If this all sounds mystifying, you’re probably wondering how on earth anyone can possibly navigate Part D to find good drug coverage. But yes, it’s possible! In Chapter 10, I describe a strategy for effectively comparing plans and finding the one that best meets your needs, and Chapter 12 lets you know who can help you do it. I also discuss what Part D covers (Chapter 2); the costs you can expect (Chapters 3 and 4); and how to troubleshoot any problems that show up (Chapters 13 and 14).
❯❯ Enroll at the right time, according to your circumstances. If you misunderstand or ignore the rules, you face permanent financial penalties and may go without coverage for several months. I explain those potential traps and how to avoid them in Chapter 6.
❯❯ Research your options. You need to understand the differences between being in the traditional Medicare program and enrolling in a private Medicare Advantage health plan. See Chapter 9 for details.
❯❯ Determine how to make smart choices if you opt for traditional Medicare. That means deciding whether you need to add Part D prescription drug coverage and, if so, how to choose the drug plan that works best for you. It also means deciding whether you want to purchase Medigap supplemental insurance and, if so, understanding when you should buy it to ensure you receive all-important federal guarantees and protections. I discuss these choices in Chapter 10.
❯❯ Figure out how to make smart choices if you opt for a Medicare Advantage plan. That means comparing plans according to your needs and preferences and understanding your options if you change your mind and want to return to traditional Medicare. See Chapter 11 for more info.
❯❯ Get help making your choices if you need to. I explain how to get personal help from legitimate, informed sources (and avoid scamsters and frauds) in Chapter 12.
❯❯ Understand your right to change your coverage every year and at other times in certain circumstances. I describe the purpose of various enrollment periods, their deadlines, and the process of switching to another plan or type of coverage in Chapter 15.
Chapter 2
Spelling Out What Medicare Covers (A Lot, but Not Everything)
IN THIS CHAPTER
Getting a handle on the coverage you get under Medicare Part A and Part B
Figuring out what Medicare Part D covers
Being aware of what Medicare doesn’t cover
Recognizing that some coverage comes with limits
Medicare is huge – a program of Titanic proportions. It covers so many medical services that just to list them all would fill this entire book. And describing each service or item in detail – in terms of the coverage requirements or limitations that apply in different circumstances – would take several books. So I need to use a big brush here.
In this chapter, I broadly paint in the categories of care that Medicare pays for under Part A, Part B, and Part D so that you get a good idea of its scope. (The Medicare Advantage program gets its own explanation in Chapters 1, 9, and 11.) I also explain some types of care that you may expect to be covered by Medicare but that actually aren’t. And finally, I show that a few services come with limitations on coverage, meaning that Medicare helps pay for them only up to a certain point in a particular period of time.
Note: I’m not skimping on giving more-detailed information that you need to know in order to deal with certain aspects of Medicare. Some coverage issues are very straightforward – basically, you just show your Medicare card (or Medicare Advantage plan card or Part D drug plan card, as appropriate) to get a covered service for the required co-pay or, in some cases, for free. But other issues are more complex and may pose pitfalls that can trip you up if you’re not expecting them. I zoom in on those issues in Chapter 14, where I share the inside scoop on some of the finer points of Medicare coverage that are good to know about in advance so you don’t have to find out the hard way.
Part A and Part B form the core of Medicare. They provide the coverage that you have if you enroll in the traditional or original Medicare program that has been around since 1966, although many more services have been added since then. Parts A and B are also the basis of your coverage if you’re in a Medicare Advantage health plan, because all those plans must by law cover the same services as the traditional program, although the plans can provide extra benefits if they want to. (I go into detail about the differences between traditional Medicare and Medicare Advantage plans in Chapter 9.)
These two parts of Medicare cover entirely different services, as explained in Chapter 1. But sometimes Parts A and B work in tandem. For example, if you need to go into the hospital, in most cases Part A covers the cost of your room, meals, and nursing care after you’ve met the deductible. But Part B covers the cost of your medical treatment – services provided by surgeons, other doctors, and anesthetists. This division of coverage also applies to staying in a skilled nursing facility for continuing care after leaving the hospital, using home health services, and receiving hospice care.
In the following sections, I describe broad categories of services that Parts A and B pay for.
Necessary medical care
In essence, Medicare covers services that are reasonable or necessary to save life and maintain or improve health. That includes really big-ticket items – such as transplants of the heart and other organs, delicate surgery to repair severe injuries, cancer treatments, and many others – that cost Medicare tens of thousands, and in some cases hundreds of thousands, of dollars. The program also, of course, covers more-routine and less-expensive services, from allergy shots to X-rays.
No doubt about it: Medicare can split hairs. It may cover a service in some circumstances but not others. One glaring example of this discrepancy is that Medicare covers powered wheelchairs (as opposed to the conventional type) only if you need one to get around inside your home but not if you need one just to be mobile outdoors. Medicare may also cover a treatment in some parts of the country but not everywhere. (I go into the difference between national coverage determinations, which cover people in need of them throughout the country, and other coverage determinations that are made regionally, in Chapter 14.) But on the whole, Medicare pays for a vast range of medical services that people need.