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

Introduction 1

About This Book 2

Foolish Assumptions 3

Icons Used in This Book 4

Beyond the Book 4

Where to Go from Here 5

Part 1: Getting Started with Medicare 7

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

Addressing Some Upfront Questions 10

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

Part A 13

Part B 14

Part C 15

Part D 15

Recognizing That You Have Choices and Must Make Timely Decisions 16

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

Understanding What Part A and Part B Cover 20

Necessary medical care 20

Preventive care 21

Specialized care in certain circumstances 24

Medical supplies and equipment 28

Knowing What Part D Covers 30

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

Finding out about formularies 32

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

The Gaps: Discovering What Medicare Doesn’t Cover 35

Routine hearing, vision, dental, and foot care 35

Home safety items 36

Nursing home care 37

Medical services abroad 38

Services that may be nice but aren’t necessary 38

Distinguishing When Coverage Comes with Limits 39

Limits on hospital stays 40

Limits on skilled nursing facility stays 41

Limits on mental health benefits 41

Limits on therapy services 42

Chapter 3: Understanding What You Pay Toward Your Costs in Medicare 45

Boning Up on Premiums, Deductibles, and Co-payments 46

Part A costs 47

Part B costs 49

Part D costs 50

Medicare Advantage costs 51

Paying Higher-Income Premiums 52

Understanding who’s liable for the surcharges 53

Figuring out what the surcharges cost you 56

Getting the surcharges waived 57

Paying Different Premiums than Other People in Certain Years 59

Paying Medicare Taxes While Receiving Medicare Benefits 61

Chapter 4: Reducing Your Out-of-Pocket Expenses in Medicare 63

Purchasing Medigap Insurance 64

Examining Medigap policies 65

Choosing and buying a Medigap policy 70

Qualifying for Help from Your State 70

Medicaid 71

Medicaid medical spend-down programs 72

Medicare Savings Programs 73

PACE plans 74

State Pharmacy Assistance Programs 75

Examining Whether Extra Help Can Lower Your Drug Costs 76

Qualifying for Extra Help 77

Applying for Extra Help 78

Choosing a drug plan with Extra Help 85

Considering Other Ways to Cut Costs 88

Taking income tax deductions for Medicare costs 88

Lowering drug costs without Extra Help 90

Part 2: The Hows and Whens of Medicare 93

Chapter 5: Qualifying for Medicare 95

Hitting the Milestone of Age 65 96

Debunking some qualification myths 96

Meeting the requirements for Parts A, B, and D 97

Qualifying for Part A on your own work record 98

Being eligible for Part A on someone else’s work record 100

Qualifying for Medicare under Age 65 on the Basis of Disability 102

Receiving disability payments 103

Suffering from permanent kidney failure (ESRD) 105

Living with Lou Gehrig’s disease (ALS) 106

Falling through the Cracks: Health-Care Options if You Can’t Get Medicare Yet 106

