Health Care Choices

Medicare’s preventive services 

The best way for you and the person you’re caring for to stay healthy is to live a healthy lifestyle. You can live a healthy lifestyle and prevent disease by exercising, eating well, keeping a healthy weight, and not smoking. Medicare can help you and the person you’re caring for focus on preventive care.

Medicare pays for many preventive services to keep people with Medicare healthy. Preventive services can find health problems early, when treatment works best, and can help prevent certain diseases or illnesses. Preventive services may include exams, lab tests, and screenings. They may also include shots, counseling, and information to help people take care of their health. 

Medicare helps pay for these preventive tests and services:  

Shots Pneumococcal 

Flu 

Hepatitis B (for people at medium to high risk)

Exams

One-Time “Welcome to Medicare” preventive visit (within the first 12 months of having Part B) Yearly “Wellness” visit

Screenings

Abdominal aortic aneurysm (for people at risk) 

Alcohol misuse (screening and counseling) 

Bone mass measurement 

Breast cancer (mammograms) 

Cardiovascular disease 

Cervical and vaginal cancer

 Colorectal cancer 

Depression Diabetes (for people at risk)

 Glaucoma (for people at high risk) 

Hepatitis C (for certain ages and people at high risk) 

HIV (for people at increased risk) 

Pap test Prostate cancer Sexually transmitted infections (screening and counseling)

Other Preventive Benefits 

Cardiovascular disease (intensive behavioral therapy)

Diabetes self-management training 

Medical nutrition therapy (for people with diabetes or renal disease)

 Obesity (intensive behavioral therapy)

Making changes to Medicare coverage

If the person you’re caring for already has Medicare, it’s a good idea to make sure the current coverage is still meeting his or her health, financial, and coverage needs. A Medicare health or prescription drug plan can change how much it costs and what it covers each year. Each fall, there’s an opportunity to change Medicare coverage options, so you should help the person review his or her current health and prescription drug coverage.

If he or she is satisfied with the current plan’s cost and coverage for the coming year, do nothing. However, if the person wants to make a change, it can be done during certain times depending on the type of coverage. 

Fall Open Enrollment Period 

Between October 15–December 7 each year, a person with Medicare can join, switch, or drop a Medicare Advantage Plan (like an HMO or PPO) or a Medicare drug plan. The coverage will begin on January 1 of the following year.  

Medicare Advantage Disenrollment Period

Between January 1–February 14 each year, if someone is in a Medicare Advantage Plan, he or she can leave that plan and switch to Original Medicare. If the person switches to Original Medicare during this period, he or she will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. The coverage will begin the first day of the month after the plan gets the enrollment form. 

Getting Medicare (continued)

• Special Enrollment Period—A person may decide to wait to sign up for Part A and/or Part B because he or she is covered by a group health plan based on his or her own or a spouse’s current employment (or if disabled, a family member’s current employment). Someone in this situation can sign up for Part A and/or Part B at any time while he or she has group health plan coverage based on current employment or during the 8-month period that begins the month after the employment ends, or the group health plan coverage ends, whichever happens first. Note: This Special Enrollment Period doesn’t apply to people with ESRD. 

• Special Enrollment Period for international volunteers—A person who waited to sign up for Part A and/or Part B because he or she had health insurance while volunteering in a foreign country has a special opportunity to sign up.

Medicare Part A and Part B premiums 

Most people don’t have to pay a monthly premium for Part A because they or a spouse paid Medicare taxes while they were working. This is called “premium-free Part A.” Most people do pay a premium each month for Part B.

Late enrollment penalties 

A person who doesn’t sign up for Part A when he or she is first eligible may have to pay a penalty equal to 10% of the Part A premium. The 10% premium penalty applies no matter how long someone delays Part A enrollment. The person will have to pay the premium penalty for twice the number of years he or she could have had Part A, but didn’t sign up. 

A person who doesn’t sign up for Part B when he or she is first eligible may have to pay a late enrollment penalty. The monthly premium for Part B may go up 10% for each full 12-month period that the person could have had Part B, but didn’t sign up for it. The person will have to pay the premium penalty for a long as he or she has Medicare

Getting Medicare

Enrollment in Medicare Part A and B is automatic when a person:

• Turns 65 and is already getting Social Security or Railroad Retirement Board (RRB) benefits. A Medicare card will be mailed about 3 months before his or her 65th birthday. 

• Is under 65 and disabled, he or she will automatically get Part A and B after getting disability benefits from Social Security or certain disability benefits from the RRB for 24 months. A Medicare card will be mailed about 3 months before the 25th month of disability. 

• Has ALS (Amyotrophic Lateral Sclerosis also known as Lou Gehrig’s disease). People with ALS automatically get Part A and Part B the month the disability benefits start. 

