Medicare Articles

Cheat Sheet / Updated 09-16-2024

If you’re new to Medicare (or soon will be), here's information on three crucial Medicare topics: a useful list of dos and don’ts to keep in mind before you embark on the program; a quick run-through of the best times to enroll, depending on your specific circumstances; and a mini-directory of organizations that can help you with Medicare issues.

Article / Updated 08-04-2022

Medicare Part B covers two kinds of health services: medically necessary care and preventive care. You need to think twice about saying no to Medicare Part B coverage, even though it costs a monthly premium to use it. (If that amount would be a hardship, you may be able to have the premiums paid by your state.) It’s an important decision you need to make during the enrollment process — especially if you’re signed up automatically — and you should be very clear on how to deal with it given your situation. There are situations when opting out of Part B is okay — in other words, not likely to cause you any regrets (or cost you money!) in the future. And there are situations when opting out is costly or causes other problems. Bizarrely, the rules are different for people who have Medicare because they’re 65 or older and those who have it at earlier ages because of a disability. So look separately at these two groups to know when people in each can confidently turn down Part B. Know when to turn down Part B if you’re 65 or older In general, when you’re 65 or older, you should decline Part B only if you have group health insurance from an employer for whom you or your spouse is still actively working and that insurance is primary to Medicare. (That is, it pays before Medicare does.) In this situation, you can delay Part B enrollment without penalty until the employment stops or the insurance ends. So if you’re not yet drawing Social Security retirement benefits, just skip signing up for Part B. Or if you’re enrolled automatically because you’re receiving those benefits, you can decline Part B by following the instructions that Social Security sends you in the letter that accompanies your Medicare card and meeting the specified deadline. Opting out ensures that you don’t have to pay Part B premiums or, if you’re receiving retirement benefits, have them deducted each month from your Social Security retirement check. But of course, if you prefer to pay for both employer insurance and Medicare coverage — and that’s entirely your choice — go ahead and enroll (or stay enrolled) in Part B. One group of people is especially prone to turn down Part B without giving it adequate thought: people age 65 and older who are in same-sex marriages or domestic arrangements with people of the same or the opposite sex and who are covered under health insurance from their partner’s employer. If you’re in either of these situations, you need to find out exactly how current law applies to you. When to turn down Part B if you’re under 65 In general, if you have Medicare based on disability, you should decline Part B only if You have health insurance from an employer for whom you or your spouse actively works, and the employer has 100 or more employees. You’re covered as a family member on somebody else’s group health plan at work, and the employer has 100 or more employees. What does family member mean? It means that the employer providing this insurance regards you as eligible for health coverage based on your domestic relationship with an employee — even if you aren’t formally married to that person and even if they are the same sex as you. When turning down Part B at any age is risky Regardless of whether you have Medicare based on disability or age, you should definitely enroll in Part B (or not refuse it) if you have health insurance that will automatically become secondary to Medicare (it will pay after Medicare does) when your Medicare benefits begin. This includes the following: Health insurance that you buy yourself on the open insurance market and that isn’t provided by an employer Health insurance from an employer with fewer than 20 employees (if you’re 65 or older) Health insurance from an employer with fewer than 100 employees (if you have Medicare because of disability) Retiree benefits from a former employer (your own or your spouse’s) Health benefits from the military’s TRICARE For Life retiree program When Medicare is primary coverage, it pays the bills You should enroll in Part B coverage in the preceding situations for a very good reason quite apart from the possibilities of late penalties down the road if you don’t. When Medicare is considered primary coverage, it pays your medical bills first. So if you’re not enrolled in Part B, you run the real risk of having your insurance plan deny any claims that Medicare could’ve paid — from basic ones like doctors’ visits and lab tests to major ones like surgery. In other words, you may face having to pay the entire bill. Worse, if your own insurer takes a while to realize that you haven’t enrolled in Part B, your plan may even ask you to pay back all the money it has spent on your medical services since you became eligible for Medicare. This kind of thing doesn’t always happen. For example, if you’re a federal retiree and receiving health insurance from a plan in the Federal Employee Health Benefits Program, you aren’t required to enroll in Part B. When deciding whether to accept or decline Part B, finding out whether Medicare would be primary or secondary to any other insurance that you have is critically important. Copyright © 2014 AARP. All rights reserved.

Article / Updated 12-22-2021

You may think that disenrolling means the same as opting out. And that may be so in general. But in a specific situation where you’re already enrolled in Part B, but then — weeks, months, or years later — you or your spouse starts a job with health benefits. If that happens, do you really need to keep on paying those Part B premiums? You can disenroll from Part B and stop paying premiums for it in this situation, regardless of whether it was you or your spouse who landed this new job. In other words, you’re allowed to delay Part B without penalty if you have health insurance from current employment and the employer plan is primary to Medicare. To disenroll from Part B, you’re required to fill out a form (CMS-1763), which you must complete either during a personal interview at a Social Security office or on the phone with a Social Security representative. For an interview, call the Social Security Administration toll-free at 800-772-1213 or call your local office. Social Security insists on an interview to make sure you know the consequences of dropping out of Part B — for example, that you may have to pay a late penalty if you want to reenroll in the program in the future. However, the penalty isn’t an issue if you’re leaving Part B to enroll in primary health insurance from an employer. In the event that you lose this coverage in the future, you won’t incur a late penalty as long as you sign up for Part B again within eight months of the job’s or the insurance’s ending (whichever happens first).

