’re eligible for SSI, you automatically qualify for
Extra Help, and are usually eligible for Medicaid.
236
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Section 7: Get help paying your health &
drug costs
You can visit ssabest.benets.gov, and use the
“Benet Eligibility Screening Tool” to nd out if you’re
eligible for SSI or other benets. Call Social Security at
1 800 772 - 1213. TTY users can call 1 800 325 - 0778.
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 State Medical Assistance
(Medicaid) oce to learn more. Visit Medicare.gov/
talk-to-someone or call 1 800 633 - 4227 to get the
phone number. TTY users can call 1 877 486 - 2048.
237
What are my Medicare rights?
All people with Medicare have certain rights and
protections. You have the right to:
•
Be treated with courtesy, dignity, and respect at all
times.
•
Be protected from discrimination.
•
Have your personal and health information kept private.
•
Get information in a way you understand from
Medicare, health care providers, and, under certain
circumstances, contractors.
•
Learn about your treatment choices in clear language
you can understand, and participate in treatment
decisions.
•
Get Medicare information and health care services in a
language you understand.
Section 8: Your
Medicare rights &
protections
Underlined words are dened on pages 289 – 296.
238
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Section 8: Your Medicare rights & protections
•
Get your Medicare information in an accessible
format, like braille or large print. Go to “Accessible
Communications” on pages 297 – 298.
Note: If you need plan information in a language other
than English or in an accessible format, contact your
plan.
•
Get answers to your Medicare questions.
•
Have access to doctors, specialists, and hospitals for
medically necessary services.
•
Get Medicare-covered services in an emergency.
•
Get a decision about health care payment, coverage
of items and services, or drug coverage. When you or
your provider files a claim, you’ll get a notice letting
you know what will and won’t be covered. This notice
comes from one of these:
•
Medicare
•
Your Medicare Advantage Plan (Part C) or other
Medicare health plan
•
Your Medicare drug plan
239
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Section 8: Your Medicare rights & protections
If you disagree with the decision on your claim, you have
the right to le an appeal. You can:
•
Request a review (appeal) of certain decisions about
health care payment, coverage of items and services,
or drug coverage.
•
File a complaint (sometimes called a “grievance”),
including complaints about the quality of your care and
other services you get from a Medicare provider.
•
Work with End-Stage Renal Disease (ESRD) Networks
and State Survey Agencies to help you with complaints
(grievances) about your dialysis or kidney transplant
care.
Visit Medicare.gov or call 1 800 633 - 4227 to learn
more about ling a complaint. TTY users can call
1 877 486 - 2048.
240
—
Section 8: Your Medicare rights & protections
What are my rights if my plan stops
participating in Medicare?
Medicare health and 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 explaining
your options. If this happens:
•
You can choose another plan from October 15 –
December 7. Your coverage will begin January 1.
•
You also have a special right to join another
Medicare plan until the last day in February.
•
You may 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
drug you think Medicare should cover.
•
A request for payment of a health care service, supply,
item, or drug you already got.
241
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Section 8: Your Medicare rights & protections
•
A request to change the amount you must pay for a
health care service, supply, item, or 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 drug
you think you still need.
•
An at-risk determination made under a Drug
Management Program that limits access to coverage
for frequently abused drugs, like opioids and
benzodiazepines. Go to page 209.
•
If your claim is denied because of an open accident
record and the claim isn’t related to the accident.
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. This will make your appeal
stronger. Keep a copy of everything related to your appeal,
including what you send to Medicare or your plan.
How do I le an appeal?
How you le an appeal depends on the type of Medicare
coverage you have.
242
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Section 8: Your Medicare rights & protections
If you have Original Medicare
•
Get the “Medicare Summary Notice” (MSN) that
shows the item or service you’re appealing. Go to
pages 137 – 139 for more information about MSNs.
•
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.
•
Include your name, phone number, and Medicare
number on the MSN. Keep a copy for your records.
•
Send the MSN, or a copy, to the company that
handles bills for Medicare (Medicare Administrative
Contractor) listed on the MSN. You can include
any information you have about your appeal, like
information from your health care provider. Or, you
can use Form CMS-20027. To get this form, visit
CMS.gov/cmsforms/downloads/cms20027.pdf, or
call 1 800 633 - 4227 to have a copy mailed to you.
TTY users can call 1 877 486 - 2048.
•
You must file your appeal by the date in the MSN. If
you missed the deadline for appealing, you may still
file an appeal and get a decision if you can show good
cause for missing the deadline (for example, if you had
an illness or accident that delayed you from sending it
by the deadline).
243
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Section 8: Your Medicare rights & protections
•
You’ll generally get a decision from the Medicare
Administrative Contractor 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.
•
You may have the right to a fast appeal if you think
your Medicare services from a hospital or other facility
are ending too soon. Go to pages 246 – 247.
If you’re in a Medicare Advantage or other Medicare
health plan
The timeframe for ling an appeal may be dierent than
Original Medicare. To learn more, look at the materials
your plan sends you, call your plan, or visit Medicare.gov/
claims-appeals/how-do-i-le-an-appeal.
In some cases, you can le a fast appeal. Review
materials from your plan and the information on
pages 246 – 247.
244
—
Section 8: Your Medicare rights & protections
If you have a separate Medicare drug plan
Even before you buy a certain drug, you have the right to:
•
Get a written explanation for drug coverage decisions
(called a “coverage determination”) from your Medicare
drug plan. A coverage determination is the first
decision your Medicare drug plan (not the pharmacy)
makes about your benefits. This can be a decision
about if the plan covers your drug, 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) believe you need a
drug that isn’t on your plan’s list of covered drugs
(formulary).
•
Ask for an exception if you or your prescriber believe
that your plan should waive a coverage rule (like prior
authorization).
•
Ask for an exception if you think you should pay less
for a higher tier drug because you or your prescriber
believe you can’t take any of the lower tier drugs for
the same condition.
245
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Section 8: Your Medicare rights & protections
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, nancial advisor, doctor, or someone else
who will act on your behalf. For more information, visit
Medicare.gov/claims-appeals/le-an-appeal/can-
someone-le-an-appeal-for-me. You can also get
help ling an appeal from your State Health Insurance
Assistance Program (SHIP). Go to pages 280 – 287 for the
phone number of your local SHIP.
How do I ask for a coverage 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 a prescription you haven’t gotten yet,
you or your prescriber may make a standard request or
an expedited (fast) 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.
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—
Section 8: Your Medicare rights & protections
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.
Important!
If you’re requesting an exception, your prescriber must
provide a statement explaining the medical reason why
your plan should approve the exception.
What are my rights if I think my services are
ending too soon?
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 (or that you’re being discharged too soon), you
can ask for a fast appeal (also known as an “immediate
appeal” or an “expedited appeal”). Your provider will give
you a notice before your services end telling you how to
ask for a fast appeal. Read this notice carefully. If you
don’t get this notice, ask your provider for it. With a fast
appeal, an independent reviewer, called a Beneciary and
Family Centered Care-Quality Improvement Organization
(BFCC-QIO), will decide if your covered services should
247
—
Section 8: Your Medicare rights & protections
continue. You can contact your BFCC-QIO for help with
ling an appeal. Go to page 277.
A fast appeal only covers the decision to end services or
discharge you from the hospital. You may need to start
a separate appeals process for any items or services
you may have gotten after the decision to end services.
Visit Medicare.gov/publications to review the booklet,
“Medicare Appeals.”
What’s an “Advance Beneciary Notice of
Non-coverage” (ABN)?
If you have Original Medicare, your doctor, other health
care provider, or supplier may give you a written notice if
they think Medicare won’t pay for the items or services
you’ll get. This notice is called an “Advance Beneciary
Notice of Non-coverage,” or ABN. The ABN lists the
items or services that your doctor or health care provider
expects Medicare will not pay for, along with an estimate
of the costs for the items and services and the reasons
why Medicare may not pay.
