Medicare


    WHAT IS MEDICARE?

    [1]

    Medicare is a national health insurance program run by the federal government.  Since it is a federal program, Medicare does not differ much from state to state.  Medicare is similar to private health insurance in that it pays for some of the cost of your medical care, but often you have to pay some too.


    WHO IS ELIGIBLE FOR MEDICARE?[2]

    Medicare is generally for U.S. citizens or people lawfully present in the U.S. who are:

    • •  65 or older

    • •  Under 65 with certain disabilities

    • •  Of any age with end-stage renal disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)

     


    WHEN AND HOW CAN I ENROLL IN MEDICARE?

     

    Medicare Parts A and B

    Some people are automatically enrolled in Medicare Parts A and B (you can read more about the different Parts of Medicare below).  If: [3]

    • •  You are already getting benefits from Social Security or the Railroad Retirement Board…

      • •  You will automatically get Parts and B starting the first day of the month you turn 65.

    • •  You are under 65 and disabled…

      • •  You will automatically get Parts A and B after you get Social Security disability benefits, or certain Railroad Retirement Board disability benefits, for 24 months

    • •  You have ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease)…

      • •  You will automatically get Parts A and B the month your disability benefits begin

     

    If you are automatically enrolled, you have a chance to decline or delay the enrollment for Part B, which usually requires you to pay a monthly premium.  You can do this by following the instructions that come with your Medicare card and sending the card back.[4]

     

    Some people have to sign up to get Medicare Part A and/or Part B, if they want them (you can read more about the different Parts of Medicare below).  You have to sign up for Medicare Part A and/or Part B if:[5]

    • •  You are almost 65 but not getting Social Security or Railroad Retirement Board benefits

    • •  You have End-Stage Renal Disease (ESRD)

     

    Initial Enrollment Period[6]

    If you are not automatically enrolled, your Initial Enrollment Period is your first opportunity to sign up for Medicare Parts A and B.  This is a seven-month period starting 3 months before the month you turn 65 and ending three months after the month you turn 65.  You should sign up within the first three months of your Initial Enrollment Period if you want your coverage to start the first day of your birthday month (if you sign up later, your coverage might be delayed).

     

    General Enrollment Period[7]

    If you were not automatically enrolled and you did not sign up during your Initial Enrollment Period, you can sign up during the general enrollment period, which starts every year on January 1 and ends on March 31.  Your coverage will then begin on July 1 of that year.  When you enroll after your Initial Enrollment Period, you may have to pay higher premiums.

     

    Special Enrollment Period[8]

    If you were not automatically enrolled and you did not sign up during your Initial Enrollment period because you were covered under a group health plan based on your or a family member’s current employment, you can sign up during a Special Enrollment Period.  The Special Enrollment Period is anytime you are still covered by the group health plan, or during the eight-month period starting the month after the employment ends or the coverage ends (whichever happens first).  Usually you don’t pay a late enrollment penalty if you sign up during a Special Enrollment Period.  COBRA coverage and retiree health plans won’t qualify you for a Special Enrollment Period because they aren’t considered coverage based on current employment.

     

    Should I Enroll in Part B?

    This depends on your specific circumstances. 

     

    If you have health coverage through your own or a spouse or family member’s employer or union, you should talk to the employer or union benefits administrator to find out how coverage works with Medicare.  Sometimes it can be better to delay signing up for Part B.  You can sign up later during a Special Enrollment Period (see Special Enrollment Period above).

     

    If you have Part A and TRICARE (a health care program for active-duty and retired uniformed services members and their families), you might have to have Part B to keep your TRICARE coverage.

     

     

    Medicare Advantage (Medicare Part C)[9]

    You can join, switch, or drop a Medicare Advantage Plan as follows:

    • •  When you first become eligible for Medicare…

      • •  You can join a Medicare Advantage Plan during the seven-month period starting 3 months before the month you turn 65 and ending three months after the month you turn 65

    • •  If you get Medicare because of a disability…

      • •  You can join a Medicare Advantage plan during the seven-month period starting 3 months before your 25th month of disability and ending three months after your 25th month of disability

    • •  If you are already eligible for Medicare because of a disability and are around age 65…

      • •  You can join, switch, or drop a Medicare Advantage Plan during the seven-month period starting 3 months before the month you turn 65 and ending three months after the month you turn 65.  If you sign up for a Medicare Advantage Plan during this time, you can drop it at any time during the next 12 months and go back to Original Medicare.

    • •  If you have Part A coverage and enrolled in Part B during the Part B General Enrollment Period (January 1 to March 31)…

      • •  You can join a Medicare Advantage Plan between April 1 and June 30

    • •  Anyone who is eligible…

      • •  Can join, switch, or drop a Medicare Advantage Plan between October 15 and December 7, and your coverage will start on January 1

    • •  If you’re in a Medicare Advantage Plan…

      • •  Between January 1 and February 14, you can leave your plan and switch to Original Medicare (Medicare Parts A and B) and, if you want to, join a Medicare Part D Prescription Drug Plan.

    • •  If you move out of your Medicare Advantage Plan’s service area…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period.  Contact your plan for more information. 

    • •  If you have Medicaid…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period.  Contact your plan for more information. 

    • •  If you qualify for Extra Help (a Medicare program that helps people with limited income and resources pay Medicare Part D Prescription Drug Plan costs)…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period.  Contact your plan for more information. 

    • •  If you live in a nursing home or other institution…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period.  Contact your plan for more information. 

     

     

    Medicare Part D[10]

    If you don’t join a Medicare drug plan when you are first eligible, you will probably have to pay a late enrollment penalty if you join a plan later, unless you have other creditable prescription drug coverage (coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage) or you get Extra Help (a Medicare program that helps people with limited income and resources pay Medicare Part D Prescription Drug Plan costs).

     

    You can join, switch, or drop a Medicare Part D Prescription Drug Plan as follows:

    • •  If you qualify for Extra Help (a Medicare program that helps people with limited income and resources pay Medicare Part D Prescription Drug Plan costs)…

      • •  You can join, switch, or drop a Medicare Prescription Drug Plan at any time

    • •  When you first become eligible for Medicare…

      • •  You can join a Medicare Part D Prescription Drug Plan during the seven-month period starting 3 months before the month you turn 65 and ending three months after the month you turn 65

    • •  If you get Medicare because of a disability…

      • •  You can join a Medicare Part D Prescription Drug Plan during the seven-month period starting 3 months before your 25th month of disability and ending three months after your 25th month of disability

    • •  If you are already eligible for Medicare because of a disability and are around age 65…

      • •  You can join, switch, or drop a Medicare Part D Prescription Drug Plan during the seven-month period starting 3 months before the month you turn 65 and ending three months after the month you turn 65. 