Article / Updated 11-03-2020

Although Medicare covers a multitude of medical services, it also has some yawning gaps. Some may surprise you, so the following sections address the broad areas that Medicare doesn’t normally cover, together with some tips for alternative ways of filling in the gaps. Being aware of them from the start is better than being disappointed if Medicare denies coverage after the fact. Routine hearing, vision, dental, and foot care The older you get, the more you’re likely to need professional attention for your ears, eyes, teeth, and feet. But Medicare doesn’t cover routine services to take care of these parts. Routine is the key word here. Medicare pays to treat problems it considers medically necessary (including cataract surgery, jaw restoration after injury, and treatment for diseases of the ear) but not the kind of care you may need on a regular basis, such as the following: Ear exams, hearing aids, or having hearing aids fitted Vision tests, eyeglasses, or contact lenses Oral exams, teeth cleaning, extractions, or dentures Toenail clipping or the removal of corns and calluses However, routine services for ears, eyes, and teeth may be covered if you’re enrolled in a Medicare Advantage plan that provides them as extra benefits. Some plans offer them as separate benefit packages for an additional premium. Not all plans offer coverage for this routine care, but those that do are identified in the plan finder program on Medicare’s website with small logos: D for dental, V for vision, and H for hearing. Of course, as always in Medicare, some exceptions exist. You can get coverage for foot care in certain circumstances — for example, if you have foot problems caused by conditions such as diabetes, cancer, multiple sclerosis, chronic kidney disease, malnutrition, or inflammation of the veins related to blood clots — especially if the act of toenail clipping would be hazardous to your health unless done by a professional. But the bottom line is that to get Medicare coverage for foot care, you need your doctor or podiatrist to provide evidence that said care is medically necessary. Home safety items Medicare spends billions of dollars a year on treating the results of falls, and older Americans are five times more likely to end up in the hospital for falls than for any other injuries. So, you’d think that Medicare would try to save at least some of those billions by covering safety items that help prevent people from falling. But no, it doesn’t. To be sure, Medicare covers a few items it deems medically reasonable if prescribed by a doctor — for example, seat lifts that help incapacitated people sit down or get up from a chair, or trapeze bars that help people sit up or alter positions when confined to bed. But Medicare doesn’t pay for equipment it considers items of convenience rather than of medical necessity. A long list of non-covered items includes stair lifts or elevators, bathtub lifts or seats, grab bars, room heaters, air conditioners, humidifiers, posture chairs, massage devices, physical fitness equipment, and medical emergency alert systems. But you may be able to get help in other ways: If you’re a veteran with disabilities, be aware that the Department of Veterans Affairs has little-known programs that provide cash grants to help eligible vets make safety improvements in their homes. Call the VA at 877-827-3702, email [email protected]. If your income is limited, contact the nonprofit organization Rebuilding Together, which provides volunteers to make housing repairs and install safety equipment free of charge. Call 800-473-4229 for local information. If you file itemized tax returns, you may be able to deduct the costs of home improvements for medical reasons. Nursing home care Many people are surprised, and often alarmed, to discover that Medicare doesn’t cover long-term care in nursing homes. I’m not talking here about short-term stays in a skilled nursing facility (most of which are nursing homes) after leaving the hospital; Medicare does cover those stays in specific circumstances. But what if you become too sick or incapacitated to live at home and need the constant long-term care that a nursing home provides? Medicare will continue to cover your medical needs, but it won’t pay for what it calls custodial care, which refers to help with the activities of daily life such as using the bathroom, dressing, and so on. Nor will Medicare pay for your room and meals in a nursing home. These same rules apply to assisted living facilities. Most people living in nursing homes pay for their custodial care out-of-pocket — with the help of long-term-care insurance, if they’ve purchased it — until their resources run dry. At that point, they usually become eligible for Medicaid, the state-run health-care system for people with very limited incomes and resources, which does pay the custodial care bills of people who qualify. (Because of the similarity in names, many people confuse Medicare and Medicaid, especially when it comes to thinking about long-term care.) Eligibility rules for Medicaid vary from state to state. (And the name of the program is different in some states — for example, MediCal in California, MassHealth in Massachusetts, and TennCare in Tennessee.) To find out how the rules apply to you or a family member, you may need to consult an informed counselor or a qualified elder care attorney. For contact information of people who can help, check out the official document “Your Guide to Choosing a Nursing Home or Other Long-Term Services and Supports.” You can also visit Medicare's nursing home comparison information. Medical services abroad Medicare doesn’t pay for medical services outside of the United States and its territories except in these extremely rare circumstances: You’re traveling between Alaska and another state and have a medical emergency that means you must be treated in Canada. A medical emergency occurs while you’re in the United States or its territories, but the nearest hospital is in a foreign country — for example, across the border in Canada or Mexico. You live within the United States or its territories and need hospital care (regardless of whether it’s an emergency), but your nearest hospital is in a foreign country. Some Medigap supplemental insurance policies (those labeled C, D, F, G, M, or N) cover emergency or urgently needed treatment abroad. In this situation, you pay a $250 deductible and 20 percent of the cost of the medical services you use up to a lifetime maximum of $50,000. Some Medicare Advantage plans also cover emergencies abroad, and so do some employer benefits and TRICARE military benefits. But otherwise, you need to buy travel insurance that includes medical emergencies when planning journeys abroad. What if you live abroad? Medical treatment in other countries is almost always less expensive than in the United States, so paying out-of-pocket may not bankrupt you. And in some circumstances, you may be taken care of by the national health program of the country you’re living in. But buying health insurance on the open market may be difficult or very expensive. One option is to join a nonprofit organization called the Association of Americans Resident Overseas, which has long lobbied Congress to make Medicare available abroad. AARO offers its members access to a variety of private health insurance plans that can be used in many countries. Services that may be nice but aren’t necessary You probably aren’t surprised to know that you can’t get a face-lift or a tummy tuck at taxpayers’ expense. Surgery solely for cosmetic purposes is one of the absolute no-no’s of Medicare coverage. (Medicare does cover bariatric surgery to reduce the size of the stomach in very obese people, but this procedure is to lessen their risk of serious health disorders and not to improve their looks.) Acupuncture and other alternative medical practices are barred under traditional Medicare. Physical fitness classes and gym memberships are also excluded. But some of these services (notably gym memberships) are covered as extras in some Medicare Advantage plans. Even something as relatively mainstream as chiropractic care may be excluded from Medicare coverage in many circumstances. Chiropractors help lessen the pain of spine and joint problems, most often by the manipulation of bones. Medicare covers manipulative treatment from a licensed chiropractic physician when you’re injured or in pain because of a problem with the spine, provided that the treatment is clearly improving your condition. But Medicare doesn’t pay for the manipulation of other joints (such as shoulders and knees) or for other types of chiropractic care such as massage or traction. And it doesn’t pay for maintenance care to keep you stable if you aren’t demonstrably improving. Finally, in the hospital, Medicare doesn’t cover a private room (unless sharing one would be medically inadvisable), private nursing, or conveniences like a telephone or television if these items are billed separately.