248
—
Section 8: Your Medicare rights & protections
What happens if I get this notice?
•
You’ll be asked to choose whether to get the items or
services listed on the notice.
•
If you choose to get the items or services listed on the
notice, you’re agreeing to pay if Medicare doesn’t.
•
You’ll be asked to sign the notice 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 a notice
for services that Medicare never covers. Go to
pages 128 – 129.
•
An ABN isn’t an official denial of coverage by
Medicare. If Medicare denies payment, you can still
file an appeal once you get the “Medicare Summary
Notice” (MSN) showing the item or service in question.
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 a notice like this for other reasons?
You may get a “Skilled Nursing Facility ABN” when the
facility believes Medicare will no longer cover your stay or
other items and services.
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Section 8: Your Medicare rights & protections
What if I didn’t get this notice?
If your provider was required to give you this notice 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?
Visit Medicare.gov/basics/your-medicare-rights/your-
protections to learn more about the dierent types of
ABNs and what to do if you get one.
Note: If you’re in a Medicare Advantage Plan, you
have the right to ask the plan in advance if it covers
a certain service, drug, or supply. Contact your plan
to request and submit a pre-service request for an
organization determination. The plan’s response will
include instructions to le a timely appeal, if you want one.
You also may get plan directed care. This is when a plan
provider refers you for a service or to a provider outside
the network without getting an organization determination
in advance. Go to page 157.
250
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Section 8: Your Medicare rights & protections
Your right to access your personal health
information
By law, you or your legal representative generally have the
right to review and/or get copies of your personal health
information from health care providers who treat you and
bill Medicare for your care. You also generally have a right
to get this information from health plans that pay for your
care, including Medicare.
These types of personal health information include:
•
Claims and billing records
•
Information related to your enrollment in health plans,
including Medicare
•
Medical and case management records
•
Other records that doctors or health plans use to make
decisions about you
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 you ask for them. You have the right
to get your information in a timely manner, but it may take
up to 30 days to get a response. If your information is
electronic, you also may request to have it sent to a third
party of your choosing, like a health care provider who
treats you, a family member, or a researcher.
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You may have to ll out a form to request copies of your
information and pay a fee. This fee typically can’t be more
than the total cost of:
•
Labor for copying the information requested
•
Supplies for creating the copy
•
Postage (if you ask your health care provider to mail
you a copy)
In most cases, you won’t be charged for reviewing,
searching, downloading, or sending your information
through an electronic portal.
For more information, visit HHS.gov/hipaa/for-
individuals/guidance-materials-for-consumers.
If you need help getting and using your health records, the
Oce of the National Coordinator for Health Information
Technology (ONC) in the U.S. Department of Health &
Human Services (HHS) created “The Guide to Getting
& Using Your Health Records.” This guide can help you
through the process of getting your health records and
show you how to make sure your records are accurate
and complete, so you can get the most out of your health
care. Visit healthit.gov/how-to-get-your-health-record
to review the guide.
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How does Medicare use my personal
information?
Medicare protects the privacy of your health information.
The next 5 pages describe how Medicare may use and
give out your information and explain how you can get this
information.
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:
•
You, to someone you name (“designate”), or someone
who has the legal right to act for you (your personal
representative)
•
The Secretary of the Department of Health & Human
Services, if necessary
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•
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:
•
Medicare Administrative Contractors use your
information to pay or deny your claims, collect your
premiums, share your benefit payment with your
other insurer(s), or prepare your “Medicare Summary
Notice.”
•
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:
•
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
federal/state Medicaid programs)
•
For public health activities (like reporting disease
outbreaks)
•
For government health care oversight activities (like
investigating fraud and abuse)
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•
For judicial and administrative proceedings (like
responding to a court order)
•
For law enforcement purposes (like providing limited
information to find a missing person)
•
For research studies that meet all privacy law
requirements (like research to prevent a disease or
disability)
•
To avoid a serious and imminent threat to health or
safety
•
To contact you about new or changed Medicare
benefits
•
To create a collection of information that no one can
trace to you
•
To health care providers and their business
associates for care coordination and quality
improvement purposes, like participation in an
Accountable Care Organization (ACO)
We don’t sell or use and share your information to tell
you about health products or services (“marketing”). We
must have your written permission (an “authorization”)
to use or share your information for any purpose that
isn’t described in this notice.
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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:
•
Review and get a copy of the information we have
about you.
•
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.
•
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.
•
Ask us to communicate with you in a different
manner or at a different place (for example, by
sending materials to a PO Box instead of your home
address).
•
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.
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•
Get a letter that tells you about the likely risk to the
privacy of your information (“breach notification”).
•
Get a separate paper copy of this notice.
•
Speak to a Customer Service Representative about
our privacy notice. Call 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:
•
The Centers for Medicare & Medicaid Services
(CMS). Visit Medicare.gov or call 1 800 633 - 4227.
•
The U.S. Department of Health & Human
Services (HHS), Office for Civil Rights (OCR). Visit
hhs.gov/hipaa/filing-a-complaint.
Filing a complaint won’t aect 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. If we make a change, we’ll mail you a
notice within 60 days of the change.
The Notice of Privacy Practices for Original
Medicare became eective September 23, 2013.
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How can I protect myself from fraud and
medical identity theft?
Medical identity theft is when someone steals or uses
your personal information (like your name, Social Security
Number, or Medicare number) to submit fraudulent claims
to Medicare and other health insurance companies
without your permission. 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 there’s an error or a provider bills
you 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 find out if the service was
billed to Medicare. If you’re in a Medicare health plan,
check the statements you get from your plan.
•
Log into (or create) your secure Medicare account at
Medicare.gov to review your Medicare claims if you
have Original Medicare. Your claims are generally
available online within 24 hours after processing. You
can also use Medicare’s Blue Button
®
to download
your claims information. Go to page 269. You can
also call 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
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•
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.
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 1 800 633 - 4227. TTY users can call
1 877 486 - 2048.
You can also call 1 800 633 - 4227 if you believe your
Medicare number has been used fraudulently.
Only give personal information, like your Medicare number,
to doctors, insurance companies (and their licensed
agents or brokers), 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 any unsolicited person who
contacts you by phone, email, or in person. Medicare, or
your Medicare plan representative, will only call you in
limited situations:
•
A Medicare plan can call you if you’re already a
member of the plan. The agent who helped you join
can also call you.
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Section 8: Your Medicare rights & protections
•
A customer service representative from
1 800 633 - 4227 can call you if you’ve left a message,
or a representative said that someone would call you
back. TTY users can call 1 877 486 - 2048.
•
If you filed a report of suspected fraud, you may get a
call from someone representing Medicare to follow up
on your investigation.
For more information about Medicare fraud, visit
Medicare.gov or contact your local Senior Medicare
Patrol. Learn more about the Senior Medicare Patrol and
nd help in your state by going to smpresource.org or
call 1 877 808 - 2468.
Plans must follow marketing rules
Medicare plans and agents must follow certain rules
when marketing their plans and getting your enrollment
information. Plans don’t need your personal information
to provide a quote. Medicare plans can’t sign you up for a
plan over the phone unless you call them and ask to sign
up, or you’ve given them permission to contact you.
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Section 8: Your Medicare rights & protections
Important!
Call 1 800 633 - 4227 to report any plans or agents
that:
•
Ask for your personal information over the phone or
email
•
Call to enroll you in a plan
•
Visit you unexpectedly
•
Use false information to mislead you
You can also call the Medicare Drug Integrity Contractor
(MEDIC) at 1 877 772 - 3379. The MEDIC ghts fraud,
waste, and abuse in Medicare Advantage Plans and
Medicare drug plans.
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.