    • •  If you don’t have Part A coverage and enrolled in Part B during the Part B General Enrollment Period (January 1 to March 31)…

      • •  You can join a Medicare Part D Prescription Drug Plan between April 1 and June 30

    • •  Anyone who is eligible…

      • •  Can join, switch, or drop a Medicare Part D Prescription Drug Plan between October 15 and December 7, and your coverage will start on January 1

    • •  If you have Medicaid…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period.   

    • •  If you live in a nursing home or other institution…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period. 

    • •  If you move out of your Medicare Part D Prescription Drug Plan’s service area or the service area of your Medicare Advantage Plan that offered Medicare prescription drug coverage…

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period. 

    • •  If you lose other creditable prescription drug coverage… 

      • •  You may be able to join, switch, or drop your plan during a Special Enrollment Period. 

     

    Should I Enroll in a Part D Plan?

    This depends on your specific circumstances.  Here are just a few things to think about:

    • •  If you have prescription drug coverage through your own or a spouse or family member’s employer or union, you should talk to the employer or union benefits administrator before signing up for a Medicare Part D Prescription Drug Plan because doing so might affect your employer or union insurance. 

    • •  If you get prescription drug coverage through Veterans Affairs or TRICARE, it might not make sense for you to also get a Part D Prescription Drug Plan.

     


    WHAT DOES MEDICARE COVER?

    Medicare is broken up into four separate parts: Medicare Part A, Medicare Part B, Medicare Advantage (Medicare Part C), and Medicare Part D.  Each of these parts is discussed in detail below.

     

    Medicare Part A[11]

    Medicare Part A is sometimes called “hospital insurance” because it pays for care in the hospital.  Part A generally covers several types of health care, although keep in mind that you must meet certain requirements before each type of care will be covered by Medicare.  These types of health care are:

    • •  Inpatient hospital care

    • •  Skilled nursing facility care (but not long-term care or custodial care (custodial care is nonskilled personal care or types of health-related care that most people do themselves))

    • •  Nursing home care (as long as you need more than just custodial care)

    • •  Hospice

    • •  Home health services

     

    You can find more detailed information about Medicare coverage of skilled nursing facility/nursing home care, hospice, and home health care under the topic on Long-Term Care.

     

    Hospital Care[12]

    For Medicare coverage purposes, coverage for “hospital care” includes the care you get when you are an inpatient in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals, as well as inpatient care as part of a qualifying clinical research study and mental health care. 

     

    You are eligible for Medicare-covered hospital care if:

    • •  Your doctor writes an official order saying you need inpatient hospital care to treat your illness or injury; and

    • •  You need the kind of care that can only be given in a hospital; and

    • •  You are formally admitted to the hospital as an inpatient; and

    • •  The hospital accepts Medicare; and

    • •  The hospital’s Utilization Review Committee approves your stay while you’re at the hospital

     

    When you are eligible for Medicare-covered hospital care, the following services are covered:

    • •  General nursing

    • •  Drugs as part of your inpatient treatment

    • •  Semi-private rooms (private rooms are not covered unless they are medically necessary)

    • •  Meals

    • •  Other hospital services and supports

     

    Even if you meet the eligibility requirements listed above, Medicare will not pay for 100% of your hospital care.

    • •  You must pay a deductible for each benefit period, which as of June 2014 was $1216.[13] 

    • •  For Days 1-60, Medicare will completely cover the cost of your hospital care for each benefit period. 

    • •  For Days 61-90, Medicare will pay a portion of the cost of your care and you must pay a portion of the cost of your care.  As of June 2014, the coinsurance that you must pay was $304 per day of each benefit period. 

    • •  After Day 90, if you have remaining lifetime reserve days[14], Medicare will pay a portion of the cost of your care and you must pay a portion of the cost of your care.  As of June 2014, the coinsurance that you must pay was $608 per lifetime reserve day for each benefit period. 

    • •  After Day 90 and all of your lifetime reserve days, Medicare does not pay for any of your hospital care.

    • •  (Also, in your lifetime, you can only receive 190 days of inpatient mental health care in a psychiatric hospital.)

     

     

    Medicare Part B[15]

    Medicare Part B covers many of the things that you typically think of health insurance as covering.  Some examples are:

    • •  Preventative care (some of the many examples include yearly wellness visit, flu shots, mammograms, prostate cancer screenings, colonoscopies, and diabetes screenings)

    • •  Doctor visits

    • •  Hospital outpatient care

    • •  Urgent care

    • •  Emergency room services

    • •  Ambulance services

    • •  Services and supplies needed to diagnosis and/or treat your medical condition (if they meet accepted standards of medical practice)

    • •  Lab tests

    • •  Other tests (like x-rays, MRIs, CT scans, and EKGs)

    • •  Surgeries

    • •  Chemotherapy

    • •  Dialysis services and supplies

    • •  Physical therapy

    • •  Durable medical equipment (DME) (like oxygen equipment, wheelchairs, walkers, and hospital beds)

    • •  Diabetes supplies (but insulin is only covered in certain situations)

    • •  Prosthetic and orthotic items (like artificial limbs, ostomy supplies, parenteral and enteral nutrition therapy, and arm, leg, neck, and back braces)

    • •  Home health services

    • •  Outpatient mental health care

    • •  Getting a second opinion before surgery

     

    Specific coverage rules depend on a number of factors, including your Medicare plan and your specific conditions.  Medicare will cover 100% of most preventative services if you get the services from a health care provider who accepts assignment.  “Assignment” is an agreement by the provider to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and to not bill you for any more than the Medicare deductible and coinsurance.  However, you may have to pay a deductible and/or coinsurance for some preventative services.

     

    Examples of things not covered by Medicare Part B (or by Medicare Part A) include[16]:

    • •  Most dental care

    • •  Dentures

    • •  Eye exams related to prescribing glasses

    • •  Hearing aids and exams for fitting them

    • •  Routine foot care

     

    Medicare Advantage (Medicare Part C)

    A Medicare Advantage plan is a type of “Medicare health plan,” and it is an alternative way to get your benefits for Medicare Parts A and B (which are referred to as “Original Medicare”).  This means that can have either Medicare Parts A and B (Original Medicare), or a Medicare Advantage plan.  A Medicare Advantage plan is sponsored by a private company that contracts with Medicare to provide you with all of your Part A and Part B benefits. 