Article / Updated 11-03-2020

Part D, Medicare's program for covering prescription drugs, is a complicated benefit that resembles no other type of drug coverage ever devised. That's why understanding how it works before plunging in is really important. Following is information on the peculiarities of Part D coverage — how it can fluctuate during the year, how different plans have their own lists of drugs they cover, and which drugs are excluded from Part D and which must be covered. Drug coverage that can vary throughout the year It sounds crazy, but you may find yourself paying different amounts for the same medicines at different times of the year. That's because Part D drug coverage is generally divided into four phases over the course of a calendar year. Whether you encounter only one phase or two, three, or all four depends mainly on the cost of the prescription drugs you take during the year — unless you qualify for Extra Help. Here's the breakdown: Phase 1, the annual deductible: If your Part D drug plan has a deductible, you must pay full price for your drugs until the cost reaches a limit set by law ($435 in 2020) and drug coverage actually begins. Many plans don't charge deductibles or charge less than the limit. But if your plan has a deductible, this period begins on January 1 or whenever you start using your Medicare drug coverage. Phase 2, the initial coverage period: This stage begins when you've met any plan deductible. Otherwise, it begins on January 1 or whenever you start using Medicare drug coverage. You then pay the co-payments required by your plan for each prescription, and the plan pays the rest. This period ends when the total cost of your drugs — what you've paid plus what your plan has paid — reaches a certain dollar limit set in law ($4,020 in 2020). Phase 3, the coverage gap: This gap — often called the doughnut hole — begins when you hit the limit of initial coverage and ends if and when the amount you've spent out-of-pocket on drugs from the beginning of the year hits another dollar limit set in law ($6,350 in 2020). Until 2011, you would've had to pay 100 percent of the cost of your drugs in the gap. Now you pay a lot less because under the Affordable Care Act, the gap is gradually shrinking. In 2020, your plan will cover at least 5 percent of the cost of covered brand-name drugs, plus you’ll get a discount of 70 percent on brand-name drugs from the manufacturer, so the amount you will pay is 25 percent of the cost. Also, as of 2020, Medicare will cover 75 percent of the price for generic drugs for those in the coverage gap, so in 2020, you will pay only 25 percent for both generic and brand-name drugs. These discounts come partly from the drug manufacturers and partly from the government. What’s more, the 50 percent that the drug manufacturers contribute to the discounts on brand-name drugs counts toward the dollar out-of-pocket limit that gets you out of the gap; that is, you get credit for having paid full price even though you’re receiving the discount. But for any discounts funded by the government, such as those for all generic drugs and anything above 50 percent for brands, only what you pay counts toward getting out of the gap. Phase 4, catastrophic coverage: If your drug costs are high enough to take you through the gap, coverage kicks in again. At this point, your share of the costs drops sharply. You pay no more than 5 percent of the price of each prescription. Catastrophic coverage ends on December 31. The next day, January 1, you return to Phase 1 (or Phase 2 if your plan has no deductible), and the whole cycle starts over again. This figure is a quick way of looking at the same cycle of coverage. The following figure shows this information in a different way. Here, you can see examples of brand-name drugs costing (for the sake of simplicity) $100, $200, or $300 per one-month prescription — and what you'd pay for them in each phase of coverage. These examples assume co-pays during the initial coverage period of $45 for each prescription, although co-pays vary widely among Part D plans. All about formularies Formulary is jargon that becomes familiar when you're in Part D because it directly affects what you pay. A formulary is simply the list of drugs that each Part D plan decides to cover. (No national formulary exists.) Here's why it's important that your drugs are included on your plan's formulary: You usually have to pay the whole tab for drugs that aren't covered. Your plan pays its share of the cost during the initial and catastrophic coverage phases (Phases 2 and 4). But for any drug the plan doesn't cover, you pay full price in all phases of coverage unless you win an exception from the plan. The difference in your out-of-pocket expenses between a covered and uncovered drug can be hundreds of dollars a month. You don't get doughnut hole credit for uncovered drugs. If you fall into the doughnut hole (Phase 3), the cost of any drugs not covered by your plan doesn't count toward the out-of-pocket limit that gets you out of the gap and triggers low-cost catastrophic coverage. You're