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How the Medicare Beneciary Ombudsman can
help you
A Medicare Beneciary Ombudsman helps you and your
representatives with questions and complaints, and makes
sure Medicare information is available to you. You can also
provide feedback to the Ombudsman to help improve your
experiences with Medicare. Visit Medicare.gov to learn
more.
•
End of Page
262
Notes
263
Get personalized help
1. Call us at 1 800 633 - 4227; TTY users can call
1 877 486 - 2048
2. Live chat with us at Medicare.gov/talk-to-someone
3. Write us at PO Box 1270, Lawrence, KS 66044
Get information 24 hours a day, including
weekends
•
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 asked for your Medicare number, say 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.
Section 9: Get more
information
Underlined words are dened on pages 289 – 296.
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Section 9: Get more information
Important!
If you need someone to be able to call Medicare on
your behalf
You can complete an “Authorization to Disclose Personal
Health Information” form that lets Medicare give your
personal health information to someone other than
you. To get this form, visit Medicare.gov/basics/
forms-publications-mailings/forms/other or call
1 800 633 - 4227. TTY users can call 1 877 486 - 2048.
You can also submit this form at Medicare.gov in your
Medicare account. Medicare must process the form
before the authorization becomes eective.
If your household got more than one copy of
“Medicare & You”
To get only one copy of this handbook in the future,
call 1 800 633 - 4227. If you want to stop getting paper
copies in the mail, you can request this by logging into (or
creating) your Medicare account at Medicare.gov.
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If you need a new copy of your Medicare card
If you need to replace your card because it’s damaged or
lost, visit Medicare.gov to log into (or create) your secure
Medicare account to print or order an ocial copy of your
Medicare card. You can also call 1 800 633 - 4227 and
ask for a replacement card to be sent in the mail. TTY
users can call 1 877 486 - 2048.
If you need to replace your card because you think
that someone else is using your Medicare number, call
1 800 633 - 4227.
State Health Insurance Assistance Programs
(SHIPs)
SHIPs 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. They
provide free, personalized counseling to you and your
family to help with these and other Medicare questions:
•
Your Medicare rights
•
Billing problems
•
Complaints about your medical care or treatment
•
Plan comparison and enrollment
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•
How Medicare works with other insurance
•
Finding help paying for health care costs
Call a SHIP in your state to get free personalized
help with your Medicare questions, or learn how
to become a volunteer SHIP counselor. Go to
pages 280 – 287 for the phone number of your local
SHIP.
Find general Medicare information online
Visit Medicare.gov
•
Get information about the Medicare health and drug
plans in your area, including what they cost and what
services they provide.
•
Find Medicare-participating doctors or other health
care providers and suppliers.
•
Find out what Medicare covers, including
preventive services (like screenings, shots or
vaccines, and yearly “Wellness” visits).
•
Get Medicare appeals information and forms.
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Section 9: Get more information
•
Get information about the quality of care provided
by plans, nursing homes, hospitals, doctors,
home health agencies, dialysis facilities, hospice
centers, inpatient rehabilitation facilities, and
long-term care hospitals.
•
Look up helpful websites and phone numbers.
You can get this handbook in other languages, like
Spanish, Chinese, Korean, or Vietnamese. Visit
Medicare.gov/about-us/information-in-other-
languages.
Get personal Medicare information online
Create your own Medicare account
Visit Medicare.gov to log into (or create) your secure
Medicare account. You can also:
•
Add your prescriptions and pharmacies to help you
better compare Medicare health and drug plans in your
area.
•
Sign up to get your yearly “Medicare & You” handbook
and claims statements, called “Medicare Summary
Notices,” electronically.
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Section 9: Get more information
•
Review your Original Medicare claims as soon as
they’re processed.
•
Print a copy of your official Medicare card.
•
Find a list of preventive services you’re eligible to get
in Original Medicare.
•
Learn about your Medicare premiums, and pay them
online if you get a bill from Medicare.
Medicare’s Blue Button
®
& Blue Button 2.0
®
Medicare’s Blue Button makes it easy for you to download
your personal health information (like your Part A, Part B,
and Part D claims) to a le on your computer or other
device. By getting your information through Blue Button,
you can:
•
Print or email the information to share with others.
•
Import your saved file into other computer-based
personal health management tools.
Visit Medicare.gov and log into (or create) your secure
Medicare account to use Blue Button.
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Medicare’s Blue Button 2.0 is a data service that makes it
easy for you to share your Part A, Part B, and Part D claim
information with authorized apps, services, and research
programs. You authorize each app individually and you
can return to your secure Medicare account online at
Medicare.gov any time to change the way an app uses
your information.
Note: If you’re enrolled in a Medicare Advantage Plan,
only Part D information is available through Blue Button
2.0. Check with your plan to nd out if they oer a similar
data service to Blue Button 2.0.
Remember: Treat your personal and health information
the same way you treat other condential information.
To learn about how to use Blue Button to save your claim
information, visit:
•
Medicare.gov/manage-your-health/share-your-
medicare-claims
•
Medicare.gov/manage-your-health/medicares-
blue-button-blue-button-20/blue-button-apps
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Find & compare health care providers
Visit Medicare.gov/care-compare to nd and compare
the quality of care health care providers like nursing
homes, hospitals, and doctors give their patients and
residents. You can nd information about providers and
facilities based on your individual needs, and get helpful
resources to make more informed decisions about where
you get your health care. Talk to your doctor or other
health care provider when choosing a new provider. You
can also ask what they think about the quality of care of
other providers.
Find & compare Medicare health & drug
plans
Visit Medicare.gov/plan-compare to nd and compare
Medicare health and drug plans, including your current
plan, if you’ve already joined one. You can compare
the prices based on the drugs you take now and the
pharmacies you choose to use, including monthly and
yearly estimated drug costs. An overall star rating for each
plan provides details about its quality and performance for
the types of services it oers.
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Did you know that you can compare the quality of health
care providers and Medicare plan services nationwide?
Call your State Health Insurance Assistance Program
(SHIP). Go to pages 280 – 287 for the phone number of
your local SHIP.
Medicare is working to better coordinate
your care
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:
Accountable Care Organizations (ACOs)
An Accountable Care Organization (ACO) is a group of
doctors, hospitals, and other health care providers that
have teamed up to coordinate your health care.
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Working as part of an ACO helps your doctors and
other health care providers understand your health
history and talk to one another about your care and your
health care needs. This may save you time, money, and
frustration by avoiding repeated tests and appointments.
More coordination also helps prevent medical errors and
unexpected drug interactions that may happen if one
provider isn’t aware of what another has prescribed you.
Important!
An ACO won’t limit your choice of health care providers.
If your doctor or other provider is part of an ACO, you
still have the right to visit any doctor, hospital, or other
provider that accepts Medicare at any time.
In addition, if your primary care doctor participates in
an Accountable Care Organization (ACO), you may
be able to get expanded benets. For example, in some
ACOs, your provider may oer more telehealth services.
This means you may be able to get some services from
home using technology, like your phone or a computer, to
communicate in real time with your health care provider.
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In addition, a doctor or other provider who is part
of an ACO may be able to send their patients for
skilled nursing facility care or rehabilitation services
even if they haven’t stayed in a hospital for 3 days rst,
which is usually a requirement in Medicare. For you to
qualify for this benet, your doctor or other provider has to
decide that you need skilled nursing facility care and meet
certain other eligibility requirements.
If your primary care doctor participates in an ACO and
you have Original Medicare, you’ll get a written notice and
nd a poster in their oce about their ACO participation.
There are now hundreds of ACOs across the country.
Log into (or create) your secure Medicare account at
Medicare.gov and choose a primary care doctor who will
help manage your health care in an ACO.
