CENTERS FOR MEDICARE & MEDICAID SERVICES

 

Medicare

^&You

2007

This is the official government handbook with important information about

                        what’s new.

                        what’s covered.

                        health plans.

                        prescription drug plans.

                        your rights.

Welcome to Medicare & You 2007

Medicare is helping you stay healthy and active. The program offers you more than ever. More of you are taking advantage of the many preventive services that Medicare covers, and an unprecedented number of you have a prescription drug plan.

Medicare is committed to providing information and tools to help you make the best health decisions for your individual needs. www.MyMedicare.gov is an exciting new service on the web. With this tool, you can see your health care claims, track which preventive services you need, and get the most up-to-date details about how to get the most out of your Medicare benefits. If you don’t have access to the web, the same information is available by calling 1-800-MEDICARE and through Medicare’s many partners in the community.

That’s just the start. Medicare is working harder than ever to improve the information you can get. Better information means you can compare and choose better care for better prices. It means helping you access new treatments and innovative practices.

As always, help is available anytime, day or night. You can visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227). Medicare is also present in your local communities to get you the answers you need.

Thank you for taking time to look at this Medicare handbook.

Michael O. Leavitt Leslie V. Norwalk, Esq. Secretary Acting Administrator Department of Health and Centers for Medicare & Human Services Medicaid Services

Medicare Basics

 

+

 

Part D
(Prescription Drug Coverage)

 

You can choose this coverage. Private companies approved by Medicare run these plans. Plans cover different drugs. Medically necessary drugs must be covered.

+

 

Medigap (Medicare Supplement Insurance) Policy

You can choose to buy this private coverage (or an employer/union may offer similar coverage) to fill in gaps in Part A and Part B coverage. Costs vary by policy and company.

A Brief Look at Medicare

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Most people get their Medicare health care coverage in one of two ways. Your costs vary depending on your plan, coverage, and the services you use.

OR

Part D
(Prescription Drug Coverage)

 

Most Part C plans cover prescription drugs. If they don’t, you may be able to choose this coverage. Plans cover different drugs. Medically necessary drugs must be covered.

For information about

                        The Original Medicare Plan, see pages 25–32.

                        Medicare Advantage Plans, see pages 33–42.

                        Medicare prescription drug coverage, see pages 43–56.

                        Other Medicare plans, see pages 58–59.

Medicare Basics

 

What’s new or important in Medicare for 2007?

                        What You Pay for Medicare—See the 2007 amounts on pages 101–104.

                        Part B Premium—If you file an individual tax return and your yearly income is above $80,000 (or $160,000 for a married couple filing a joint tax return), your monthly Part B premium will be higher than the standard premium amount. For more information, see page 11.

                        Medicare Advantage Plans (Part C) (like HMOs and PPOs)—

Information on these plans starts on page 33.

                        Medicare Prescription Drug Plans (Part D)—Information on these plans starts on page 43.

                        Outpatient physical and occupational therapy, and speech-language pathology—There may be limits in 2007, see page 103.

                        Medicare Medical Savings Account (MSA) Plans—MSAs are a new way to get your Medicare health care, see page 39.

“Medicare & You 2007” explains the Medicare Program. It isn’t a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Medicare Basics

 

Where can I get help or more information?

                        Visit www.medicare.gov on the web.

                        Call 1-800-MEDICARE (1-800-633-4227) to get help in English, Spanish, and other languages. TTY users should call 1-877-486-2048.

                        Register for MyMedicare.gov on the web. You can access the Medicare information you need on the web at any time. View claims, order forms and publications, and more (see page 89). If you don’t have a computer, Medicare’s partners can help you access this tool.

                        Call your State Health Insurance Assistance Program for free counseling about choosing plans, buying a Medigap policy, and your Medicare rights, including appeals (see pages 92–95 for their telephone number).

                        Medicare works with many organizations around the country and in your local community. For a more detailed list of telephone numbers and places to get personalized help, see pages 89–95.

How do I find information I need in this handbook?

1                    Look at the “Table of Contents,” or

2                    Look at the “List of Topics (Index)” that starts on page 1. This alphabetical list of specific topics is the easiest way to find information.

Blue words in the text are defined on pages 97–100.

Medicare Basics

 

If You’re New to Medicare...

 

“To Do” List

 

                 � Decide how you want to get Medicare coverage, see pages 23–24.

 

                 � Check pages 63–70 to see about help paying health care costs.

 

                 � Check if current insurance works with Medicare, see pages 60–61.