more likely to properly fill and take your medicines. You need the meds you're prescribed for the sake of your health. If you get coverage for them and don't have to pay full price, you're much more likely to fill all your prescriptions and not skip doses. No Part D plan covers all prescription drugs, and the number covered varies greatly among plans. In 2019, 63 percent of drugs were covered by Medicare Part D plans, according to an analysis by the health research group Avalere Health. So, the goal is to choose a plan that covers all, or at least most, of the specific drugs you take. The drugs Part D plans must cover Although Medicare law doesn't require Part D plans to cover every drug, it does insist that each plan covers at least two drugs in each class of medications. A class means all the similar drugs that are used to treat the same medical condition. Many plans cover more than two in each class. But every plan must cover "all or substantially all" drugs in each of the following six classes: Anticancer drugs (used to halt or slow the growth of cancers) Anticonvulsants (used mainly to prevent epileptic seizures) Antidepressants (used to counteract depression and anxiety disorders) Antipsychotics (used to treat mental illnesses such as schizophrenia, mania, bipolar disorder, and other delusional conditions) HIV/AIDS drugs (used to block or slow HIV infection and treat symptoms and side effects) Immunosuppressants (used to prevent rejection of transplanted organs and tissues and treat immune system disorders and some inflammatory diseases) Medicare requires every Part D plan to cover pretty much all drugs in these categories because of the clinical problems that can occur when patients abruptly stop taking such medications or switch to others. The drugs Medicare doesn't pay for By law, Medicare doesn't pay for certain kinds of drugs. Part D plans aren't prohibited from covering them; Medicare just doesn't reimburse their cost. So although a few plans may cover some of these drugs, most plans don't cover any. The types of excluded drugs are Medicines sold over the counter (not needing a doctor's prescription) Drugs used for anorexia, weight loss, or weight gain Drugs used for cosmetic reasons and hair growth Drugs used to promote fertility Drugs used to treat sexual or erectile dysfunction Medicines used to treat cough or cold symptoms Prescription vitamins and mineral products Sometimes Medicare will pay for medications in these categories if they're used for a "medically acceptable" purpose — for example, cough medicines when prescribed by a doctor to alleviate medical conditions such as asthma, drugs for impotency when prescribed to treat different medical conditions that affect veins and arteries, or antismoking drugs if prescribed by a doctor rather than bought over the counter. Until 2013, Medicare also excluded barbiturates (used for anxiety and seizures) and benzodiazepines (used for anxiety and sleeping problems) because these drugs are often abused. But the ban has now been lifted wholly on both types of drugs, allowing Part D plans to cover them for any medically accepted indication. When drugs are covered by Part A, Part B, or Part D As confusing as it sounds, some medications may be covered not only under Medicare Part D but also under Part A or Part B. Sometimes an identical drug may be covered by all three but charged under one or another according to different circumstances. That's because certain drugs were covered under A or B before D came into existence, and that practice continued. Here's the general rule of thumb: Part A covers drugs administered when you're a patient in the hospital or a skilled nursing facility. Part B covers drugs administered in a doctor's office (such as injected chemotherapy drugs), hospital outpatient departments, and, in some circumstances, by a hospice or home health-care professional. Part D covers outpatient drugs that you administer to yourself, a caregiver administers to you at your home, or you receive if you live in a nursing home. (These drugs are usually pills but also include self-injected insulin for diabetes, for example.) These general rules are more complicated in some situations. For example, if your organ transplant was covered by Medicare, the immunosuppressant drugs you need afterward are covered by Part B. But if your transplant surgery wasn't covered by Medicare (perhaps because you had it before joining the program), the drugs are covered under Part D. Part D doesn't pay for drugs covered by Parts A or B. So if any of your meds are in question, your Part D plan may require information from you and your doctor — usually concerning any related medical treatment, such as surgery — before covering them. For this reason, Part D plans often place a prior authorization restriction on such drugs to determine whether Part A, B, or D should cover them. Your doctor may be able to settle this matter over the phone or may help you file a speedy exception request. Either way, your doctor needs to explain why a prior authorization shouldn't apply in this case.

