Medicare FAQs

• After people enroll in Medicare, how do they get their benefits?

  People must decide how to get their Medicare benefits. They can choose Original Medicare, one of the Medicare Advantage Plans, or other Medicare health plans. If a person is receiving Social Security retirement benefits and does nothing when first eligible for Medicare, he or she will automatically be enrolled in Original Medicare.

• What if a person has prescription drug coverage from a former or current employer?

  If a person has prescription drug coverage from a former or current employer or union, contact the plan′s benefits administrator before making any changes to the drug coverage. Joining a Medicare drug plan could change how the person′s employer or union coverage works, both for the person and any dependents covered by the plan.

  Also, if a person has prescription drug coverage from TRICARE, the Department of Veterans Affairs (VA), or the Federal Employee Health Benefits Program (FEHBP), contact the plan′s benefits administrator or insurer before making any changes. In most cases, it will be to the person′s advantage to keep the current coverage. However, in some cases, adding Medicare prescription drug coverage can provide extra coverage and savings, especially if the person qualifies for extra help.

• How can I find out what drugs a Medicare drug plan covers?

  Each Medicare drug plan has a list of prescription drugs that it covers, called a formulary, or drug list. Plans may cover both generic and brand-name prescription drugs. Most prescription drugs used by people with Medicare will be on a plan′s drug list. To find out which drugs a plan covers, contact the plan or visit the plan′s website. All Medicare drug plans must make sure that the people in their plan can get medically-necessary drugs to treat their conditions.

• What payments does a person make in a Medicare drug plan?

  If a person joins a Medicare drug plan he or she usually pays a separate monthly fee, or premium, in addition to the Part B premium. If someone belongs to a Medicare Advantage Plan (like an HMO or PPO) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium may include an amount for prescription drug coverage. The amount of the monthly premium isn′t affected by the person′s health status or how many prescriptions he or she uses.

  Other payments a person may make include yearly deductibles, co-payments, and co-insurance. There are also costs associated with the coverage gap and catastrophic coverage.

  The yearly deductible is the amount a person pays for prescriptions before the plan begins to pay. Some drug plans charge no deductible.

  Co-payments or coinsurance are the amounts a person pays for prescriptions after the deductible. The person pays his or her share, and the plan pays its share for covered drugs. In some plans, a person pays the same co-payment or coinsurance for any prescription. In other plans, there might be different levels or "tiers," with different costs. For example, a person might have to pay less for generic drugs than brand names. Or, some brand names might have a lower co-payment than other brand names. Also, in some plans, a person′s share of the cost can increase when the prescription drug costs reach a certain limit.

• What are some health care costs NOT covered by Medicare?

  Medicare doesn′t cover everything. For example, Medicare doesn′t cover cosmetic surgery, health care you get while traveling outside of the United States (except in limited cases), hearing aids, most hearing exams, most eyeglasses, most dental care and dentures, and more. It also does not cover long-term care (except for skilled nursing care services that are needed daily on a short-term basis after a 3-day qualifying hospital stay). Some of these services may be covered by a Medicare Advantage Plan, such as an HMO (health maintenance organization) or PPO (preferred provider organization). A Medicare supplement can help with expenses not fully paid by Medicare.

• What is the difference between Medicare and Medicaid?

  Some people think that Medicare and Medicaid are the same. Actually, they are two different programs. Medicaid is a state-run program that provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicare and Medicaid.

  If you have questions about Medicaid, you can call your State Medical Assistance (Medicaid) office for more information.

• How does the Medicare PACE program help older adults?

  PACE (Programs of All-Inclusive Care for the Elderly) combines medical, social, and long-term care services, and prescription drug coverage for frail, elderly people who get health care in the community.

  To qualify for PACE, people must be at least age 55, live in the PACE service area, meet their state′s standard for nursing home level care, and be able to live safely in a community setting at the time of enrollment. Call your State Medical Assistance (Medicaid) office to find out about eligibility and to see if there is a PACE site nearby.

• How does a person keep track of the services that Medicare bills and pays for?

  If a person is in Original Medicare, he or she will get a Medicare Summary Notice (MSN) in the mail every three months if he or she had a Medicare-covered service during that period. The notice lists the services the person you care for received and the amount he or she may be billed by a hospital, doctor, or other provider. These notices are sent by companies that handle bills for Medicare.

  Notices and bills for Medicare Advantage Plans and Medigap policies will look different than the MSN for people in Original Medicare.

  If you have a question about a Medicare Advantage Plan or Medigap policy, you will need to call the benefits coordinator at the company or health plan that offers the plan. To locate telephone numbers, you can look at the notice or bill from the plan.

• If a person with Medicare is covered by another health insurance plan, who pays?

  When a person with Medicare is covered by more than one health insurance plan, there are rules about whether Medicare or the other insurer pays health care bills first. This is called "coordination of benefits." Sometimes, the other health insurance pays the person′s health care bills first, and the person′s Original Medicare Plan or Medicare Advantage (MA) Plan pays second.

  Other insurance that may pay first includes an employer′s or union′s group health plan coverage, no-fault insurance, liability insurance, black lung benefits, or workers′ compensation.

  If the person has other insurance, it is important to tell his or her doctor, hospital, and pharmacy so that the bills get paid correctly.

• What if a person has a concern about the quality of care received while on Medicare?

  If you have a concern about the quality of care received while on Medicare, contact your state Quality Improvement Organization, or QIO. QIOs are groups of doctors and health care experts who check on and improve the care given to people with Medicare. To get the address and phone number of the QIO in your state or territory, call 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048.

• What if a person disagrees with a decision Medicare makes about coverage or payment for a service?

  A person with Medicare has the right to appeal any decision about his or her Medicare services. This is true whether the person is in Original Medicare, a Medicare managed care plan, or a Medicare prescription drug plan. If the person doesn′t agree with the amount that Medicare paid, or thinks that a service has been unreasonably denied, the person can appeal.

  Information on how to file an appeal is on the Medicare Summary Notice (MSN), in the health plan materials, or in the drug plan materials. If the person you care for decides to file an appeal, ask the doctor or provider for any information that may help the case. You can also call the State Health Insurance Assistance Program (SHIP) for help filing an appeal. If the person you care for wants someone to file an appeal on his or her behalf, he or she will need to complete an "Appointment of Representative" form.

• Am I eligible for Medicare?

  Generally, you are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment and you are 65 years or older and a citizen or permanent resident of the United States. If you aren′t yet 65, you might also qualify for coverage if you have a disability or with End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).

• What is my Medicare effective date?

  To determine your Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) effective date, refer to the lower right corner of your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board.

  

• What do I do if I live in Massachusetts, Minnesota or Wisconsin and want to purchase a Medicare Supplement plan?

  Medicare Supplement policies have standardized names and benefits that are available in all states except Massachusetts, Minnesota or Wisconsin. To view a chart of the basic benefits included in Medicare Supplement policies in these states, refer to pages 46 through 48 of Choosing a Medicare Supplement Policy: A Guide To Health Insurance For People With Medicare .