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 As your parents, grandparents, relatives, or friends face health care decisions, they might need to rely on you for help. Medicare can be an important factor in many of those decisions. If you aren’t familiar with Medicare or the other resources that are available for the person you are helping or caring for, or if you just want to brush up on what you already know, this booklet is for you.
“Medicare Basics” highlights several topics related to the health and care of a person with Medicare. For each of these topics, you’ll find basic information about Medicare and suggestions on where to go to find more information. Words you see in blue are defi ned in the “Words to Know” section.
“Medicare Basics” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings.
You can’t always plan ahead when you need health care, but when you can, take time to compare. Medicare collects information about the quality of care and services given by most Medicare plans and other health care providers. Visit www.medicare.gov to compare the quality of care and services given by health and prescription drug plans, health care providers, and facilities nationwide.
If you have a question or complaint about the quality of care that the person you are caring for has received, call your local Quality Improvement Organization (QIO). Call 1-800-MEDICARE (1-800-633-4227) to get your QIO’s telephone number. TTY users should call 1-877-486-2048. You can also visit www.medicare.gov, and select “Find Helpful Phone Numbers and Websites.”
Download Medicare Basics: A Guide for Families and Friends of People with Medicare
PDF format, 1.3MB, 56Pages.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850
TABLE OF CONTENTS
Section 1: Getting OrganizedInformation to Know ................ 4–5
Planning for Future Health Care Decisions ........................................ 5–6
Managing Health Care ................................................................................7
Section 2: Navigating MedicareMedicare Overview ............................... 10–13
Checking Current Coverage .............................................................. 14–15
Getting Medicare ................................................................................. 16–18
Making Changes to Medicare Coverage .......................................... 19–20
Section 3: Health Care ChoicesMedicare’s Preventive Services ......................... 22–23
Finding a Doctor, Provider, or Supplier ......................................... 23–24
Help with Hospitalization ................................................................ 25–26
Home Health Care ............................................................................ 26–28
Long-Term Care Options ................................................................. 28–31
Considering Hospice Care ............................................................... 32–34
Section 4: Help With Billing How to Use a Medicare Summary Notice ........... 36–37
Appeals & Grievances ............................................................................ 38
Reporting Fraud .............................................. 39
Section 5: How to Help - Next Steps Coping with Illness ............................. 42–43
Ask Medicare - Information to Help You Care for Others ............... 44
State Health Insurance Assistance Programs (SHIPs) ........................ 45
Medicare.gov and MyMedicare.gov ....................................................... 46
1-800-MEDICARE .................................................................................... 47
Section 6: Words to Know Definitions ................................. 49–52
WORDS TO KNOW
Advance Directive
A written document stating how you want medical decisions to be made if you lose the ability to make them for yourself. It may include a Living Will and a Durable Power of Attorney for health care.
Coinsurance
An amount you may be required to pay as your share of the cost for services aft er you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).
Copayment
An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit or prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription.
Deductible
The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
Durable Power of Attorney
A legal document that enables you to designate another person to act on your behalf in the event you become disabled or incapacitated.
Home Health Agency
An organization that provides home health care.
Home Health Care
Health care services and supplies a doctor decides you may receive in your home under a plan of care established by your doctor. Medicare only covers home health care on a limited basis as ordered by your doctor.
Hospice
A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver as well.
Living Will
A legal document also known as a medical directive or advance directive. It states your wishes regarding life-support or other medical treatment in certain circumstances, usually when death is imminent.
Long-term Care
A variety of services that help people with their medical and non-medical needs over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care you need.
Long-term Care Ombudsman
An independent advocate (supporter) for nursing home and assisted living facility residents who works to solve problems between residents and nursing homes or assisted living facilities. They may be able to provide information about home health agencies in their area.
Medicare Advantage Plan (Part C)
A type of Medicare health plan off ered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefi ts. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
Medicare-approved Amount
In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It includes what Medicare pays and any deductible, coinsurance, or copayment that you pay. It may be less than the actual amount a doctor or supplier charges.
Medicare Cost Plan
A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan’s network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services or urgently needed services).
Medicare Medical Savings Account (MSA) Plan
MSA Plans combine a high-deductible Medicare Advantage Plan and a bank account. Th e plan deposits money from Medicare into the account. You can use the money in this account to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you generally will have to pay out-of-pocket before your coverage begins. MSA Plans can’t offer Part D prescription drug coverage, but you can enroll in a Medicare prescription drug plan while you are enrolled in a MSA Plan.
Medicare Part A (Hospital Insurance)
Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B (Medical Insurance)
Coverage for certain doctors’ services, outpatient care, medical supplies, and preventive services.
Medicare Prescription Drug Plan
A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are off ered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
Medigap Policy
Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage.
Original Medicare
Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A and/or Part B benefits.
Power of Attorney
A document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a health care proxy, appointment of health care agent, or a durable power of attorney for health care.
Programs of All-Inclusive Care for the Elderly (PACE)
A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically-necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.
Rehabilitation Services
Services that help you regain abilities, such as speech or walking, that have been impaired by an illness or injury. These services are given by nurses, and physical, occupational and speech therapists. Examples include working with a physical therapist to help you walk and with an occupational therapist to help you get dressed.
Respite Care
Temporary or periodic care provided in a nursing home, assisted living facility, or other type of long-term care program so that a family member or friend who is the patient’s caregiver can rest or take some time off.
Skilled Nursing Facility (SNF) Care
Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility.
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