Article / Updated 11-03-2020

Part A and Part B form the core of Medicare. They provide the coverage that you have if you enroll in the traditional or original Medicare program that has been around since 1966, although many more services have been added since then. Parts A and B are also the basis of your coverage if you’re in a Medicare Advantage health plan, because all those plans must by law cover the same services as the traditional program, although the plans can provide extra benefits if they want to. These two parts of Medicare cover entirely different services. But sometimes Parts A and B work in tandem. For example, if you need to go into the hospital, in most cases Part A covers the cost of your room, meals, and nursing care after you’ve met the deductible. But Part B covers the cost of your medical treatment — services provided by surgeons, other doctors, and anesthetists. This division of coverage also applies to staying in a skilled nursing facility for continuing care after leaving the hospital, using home health services, and receiving hospice care. Necessary medical care In essence, Medicare covers services that are reasonable or necessary to save life and maintain or improve health. That includes really big-ticket items — such as transplants of the heart and other organs, delicate surgery to repair severe injuries, cancer treatments, and many others — that cost Medicare tens of thousands, and in some cases hundreds of thousands, of dollars. The program also, of course, covers more-routine and less-expensive services, from allergy shots to X-rays. No doubt about it: Medicare can split hairs. It may cover a service in some circumstances but not others. One glaring example of this discrepancy is that Medicare covers power-operated vehicles, such as scooters and manual wheelchairs (as opposed to the conventional type) only if you need one to get around inside your home but not if you need one just to be mobile outdoors. In 2018, Medicare began requiring prior authorization for the coverage of certain types of power wheelchairs (33 in all) before Medicare will cover the cost. Medicare may also cover a treatment in some parts of the country but not everywhere. But on the whole, Medicare pays for a vast range of medical services that people need. Sometimes people who’ve used a lot of services, or a few really expensive ones, and are scared to death that their Medicare coverage is going to “run out.” This isn’t something to worry about. In general, no limit caps the amount of coverage you can get from Medicare for necessary services — except for a few specific situations. Preventive care Being able to treat a medical problem is good, but dodging it altogether is better! These days, that seems an obvious truth. Yet Medicare has only fairly recently expanded coverage for services that help prevent or stave off some of the diseases that make people very ill and — not coincidentally — cost Medicare mountains of money. Even better: Many of these preventive tests, screenings, and counseling sessions now come free (no co-pays or deductibles) thanks to the 2010 Affordable Care Act. As of 2020, some 44 million people with Medicare took advantage of these services, at no cost to themselves, according to government reports. But to get these services for free, know that you need to see a doctor who accepts assignment — meaning that she has agreed to accept the Medicare-approved amount as full payment for any service provided to a Medicare patient. Otherwise, you have to pony up a co-pay or, in some circumstances, even the full cost. Now take a look at this table, which shows the range of preventive tests, screenings, and counseling sessions that Medicare covers under Part B and whether they cost you anything. It’s a pretty impressive list! Preventive Care Services Medicare Covers Service Frequency Covered Cost to You “Welcome to Medicare” checkup Once only, during first 12 months in Part B. Free, but any other tests the doctor refers you for may require a co-pay. Wellness checkup Once every 12 months, after you’ve had Part B for one year. Free as long as you ask for a wellness visit and not a “physical.” Abdominal aortic aneurysm screening One-time ultrasound for people at risk. Free. Alcohol misuse screening and counseling One screening and up to four counseling sessions a year. Free. Bone mass measurements Once a year if you’re at risk for broken bones; more if medically necessary. Free. Breast cancer screening (mammograms) Once a year for women age 40 or older. Free. Cardiovascular disease (behavioral therapy) Once a year. Free. Cardiovascular disease screening Once every five years. Free for the tests, but a co-pay is usually required for the doctor visit. Cervical/vaginal cancer screening Once every 24 months, or every 12 months if you’re at high risk. Free. Colorectal cancer screening — barium enema (when used instead of flexible sigmoidoscopy or colonoscopy) Once every 48 months, or every 24 months if at high risk. A co-pay is required. Colorectal cancer screening — colonoscopy Once every 120 months, or every 24 months if at high risk. Free for the test, but a co-pay is required if a polyp is found and removed during the test. Colorectal cancer screening — fecal occult blood test Once every 12 months if you’re 50 or older. Free. Colorectal cancer screening — flexible sigmoidoscopy Once every 48 months if you’re 50 or older. Free. Depression screening Once a year in a primary-care setting. Free screening, but a co-pay is required for doctor visit and follow-up care. Diabetes training Training on how to self-manage diabetes — up to 12 hours in the first year and up to two hours every year after that. A co-pay is required, and your Part B deductible applies. Diabetes screening Up to two screenings a year if you’re at risk of developing diabetes. Free. Flu shots Once a year in flu season. Free. Glaucoma (eye disease) tests Once every 12 months if you’re at high risk. A co-pay is required, and your Part B deductible applies. Hepatitis B virus (HPV) infection screening Annually only for those considered at risk who don’t get a Hepatitis B vaccination. Free. Hepatitis C screening test One-time screening; yearly screening for people at high risk or those born between 1945 and 1965. Free. HIV screenings Once every 12 months or up to three times during pregnancy. Free. Lung cancer screening Once a year for people age 55–77, who are current or former smokers averaging one pack a day for 30 years, but without symptoms of lung disease. Free. Obesity screening and counseling Behavioral counseling sessions if your body mass index (BMI) is 30 or higher. Free. Pneumococcal shot After age 65, one type of shot followed at least one year later by a second shot. Free. Prostate cancer digital rectal exam Once every 12 months for men over 50. A co-pay is required, and the Part B deductible applies. Prostate cancer PSA test Once every 12 months for men over 50. Free. Sexually transmitted infections screenings and counseling Tests once every 12 months or more often if pregnant. Up to two counseling sessions with a primary-care provider. Free if tests are ordered by a doctor and performed in a Medicare-approved laboratory. Smoking and tobacco use cessation counseling Up to eight sessions in any 12-month period. Free. X-rays, MRIs, CT scans, EKGs, and so on As ordered for diagnosis by a doctor. A co-pay is required, and your Part B deductible applies. Source: Centers for Medicare & Medicaid Services Note: Services labeled “free” (meaning no co-pay or deductible required) assume that you go to a doctor who accepts Medicare’s payment in full. Specialized Care in Certain Circumstances Medicare Part A is usually associated with care within the hospital, of course. But it also covers certain specialized services outside the hospital, most of which focus on nursing. Part B, too, covers some types of specialized care, such as physical therapy. Care in a skilled nursing facility Home health-care services Hospice care Palliative care End-of-life care counseling Pregnancy and childbirth