 

                 � Schedule a “Welcome to Medicare” physical exam, see page 17.

 

                 � Ask your doctor what preventive services you should get, see page 12.

                 � Consider Medicare prescription drug coverage, see pages 43–56. If you have employer or union coverage, see page 50.

                 � Write important telephone numbers on the inside back cover.

                 � Register at www.MyMedicare.gov to access personalized information, see page 89.

Table of Contents

 

Section 1
Section 2

 

Section 3
Section 4

 

Section 5

 

Pages

List of Topics (Index)............................................................1–6

 

What’s Covered

What Is Medicare Part A? ......................................................................7–8 Medicare Part A-Covered Services and Items ..........................................9 What Is Medicare Part B? ..................................................................10–11 Medicare Part B-Covered Services and Items ..................................12–20 What Isn’t Covered....................................................................................21 Deciding How to Get Your Medicare Benefits ....23–24 Original Medicare Plan

What it Is and How it Works ..............................................................25–26 Your Costs in the Original Medicare Plan ..............................................26 What Is “Assignment” and Why Is it Important? ..................................27 Adding Prescription Drug Coverage to the Original Medicare Plan ....28 Buying a Medigap (Medicare Supplement Insurance) Policy ........29–31 How Your Bills Get Paid If You Have Other Health Insurance......31–32 Other Options to Consider..............................................................32

Medicare Advantage Plans (Part C)

What Are Medicare Advantage Plans (like HMOs and PPOs)? ............33
Who Can Join? ..........................................................................................34
If You Join ..................................................................................................35
How Medicare Advantage Plans Work ............................................36–39
Medicare Advantage Plans with Prescription Drug Coverage ..............40
Your Out-of-Pocket Costs Depend on......................................................40
Saving on Premiums ................................................................................41
How Your Bills Get Paid If You Have Other Health Insurance........41–42
Other Options to Consider..............................................................42

 

(Continued)

 

Table of Contents

 

Section 6
Section 7

 

Section 8

 

Section 9
Section 10
Section 11

 

Section 12
Section 13

 

Pages

Medicare Prescription Drug Coverage (Part D)........43–56

 

Other Medicare Plans, Government, and Private Insurance ..............................................................57–62 Help for People with Limited Income and Resources ..............................................................................63–70 How to Join and Switch Plans ....................................71–78 Your Medicare Rights ......................................................79–88 For More Information

Get Personalized Medicare Information Anytime ..............................89
1-800-MEDICARE (1-800-633-4227) ............................................90
Other Important Contacts ................................................................91
Your State Health Insurance Assistance Program ......................92–95
Medicare Publications ......................................................................96
Definitions of Words in Blue......................................97–100
2007 Medicare Costs ..........................................................101–104

 

A more detailed listing of topics in this handbook starts on the

next page.

The information in this handbook was correct when it was printed. Changes may occur after printing. Visit www.medicare.gov on the web or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users should call 1-877-486-2048.

List of Topics (Index)

1-800-MEDICARE ..............................90

 

A

Acupuncture ..........................................21
Advance Beneficiary Notice................80
Ambulance Services ............................13
Ambulatory Surgery Center ................13
Appeal....................97, 26, 79–82, 89–90
Artificial Eyes and Limbs ....................18
Assignment......................................27, 26

 

B

Balance Exam ......................................16
Barbiturates ..........................................53
Barium Enema ......................................14

 

Benefit Period ..........................97, 9, 102 Benzodiazepines....................................53 Bills (Claims)

Part A ..........26–27, 31–32, 80, 87, 89
Part B ..........26–27, 31–32, 80, 87, 89

 

Part C ..........................................41–42
Blood ................................9, 13, 102–103
Bone Mass Measurement ....................13
Braces (arm, leg, back, and neck)........18
Brand-Name Drugs ........................53–55

 

C Cancer Drugs ........................................18 Cardiovascular Screenings....................13 Catastrophic Coverage..........................45 Check-up (see Physical Exam)..17, 15, 21 Chiropractic Services ....................13, 21 Cholesterol Screening ..........................13 Claims (see Bills) ........26–27, 31–32, 89 Clinical Breast Exam (see Pap Test)....17

Section 1: List of Topics (Index)

 

C (continued)

