Recognizing That You Have Choices and Must Make Timely Decisions
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
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, also known as Part C, 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.
Understanding What Part A and Part B Cover
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 I explain 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 power-operated vehicles, such as scooters and manual 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. In 2018, Medicare began requiring prior authorization for the coverage of certain types of power wheelchairs (33 in all) before Medicare will cover the cost. Medicare may also