Article / Updated 11-02-2020

Do you really need to know the details of what Parts A, B, C, and D stand for? Doesn’t Medicare just pay its share of your bills and that’s it? Well, not entirely. Medicare’s architecture is more than a tad weird, but each of its building blocks determines the coverage you get and what you pay. Besides that, however, is the simple fact that making sense of Medicare is difficult unless you understand what Parts A, B, C, and D actually mean. Part A Medicare Part A is usually described as hospital insurance — a term originally coined to distinguish it from medical insurance (Part B). But the phrase is misleading. “Hospital insurance” sounds as though Part A covers your entire bill if you’re admitted to a hospital, but it doesn’t work that way. The services you receive from doctors, surgeons, or anesthetists while you’re in the hospital are billed separately and are covered under Part B. And you don’t even have to be hospitalized to get services under Part A, because some are provided in settings outside the hospital or even in your own home. A more accurate way to think of Part A is as coverage primarily for nursing care. It helps pay for the following: The services of professional nurses when you’re admitted to a hospital or a skilled nursing facility (such as a nursing home or rehab center) for short-term stays or when you qualify for home health services or hospice care in your own home A semiprivate room in the hospital or nursing facility All meals provided directly by the hospital or nursing facility Other services provided directly by the hospital or nursing facility, including lab tests, prescription drugs, medical appliances and supplies, and rehabilitation therapy All services provided by a home health agency if you qualify for continuing care at home All services provided by a hospice program if you choose to stop treatment for a terminal illness The vast majority of people in Medicare are eligible for Part A services without paying any premiums for it. That’s because Part A is essentially paid for in advance by the Medicare payroll taxes that you or your spouse contributed from every paycheck while working. But, of course, Part A services themselves aren’t free. You still pay deductibles and co-payments for specific services. Part B Many people in Medicare never need to go into the hospital, but almost everybody sees a doctor or needs diagnostic screenings and lab tests sooner or later. That’s where Part B — known as medical insurance — comes in. The wide range of services it covers includes the following: Approved medical and surgical services from any doctor who accepts Medicare patients, whether those services are provided in a doctor’s office, in a hospital, in a long-term-care facility, or at home Diagnostic and lab tests done outside hospitals and nursing facilities Preventive services such as flu shots, mammograms, screenings for depression and diabetes, and so on, many of which are free Some medical equipment and supplies (for example, wheelchairs, walkers, oxygen, diabetic supplies, and units of blood) Some outpatient hospital treatment received in an emergency room, clinic, or ambulatory surgical unit Some inpatient care in cases where patients are placed under observation in the hospital instead of being formally admitted Inpatient prescription drugs given in a hospital or doctor’s office, usually by injection (such as chemotherapy drugs for cancer) Some coverage for physical, occupational, and speech therapies Outpatient mental health care Second opinions for non-emergency surgery in some circumstances Approved home health services not covered by Part A Ambulance or air rescue service in circumstances where any other kind of transportation would endanger the patient’s health Free counseling to help curb obesity, smoking, or alcohol abuse You must pay a monthly premium to receive Part B services unless your income is low enough to qualify you for assistance from your state. Most people pay the standard Part B premium, which is determined each year by a formula set by law ($144.60 in 2020). If your income is over a certain level, however, you’re required to pay more. You also pay a share of the cost of most Part B services. In traditional Medicare, this amount is almost always 20 percent of the Medicare-approved cost. Medicare Advantage health plans charge different amounts — usually flat dollar co-pays for each service. Part C The coverage provided by Part A and Part B together form what is known as traditional or original Medicare — so named because that was the extent of the program’s coverage when it began back in 1966. It’s also called fee-for-service Medicare because each provider — whether it’s a doctor, hospital, laboratory, medical equipment supplier, or whatever — is paid a fee for each service. But these days Medicare also offers an alternative to the traditional program: a range of health plans that mainly provide managed care through health maintenance organizations (HMOs) or preferred provider organizations (PPOs). These plans are run by private insurance companies, which decide each year whether to stay in the program. Medicare pays each plan a fixed fee for everyone who joins that plan, regardless of how much or little health care a person actually uses. This health plan program is called Medicare Advantage or Medicare Part C. Medicare Advantage plans must, by law, cover exactly the same services under Part A and Part B as traditional Medicare does. (So, if you need a knee replacement, for example, the procedure is covered — regardless of whether you’re enrolled in a Medicare Advantage plan or in the traditional program.) But the plans may also offer extra benefits that traditional Medicare doesn’t cover — such as routine vision, hearing, and dental care. Most plans include Part D prescription drug coverage as part of their benefits package. Still, being enrolled in one of these plans is a very different experience from using the traditional Medicare program. Your out-of-pocket costs are different, and so are your choices of doctors and other providers. Part D Part D is insurance for outpatient prescription drugs — meaning medications you take yourself instead of having them administered in a hospital or doctor’s office. Medicare’s drug benefit was only added to the program in 2006, a full 40 years after Medicare began. Since then, it has saved huge amounts of money for millions of people and allowed many to get the meds they need for the first time. Part D is a complicated benefit that takes a lot of getting used to. Here are just some of the peculiar ways it differs from other drug coverage you may have used in the past: Coverage goes through four distinct phases during a calendar year, and in each phase the same drug can cost a different amount. To get coverage, you must select just one private plan that provides Part D drugs out of many plans (at least 15) that are available to you. Different plans cover different sets of drugs, and no plan covers all drugs. Plans set their own co-pays for each drug, and these amounts can vary enormously, even for the same drug. Plans may require you or your doctor to ask permission before they cover certain drugs or to try a less-expensive version before they cover the one you were prescribed. Plans are allowed to change their costs and benefits or to withdraw from Medicare entirely each calendar year. If this all sounds mystifying, you’re probably wondering how on earth anyone can possibly navigate Part D to find good drug coverage. But yes, it’s possible!