Clinical Laboratory Services....13, 21, 103 Clinical Trials ........................................13 COBRA ..........................................61, 11 Coinsurance..........97, 25, 35, 44, 102–103 Colonoscopy..........................................14 Colorectal Cancer Screenings ..............14 Complaints (Appeals)..........8, 79–85, 12 Comprehensive Outpatient Rehabilitation Facility ........................81 Conditional Payment ............................31 Consolidated Omnibus Budget Reconciliation Act (COBRA) ........61, 11 Coordination of Benefits Contractor................................32, 42, 91 Copayment ..97, 25, 33, 35, 44, 102–103 Cosmetic Surgery..................................21 Costs 2007 ........................................101–104 Assignment ................................27, 26 Coinsurance ..97, 25, 35, 44, 102–103 Copayment ....97, 25, 33, 35, 102–103 Deductible......97, 10, 21, 25, 40, 44, 103 Help with Costs..........................63–70 Coverage (see Covered Services) ..9, 12–20 Coverage Determination (Part D)......93, 81 Coverage Gap ................................45, 44, 53 Covered Services (Part A & B) ................................9, 12–20 Creditable Prescription Drug Coverage..97, 47, 49, 50, 61, 72–73, 100

C (continued) Critical Access Hospitals..............97, 7, 9 CT Scans ..............................................19 Custodial Care....................7, 21, 98, 100

D

Deductible ........97, 10, 25, 40, 44, 64, 103 Definitions ....................................97–100 Demonstrations/Pilot Programs ....59, 86 Dental Care ....................................21, 35 Dentures ................................................21 Department of Defense ........................91 Department of Health and Human

Services (Office of the Inspector

General) ..................................86–87, 91 Department of Veterans

Affairs......................................24, 60, 91 Dialysis (Kidney Dialysis)..16, 34, 71, 74 Diabetes........................14–15, 17, 21, 38 Disabled..........................8, 38, 47, 68, 72 Discrimination ......................................88 Dispute (see Complaints) ....8, 79–85, 12 Doctor/Physician

Services..................................10, 15, 103 Donut Hole

(see Coverage Gap)..........45, 44, 53, 55 Drug Plan (see Medicare Prescription

Drug Plan) ..................99, 28, 43–56, 23 Drugs

(prescription)..........18, 21, 28, 36, 43–56 Durable Medical Equipment

(like wheelchairs) ....9, 15, 16, 102–103

Section 1: List of Topics (Index)

 

E

EKGs ....................................................19 Emergency Room Services......15, 33, 78 Employer/Union Drug

Coverage..61, 50, 19, 31, 41, 43, 47, 97 Employer/Union Health

Coverage................61, 11, 31, 41, 50, 72, 97 End-Stage Renal Disease

(ESRD) ............................16, 34, 71, 74 Erectile Dysfunction Drugs ......................53 Exception ................................98, 53–54, 82 Extra Help Paying

Medicare Drug Costs ................64–65, 49

 

Medical Costs....................................66–67
Eye Care (Vision) ....................21, 23, 35
Glaucoma Testing ..............................15
Eyeglasses ......................................15, 21

 

F Fecal Occult Blood Test........................14 Federal Employee Health

Benefits Program (FEHBP) ........59, 51
Flu Shot ................................................15
Foot Care ........................................15, 21
Foreign Travel ................................19, 21
Formulary ....................98, 28, 46, 53, 55
Fraud (Billing) ................................87–88
Fraud Hotline ..................................86–87

 

G Generic Drugs ................................53–55 Glaucoma Testing..................................15 Grief Counseling ....................................9 Group Health Plan ......61, 11, 19, 31, 41

H Health Maintenance Organization

(HMO) ..98, 33–34, 37, 71–78, 80, 100 Hearing Aids ............................16, 21, 23 Hearing Exams ........................16, 21, 35 Help..................................63–70, 81, 89–95 Hepatitis B Shot ....................................16 HMO........98, 33–34, 37, 71–78, 80, 100 Home Health Care ....9, 16, 81, 102–103 Hospice Care ............................9, 81, 102 Hospital Bed ..............................9, 15, 16 Hospital (care, inpatient

coverage)..................7, 9, 81, 97–98, 101

 

I Identity Theft ........................................86 ID Theft Hotline....................................86 Immunosuppressive Drug Therapy......19 Income-based (Part B) Premium ........11 Inspector General’s Hotline............86–87 Institution......................98, 38, 49, 54, 72 Internet ..................................................89

J

Joining/Switching Plans ......71–78, 34, 51

K Kidney Dialysis..................16, 34, 71, 74 Kidney Transplant..19, 16–17, 34, 71, 74