Nice work if you can get it: Landing a job with benefits 106

Paying for COBRA temporary insurance 107

Purchasing individual insurance through the online Marketplace 107

Buying health insurance outside of the Obamacare Marketplace 109

Getting health care without insurance 110

Chapter 6: Enrolling in Medicare at the Right Time for You 111

At a Glance: Surveying Situations That Affect Enrollment Timing 112

Understanding Your Initial Enrollment Period 114

Using your IEP at age 65 114

Taking advantage of your IEP when you have disabilities 115

Delaying Part B if You’ll Qualify for a Special Enrollment Period Later 116

Being able to delay Part B without penalty 117

Knowing what to do about Part A if you delay Part B 119

Heeding a special warning if you have a health savings account at work 120

Using the special enrollment period 122

Enrolling in Other Specific Situations 123

You’re a legal permanent resident 123

You live outside the United States 124

You’re in a nontraditional marriage or domestic partnership 127

You’re incarcerated 128

Deciding Whether and When to Sign Up for Part D Drug Coverage 129

Assessing drug coverage you have from elsewhere 129

Debating whether you need Part D if you don’t take medications 131

Figuring the best time to enroll in Part D 132

Understanding the Consequences of Not Signing Up at the Right Time 133

Missing your deadline for Part B 135

Passing your deadline for Part A 138

Neglecting your deadline for Part D 140

Figuring out whether you can get a late penalty revoked 142

Chapter 7: Discovering How to Sign Up for Medicare 145

Being Automatically Enrolled in Medicare Parts A and B 146

Sign Me Up! Applying for Medicare Parts A and B 147

Signing up from inside the United States 148

Enrolling while you’re living abroad 152

Opting Out of or Disenrolling from Part A or Part B 153

Declining Part A 154

Opting out of Part B 155

Disenrolling from Part B 157

Knowing When Your Coverage Begins 158

When you sign up during the first three months of your IEP 160

When you sign up during IEP months four through seven 160

When you are awarded Medicare coverage retroactively 161

Transitioning from Obamacare to Medicare 162

Figuring out whether you need to make the switch 163

Knowing how and when to switch from Marketplace to Medicare 165

Chapter 8: Understanding How Medicare Fits In with Other Health Insurance 169

Understanding Medicare’s Coordination of Benefits System 170

Helping Medicare help you: Filling out your initial enrollment questionnaire 171

Keeping Medicare informed if your coverage changes 172

Seeing How Medicare Works with an Employer’s Health Insurance Plan 172

Working with insurance from a current employer 173

Having insurance from a former employer 176

Figuring Out How Other Federal Health Benefits Fit In with Medicare 180

The Federal Employees Health Benefits Program 180

TRICARE and TRICARE For Life 183

The Veterans Affairs health system 186

The Indian Health Service 188

The Black Lung Program 188

Mixing Medicare with Workers’ Comp or No-Fault or Liability Insurance 189

When you first make a claim 190

If the claim isn’t settled promptly 190

When the claim has been settled 191

Part 3: Making Smart Choices among Medicare’s Many Options 193

Chapter 9: Making Sense of Medicare’s Many Options 195

Seeing the Big Picture: Your Starting Point to Navigating the Medicare Maze 196

Understanding the consequences of your choice of system 196

Weighing the two systems 199

Recognizing when you may not have a choice 202

Being on your guard against “auto-enrollment” 203

Digging into the Details of Traditional Medicare versus Medicare Advantage 205

Opting for traditional Medicare 205

Looking at Medicare Advantage plans 207

Checking out three other types of Medicare health plans 211

Discovering How Medigap Policies Differ from Medicare Advantage Plans 212

Chapter 10: Choosing Wisely If You Go with Traditional Medicare 215

Understanding the Need to Compare Part D Plans Carefully 216

Knowing what not to do 216

Defining “the best plan” 217

Recognizing that comparing plans is worth the effort 218

Seeing how comparing plans can save big bucks 219

Getting organized with two crucial lists 221

Picking the Part D Plan That’s Best for You 223

Assessing the Plan Finder’s reliability 224

Using the Medicare Plan Finder to discover options available to you 225

Drilling down to important bits of info when comparing Part D plans 228

Choosing the Medigap Supplemental Policy That’s Best for You 233

Choosing a Medigap policy 233

Buying a Medigap policy at the right time 235

Buying Medigap if you’re under 65 237

Suspending a Medigap policy 239

Chapter 11: Making Smart Choices If You Opt for Medicare Advantage 241

Comparing Medicare Advantage Plans 242

Comparing plans’ medical benefits 243

Adding prescription drug coverage 247

Choosing the Medicare Advantage Plan That’s Right for You 250

Figuring out which providers accept the plans you’re considering 250

Enrolling in a Medicare Advantage plan 251

Taking action if you change your mind 252

Chapter 12: Getting Help in Making Medicare Choices 255

One on One: Getting Personal Help on Medicare Issues 256

Asking family and friends 256

Contacting State Health Insurance Assistance Programs 257

Calling Medicare’s help line 258

Seeking advice from other sources 260

Buyer Beware! Avoiding Scams and Hard-Sell Marketing 261