Sharing your health care information with ACOs
One of the most important benets of an ACO is that
your doctors and other providers can communicate
and coordinate your care. To help with that, Medicare
allows your health care provider’s ACO to ask for certain
information about your care. Having Medicare share your
data in this way helps make sure all the people involved
in your care have access to your health information when
they need it to help you.
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If you don’t want Medicare to share your health
information with your doctors for care coordination, call
1 800 633 - 4227 and let the representative know. TTY
users can call 1 877 486 - 2048. Medicare may still share
general information to measure provider quality.
To learn more about ACOs, visit Medicare.gov/
manage-your-health/coordinating-your-
care/accountable-care-organizations or call
1 800 633 - 4227.
Electronic Health Records
Electronic health records are a history of your medical
conditions, health care, and treatment that your doctor,
other health care provider, medical oce sta, or hospital
keeps on a computer.
•
They can help lower the chances of medical errors,
eliminate duplicate tests, and may improve your overall
quality of care.
•
Your doctor’s electronic health records may be able
to link to a hospital, lab, pharmacy, other doctors, or
immunization information systems (registries), so the
people who care for you can have a more complete
picture of your health.
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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 and
time, and help keep you safe.
Other ways to get Medicare information
Medicare emails
Visit Medicare.gov to create your secure Medicare
account. Include your email address to get important
reminders and information about Medicare.
Publications
Visit Medicare.gov/publications to review, print, or
download copies of publications on dierent Medicare
topics. You can also call 1 800 633 - 4227. TTY users
can call 1 877 486 - 2048. Go to page 297 for information
about getting publications in accessible formats at no
cost.
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Social media
Stay up to date and connect with other people
with Medicare by following us on Facebook
(facebook.com/Medicare) and Twitter
(twitter.com/MedicareGov).
Videos
Find videos about Medicare and other health care topics
at YouTube.com/cmshhsgov.
Other helpful contacts
Social Security
Visit SSA.gov to apply for and sign up for Original
Medicare, and nd out if you qualify for Extra Help with
Medicare drug costs. Also, when you open a personal
“my Social Security” account, you can review your
Social Security Statement, verify your earnings, change
your direct deposit information, request a replacement
Medicare card, update your address, and more. Visit
SSA.gov/myaccount to open your personal account.
You can also call Social Security at 1 800 772 - 1213.
TTY users can call 1 800 325 - 0778.
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Benets Coordination & Recovery Center
Contact the Benets Coordination & Recovery Center
at 1 855 798 - 2627 to report changes in your insurance
information or to let Medicare know if you have other
insurance. TTY users can call 1 855 797 - 2627.
Beneciary and Family Centered Care-Quality
Improvement Organization
Contact your Beneciary and Family Centered Care-
Quality Improvement Organization (BFCC-QIO) if you
think Medicare coverage for your service is ending
too soon (like if your hospital says that you must be
discharged and you disagree). You may have the right
to a fast appeal. You can also contact the BFCC-QIO
or your state’s survey agency to ask questions, report
complaints about the quality of care you or a loved one
got for a Medicare-covered service, or if you aren’t
satised with your provider’s response to your concern.
Call 1 800 633 - 4227 to get the phone number of your
BFCC-QIO or your state’s survey agency. TTY users
can call 1 877 486 - 2048. For more information, visit
Medicare.gov/claims-appeals/le-a-complaint-
grievance/ling-a-complaint-about-your-quality-of-
care.
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Department of Defense
Get information about TRICARE For Life (TFL) and the
TRICARE Pharmacy Program.
TFL:
1 866 773 - 0404, TTY: 1 866 773 - 0405
tricare.mil/t
tricare4u.com
TRICARE Pharmacy Program:
1 877 363 - 1303, TTY: 1 877 540 - 6261
tricare.mil/pharmacy
militaryrx.express-scripts.com
Department of Veterans Aairs (VA)
Contact the VA if you’re a veteran or have served in
the U.S. military and you have questions about veteran
benets.
1 800 827 - 1000, TTY: 711
va.gov
eBenets.va.gov
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Section 9: Get more information
Oce of Personnel Management
Get information about the Federal Employee Health
Benets Program for current and retired federal
employees.
Federal retirees:
1 888 767 - 6738, TTY: 711
opm.gov/healthcare-insurance/Guide-Me/Retirees-
Survivors
Active federal employees:
Contact your Benets Ocer. Visit
apps.opm.gov/abo for a list of Benets Ocers.
Railroad Retirement Board (RRB)
If you get benets from the RRB, call them to change your
address or name, check eligibility, sign up for Medicare,
replace your Medicare card, or report a death.
1 877 772 - 5772, TTY: 1 312 751 - 4701
rrb.gov
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State Health Insurance Assistance Programs
(SHIPs)
For free, personalized help with questions about appeals,
buying other insurance, choosing a health plan, buying a
Medigap policy, and Medicare rights and protections.
Alabama
State Health Insurance Assistance Program (SHIP)
1 800 243 - 5463
Alaska
Medicare Information Oce
1 800 478 - 6065 TTY: 1 800 770 - 8973
Arizona
Arizona State Health Insurance Assistance Program (SHIP)
1 800 432 - 4040
Arkansas
Senior Health Insurance Information Program (SHIIP)
1 800 224 - 6330
California
California Health Insurance Counseling & Advocacy
Program (HICAP) 1 800 434 - 0222
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Colorado
State Health Insurance Assistance Program (SHIP)
1 888 696 - 7213
Connecticut
Connecticut’s Program for Health Insurance Assistance,
Outreach, Information and Referral, Counseling, Eligibility
Screening (CHOICES) 1 800 994 - 9422
Delaware
Delaware Medicare Assistance Bureau
1 800 336 - 9500
Florida
Serving Health Insurance Needs of Elders (SHINE)
1 800 963 - 5337 TTY: 1 800 955 - 8770
Georgia
Georgia State Health Insurance Assistance Program
(SHIP) 1 866 552 - 4464 (option 4)
Guam
Guam Medicare Assistance Program (GUAM MAP)
1 671 735 - 7415
Hawaii
Hawaii SHIP 1 888 875 - 9229 TTY: 1 866 810 - 4379
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Idaho
Senior Health Insurance Benets Advisors (SHIBA)
1 800 247 - 4422
Illinois
Senior Health Insurance Program (SHIP)
1 800 252 - 8966 TTY: 1 888 206 - 1327
Indiana
State Health Insurance Assistance Program (SHIP)
1 800 452 - 4800 TTY: 1 866 846 - 0139
Iowa
Senior Health Insurance Information Program (SHIIP)
1 800 351 - 4664 TTY: 1 800 735 - 2942
Kansas
Senior Health Insurance Counseling for Kansas (SHICK)
1 800 860 - 5260
Kentucky
State Health Insurance Assistance Program (SHIP)
1 877 293 - 7447
Louisiana
Senior Health Insurance Information Program (SHIIP)
1 800 259 - 5300
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Maine
Maine State Health Insurance Assistance Program (SHIP)
1 800 262 - 2232
Maryland
State Health Insurance Assistance Program (SHIP)
1 800 243 - 3425
Massachusetts
Serving Health Insurance Needs of Everyone (SHINE)
1 800 243 - 4636 TTY: 1 877 610 - 0241
Michigan
MMAP, Inc. 1 800 803 - 7174
Minnesota
Minnesota State Health Insurance Assistance Program/
Senior LinkAge Line 1 800 333 - 2433
Mississippi
MS State Health Insurance Assistance Program (SHIP)
1 844 822 - 4622
Missouri
Missouri SHIP 1 800 390 - 3330
Montana
Montana State Health Insurance Assistance Program
(SHIP) 1 800 551 - 3191
284
—
Section 9: Get more information
Nebraska
Nebraska SHIP 1 800 234 - 7119
Nevada
Nevada Medicare Assistance Program (MAP)
1 800 307 - 4444
New Hampshire
NH SHIP – ServiceLink Resource Center
1 866 634 - 9412