Article / Updated 11-02-2020

When the prospect of becoming a Medicare beneficiary looms on the horizon, you suddenly become aware — if you’re like most people — of how little you know about the program. And even if you think you know, can you be sure that the information you have is accurate? Based on the questions most frequently asked, it seems a lot of perceptions about Medicare are way off base; quite often, they’re gleaned from the Internet or even mass e-mails that are deliberately designed to spread misleading information and scare seniors. But if you’ve had health insurance in the past, especially from an employer, you may naturally be nervous about how Medicare coverage compares with it. As a government-run system, will Medicare give me inferior care? No (or at least, not inherently). The federal government runs and regulates Medicare and also largely pays for the medical services you use. Even so, those actual services are almost wholly private. The doctors you go to are not government employees; the hospitals and laboratories that provide services to you are not government-owned. Instead, they’re free to enter or not enter into contracts with Medicare as they choose. Those who accept you as a Medicare patient are the same kind of independent, private practitioners that you would’ve seen for diagnosis and treatment before coming into Medicare. Will Medicare allow me fewer choices than I have now? No. In fact, the reverse may be true. If you’ve had health insurance from a private employer, for example, you probably had only two or three plans to choose from each year. In contrast, Medicare offers a choice between the traditional program (in which you can go to any doctor or other provider in the United States that accepts Medicare patients) and a variety of private Medicare Advantage health plans, which are likely similar to health plans you may have known in the past. Depending on where you live, you may be overwhelmed by the number of options; in some areas, the average beneficiary may be able to choose from as many as 28 Medicare Advantage plans. Also, there are up to 50 Part D plans available in each state that offer Medicare prescription drug coverage. Will my health issues and preexisting medical conditions work against me? Current and past health problems don’t bar anybody from Medicare coverage or cause anybody to pay higher premiums or co-pays than somebody who is in perfect health. That kind of discrimination, so common in the past in private health insurance, has never existed in Medicare. The one exception is that people with advanced kidney failure can’t enroll in a Medicare Advantage health plan; however, they still receive coverage for the appropriate care — regular dialysis or a kidney transplant — under the traditional Medicare program. (For the record: A history of smoking, alcohol use, or obesity doesn’t increase rates either.) Will Medicare be less expensive than the insurance I have now? Medicare isn’t free. Just like other insurance, it requires monthly premiums, deductibles, and co-pays that you’re responsible for paying unless you qualify for a low-income program or have extra insurance that covers these costs. However, you need to consider the alternatives. Without Medicare, most older and disabled people wouldn’t be able to find affordable insurance on the open market. Compared to most employer insurance (which as a whole covers younger and healthier people), Medicare is reasonably priced. In 2020, Medicare Part B premiums cost $144.60 per month per person, whereas, according to the Kaiser Family Foundation’s 2019 survey of employer health benefits, workers’ monthly contributions to employer insurance averaged $99 for a single person and $462 for a family of two or more. Still, this isn’t an apples-to-apples comparison; many employees pay more than these averages for health benefits, and Medicare beneficiaries usually pay extra for drug coverage, while those with higher incomes pay higher Part B premiums than the standard premiums.. Will I pay a large deductible before getting Medicare coverage? Medicare does have some deductibles, but they’re relatively small compared with the ones many people pay in high-deductible health plans that are sponsored by employers or bought through the 2010 Patient Protection and Affordable Care Act (commonly known as the Affordable Care Act or Obamacare) or on the open insurance market. Will my out-of-pocket expenses be capped in Medicare? Not necessarily. Traditional Medicare sets no limit on the costs you pay out of pocket during a year, although you may buy Medigap insurance to cover those costs. But all Medicare Advantage plans are required by law to set caps on these expenses (up to $6,700 per year for in-network services and $10,000 per year for out-of-network services, but some plans have lower limits). And in the Part D program, after you’ve spent a certain amount out of pocket on your prescription drugs in a year, you qualify for catastrophic coverage that greatly lowers your costs for the remainder of the calendar year. Do I have to sign up for Medicare again every year? No; your coverage just rolls over from year to year unless you decide to change it. But you do have the opportunity to change your coverage if you want to during the open enrollment period that runs from October 15 to December 7 each year. During this time, you can switch from traditional Medicare to a Medicare Advantage plan (or vice versa), from one Medicare Advantage plan to another, or from one Part D prescription drug plan to another. Will Medicare cover my younger spouse or other dependents? No. Family coverage doesn’t exist in Medicare — not for spouses, dependent children, or other family members. Each person must wait until age 65 to join the program unless he qualifies through disability at a younger age. Also, if you and your spouse are both in Medicare, each of you must pay premiums separately and in full unless you receive government assistance to help pay for them. Medicare doesn’t give price breaks for married couples, even in its private Medicare Advantage health plans and Part D drug plans. Will Medicare coverage be cut off when I grow old? No! Medicare coverage is based on medical necessity, not age. So if you need a hip replacement when you’re in your 90s or even over 100, Medicare picks up most of the cost in the usual way. The idea of Medicare rationing care and denying coverage for people over a certain age has been spread through mass emails designed to discredit the Affordable Care Act. In fact, the act doesn’t cut Medicare benefits or allow rationing, and no Medicare regulation limits care for people based on their age.