     

    There are several different types of Medicare Advantage plans, including[17]:

    • •  Special Needs Plans (SNPs)

    • •  Health Maintenance Organization (HMO) Plans

    • •  Preferred Provider Organization (PPO) Plans

    • •  Private Fee-for-Service (PFFS) Plans

     

    Special Needs Plans are a type of Medicare Advantage plan that provide focused and specialized health care for specific groups of people.  These plans are only for people who live in nursing homes or other institutions or need nursing care at home; people who are eligible for both Medicare and Medicaid; or people with specific chronic or disabling conditions, like diabetes, dementia, chronic heart failure, End-Stage Renal Disease, or HIV/AIDS.[18]

     

    All Medicare Advantage plans are required to cover almost all of the benefits that are covered under Medicare Parts A and B.  (The exceptions are hospice care and some care in qualifying clinical research studies.  Original Medicare will cover hospice care and some costs for clinical research studies even if you have a Medicare Advantage Plan.)[19] 

     

    Medicare Advantage Plans can also choose to offer additional coverage.  Some Medicare Advantage plans offer extra coverage for things like vision, hearing, dental, and/or health and wellness programs.  Many plans also include prescription drug coverage (Medicare Part D).  If your plan includes drug coverage, you cannot also have a Medicare Part D prescription drug plan (if you sign up for a Part D plan, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare).  If your plan does not offer prescription drug coverage, you can join a Medicare Prescription Drug Plan.[20] 

     

    Medigap policies can’t work with Medicare Advantage Plans.  You can’t use a Medigap policy to pay for your Medicare Advantage Plan copayments, deductibles, or premiums.  If you already have a Medigap policy and join a Medicare Advantage Plan, you may want to drop your Medigap policy.  But keep in mind that if you cancel the policy and then leave the Medicare Advantage Plan, it might be difficult or impossible for you to get the same Medigap policy back or sign up for any Medigap policy at all.[21]

     

    Different Medicare Advantage Plans work differently, so you should take the time to carefully research a plan before deciding to join it.  You can search for Medicare Advantage Plans and other Medicare health plans available in your area here

     

    Each Medicare Advantage Plan has a specific service area, and you must live in a plan’s service area to be able to join that plan.  Different plans can have different rules for how you get services (like for example whether you have to go to providers that belong to the plan for non-urgent care).[22]  

     

    Sometimes joining a Medicare Advantage Plan can cause you to lose any employer or union coverage that you have, so you should make sure to talk to your employer, union, or other benefits administrator before joining a Medicare Advantage plan.[23]

     

    If you have end-stage renal disease, you will usually get your health care through Original Medicare and can only join a Medicare Advantage plan in certain situations.  You can learn more about these situations here[24]

     

     

    Medicare Part D

    Medicare Part D provides coverage for prescription drugs for people with certain types of Medicare.  If you have Original Medicare (Medicare Parts A and B), you can get a Medicare Part D plan.  Part D works a little bit differently than Parts A and B: you get Medicare prescription drug coverage by joining a plan run by a private company approved by Medicare.  These plans are called Medicare Prescription Drug Plans (sometimes simply called “PDPs”).  The cost of each plan and the drugs it covers vary from plan to plan.[25]

     

    Usually prescription drugs that you get in an outpatient setting like an emergency room aren’t covered by Medicare Part B.  Your Medicare Prescription Drug Plan might cover these drugs under certain circumstances, but you will probably have to pay out-of-pocket for them and submit a claim to your drug plan.[26]

     

    Medicare Prescription Drug Plans may have certain coverage rules, although if you or the provider prescribing a drug for you think that a rule should be waived, you can ask for an exception.  These rules might include[27]:

    • •  Prior authorization, where you or the provider prescribing a drug for you must contact the plan before you can fill certain prescriptions.  (The provider may need to show that the drug is medically necessary before the plan will cover it.)

    • •  Quantity limits, where there are limits on how much medication you can get at one time

    • •  Step therapy, where you must try one or more similar, lower-cost drugs before the plan will cover the prescribed drug

     

    If you have a Medicare Advantage Plan and your plan includes drug coverage, you cannot also have a Medicare Part D prescription drug plan.  If you sign up for a Part D plan, you will be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.  If your Medicare Advantage plan does not offer prescription drug coverage, you can join a Medicare Prescription Drug Plan.[28]

     

    You must live in a Medicare Prescription Drug Plan’s service area to join that plan.  You can search for Medicare Prescription Drug Plans available in your area here

     

    Supplemental Insurance: Medigap and Other Insurance

    Because Original Medicare (Parts A and B) does not pay for all of someone’s health care costs, some people have some kind of supplemental insurance to cover some of the things that Original Medicare won’t.  Here are some examples of things that Original Medicare does not pay for but supplemental insurance might pay for part or all of:

    • •  Part A hospital deductible

    • •  Part B yearly deductible

    • •  20% of the Medicare-approved amount of many outpatient services and supplies

    • •  Part A hospitalization coinsurance after Day 60

    • •  Skilled nursing facility coinsurance after Day 20

     

    There are two main kinds of supplemental insurance: Medigap policies, and other kinds of insurance or coverage.  It may not make sense to join a Medigap plan if you have some other kind of insurance or coverage, although this depends on the other insurance or coverage that you have.

    Medigap

    What is Medigap?

    Medigap, also called Medicare supplement insurance, is a type of insurance that you can buy from a private company to help pay some of the costs that Original Medicare will not cover.  You must have Medicare Parts A and B to get a Medigap policy.[29]  

     

    There are eleven different standard Medigap policies that you can buy in Michigan, which are labeled A, B, C, D, F, high-deductible F, G, K, L, M, and N.  The cost of a policy and the services it covers vary from policy to policy.  Medigap policies do not cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing.[30]

     

    You can see a chart identifying what each of the eleven standard Medigap policies covers here.

     

    There are many different companies that sell Medigap plans, but every company must sell the exact same standard benefits of each plan.  For example, Plan G sold by Company X must have the same benefits as Plan G sold by Company Y.[31] 

     

    You can see a list of the companies that are authorized by the state of Michigan to write Medicare Supplement insurance in Michigan here

     

    How Much Do Medigap Policies Cost?

    Even though a plan has to have the exact same standard benefits regardless of the company selling it, companies often charge different amounts for the same standard plan.  For example, Plan G sold by Company X may be more expensive than Plan G sold by Company Y, even though the plans are exactly the same.[32] 

     

    The cost of a plan can differ for many reasons, including how old you were when you bought the plan, your current age, whether you are a smoker, the number of people in the plan, whether the company uses medical underwriting, and whether the company offers discounts (for example, if you are a woman, married, a non-smoker, and/or pay your premiums using electronic funds transfer).  If you are looking for a Medigap policy, you may want to shop around, considering factors like the cost of the policy, how often the company’s premiums for the plan change and by how much, if the premium will change as you get older, and how long the wait is for pre-existing conditions (if you did not have health insurance as good as Medigap in the months before you wanted to buy a Medigap policy, you may have to wait up to six months to be covered for certain health conditions).[33]

     

    When Can I Buy a Medigap Policy?