New Jersey
State Health Insurance Assistance Program (SHIP)
1 800 792 - 8820
New Mexico
New Mexico ADRC-SHIP 1 800 432 - 2080
New York
Health Insurance Information Counseling and Assistance
Program (HIICAP) 1 800 701 - 0501
North Carolina
Seniors’ Health Insurance Information Program (SHIIP)
1 855 408 - 1212
North Dakota
State Health Insurance Counseling (SHIC)
1 888 575 - 6611 TTY: 1 800 366 - 6888
285
—
Section 9: Get more information
Ohio
Ohio Senior Health Insurance Information Program
(OSHIIP)
1 800 686 - 1578 TTY: 1 614 644 - 3745
Oklahoma
Oklahoma Medicare Assistance Program (MAP)
1 800 763 - 2828
Oregon
Senior Health Insurance Benets Assistance (SHIBA)
1 800 722 - 4134
Pennsylvania
Pennsylvania Medicare Education and Decision Insight
(PA MEDI) 1 800 783 - 7067
Puerto Rico
State Health Insurance Assistance Program (SHIP)
1 877 725 - 4300 TTY: 1 878 919 - 7291
Rhode Island
Senior Health Insurance Program (SHIP)
1 888 884 - 8721 TTY: 401 462 - 0740
South Carolina
(I-CARE) Insurance Counseling Assistance and Referrals
for Elders 1 800 868 - 9095
286
—
Section 9: Get more information
South Dakota
Senior Health Information & Insurance Education (SHIINE)
1 800 536 - 8197
Tennessee
TN SHIP 1 877 801 - 0044 TTY: 1 800 848 - 0299
Texas
Health Information Counseling and Advocacy Program
(HICAP) 1 800 252 - 9240
Utah
Senior Health Insurance Information Program (SHIP)
1 800 541 - 7735
Vermont
Vermont State Health Insurance Assistance Program
1 800 642 - 5119
Virgin Islands
Virgin Islands State Health Insurance Assistance Program
(VISHIP)
1 340 772 - 7368 St. Croix area
1 340 714 - 4354 St. Thomas area
Virginia
Virginia Insurance Counseling and Assistance Program
(VICAP) 1 800 552 - 3402
287
—
Section 9: Get more information
Washington
Statewide Health Insurance Benets Advisors (SHIBA)
1 800 562 - 6900 TTY: 1 360 586 - 0241
Washington D.C.
DC SHIP 202 727 - 8370
West Virginia
West Virginia State Health Insurance Assistance Program
(WV SHIP) 1 877 987 - 4463
Wisconsin
WI State Health Insurance Assistance Program (SHIP)
1 800 242 - 1060 TTY: 711
Wyoming
Wyoming State Health Insurance Information Program
(WSHIIP) 1 800 856 - 4398
288
Notes
289
Section 10:
Denitions
Accountable Care Organization (ACO)
Groups of doctors, hospitals, and other health care
professionals working together to give you high-quality,
coordinated service and health care.
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.
Benet period
The way that Original Medicare measures your use of
hospital and skilled nursing facility services. A benet
period begins the day you’re admitted as an inpatient in a
hospital or skilled nursing facility. The benet period ends
when you haven’t gotten any inpatient hospital care (or
skilled care in a skilled nursing facility) for 60 days in a row.
If you go into a hospital or a skilled nursing facility after one
benet period has ended, a new benet period begins. You
must pay the inpatient hospital deductible for each benet
period. There’s no limit to the number of benet periods.
290
—
Section 10: Denitions
Coinsurance
An amount you may be required to pay as your share
of the cost for benets after you pay any deductibles.
Coinsurance is usually a percentage (for example, 20%).
Copayment
An amount you may be required to pay as your share
of the cost for benets after you pay any deductibles. A
copayment is a xed amount, like $30.
Creditable prescription drug coverage
Prescription drug coverage that’s expected to pay, on
average, at least as much as Medicare drug coverage.
This could include drug coverage from a current or former
employer or union, TRICARE, Indian Health Service, VA, or
individual health insurance coverage.
Critical access hospital
A small facility located in a rural area more than 35 miles
(or 15 miles if mountainous terrain or in areas with only
secondary roads) from another hospital or critical access
hospital. This facility provides 24/7 emergency care, has
25 or fewer inpatient beds, and maintains an average
length of stay of 96 hours or less for acute care patients.
291
—
Section 10: Denitions
Deductible
The amount you must pay for health care or prescriptions
before Original Medicare, your Medicare Advantage Plan,
your Medicare 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 specic group of
people, and in specic areas.
Extra Help
A Medicare program to help people with limited income
and resources pay Medicare prescription drug program
costs, like premiums, deductibles, and coinsurance.
Formulary
A list of prescription drugs covered by a prescription drug
plan or another insurance plan oering prescription drug
benets. Also called a drug list.
Inpatient rehabilitation facility
A hospital, or part of a hospital, that provides an intensive
rehabilitation program to inpatients.
292
—
Section 10: Denitions
Lifetime reserve days
In Original Medicare, these are additional days that
Medicare will pay for when you’re in a hospital for more
than 90 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.
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.
Medicaid
A joint federal and state program that helps with medical
costs for some people with limited income and (in some
cases) resources. Medicaid programs vary from state to
state, but most health care costs are covered if you qualify
for both Medicare and Medicaid.
Medically necessary
Health care services or supplies needed to diagnose or
treat an illness, injury, condition, disease, or its symptoms
and that meet accepted standards of medicine.
293
—
Section 10: Denitions
Medicare Advantage Plan (Part C)
A type of Medicare health plan oered by a private
company that contracts with Medicare. Medicare
Advantage Plans provide all of your Part A and Part B
benets, with a few exclusions, for example, certain
aspects of clinical trials which are covered by Original
Medicare even though you’re still in the plan. Medicare
Advantage Plans include:
•
Health Maintenance Organizations
•
Preferred Provider Organizations
•
Private Fee-for-Service Plans
•
Special Needs Plans
•
Medicare Medical Savings Account Plans
If you’re enrolled in a Medicare Advantage Plan:
•
Most Medicare services are covered through the plan
•
Most Medicare services aren’t paid for by Original
Medicare
•
Most Medicare Advantage Plans offer prescription
drug coverage
294
—
Section 10: Denitions
Medicare-approved amount
The payment amount that Original Medicare sets for a
covered service or item. When your provider accepts
assignment, Medicare pays its share and you pay your
share of that amount.
Medicare health plan
Plans oered by private companies that contract with
Medicare to provide Part A, Part B, and in many cases,
Part D benets. Includes Medicare Advantage Plans and
certain other types of coverage (like Medicare Cost Plans,
PACE programs, and demonstration/pilot programs).
Medicare plan
Any way other than Original Medicare that you can get
your Medicare health or drug coverage. This term includes
all Medicare health plans and Medicare drug plans.
Medigap
Medicare Supplement Insurance sold by private insurance
companies to ll “gaps” in Original Medicare coverage.
Premium
The periodic payment to Medicare, an insurance
company, or a health care plan for health or prescription
drug coverage.
295
—
Section 10: Denitions
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 shots, and
screening mammograms).
Primary care doctor
The doctor you go to rst for most health problems. They
also may talk with other doctors and health care providers
about your care and refer you to them.
Referral
A written order from your primary care doctor for you to
visit a specialist or get certain medical services. Without
a referral, your plan may not pay for services from a
specialist.
Service area
An area you must live in for the plan to accept you as a
member. 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. Plans can, and in
some cases must, disenroll you if you move outside their
service area.
296
—
Section 10: Denitions
Skilled nursing facility (SNF)
A nursing facility with the sta and equipment to
give skilled nursing care and, in most cases, skilled
rehabilitative services and other related health services.