Note: Part B is optional. Someone who doesn’t want Part B must follow the instructions that come with the Medicare card, and send the card back. A person who keeps the card keeps Part B and will pay Part B premiums.

A person must sign up for Medicare Part A and/or Part B if he or she: 

• Isn’t getting Social Security or RRB benefits (for instance, because he or she is still working) and wants Part A or Part B. The person should contact Social Security 3 months before he or she turns 65. People who worked for a railroad should contact the RRB to sign up.

• Has End Stage Renal Disease (ESRD) (permanent kidney failure that requires dialysis or a kidney transplant). The person should visit the local Social Security office, or call Social Security at 1-800-772-1213 to sign up for Part A and Part B. TTY users should call 1-800-325-0778. For more information, visit Medicare.gov/publications to view the booklet, “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services.” 

• Isn’t eligible for premium-free Part A (see page 17) but wants to buy Part A. The person must also sign up for Part B, and should contact Social Security 3 months before he or she turns 65. 

Understanding Medicare

What’s Medicare? 

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

Medicare Part A (Hospital Insurance) helps cover: 

• Inpatient care in hospitals 

• Skilled nursing facility care 

• Hospice care 

• Home health care 

Medicare Part B (Medical Insurance) helps cover: 

• Services from doctors and other health care providers 

• Outpatient care 

• Home health care 

• Durable medical equipment 

• Some preventive services 

Medicare Part C (Medicare Advantage Plans) 

• Includes all benefits and services covered under Part A and Part B 

• Usually includes Medicare prescription drug coverage (Part D) as part of the plan 

• Run by Medicare-approved private insurance companies 

• May include extra benefits and services for an extra cost 

Medicare Part D (Prescription Drug Coverage) 

• Helps cover the cost of prescription drugs

• Run by Medicare-approved private insurance companies

• May help lower your prescription drug costs and help protect against higher costs in the future

Other Medicare health plans

 Some types of Medicare health plans that provide health care coverage aren’t Medicare Advantage Plans but are still part of Medicare. Some of these plans provide Part A and/or Part B coverage, and some also provide Medicare prescription drug coverage. These plans have some of the same rules as Medicare Advantage Plans. Some examples include Medicare Cost Plans, Demonstration or Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). 

Planning for future health care decisions

• A health care proxy (also called a durable power of attorney). This document names a specific person to make health care decisions for someone who isn’t able to make decisions for him or herself. 

• A living will. Living wills give directions about the kind of health care a person wants, and which medical treatments a person wants if his or her life were threatened, including things like: – Dialysis and breathing machines – Resuscitation if the person’s breathing or heart stops – Tube feeding 

• After-death wishes. These documents may include decisions like organ and tissue donation. 

If the person you’re caring for has advance directives, make sure you know where these documents are, and give copies to his or her doctors, nursing home, caregivers, and other health care providers, and anyone named in the advance directives. 

Managing health care 

The person you’re caring for may have health information in lots of places—at home or in doctor or hospital records. You may need to know certain information about his or her health care like the last time he or she had a certain medical procedure. It may seem overwhelming to remember all of these details, and trying to find the information when it’s in lots of places can be hard. 

You may be able to help him or her set up a Personal Health Record (PHR). A PHR is usually an electronic file or record of health information and recent services. With a PHR, a person can keep track of his or her health information, like the date of his or her last physical, major illnesses, operations, allergies, or list of medicines. This information can be stored in one place, and then shared with others, as needed. 

OTHER REPORTS

 Credit Balance Reports 

 Due 30 days after the end of each fiscal quarter 

 Report over-payments from Medicare 

 No payments will be made if you do not complete this report 

 CMS billing audit reports 

 CMS may ask for 25 patients specific billing for a date of service and the office notes to support the billing. 

 An adjudicator reviews and decides if the service was a medical necessity. 

 Monies can be taken back by Medicare. There is an appeal process through the adjudicator.

Gathering important information

Start by helping the person you’re caring for gather this information so it’s available when you need it:

• Social Security Number 

• Medicare number (You can find this on his or her red, white, and blue Medicare card.) 

• Medicare plan enrollment (See pages 13–14 for information on how to check his or her current coverage.)

• Other insurance plans and policy numbers, including long-term care insurance 

• Contact information for health care providers, like doctors, nurses, hospitals, pharmacies, and medical suppliers 

• List of current prescription drugs and dosages 

• Current health conditions, symptoms, and treatments 

• History of past health problems 

• Allergies or food restrictions

• Emergency contacts, like close friends, family, neighbors, clergy, or housing manager

• Financial and legal information

Next steps 

For help keeping track of this information: 

• Visit MyMedicare.gov to help the person you’re caring for get personalized information about his or her Medicare benefits and services, like plan enrollment, claims, and more. See pages 42–43 for more information.