    It is illegal for a company to sell you a Medigap policy if the company knows you have Medicaid (except in certain situations) or if the company knows you are in a Medicare Advantage Plan (unless your coverage under that plan will end before the effective date of the Medigap policy).[34]

     

    You are first eligible to buy a Medigap policy during your six-month Medigap open enrollment period, which automatically starts on the first day of the month in which you are both 65 or older and enrolled in Medicare Part B.  During these six months, you can buy any Medigap policy sold in Michigan, even if you have health problems, for the same price as people with good health.[35] 

     

    However, in Michigan, in addition to the six-month open enrollment period, there are a few companies that must offer Plan A and Plan C to people with Medicare who are under age 65.  These companies are allowed to charge people under age 65 more for those plans, except Blue Cross Blue Shield of Michigan (which can’t charge more because someone is under 65).[36]

     

    Are There Any Restrictions on When I Can Have a Medigap Policy?

    Medigap policies are to cover gaps in Original Medicare (Parts A and B), so Medigap policies can’t work with Medicare Advantage Plans.  You can’t use a Medigap policy to pay for your Medicare Advantage Plan copayments, deductibles, or premiums.  If you already have a Medigap policy and join a Medicare Advantage Plan, you may want to drop your Medigap policy.  But keep in mind that if you cancel the policy and then leave the Medicare Advantage Plan, it might be difficult or impossible for you to get the same Medigap policy back or sign up for any Medigap policy at all.[37]

     

    You also cannot have both a Medigap policy with prescription drug coverage and a Medicare Part D Prescription Drug plan.  Medigap policies sold after January 1, 2006 are not allowed to include prescription drug coverage.  If your Medigap policy covers prescription drugs and you join a Medicare Part D Prescription Drug Plan, you have to tell your Medigap insurance company so they can remove the prescription drug coverage from your policy and adjust your premium.  However, once the drug coverage is removed, you can’t get it back.[38] 

     

    If you have a Medigap policy with prescription drug coverage but you want to join a Medicare Part D Prescription Drug plan, it is important to figure out if your Medigap policy included “creditable prescription drug coverage.”  Creditable prescription drug coverage is coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.  If your Medigap policy included creditable prescription drug coverage, you can join a Medicare Part D Prescription Drug Plan between October 15 and December 7 (unless you lose your Medigap policy, in which case you can join at the time you lose your Medigap policy).  If your Medigap policy did not include credible prescription drug coverage, you will probably pay a higher premium than if you joined when you were first eligible, and each month that you wait to join a Medicare Part D Prescription Drug Plan will make your late enrollment penalty higher.[39] 

     

    How Does My Medigap Policy Work Once I’ve Bought It?

    Sometimes companies are allowed to have up to a six-month waiting period before your coverage will start, or up to a six-month waiting period before the policy will cover your pre-existing conditions.[40] 

     

    When you buy a Medigap policy, by law you get a 30-day “free look” or “trial period.”  If you change your mind within 30 days of the day your policy started, you can cancel your policy and get a refund.[41] 

     

    Generally once you have a Medigap policy, it is “guaranteed renewable.”  This means that, as long as you pay your premium, the company cannot cancel your Medigap policy, even if you have health problems.[42]

     

    Usually your Medigap insurance company pays your health care providers directly, but depending on the company and your provider(s), you may have to send claims to your Medigap insurance company and pay your provider(s) yourself.[43]

     

    If you have a Medigap policy and decide to cancel it, you should be careful about the timing.  Depending on your coverage and when you drop the policy, you may have to pay a late enrollment penalty if you choose to join a Medicare Part D Prescription Drug Plan.[44]

     

    Where Can I Go To Learn More About Medigap Policies?

    For more information about Medigap policies, see the following resources:

     

    To find Medigap policies in your area, see:

     

    Other Insurance or Coverage[45]

    Some people use a variety of other insurances or coverages to pay for care that Medicare does not cover.  Depending on the insurance or coverage you have, it may not make sense to also join a Medigap plan.  Examples of these other insurances or coverages include:

    • •  Medicaid

    • •  Retiree insurance

    • •  Employer-sponsored coverage

    • •  Coverage from a union

    • •  Coverage from the Veterans Administration

    • •  TRICARE (a health care program for active-duty and retired uniformed services members and their families)

    • •  Long-term care insurance

    • •  Indian Health Service, Tribal, and Urban Indian Health benefits

     


    HOW MUCH DOES MEDICARE COST, AND HOW MUCH WILL I HAVE TO PAY FOR HEALTH CARE?

    Medicare Part A[46]

    If you or your spouse paid Medicare taxes while working, usually you don’t have to pay any monthly premium for Medicare Part A. 

     

    If you aren’t eligible for “premium-free Part A,” you may be able to buy Part A, which costs up to $426 per month as of 2014.  Usually if you buy Part A, you must also have Part B and pay monthly premiums for both.  You may be able to buy Part A if:

    • •  You are 65 or older, you have or are enrolling in Part B, and you meet certain citizenship and residency requirements

    • •  You are under 65, disabled, and your premium-free Part A coverage ended because you returned to work

     

    If you buy Part A, you will get a bill for your premium.  (Unlike your Part B premium, it won’t automatically be deducted from any benefits checks you might get.)

     

    In addition to your premium, you may have to pay copayments, coinsurance, or deductibles when you get services covered by Part A.  You can find more detailed information about how much you may be required to pay for inpatient hospital care above. You can find more detailed information about how much you may be required to pay for skilled nursing facility/nursing home care, hospice, and home health care under the topic on Long-Term Care.

     

    Medicare Part B[47]

    You have to pay a Part B premium each month.  If you made $85,000 or less in 2012 (or you and your spouse filed a joint tax return and made $170,000 or less in 2012), your monthly premium in 2014 is $104.90.

     

    If you get Social Security benefits, (or Railroad Retirement Board or Office of Personnel Management benefits) your Part B premium will be automatically deducted from your benefit payment.  If you don’t get these benefit payments, you will get a bill for your premium.

     

    In addition to your premium, you may have to pay copayments, coinsurance, or deductibles when you get services covered by Part B.  You may have a Part B deductible (which is $147 in 2014).  Usually after your deductible is met, and if your health care provider accepts assignment, you have to pay 20% of the Medicare-approved amount of the service.  “Assignment” is an agreement by the provider to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and to not bill you for any more than the Medicare deductible and coinsurance.  The “Medicare-approved amount” in Original Medicare (Medicare Parts A and B) is the amount a doctor or supplier that accepts assignment can be paid.