Skilled nursing facility (SNF) care
Skilled nursing care and therapy services provided on
a daily basis in a skilled nursing facility. Examples of
skilled nursing facility care include physical therapy or
intravenous injections that can only be given by a physical
therapist or a registered nurse.
297
Accessible Communications
Medicare provides free auxiliary aids and services,
including information in accessible formats like braille,
large print, data or audio les, relay services and TTY
communications. If you request information in an
accessible format, you won’t be disadvantaged by any
additional time necessary to provide it. This means you’ll
get extra time to take any action if there’s a delay in
fullling your request.
To request Medicare or Marketplace information in an
accessible format you can:
1. Call us:
For Medicare: 1 800 633 - 4227
TTY: 1 877 486 - 2048
For Marketplace: 1 800 318 - 2596
TTY: 1 855 889 - 4325
3. Send us a fax: 1 844 530 - 3676
4. Send us a letter:
Centers for Medicare & Medicaid Services
Oces of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop DO-01-20
Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Sta (CARS)
298
—
Accessible Communications
Your request should include your name, phone number,
type of information you need (if known), and the mailing
address where we should send the materials. We may
contact you for additional information.
Note: If you’re enrolled in a Medicare Advantage Plan
or Medicare drug plan, contact your plan to request its
information in an accessible format. For Medicaid, contact
your State Medical Assistance (Medicaid) oce.
•
End of Page
299
•
End of Page
Nondiscrimination Notice
The Centers for Medicare & Medicaid Services (CMS)
doesn’t exclude, deny benets to, or otherwise
discriminate against any person on the basis of race,
color, national origin, disability, sex (including sexual
orientation and gender identity), or age in admission to,
participation in, or receipt of the services and benets
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.
You can contact CMS in any of the ways included in this
notice if you have any concerns about getting information
in a format that you can use.
300
—
Nondiscrimination Notice
You may also le a complaint if you think you’ve been
subjected to discrimination in a CMS program or activity,
including experiencing issues with getting information
in an accessible format from any Medicare Advantage
Plan, Medicare drug plan, state or local Medicaid oce,
or Marketplace Qualied Health Plans. There are 3 ways
to le a complaint with the U.S. Department of Health &
Human Services, Oce for Civil Rights:
1. Online:
hhs.gov/civil-rights/filing-a-complaint/complaint-
process/index.html
2. By phone:
Call 1 800 368 - 1019. TTY users can call
1 800 537 - 7697.
3. In writing: Send information about your complaint to:
Oce for Civil Rights
U.S. Department of Health & Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
Note: The page numbers shown in bold provide
the most detailed information.
301
Index of topics
A
Abdominal aortic aneurysm 60
Accessible Communications 297
Accountable Care Organization (ACOs) 57, 118, 178, 254,
271–274, 289
Acupuncture 60–61, 212
Advance Beneciary Notice of Non-coverage 247–249
Advance care planning 61–62, 75, 126
Advantage Plan. Go to Medicare Advantage Plan.
Alcohol misuse screenings & counseling 63
Ambulance services 63–64, 122
Ambulatory surgical centers 65
Amyotrophic lateral sclerosis (ALS) 21
Appeal 56, 137, 157, 211, 239–249, 277
Articial limbs 112
Assignment 58–60, 62–63, 65, 67, 69–70, 76–77, 79,
82–85, 87, 89, 92, 94, 95–97, 102–103, 107, 111, 115, 125,
127, 136, 139–141, 156, 289
302
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
B
Balance exam 93
Barium enema 75
Behavioral health integration services 66, 212
Beneciary and Family Centered Care-Quality
Improvement Organizations 246–247, 277
Benet period 53–55, 57, 289
Benets coordination 39, 217, 222, 277
Bills 43–46, 137, 198, 217, 242, 257
Blood 50, 67, 69, 76–77, 83–84, 94, 96, 101, 182
Blood-based biomarker test 77
Blue Button
®
138, 257, 268
Blue Button 2.0
®
138, 268–269
Braces (arm, leg, back, neck) 112
C
Cardiac rehabilitation 68
Catastrophic coverage 197, 201
Cervical and vaginal cancer screenings 70
Chemotherapy 71, 155
Chiropractic services 71
303
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Chronic care management services 72
Chronic pain management and treatment services 73
Claims 48, 135, 138, 250, 253, 255, 257, 267–269
Clinical research studies 53, 73, 145
COBRA 29–32, 217
Cognitive assessment 74 –75, 127
Colonoscopies 76
Continuous Positive Airway Pressure (CPAP) devices,
accessories, & therapy 78
Coronavirus disease 2019 (COVID-19) 79–81, 113, 115
Cosmetic surgery 129
Cost Plan. Go to Medicare Cost Plans.
Costs (copayments, coinsurance, deductibles, and
premiums)
Extra Help paying for Part D 226–232
Medicare Advantage Plans 154–156
Original Medicare 136–137
Part A and Part B 39–42, 48–128
Part D late enrollment penalty 202–206
Counseling to prevent tobacco use & tobacco-caused
disease 79
Coverage determination (Part D) 244–246
304
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Covered services (Part A and Part B) 47–128
Creditable prescription drug coverage 153, 191, 196,
202–206, 217–219, 230, 290
D
Debrillators 82
Dementia 74, 127, 168
Demonstrations/pilot programs 178, 234, 291
Dental care and dentures 10, 14, 128, 145, 146, 161, 179,
233
Department of Defense 278
Department of Health and Human Services. Go to Oce
for Civil Rights.
Department of Veterans Aairs 203, 220–221, 278
Depression 66, 74, 82, 105, 127
Diabetes 72, 83–84, 92–93, 104–105, 118, 168
Dialysis (kidney dialysis) 23–34, 64, 100–101, 155, 239,
267
Disability 21–32, 28, 32, 37, 62, 126–128, 130, 225, 235,
254, 299
305
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Drug coverage (Part D) 191–222
Appeals 239–249
Coverage under Part A 50–57
Coverage under Part B 86–88
Join, switch, or drop 193–194
Medicare Advantage Plans 143–153
Drug plan
Costs 197–206
Enrollment 193–194
Types of plans 192
What’s covered 207–215
Drugs (outpatient) 86–88
Dual eligibles (Medicare-Medicaid plans) 167, 234
Durable medical equipment (like walkers) 7, 51, 58, 86,
88–89, 99–100
E
EKG/ECG 89, 119
Electronic handbook 20, 150
Electronic Health Records 274
Electronic Medicare Summary (eMSN) 138, 267
306
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Electronic prescribing 275
Emergency department services 90
Employer group health plan coverage
Costs for Part A may be dierent 49
Drug coverage 193, 203, 216
How it works with Medicare 36–38
Medigap Open Enrollment 185–186
End-Stage Renal Disease (ESRD) 23, 28, 37, 64, 94,
100–101, 117, 121, 152, 168, 178, 239
Enroll
Medicare Advantage Plans (Part C) 151–154
Medicare drug coverage (Part D) 193–195
Extra Help (help paying Medicare drug costs) 191, 197,
201, 215, 233, 276, 291
Eyeglasses 91, 129, 179
F
Fecal occult blood tests 76–77
Federal Employee Health Benets (FEHB) Program 219
Federally Qualied Health Center services 91, 106
Flexible sigmoidoscopies 76
307
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Flu shot 92
Foot care 92
Formulary 197, 207–208, 209, 214, 244, 291
Fraud 208, 253, 257–260
G
General Enrollment Period 31, 42, 170, 194
Glaucoma test 93
H
Health Insurance Marketplace
®
29, 32, 34
Health Maintenance Organization (HMO) plan 144, 152,
158
Health risk assessment 126
Health Savings Accounts (HSAs) 35–36
Hearing aids 93, 129, 179
Help in other languages 320–323
Hepatitis B shot 94, 115
Hepatitis C screening 96
HIV screenings 97
Home health care/services 7, 48, 50, 58, 98–99, 246, 267
308
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Home infusion therapy services & supplies 86, 100
Hospice care 7, 48, 50–52, 145, 211, 246, 267
HSA. Go to Health Savings Accounts (HSAs).