Steering clear of outright scams 262

Resisting hard-sell marketing tactics 265

Part 4: Navigating Medicare from the Inside 269

Chapter 13: Starting Out as a New Medicare Beneficiary 271

Playing Your Cards Right 272

Understanding when to use each card 272

Replacing your cards 275

Beyond the Cards: Checking Out the Extent and Limits of Your Coverage 275

Managing Premiums 277

Discovering different ways to pay Medicare premiums 277

Knowing what can happen when you don’t pay your premiums on time 281

Keeping Track of Your Expenses 284

Understanding Medicare Summary Notices 284

Maintaining hard-copy records you can rely on 287

Tracking information online 288

Dealing with Doctors 288

Finding doctors who accept Medicare patients 289

Understanding what doctors can charge you 289

Filling Prescriptions for the First Time with a Part D Plan 292

When does my coverage begin? 292

Which kind of pharmacy can I use? 293

What happens if I go to an out-of-network pharmacy? 295

How do I prove I have Part D coverage? 296

How can I ensure I get my meds? 297

Chapter 14: Getting the Inside Scoop on Using Certain Medicare Benefits 301

Taking a Closer Look at Part A 302

Understanding hospital benefit periods 302

Taking note of the three-day rule 304

Defining observation status 305

Being aware of the improvement standard 308

Fighting premature hospital discharge 309

Proceeding if the hospital makes a mistake 310

Knowing your rights in a skilled nursing facility 310

Zooming In on Part B 314

Checking on whether Medicare will cover your treatment 314

Receiving a notice saying that Medicare may not pay 315

Determining whether you can find out a service’s cost in advance 317

Maximizing your chances for coverage 318

Recognizing your right to second opinions 319

Filing a claim directly to Medicare 320

Delving into Part D 321

Understanding how a plan may restrict your drug coverage 322

Grappling with the tier system of co-pays 324

Navigating the doughnut hole 327

Using Part D to get the shingles vaccine 328

Taking advantage of free Medication Therapy Management benefits 329

Chapter 15: Changing Your Medicare and Medigap Coverage 331

Switching Coverage during Open Enrollment or Disenrollment 332

The open enrollment period 332

The disenrollment period 333

Taking Advantage of Special Enrollment Periods 334

Recognizing when you can use SEPs to change plans 335

Making sure your records and prescriptions are transferred 339

Dropping a Plan (Or Being Dropped) 341

Leaving a plan on your own 341

Getting the boot from your plan 342

Deciding Whether to Stay or Switch to Another Plan for Next Year 344

Reading your Annual Notice of Change to understand plan alterations 344

Comparing plans (yes, all over again!) 346

Looking at extra factors influencing your decision 347

Changing to Another Medigap Policy 348

Knowing the consequences of switching Medigap policies 349

Exploring a change of Medigap coverage 350

Exercising your right to a 30-day free look 350

Chapter 16: Knowing Your Rights 351

Understanding Your Right to Accurate Information 351

Knowing whom to call 352

Seeking a second opinion 353

Asking for an Investigation 354

Requesting equitable relief 354

Contacting an ombudsman 355

Reaching out to your Quality Improvement Organization 355

Getting ahold of your plan 356

Filing a grievance 356

Taking Steps toward an Appeal 357

Obtaining a formal denial 358

Requesting a coverage determination 358

Having a game plan in mind before you move ahead with an appeal 360

Filing a Formal Appeal 361

Walking through the five levels of appeal 361

Getting help in making an appeal 366

Part 5: The Part of Tens 367

Chapter 17: Top Ten Medicare Mistakes 369

Thinking You Must Reach Full Retirement Age before Signing Up 370

Assuming You Don’t Qualify If You Haven’t Worked Long Enough 370

Failing to Enroll in Part B When You Should 371

Believing You Don’t Need Part B If You Have Retiree or COBRA Coverage 371

Not Signing Up for Part D Because You Don’t Use Prescription Drugs 372

Picking a Part D Drug Plan for the Wrong Reasons 372

Misunderstanding Enrollment Periods 373

Being Too Late to Buy Medigap with Full Protections 373

Failing to Read Your Annual Notice of Change 374

Not Realizing You May Qualify for Help to Lower Your Costs 375

Chapter 18: Ten Ways to Stay Healthier beyond Age 65 377

Taking Action to Avoid Falls 377

Exercising Regularly 379

Quitting Smoking 379

Eating Healthfully 380

Cutting Out Soft Drinks and Extra Sugar 381

Keeping an Eye on Prescription Drugs 381

Continuing to Work or Stay Active 382

Staying Connected and Engaged 382

Keeping Your Brain in Shape 383

Addressing Tough Choices before They’re Necessary 383

Part 6: Appendixes 385

Appendix A: Sources of Help and Information 387

Government Help Lines and Websites 387

The Centers for Medicare & Medicaid Services 388

The Social Security Administration 388

State Health Insurance Assistance Programs 389

The Eldercare Locator 394

Independent Sources of Direct Help 394

The Medicare Rights Center 394

The National Alliance for Hispanic Health 395

The National Asian Pacific Center on Aging 395

Resources for Saving Money 396

Consumer Information and Advocacy Organizations 397

Sources for Updates on Medicare 398

Appendix B: Glossary 399

Index 405

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