     

     

    Medicare Advantage (Part C)

    Most people who have a Medicare Advantage Plan pay their Part B premium and an additional monthly premium for the Medicare Advantage Plan.[48]

     

    Different plans can charge different out-of-pocket costs (for example, premiums, coinsurances, and deductibles).  Plans establish these amounts each year and can only change what you pay the plan once a year, on January 1.  Your out-of-pocket costs in a Medicare Advantage Plan depend on a lot of different factors, such as:[49]

    • •  Whether you have Medicaid or get help from your state

    • •  The type of health care services you need and how often you get them

    • •  Whether the plan charges a monthly premium

    • •  Whether the plan pays any of your monthly Medicare Part B premium

    • •  Whether the plan has a yearly deductible or any additional deductibles

    • •  The plan's yearly limit on your out-of-pocket costs for all medical services

    • •  How much you pay for each visit or service (copayment or coinsurance)

    • •  Whether you go to a provider who accepts assignment (if you're in certain plans and you go out-of-network)

    • •  Whether you follow the plan's rules, like using network providers

    • •  Whether you need extra benefits and if the plan charges for it

     

    Medicare Advantage Plans have a yearly cap on how much you pay for Medicare Part A and Part B services.  This cap can be different for different Medicare Advantage Plans, and it can change each year.[50]

     

    Every fall, your plan should send you an Evidence of Coverage (EOC) that provides lots of information, including information about what your plan covers and how much you pay.  They should also send you an Annual Notice of Change (ANOC) that explains any changes in coverage, costs, or service area that will be effective starting January 1.[51]

     

    Medicare Advantage Plans can choose not to cover services that are not “medically necessary” under Medicare.  You may have to pay all the costs of a service that the plan says isn’t medically necessary.  However, you can appeal the plan’s decision that a service isn’t medically necessary, or you can ask for a written advance coverage decision from the plan before you get the service to make sure it is medically necessary and will be covered.[52]

     

    If you use a health care provider that doesn’t belong to your Medicare Advantage Plan, your services might not be covered or you might have to pay more.[53]

     

    Medicare Part D[54]

    Most Medicare Part D Prescription Drug Plans charge a monthly premium.  This premium differs from plan to plan.  You can have this monthly fee deducted from your Social Security (or Railroad Retirement Board) check, or you can be billed directly for it. 

     

    Some Medicare Part D plans have a yearly deductible.  Most Medicare Part D plans have copayments or coinsurance, which differ from plan to plan.

     

    Your actual Medicare Part D Prescription Drug Plan costs depend on a lot of different factors, such as:

    • •  The plan you choose

    • •  Your prescriptions and whether they are on your plan’s drug list

    • •  What kind of pharmacy you use (preferred, non-preferred, out-of-network, or mail order)

    • •  Whether you get Extra Help (a Medicare program that helps people with limited income and resources pay Medicare Part D Prescription Drug Plan costs) paying your Part D costs

     

    Most Medicare Part D Prescription Drug Plans have different “tiers” for their drugs, and drugs in different tiers have different costs.  Usually a drug in a lower tier costs less than a drug in a higher tier.
     

    Most Medicare Part D Prescription Drug Plans have a coverage gap that is often called the “donut hole.”  If you and your plan together spend a certain amount of money for covered prescription drugs, you will then enter the donut hole, where you have to pay a higher percentage for your medications.  In 2014, the amount you have to pay when you’re in the donut hole is 47.5% of your plan’s cost for covered brand-name drugs and 72% of the plan’s cost for covered generic drugs.
     

    Once you’ve spent enough money on covered drugs, you will be out of the donut hole.  Things like your deductible, coinsurance, copayments, payments you make in the coverage gap, and discounts you get on covered brand-name drugs in the coverage gap will all count towards you getting out of the donut hole.  Once you’re out of the donut hole, you will automatically get “catastrophic coverage,” where you only pay a small coinsurance or copayment for covered drugs for the rest of the year.  If you get Extra Help, you won’t have some of these costs.
     

    The “donut hole” will close in 2020.  Until then, there will be more and more coverage each year for drugs in the donut hole.  Some plans might also offer additional coverage in the donut hole, (like for generic drugs) but they might charge a higher monthly premium.

     

    It might be helpful to think of the costs you will have to pay for a Medicare Part D Prescription Drug Plan in four phases:

    1. Yearly deductible – you pay 100% of the costs of your covered drugs up until a certain amount

    2. Copayment or coinsurance – you pay a copayment or coinsurance for each covered drug you get until you reach the donut hole threshold

    3. Donut hole – you pay a large percentage of each covered drug you get until you get out of the donut hole

    4. Catastrophic coverage – you pay a small copayment or coinsurance for each covered drug you get until the end of the year

     


    WHAT IF I CAN'T AFFORD MEDICARE?

     

    Medicaid[55]

    If you qualify for both Medicare and Medicaid, you are called a “dual eligible.”  If you have Medicare and full Medicaid coverage:

    • •  Most of your health care costs will be covered

    • •  You can get your Medicare coverage through Original Medicare or a Medicare Advantage Plan

    • •  Medicare will cover your Part D prescription drugs, but Medicaid may still cover some drugs and other care that Medicare doesn’t

     

    If you are eligible for both Medicare and Medicaid (“dually eligible”), you may be eligible to participate in MI Health Link.  This is a program of integrated care for dual eligibles.  You can read more about this in the Topic on Integrated Care for Dual Eligibles.

     

    Medicare Savings Programs[56]

    If you have limited income and resources and meet certain conditions, you may be able to take advantage of the Medicare Savings Program (also called the Medicare Buy-In Program in Michigan) and get help from the state of Michigan to pay your Medicare costs.

     

    In Michigan, you can be classified in one of three categories for the Medicare Savings Program, and how you are classified determines what help you will get from Medicaid.

    Category

    Income Requirements

    What the Program Will Pay

    Qualified Medicare Beneficiary (QMB)

    Net income is not more than 100% of the poverty level

    • Your Medicare Part A and Part B premiums; and

    • Your Medicare coinsurances; and

    • Your Medicare deductibles

     

    Specified Low Income Medicare Beneficiary (SLM/SLMB)

    Net income is between 100% and 120% of the poverty level

    • Your Medicare Part B premiums

    Additional Low Income Medicare Beneficiary (ALMB)

    Net income is between 120% and 135% of the poverty level

    • Your Medicare Part B premiums if funding is available

     

    In addition to income requirements, there are also other eligibility requirements, like whether you are entitled to Medicare Part A and whether you are eligible for Medical Assistance (MA) in Michigan.

     

    Medicaid will not help pay your Medicare costs unless:

    • •  You have applied for Medicare

    • •  The Social Security Administration knows that you are Medicaid-eligible

    • •  You have applied for the Medicare Savings Program through your local DHS office

     

     

    Extra Help[57]

    Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs.  Extra Help is sometimes called the “low-income subsidy” (LIS).