I
Immunosuppressive drug benet 121–122
Income Related Monthly Adjustment Amount (IRMAA) 41,
199–200
Indian Health Service 203, 222
Initial Enrollment Period 27, 28, 31, 35, 42, 169, 193, 202,
204
Inpatient hospital care 53–55
Institution 167, 230
Insulin 84, 214–215
J
Join
Medicare drug plan 191–195
Medicare health plan 151–154
309
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
K
Kidney disease education 101
Kidney (renal) dialysis. Go to Dialysis.
Kidney transplant 23, 101, 120–122
L
Laboratory tests 101, 119
Late enrollment penalty. Go to Penalty.
Lifetime reserve days 53–54, 292
Long-term care 130–131
Lost Medicare card. Go to Replacement Medicare card.
Lung cancer screenings 102
Lymphedema compression treatment items 103
M
Mammogram 103, 159, 167, 295
Marketplace. Go to Health Insurance Marketplace
®
.
Medicaid 33, 37, 49, 58, 72, 130–131, 156, 167, 176–177,
224–230, 253, 292
Medical identity theft 257–258
310
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Medical nutrition therapy services 83, 104, 118
Medical Savings Account (MSA) plan 36, 144, 152, 156,
160–161, 192, 293
Medicare
Part A (Hospital Insurance) 48–57
Part B (Medical Insurance) 58–128
Part C (Medicare Advantage Plans) 143–175
Part D (Medicare drug coverage) 191–222
Medicare account 20, 44–46, 138, 224, 257, 264–265,
267–269
Medicare Administrative Contractor 242–243, 253
Medicare Advantage Open Enrollment Period 18,
171–172, 194
Medicare Advantage Plan 293
How they work with other coverage 153
Plan types 158–168
Medicare Authorization to Disclose Personal Health
Information 264
Medicare Beneciary Ombudsman 261
Medicare card 22, 44–47, 80, 144, 263, 268, 276
Medicare Cost Plans 128, 173, 192, 198, 294
311
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Medicare drug plan 192
Medicare-Medicaid Plans 234
Medicare Savings Programs (MSPs) 223–226
Medicare Summary Notice (MSN) 137, 138, 224, 242, 248,
257, 267
Medicare Supplement Insurance (Medigap) 9–12, 58,
130–131, 154, 174, 179–189, 218, 294
Medication Therapy Management program 214
Medigap. Go to Medicare Supplement Insurance.
Mental health care 105–106
MSN. Go to Medicare Summary Notice.
N
Notices 55, 138, 148–150, 165, 196, 208, 224, 238,
242–243, 252–256, 267, 299–300
Annual Notice of Change 149, 165, 196
Medicare Outpatient Observation Notice
(also called “MOON”) 55
Medicare Summary Notice (MSN) 137, 224, 242, 248,
257, 267
Nondiscrimination Notice 299–300
Notice of Privacy Practices 252–256
312
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Nurse practitioner 85, 90, 105, 110, 123
Nursing home 51, 130, 167, 176 –177, 229, 230, 233–234,
267, 270
Nutrition therapy services. Go to
Medical nutrition therapy.
O
Observation 54
Occupational therapy services 98, 107
Oce for Civil Rights 256
Oce of Personnel Management 43, 279
Open Enrollment 18, 170 –172, 185–188, 193–194, 204
Opioid use disorder treatment 53, 86, 108–109, 125
OPM. Go to Oce of Personnel Management.
Opt out (providers) 141–142
Orthotic items 112
Outpatient hospital services 109–110
Oxygen 88
313
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
P
PACE. Go to Program of All-inclusive Care for the Elderly.
Payment options (premium) 43–46
Pelvic exam 70
Penalty (late enrollment)
Part A (Hospital Insurance) 28, 40
Part B (Medical Insurance) 22, 28, 42
Part D (Medicare drug coverage) 191, 196–199, 217,
230
Pharmaceutical Assistance Programs 235
Physical therapy services 110
Physician assistant 85, 90, 105, 123
Pilot/demonstration programs 234, 291, 294
Pneumococcal shots 111, 115, 125
Preventive services 7, 19, 58–60, 63, 65, 67, 69, 70, 75–77,
79–83, 85, 91–97, 102–105, 107, 109, 111–114, 125–128,
222, 266–268, 295
Primary care doctor 63, 69, 96, 107, 114, 115, 134,
158–166, 272, 273, 295
Principal care management services 111
Privacy notice 252–256
314
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Private Fee-for-Service (PFFS) plan 164–165
Program of All-inclusive Care for the Elderly (PACE)
176 –177, 235, 294
Prostate cancer screening (PSA test) 112
Prosthetic/orthotic items 112
Puerto Rico 21, 24, 122, 228, 236
Pulmonary rehabilitation programs 113
Q
Quality of care 239, 267, 270–274, 277, 291
R
Railroad Retirement Board (RRB) 21–26, 35, 43, 137,
198–199, 279
Referral
Denition 295
Medicare Advantage Plans 11, 60, 147, 149, 159–167
Original Medicare 11, 134, 149
Part B-covered services 60–128
Religious non-medical health care institution 48, 55
Replacement Medicare card 265, 276
Respite care 52
315
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Retiree health insurance (coverage) 29, 32, 36, 38, 43, 49,
58, 59, 133, 135, 153, 216–217
RRB. Go to
Railroad Retirement Board.
Rural emergency hospital 63
Rural health clinic 106, 113
S
Screenings. Go to Preventive services.
Senior Medicare Patrol Program 259
Service area 11, 149, 150, 151, 176, 192, 196, 295
Sexually transmitted infection screenings and
counseling 114 –115
SHIP. Go to State Health Insurance Assistance Program.
Shots (vaccines) 7, 8, 19, 92, 94, 111, 115, 125, 266, 295
Sigmoidoscopy 75
Skilled nursing facility (SNF) care 7, 48, 51, 54, 55, 56–57,
63, 114, 119, 155, 178, 182, 246, 248, 273, 289, 296
SNF. Go to
Skilled nursing facility (SNF) care.
S N P. Go to Special Needs Plan.
316
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Social Security
Change address on MSN 137
Extra Help paying Part D costs 230, 232
Other helpful contacts 276
Part A and Part B premiums 39–46
Part D premium 198–200
Sign up for Part A and Part B 21–33
Supplemental Security Income (SSI) benets 235–236
S PA P. Go to State Pharmacy Assistance Program.
Special Enrollment Period
Part A and Part B 28–31, 42
Part C (Medicare Advantage plans) 169–175
Part D (Medicare drug plans) 192–194, 217
Special Needs Plan (SNP) 144, 166–168
Speech-language pathology 116
SSI. Go to Supplemental Security Income.
State Health Insurance Assistance Program (SHIP) 19, 25,
131, 141, 175, 186, 189, 195, 201, 217, 232, 234, 245, 258,
265–266, 271, 280–287
317
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
State Medical Assistance (Medicaid) oce 33, 131, 135,
167, 226, 233, 236, 298
State Pharmaceutical Assistance Program 234
Substance use disorder treatments 86, 108, 118, 125, 127,
210–214
Supplemental insurance (Medigap)
Drug coverage 218
Open Enrollment 184–186
Original Medicare 134–135
Supplemental Security Income (SSI) 229, 235–236
Supplies (medical) 14, 53, 56, 78, 84, 98, 100, 110, 112,
116, 135, 136, 137, 179, 214, 220, 292
Surgical dressing services 116
T
Tax forms 39–41
Telehealth 91, 113, 117–118, 272
Tests (Non-laboratory) 119
Tiers (drug formulary) 197, 207–208, 244
Transitional care management services 119
318
—
Index of topics
Note: The page numbers shown in bold provide
the most detailed information.