L

Lab Services (see Clinical Laboratory

Services)................................13, 21, 103 Late Enrollment Penalty

(see Part B, Part C, or Part D Penalty)

Section 1: List of Topics (Index)

 

L (continued)
Life Insurance ............................................62
Lifetime Reserve Days ....................98, 102
Limited Income ........................63–70, 49
Limiting Charge ....................................27
Long-term Care................98, 62, 7, 9, 21

 

M

Mammogram ..................................16, 37 Medicaid ............98, 66, 49, 64, 69, 71–72 Medical Equipment ......9, 15–16, 102–103 Medically Necessary..98, 9–10, 12–19, 54 Medical Nutrition Therapy ..................17 Medicare Advantage

Plans ....................98, 23, 33–42, 71–78

 

Prescription Coverage..35–38, 40–41, 99 Medicare-Approved

Amount ........................98, 27, 102–104 Medicare Beneficiary Ombudsman ....85 Medicare Card......................7, 25, 89–91 Medicare Cost Plan ....................99, 58, 43 Medicare Helpline ................................90 Medicare Medical Savings Account

(MSA) Plans ....................99, 39, 35, 43 Medicare Part A ......7–9, 21, 25, 101–102 Medicare Part B ......10–21, 25, 101, 103 Medicare Part C ................33–42, 94, 104 Medicare Part D..................43–56, 28, 104 Medicare Prescription Drug

Coverage ..................43–56, 35, 40, 104 Medicare Prescription Drug

Plans ..................99, 28, 43–56, 23, 104

 

M (continued) Medicare Savings Programs ....67, 49, 64 Medicare SELECT ..........................75 Medicare Summary

Notice ..................26, 79–80, 83, 87, 89 Medigap (Medicare Supplement

Insurance) Policies ....99, 11, 29–31, 74
Mental Health Care ................9, 17, 103
Military Benefits ........60, 10, 24, 51, 91
MRIs ......................................................19
MyMedicare.gov ..................................89

 

N National Average Benchmark

Premium (Part D) ......................48, 104
Network ....................................36–37, 58
Notice of Privacy Practices ............83–84
Nursing Homes ..................98, 38, 49, 21
Nutrition Therapy Services ..................17

 

O

Occupational Therapy ........103, 9, 16–17 Office for Civil Rights ..................88, 91 Office of Personnel Management ........59 Office of the Inspector General..86–88, 91 Original Medicare

Plan ..................................99, 23–32, 77

 

Costs ............................26–27, 101–103
Orthopedic Shoes..................................21
Orthotic Items ......................................18
Outpatient Care ..............................10, 17
Outpatient Hospital Services ......17, 103
Oxygen..................................9, 15–16, 90

 

Section 1: List of Topics (Index)

 

P

PACE (Programs of All-inclusive Care for the Elderly) ....................69, 59 Pap Test............................................17, 37

Part A (Hospital Insurance) ..7–9, 21, 25, 33–35, 40, 102 Premium........................................8, 101

Part B (Medical Insurance) ..........10–21, 33–35, 25, 103 Penalty ..................................10, 99, 101 Premium ..8, 10, 11, 35, 41, 44, 99, 101

Part C................................98, 33–41, 104
Penalty ........................................95, 104
Premium ..................35–37, 41, 44, 101

 

Part D ..........................35, 23, 28, 43–56 Penalty ......47–48, 30, 50–51, 73, 95, 104 Premium ..47, 36, 43, 56, 101–104, 104

Pelvic Exam ....................................17, 37 Penalty ......99, 10, 30, 43, 47–51, 61, 73 Phone Numbers ..90–95, inside back cover Physical Exams ........................15, 17, 21 Physical Therapy ................9, 16, 18, 102 Pilot Programs ................................59, 86 Pneumococcal Shot ..............................18 Point-of-Service Option ................99, 37 PPO ........................99, 36, 33–34, 23, 43 Practitioner Services ............................18 Preferred Provider Organization

(PPO) Plan ....99, 36, 33–34, 43, 71–78 Premium ..........99, 101, 11, 35–37, 43, 56

P (continued)

Prescription

Drugs....................18, 21, 28, 36, 43–56 Preventive Services....99, 10–18, 89, 103 Primary Care Doctor........99, 36–37, 100 Prior Authorization ........................54, 97 Privacy Practices ............................83–84 Private Fee-for-Service (PFFS)