     

    You automatically qualify for Extra Help if you have Medicare and meet any of these conditions:

    • •  You have full Medicaid coverage

    • •  You get help from your state Medicaid program paying your Part B premiums

    • •  You get Supplemental Security Income (SSI) benefits

     

    If you automatically qualify for Extra Help, Medicare will mail you a purple letter.  If you get this letter, you don’t have to apply for Extra Help, and if you have any problems, you can use this letter as proof that you qualify. 

     

    To use Extra Help after you get the purple letter you have to join a Medicare Part D Prescription Drug Plan.  If you don’t join a prescription drug plan on your own, Medicare might enroll you in one so that you’ll be able to use the Extra Help.  If Medicare does this, you will get a yellow or green letter telling you when your coverage begins.  If you don’t want to be in a prescription drug plan, you can call the plan listed in your letter and tell them that you “opt out.”  But if you do this, you’ll have to pay a penalty to join later unless you still qualify for Extra Help or you had some other creditable prescription drug coverage (coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage).

     

    If you don’t automatically qualify for Extra Help, you can apply for it.  In 2014, you are eligible for Extra Help when:

    • •  If you are not married or don’t live with your spouse…

      • •  If your annual income is no more than $17,235; and

      •  •  If your resources are no more than $13,400   

    • •  If you are married and live with your spouse…

      • •  If your annual income is no more than $23,265; and

      • •  If your resources are no more than $26,860

     

    (As an example, bank accounts count as resources, but your home and car do not.)  If your annual income is higher than these amounts, you still might be able to get some help.

     

    If you apply for Extra Help and Social Security finds that you qualify, you will get a Notice of Award.  If you have any problems you can show this notice as proof that you qualify.

     

    If you qualify for Extra Help and join a Medicare drug plan:

    • •  You can get help paying your Medicare drug plan’s monthly premium, yearly deductible, coinsurance, and copayments 

    • •  You generally won’t pay more than $2.55 for each generic drug and $6.35 for each brand-name drug in 2014

    • •  If you have Medicaid and live in a nursing home or certain other institutions or get home and community-based services, you won’t pay anything for your covered prescription drugs

    • •  You won’t have a late enrollment penalty

    • •  You can switch to another Medicare drug plan at any time, and your new coverage will start on the first day of the next month

     

    If you aren’t already enrolled in a Medicare drug plan and paid for prescriptions since you qualified for Extra Help, you may be able to get back part of what you paid.  Keep your receipts, and call Medicare’s Limited Income Newly Eligible Transition (NET) Program at 1-800-783-1307.        

                 


    WHAT RIGHTS DO I HAVE AS A MEDICARE BENEFICIARY?

    If you have Medicare, regardless of how you get your Medicare, you have the right to[58]:

    • •  Be treated with 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 Medicare contractors

    • •  Get understandable information about Medicare to help you make health care decisions, including information about what is covered, what Medicare pays, how much you have to pay, and what to do if you want to file a complaint or appeal

    • •  Have questions about Medicare answered

    • •  Have access to doctors, other health care providers, specialists, and hospitals

    • •  Learn about your treatment choices in clear language that you can understand, and participate in treatment decisions

    • •  Get health care services in a language you understand and in a culturally-sensitive way

    • •  Get emergency care when and where you need it

    • •  Get a decision about health care payment, coverage of services, or prescription drug coverage

    • •  Request a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage

    • •  File complaints (sometimes called grievances), including complaints about the quality of your care

     

    Depending on the kind of Medicare you have, you also have additional rights.

     

    If you have Original Medicare (Medicare Parts A and B), you also have the right to[59]:

    • •  See any doctor or specialist (including women's health specialists), or go to any Medicare-certified hospital, that participates in Medicare

    • •  Get certain information, notices, and appeal rights that help you resolve issues when Medicare may not or doesn't pay for health care

    • •  Request an appeal of health coverage or payment decisions

    • •  Buy a Medicare Supplement Insurance (Medigap policy)

     

    If you have a Medicare Advantage Plan (Medicare Part C), you also have the right to[60]:

    • •  Choose health care providers within the plan, so you can get the health care you need

    • •  Get a treatment plan from your doctor

      • •  If you have a complex or serious medical condition, a treatment plan lets you directly see a specialist within the plan as many times as you and your doctor think you need

      • •  Women have the right to go directly to a women's health care specialist without a referral within the plan for routine and preventive health care services

    • •  Know how your doctors are paid

    • •  When you ask your plan how it pays its doctors, the plan must tell you

    • •  Medicare doesn't allow a plan to pay doctors in a way that could interfere with you getting the care you need

    • •  Request an appeal to resolve differences with your plan

    • •  File a complaint (called a "grievance") about other concerns or problems with your plan

    • •  Get a coverage decision or coverage information from your plan before getting services

     

    If you have a Medicare Prescription Drug Plan (Medicare Part D), you also have the right to[61]:

    • •  Request a coverage determination or appeal to resolve differences with your plan

    • •  File a complaint (called a “grievance”) with the plan

    • •  Have the privacy of your health and prescription drug information protected

     

    If you are having problems with your rights being violated or denied, you can contact the following people and organizations who might be able to help[62]:

    • •  Medicare Beneficiary Ombudsman, at 1-800-MEDICARE.  This person can review and help you with your Medicare complaints and can give you information about your Medicare rights and how you can get issues resolved.

    • •  MMAP, Inc.  MMAP is the State Health Insurance Assistance Program (SHIP) in Michigan.  MMAP should be able to provide information and counseling to help you with a wide variety of Medicare issues.

    • •  Michigan Peer Review Organization (MPRO).  MPRO is the Quality Improvement Organization (QIO) in Michigan. MPRO should be able to provide information regarding and receive complaints you have about the quality of care you’re getting or have gotten.

    • •  An attorney.  If you can’t afford an attorney, a legal services program might be able to help you.  You can find information about legal services programs in your area here.  

     


    WHAT DO I DO IF MY PROVIDER SAYS MEDICARE WON'T COVER MY SERVICES, OR IF MEDICARE SAYS SOMETHING ISN'T COVERED?

     

    Original Medicare (Medicare Parts A and B)

     

    Figuring It Out[63]

    If you have Original Medicare (Medicare Parts A and B), every three months you will be mailed a Medicare Summary Notice (MSN).  This Notice:

    • •  Lists all the services that were billed to Medicare

    • •  Shows what Medicare paid

    • •  Shows if Medicare fully or partially denied your medical claim

    • •  Shows what you may still owe your health care provider

     

    When you get this Notice, you should:

    • •  Check to make sure that you really got all of the services listed there

    • •  If you have other insurance or coverage (like Medicaid or a Medigap policy), see if it covers anything that Medicare didn’t

    • •  If you already paid a bill, make sure you paid the right amount according to the Medicare Summary Notice

    • •  If Medicare denied coverage for something, call your health call provider to make sure they submitted the right information (if there was a mistake, they can resubmit the claim to Medicare)

     

    If you disagree with a decision that Medicare made, you can appeal it.  The MSN will have information about your appeal rights.