Transplant services 23, 68, 101, 104, 120, 121, 145, 152,
239
Travel 15, 63, 122, 179, 183
TRICARE 33, 37, 121, 203, 221, 278, 290
U
Union
Costs for Part A may be dierent 49
Drug coverage 191–192, 203, 216, 230
Medicare Advantage Plan 58, 153
Signing up for Part B 32
Urgently needed care 15, 123, 142
V
VA. Go to Veterans’ benets.
Vaccines. Go to Shots.
Veterans’ benets (VA) 203, 220, 278
Vision (eye care) 91, 129
320
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ُ
ﺗﺔﻠﺋﺳأصوﺻﺧﺑ
Medicare نﺈﻓنﻣكﻘﺣلوﺻﺣﻟاﻰﻠﻋةدﻋﺎﺳﻣﻟاوتﺎﻣوﻠﻌﻣﻟاكﺗﻐﻠﺑنﻣنود
يأﺔﻔﻠﻛﺗ .ثدﺣﺗﻠﻟﻊﻣمﺟرﺗﻣلﺻﺗإمﻗرﻟﺎﺑMEDICARE )4227-633-800-1.(
հ
հ
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ա
յ
յ
ե
ե
ր
ր
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ե
ն
ն
(Armenian) Եթե Դուք կամ Ձեր կողմից
օգնություն ստացող անձը հարցեր ունի Medicare-ի
մասին, ապա Դուք իրավունք ունեք անվճար օգնություն
և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։
Թարգմանչի հետ խոսելու համար զանգահարեք
1-8009-MEDICARE (1-800-633-4227) հեռախոսահամարով։
中
中
文
文
(Chinese-Traditional) 如果您，或是您正在協助的個
人，有關於聯邦醫療保險的問題，您有權免費以您的母語，
獲得幫助和訊息。與翻譯員交談，請致電 1-800-MEDICARE
(1-800-633-4227).
ﯽﺳرﺎﻓ (Farsi) رﮔا،ﺎﻣﺷﺎﯾﯽﺻﺧﺷﮫﮐﮫﺑواﮏﻣﮐدﯾﻧﺎﺳرﯾﻣﯽﻟاوﺳرددروﻣ
ﮫﯾﻣﻼﻋارﺻﺗﺧﻣ،دﯾرادرﮑﯾدﻣﻖﺣنﯾااردﯾرادﮫﮐﮏﻣﮐوتﺎﻋﻼطاﮫﺑنﺎﺑزدوﺧ
ﮫﺑروطنﺎﮕﯾارتﻓﺎﯾرددﯾﯾﺎﻣﻧ .یارﺑﮫﻣﻟﺎﮑﻣﺎﺑمﺟرﺗﻣﺎﺑنﯾاهرﺎﻣﺷرﯾزسﺎﻣﺗ
دﯾرﯾﮕﺑ1-800-MEDICARE .(1-800-633-4227)
Help in other languages
If you, or someone you’re helping, has questions about
Medicare, you have the right to get help and information
in your language at no cost. To talk to an interpreter, call
1 8 0 0 6 3 3 - 4 2 2 7.
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Help in other languages
Français (French) Si vous, ou quelqu'un que vous êtes en train
d’aider, a des questions au sujet de l'assurance-maladie
Medicare, vous avez le droit d'obtenir de l'aide et de
l'information dans votre langue à aucun coût. Pour parler à un
interprète, composez le 1-800-MEDICARE (1-800-633-4227).
Deutsch (German) Falls Sie oder jemand, dem Sie helfen,
Fragen zu Medicare haben, haben Sie das Recht, kostenlose
Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit
einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer
1-800-MEDICARE (1-800-633-4227) an.
Kreyòl (Haitian Creole) Si oumenm oswa yon moun w ap ede,
gen kesyon konsènan Medicare, se dwa w pou jwenn èd ak
enfòmasyon nan lang ou pale a, san pou pa peye pou sa. Pou w
pale avèk yon entèprèt, rele nan 1-800-MEDICARE
(1-800-633-
4227).
Italiano (Italian) Se voi, o una persona che state aiutando,
vogliate chiarimenti a riguardo del Medicare, avete il diritto di
ottenere assistenza e informazioni nella vostra lingua a titolo
gratuito. Per parlare con un interprete, chiamate il numero
1-800-MEDICARE (1-800-633-4227).
日
日
本
本
語
語
(Japanese) Medicare (メディケア) に関するご質問が
ある場合は、ご希望の言語で情報を取得し、サポートを受
ける権利があります (無料)。通訳をご希望の方は、
1-800-MEDICARE (1-800-633-4227) までお電話ください。
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Help in other languages
한국어(Korean) 만약 귀하나 귀하가 돕는 어느 분이
메디케어에 관해서 질문을 가지고 있다면 비용 부담이 없이
필요한 도움과 정보를 귀하의 언어로 얻을 수 있는 권리가
귀하에게 있습니다. 통역사와 말씀을 나누시려면
1-800-MEDICARE (1-800-633-4227)로 전화하십시오.
Polski (Polish) Jeżeli Państwo lub ktoś komu Państwo pomagają
macie pytania dotyczące Medicare, mają Państwo prawo do
uzyskania bezpłatnej pomocy i informacji w swoim języku. Aby
rozmawiać z tłumaczem, prosimy dzwonić pod numer telefonu
1-800-MEDICARE (1-800-633-4227).
Português (Portuguese) Se você (ou alguém que você esteja
ajudando) tiver dúvidas sobre a Medicare, você tem o direito
de obter ajuda e informações em seu idioma, gratuitamente.
Para falar com um intérprete, ligue para 1-800-MEDICARE
(1-800-633-4227).
Русский
(Russian) Если у вас или лица, которому вы
помогаете, возникли вопросы по поводу программы
Медикэр (Medicare), вы имеете право на бесплатную
помощь и информацию на вашем языке. Чтобы
воспользоваться услугами переводчика, позвоните по
телефону 1-800-MEDICARE (1-800-633-4227).
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Help in other languages
Español (Spanish) Si usted, o alguien que esta ayudando,
tiene preguntas sobre Medicare, usted tiene el derecho a
obtener ayuda e informacion en su idioma sin costo alguno.
Para hablar con un interprete, llame al 1 800 633 - 4227.
Tagalog (Tagalog) Kung ikaw, o 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-MEDICARE
(1-800-633-4227).
Tiếng Việt (Vietnamese) Nếu quý vị, hay người mà quý vị đang
giúp đỡ, có câu hỏi về Medicare, quý vị sẽ có quyền được giúp
và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói
chuyện qua thông dịch viên, gọi số 1-800-MEDICARE
(1-800-633-4227).
Copies of this product are available free of charge at
Medicare.gov or by calling 1 800 633 - 4227.
Health Insurance Marketplace
®
is a registered service
mark of the U.S. Department of Health & Human Services.
“Medicare & You” isn’t a legal document. Ocial Medicare
Program legal guidance is contained in the relevant
statutes, regulations, and rulings.
This product was produced at U.S. taxpayer expense.
Moving?
Visit SSA.gov, or call Social Security at 1 800 772 - 1213.
TTY users can call 1 800 325 - 0778. If you get RRB
benets, contact the RRB at 1 877 772 - 5772. TTY users
can call 1 312 751 - 4701.
¿Necesita usted una copia de este manual en
Español?
Llame al 1 800 633 - 4227. Los usuarios de TTY pueden
llamar al 1 877 486 - 2048.
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244 - 1850
Ocial Business
Penalty for Private Use, $300
CMS Product No. 10050 - LE
January 2024
National Medicare Handbook