Plans................................100, 35, 37, 43 Private Insurance ............................61–62 Programs of All-inclusive Care

for the Elderly (PACE) ................69, 59
Prostate Screening (PSA Test)..............18
Prosthetic Devices ................................18
PSA Test (Prostate Screening)..............18
Publications ..........................................92

 

Q

Quality ................................8, 12, 23, 89 Quality Improvement

Organization ..............................8, 12, 90
Quantity Limits ................................54, 98

 

R

Railroad Retirement

Board (RRB)......................7, 10, 90–91 Referral ............................100, 23, 36–37 Regional Preferred Provider

Organization..................................36, 78
Respite Care....................................9, 102
Reverse Mortgage ................................62
Rights..................................76–77, 79–85

 

Section 1: List of Topics (Index)

 

S

Second Surgical Opinions ....................18
Service Area ..........33–34, 56, 71, 77–78
SHIP........................................92–95, 100
Shoes (Therapeutic) ..............................15
Shots (Vaccinations) ..........15, 16, 18, 21
Sigmoidoscopy......................................14
Skilled Nursing Facility

 

(SNF) Care ..............100, 9, 81, 97, 102 Smoking Cessation ..............................18 Social Security ......7–8, 10–11, 65, 68, 91 Special Enrollment Period ..100, 10, 61, 73 Special Needs Plan ................100, 38, 74 Specialist ........................................36–37 Speech Language Pathology

Services ............................9, 16, 19, 103 State Children’s Health

Insurance Program..............................63 State Health Insurance Assistance

Program ................................92–95, 100 State Insurance Department ................90 State Medical Assistance(Medicaid)

Office......................................65–70, 90 Step Therapy..........................................54 Subluxation............................................13 Supplement Policy (see Medigap

Policies)................99, 11, 29–31, 35, 74 Supplemental Security

Income (SSI) ..........................68, 64, 49
Supplies (Medical) ........9, 16–17, 27, 87

 

Diabetic ..................................15, 21, 27
Surgical Dressings ................................19
Switching Plans............34, 48, 51, 71–78

 

T Telemedicine ................................100, 19 Telephone

Numbers ........90–95, inside back cover
Territories ........................................70, 64
Tests ..........................................13–19, 21
Tiers (formulary) ............................55, 98
Transplants ......................................19, 74
Travel ..............................................19, 21
TRICARE ....................60, 10, 24, 51, 91
TTY ........................................100, 90–91

 

U

Union

Coverage..61, 11, 19, 31, 41, 43, 50, 75 Urgently Needed Care..............19, 33, 82

V Vaccinations (shots) ..........15, 16, 18, 21 Veterans’ Benefits (VA) ....60, 24, 51, 91

W Walker ..................................9, 15, 16, 90 Web ........................................................89 “Welcome to Medicare”

Physical Examination ........................17
Wheelchair..................................9, 15, 16
www.medicare.gov................................89

 

X

X-ray ......................................................19

 

What’s Covered

Medicare covers certain medical services and items in hospitals and other settings. Some are covered under Medicare Part A, and some are covered under Medicare Part B. As long as you have both Part A and Part B, these services and items are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO).

What Is Medicare Part A?

Part A helps cover your inpatient care in hospitals. This includes critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and home health care. You must meet certain conditions to get these benefits.

If you aren’t sure if you have Part A, look on your red, white, and blue Medicare card (see sample card below). If you have Part A, “HOSPITAL (PART A)” is printed on your card.

Note: Your card may be slightly different. It’s still valid.

Blue words in the text are defined on pages 97–100.

Do you need to replace your Medicare card?

If your Medicare card is lost or damaged, you can order a new card at www.socialsecurity.gov on the web. Or, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772, or visit www.rrb.gov on the web and select “Benefit Online Services.”

Section 2: What’s Covered

What Is Medicare Part A? (continued)

Cost: Most people automatically get Part A coverage without having to pay a monthly payment, called a premium. This is because they or a spouse paid Medicare taxes while working.

If you don’t automatically get premium-free Part A, you may be able to buy it if

                  you (or your spouse) aren’t entitled to Social Security because you didn’t work or didn’t pay enough Medicare taxes while you worked and you are age 65 or older, or

                  you are disabled but no longer get premium-free Part A because you returned to work.

For most people, if you buy Part A coverage, you must also enroll in Part B and pay the Part B premium.

If you have limited income and resources, your state may help you pay for Part A and/or Part B (see page 67). For more information, visit www.socialsecurity.gov on the web or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Section 2: What’s Covered

Medicare Part A Helps Cover Your Medically-Necessary...