     

    Appeal

    If you disagree with certain decisions that Medicare or any of your Medicare plans (like your Medicare Advantage Plan or Medicare Prescription Drug Plan) has made, you can file an appeal. 

     

    If you decide to appeal, you can ask your health care provider for any information that might help your case.  You should keep a copy of everything you send to Medicare as part of your appeal.

     

    You have a right to appeal if Medicare or any of your Medicare plans:

    • •  Denies a request for something that you think you should be able to get

    • •  Denies a request for payment for something you already got

    • •  Denies a request to change the amount you have to pay for something

    • •  Stops providing or paying for all or part of something you think you still need

     

    If you want to, you can appoint a representative to help you with your appeal or file your appeal for you.  You can appoint anyone you want to be your representative, including a family member, friend, lawyer, or doctor.  Sometimes your doctor might be able to help you challenge decisions by Medicare or any of your Medicare plans without being officially appointed as your representative.

     

    There are two ways to appoint a representative.  Either way, you need to send the paperwork to the company that handles your bills for Medicare, or if you’ve appealed, with your appeal request.

    1. You can fill out an “Appointment of Representative” form, which you can find here: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf

    2. You can submit a written request that has all of the following information:

      • •  Your name, address, and phone number

      • •  Your Medicare number 

      • •  A statement appointing someone as your representative

      • •  The name, address, and phone number of your representative

      • •  The professional status of your representative or his or her relationship to you

      • •  A statement authorizing the release of your personal and identifiable health information to your representative

      • •  A statement explaining why you’re being represented

      • •  Your signature and the date you signed the request

      • •  Your representative’s signature and the date he or she signed the request

     

    The appeals process works differently depending on whether you have Original Medicare (Medicare Parts A and B), Medicare Advantage, or a Medicare Part D Prescription Drug Plan.

     

    Original Medicare’s (Medicare Parts A and B) Appeal Process

    The appeal process for Original Medicare has five levels.  If you disagree with the decision made at any level of the process, you can generally go on to the next level, or you can stop at any time. 

     

    Medicare Prescription Drug Plan (Medicare Part D)

    Figuring It Out[64]

    If you have a Medicare Part D Prescription Drug Plan, every month that you fill a prescription your drug plan will mail you an Explanation of Benefits (EOB) notice.  This notice gives you a summary of your prescription drug claims and your costs.

     

    When you get this notice, you should:

    • •  Review it and check for any mistakes

    • •  Contact your plan if you have questions or find mistakes

     


    RESOURCES

     

    General Information about Medicare

    • •  Medicare & You (2014).  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                      

      • •  “[T]he official U.S. government Medicare handbook.”  This handbook, written in easy-to-understand language, includes detailed information about Medicare, including information about how Medicare works, enrollment, what Medicare covers, making plan and coverage choices, prescription drug coverage, paying for Medicare costs, your rights under Medicare, how to appeal adverse decisions, and more.

    • •  Medicare Plan FinderU.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                            

      • •  An online tool to search for a range of Medicare plans in your area.

    • •  Overview of the Medicare Program.  National Council on Aging, Center for Benefits Access.                                                                      

    • •  Medicare Basics.  Center for Medicare Advocacy.  

    • •  Medicare and Home Health CareU.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

     

    Medicare Rights

     

     

    Medicare Eligibility and Enrollment

    • •  Getting Started with MedicareU.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                   

    • •  When can I join a health or drug plan?  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                           

     

     

    Paying for Medicare and Medicare Savings Programs

     

    Original Medicare (Medicare Parts A and B)

     

    Medicare Advantage (Medicare Part C)

     

    Medicare Part D Prescription Drug Plans

    • •  How to get drug coverage.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                               

    • •  Medicare Plan FinderU.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                            

      • •  An online tool to search for a range of Medicare plans (including Medicare Prescription Drug Plans) in your area.

    • •  How Medigap policies work with Medicare drug coverage (Part D).  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

     

    Extra Help (Low-Income Subsidy)

     

    Medigap (Medicare Supplement Insurance)

    • •  Medicare Supplement Insurance: Getting Started.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.  

    • •  What’s Medicare supplement (Medigap) insurance?  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

    • •  Supplemental Coverage/Medigap. My Medicare Matters (the National Council on Aging).                                                                      

    • •  When can I buy Medigap? U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                           

    • •  Medicare, Medicare Supplement, Medicare Advantage and Long-Term Care Insurance. Michigan Department of Insurance and Financial Services.  

      • •  See Medicare and Medicare Supplement Insurance section.

    • •  Authorized Medicare Supplement CompaniesMichigan Department of Insurance and Financial Services.                         

      • •  A list of the companies (and their contact information) that are authorized by the state of Michigan to write Medicare Supplement insurance in Michigan.

    • •  Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                                              

    • •  How to compare Medigap policies.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                        

      • •  Includes a chart identifying what each of the eleven standard Medigap policies covers.

    • •  Choosing a Policy – 5 Simple StepsMy Medicare Matters (the National Council on Aging).                                                                        

    • •  Medigap Policy Search.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                                      

      • •  An online tool to search for Medigap policies in your area.

    • •  Rights with Medigap. My Medicare Matters (the National Council on Aging).                                             

    • •  Costs of Medigap policies. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                           

    • •  Medigap costsU.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.  

    • •  10 illegal Medigap practices to watch for.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.  

    • •  How Medigap policies work with Medicare drug coverage (Part D).  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.  

    • •  How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                                                        

    • •  Medicare Advantage vs. MedigapMy Medicare Matters (the National Council on Aging).                                                                         

     

    Contesting Adverse Decisions by Medicare

    • •  Medicare Appeals.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                     

      • •  This handbook, written in easy-to-understand language, includes detailed information about the process to contest or appeal Medicare decisions with which you disagree.

    • •  Appointment of Representative formU.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services.                          

      • •  Use this form to appoint a representative to help you with your Medicare appeal or file your appeal for you.

    • •  Medicare Redetermination Request Form – 1st Level of Appeal. U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

      • •  Use this form to request a redetermination if you disagree with the initial determination on your Medicare Summary Notice.

    • •  Medicare Reconsideration Request Form – 2nd Level of Appeal.  U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. 

      • •  Use this form to request a reconsideration if you disagree with the redetermination decision (at the 1st level of appeal).

     

    Resources to Contact If You Have Questions About or Problems with Medicare

    • •  Medicare Beneficiary Ombudsman, at 1-800-MEDICARE 

      • •  This person can review and help you with your Medicare complaints and can give you information about your Medicare rights and how you can get issues resolved.

    • •  MMAP, Inc 

      • •  MMAP is the State Health Insurance Assistance Program (SHIP) in Michigan.  MMAP should be able to provide information and counseling to help you with a wide variety of Medicare issues.