Article / Updated 12-12-2017

Copyright © 2018 by AARP. All rights reserved. What Medicare pays toward your medical care is coverage. What you contribute out of your own pocket can be several kinds of expenses: premiums, deductibles, and co-payments. If you've had U.S.-style health insurance before, you know exactly what these terms mean. If not, here's a quick primer: Premium: A premium is an amount you pay each month to receive coverage. In other words, it's your entrance ticket to the program. Deductible: A deductible is an amount you pay before coverage kicks in. You can think of it as a kind of down payment before getting the goods. Co-payment: This amount is what you pay as your share of the cost of each service you receive. Strictly speaking, co-pays are fixed dollar amounts (such as $20), whereas coinsurance is the correct term when your share is a percentage of the cost (such as 20 percent). If you had insurance in the past, you probably paid a single premium for all your health care and a single deductible for the whole year (maybe a hefty one if you were in a high-deductible plan), with co-pays for each service. But Medicare, of course, is divided into four parts, each with its own costs and charges. The following sections explain each set of costs under Part A, Part B, Part D, and Medicare Advantage (Part C) plans. Finally, the figure shows the costs for Parts A, B, and D at a glance. Note: The costs in the chart are for people enrolled in traditional Medicare plus stand-alone Part D drug plans. Medicare Advantage plan costs are different and vary among plans.

Article / Updated 12-12-2017

Copyright © 2018 by AARP. All rights reserved. Medicare doesn't pay for medical services outside of the United States and its territories except in these extremely rare circumstances, including the following: You're traveling between Alaska and another state and have a medical emergency that means you must be treated in Canada. A medical emergency occurs while you're in the United States or its territories, but the nearest hospital is in a foreign country — for example, across the border in Canada or Mexico. You live within the United States or its territories and need hospital care (regardless of whether it's an emergency), but your nearest hospital is in a foreign country. Some Medigap supplemental insurance policies (those labeled C, D, F, G, M, or N) cover emergency or urgently needed treatment abroad. (I explain Medigap insurance in Chapter 4.) In this situation, you pay a $250 deductible and 20 percent of the cost of the medical services you use up to a lifetime maximum of $50,000. Some Medicare Advantage plans also cover emergencies abroad, and so do some employer benefits and TRICARE military benefits. But otherwise, you need to buy travel insurance that includes medical emergencies when planning journeys abroad. What if you live abroad? Medical treatment in other countries is almost always less expensive than in the United States, so paying out-of-pocket may not bankrupt you. And in some circumstances, you may be taken care of by the national health program of the country you're living in. But buying health insurance on the open market may be difficult or very expensive. One option is to join a nonprofit organization called the Association of Americans Resident Overseas, which has long lobbied Congress to make Medicare available abroad. AARO offers its members access to a variety of private health insurance plans that can be used in many countries. (You may be able to enroll in Medicare while living abroad, however.)