    • •  Michigan Peer Review Organization (MPRO)

      • •  MPRO is the Quality Improvement Organization (QIO) in Michigan. MPRO should be able to provide information regarding and receive complaints you have about the quality of care you’re getting or have gotten.

    • •  An attorney

      • •  If you can’t afford an attorney, a legal services program might be able to help you.  You can find information about legal services programs in your area here

     

     


    [1] Center for Medicare Advocacy.  Medicare Basics.  http://www.medicareadvocacy.org/medicare-info/medicare-basics-2/

    [2] Centers for Medicare & Medicaid Services. Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, p. 6. https://www.medicare.gov/Pubs/pdf/02110.pdf

    [3] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 19.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [4] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 19.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [5] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 20.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [6] Id. at 21.

    [7] Id.

    [8] Id. at 21-22.

    [9] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 80, 146.  http://www.medicare.gov/Pubs/pdf/10050.pdf; Medicare.gov. When can I join a health or drug plan? http://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/when-can-i-join-a-health-or-drug-plan.html#collapse-3188

    [10] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 87-88, 101, 145-146.  http://www.medicare.gov/Pubs/pdf/10050.pdf; Medicare.gov. When can I join a health or drug plan? http://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/when-can-i-join-a-health-or-drug-plan.html#collapse-3188

    [11]Medicare.gov.  What does Medicare Part A cover? http://www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html; Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 29-33 and p. 146.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [12] Medicare.gov. Your Medicare Coverage, Inpatient hospital care. http://www.medicare.gov/coverage/inpatient-hospital-care.html. Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 32.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [13] Your benefit period begins the day you are admitted as an inpatient in a hospital or skilled nursing facility and ends when you have not received any inpatient hospital care or skilled care in a skilled nursing facility for 60 days in a row.

    [14] Lifetime reserve days are additional days that Medicare will pay for when you’re in a hospital for more than 90 days.  You have 60 total reserve days that can be used during your lifetime.

    [15] Medicare.gov. What does Medicare Part B cover? http://www.medicare.gov/what-medicare-covers/part-b/what-medicare-part-b-covers.html.  Centers for Medicare & Medicaid Services. Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, p. 6. http://www.medicare.gov/Publications/Pubs/pdf/02110.pdf.  Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 34-54.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [17] Medicare.gov.  Different types of Medicare Advantage Plans. http://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/types-of-medicare-advantage-plans.html .  Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 73.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [18] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 79.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [19] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 72.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [21] Medicare.gov.  How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans. http://www.medicare.gov/supplement-other-insurance/medigap/medigap-and-medicare-advantage/medigap-and-medicare-advantage-plans.html

    [26] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 97.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [27] Id.

    [29] MyMedicareMatters.  Supplemental Coverage/Medigap. https://www.mymedicarematters.org/about-medicare/types-of-coverage/supplemental-coveragemedigap/; Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 70.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [30] MyMedicareMatters.  Supplemental Coverage/Medigap. https://www.mymedicarematters.org/about-medicare/types-of-coverage/supplemental-coveragemedigap/. Medicare.gov.  What’s Medicare supplement (Medigap) insurance? http://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

    [35] Medicare.gov.  When can I buy Medigap? http://www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/when-can-i-buy-medigap.html#collapse-2283; Michigan Department of Insurance and Financial Services.  Medicare, Medicare Supplement, Medicare Advantage and Long-Term Care Insurance. http://www.michigan.gov/difs/0,5269,7-303-12902_35510-264007--,00.html

    [36] Michigan Department of Insurance and Financial Services.  Medicare, Medicare Supplement, Medicare Advantage and Long-Term Care Insurance. http://www.michigan.gov/difs/0,5269,7-303-12902_35510-264007--,00.html

    [37] Medicare.gov.  How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans. http://www.medicare.gov/supplement-other-insurance/medigap/medigap-and-medicare-advantage/medigap-and-medicare-advantage-plans.html

    [38] Medicare.gov.  How Medigap policies work with Medicare drug coverage (Part D).  http://www.medicare.gov/supplement-other-insurance/medigap/medigap-and-part-d/medigap-plans-and-part-d.html; Centers for Medicare & Medicaid Services. Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, p. 14. http://www.medicare.gov/Publications/Pubs/pdf/02110.pdf

    [39] Medicare.gov.  How Medigap policies work with Medicare drug coverage (Part D).  http://www.medicare.gov/supplement-other-insurance/medigap/medigap-and-part-d/medigap-plans-and-part-d.html

    [41] Id.

    [42] Medicare.gov.  What’s Medicare supplement (Medigap) insurance? http://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

    [44] Medicare.gov.  What’s Medicare supplement (Medigap) insurance? http://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

    [45] MyMedicareMatters.  Supplemental Coverage/Medigap. https://www.mymedicarematters.org/about-medicare/types-of-coverage/supplemental-coveragemedigap/.  National Council on Aging, Center for Benefits Access.  Overview of the Medicare Program.  http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-overview.pdf.  Medicare.gov.  What’s Medicare supplement (Medigap) insurance? http://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

    [46] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 26, 30.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [47] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 27-28, 145.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [50] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 74.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [53] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 74.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [54] Id. at p. 90-93, 96.

    [55] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 110.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [56]Michigan Department of Human Services.  Bridges Eligibility Manual, BEM 165. http://www.mfia.state.mi.us/olmweb/ex/BP/Public/BEM/165.pdf Michigan Department of Community Health.  Medicare Provider Manual, Coordination of Benefits Chapter, p. 8-9.  http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf.  Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 108-109.  http://www.medicare.gov/Pubs/pdf/10050.pdf

    [57] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 103-107.  http://www.medicare.gov/Pubs/pdf/10050.pdf; Social Security Administration.  Apply Online For Extra Help with Medicare Prescription Drug Costs: 2014.  http://www.ssa.gov/pubs/EN-05-10525.pdf

    [58] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 113.  http://www.medicare.gov/Pubs/pdf/10050.pdf.  Medicare.gov.  Rights & protections for everyone with Medicare. http://www.medicare.gov/claims-and-appeals/medicare-rights/everyone/rights-for-everyone.html

    [60] Medicare.gov.  Your rights in a Medicare Advantage Plan or other Medicare health plan. http://www.medicare.gov/claims-and-appeals/medicare-rights/medicare-health-plans/rights-in-medicare-health-plans.html

    [62] Medicare.gov. Get help with your rights & protections. http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

    [63] Centers for Medicare & Medicaid Services.  Medicare Appeals. http://www.medicare.gov/Pubs/pdf/11525.pdf 

    [64] Centers for Medicare & Medicaid Services.  Medicare & You (2014), p. 96.  http://www.medicare.gov/Pubs/pdf/10050.pdf