In 1965 Congress created the Medicare Program to be a health insurance program for persons aged 65 years or older. Today, Medicare coverage is also extended to people who have been receiving Social Security Disability benefits for a set amount of time (usually 24 months) and people with end-stage renal disease. Medicare is a federal program and, as such, is paid for and administered by the federal government, specifically the Centers for Medicare & Medicaid Services, an agency within the Department of Health and Human Services. Medicare eligibility is based on entitlement to Social Security or Railroad Retirement benefits and not on level of income or assets (excluding Part D).

Medicare is divided into several parts - Part A is hospital insurance, Part B is medical insurance, Part C is the Medicare Advantage (formerly Medicare+Choice) program, and Part D is the prescription drug benefit. Parts A and B are commonly referred to as Original Medicare and Part C as Medicare Advantage.

Medicare Part A can help pay for hospitalization, skilled nursing facility care, home health care, and hospice care. Part B covers doctors' services, outpatient hospital care and surgery, ambulance transportation, durable medical equipment, prosthetics, orthotics, and medical supplies, outpatient physical and speech therapy, rural health clinic care, and home health care. Parts A and B comprise Original, or traditional, Medicare

Part C, introduced in 2006, is an option to enroll in Medicare through private insurance providers. Beneficiaries who choose to enroll in a Part C plan will receive services under private health care plans. Medicare pays for the plan for the cost of the beneficiary's care, and the beneficiary is responsible for paying possible other costs. These other costs differ from those under the Original Medicare plans.

An individual with a Medicare Card can determine which kind of coverage he has by looking below his Medicare number. A letter of the alphabet follows the Medicare number; this letter signifies the status of the cardholder. Alphabet letters corresponding to the benefit package will be below the Medicare number.

People who receive Social Security or Railroad Retirement income and who are at least 65 years old or deemed disabled by the Social Security Administration may be automatically enrolled in Medicare Part A without a monthly premium. Beneficiaries must choose to be in Medicare Part B, but if chosen, the monthly premiums are usually deducted from the beneficiary's monthly Social Security or Retirement benefit check. If a person participates in both Parts A and B, he is also eligible to enroll in a Medicare supplemental policy, or into Medicare Advantage if it is available in that particular area.

A comparison of the health plans available in each zip code may be found by using the "Medicare Personal Plan Finder" listed under the "Find Out What Medicare Covers" option at www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). The local Area Agency on Aging Health Insurance Assistance Program (SHIP) is another excellent source of information and may be contacted at 1-800-345-6347. This statewide toll-free number automatically routes to the nearest Area Agency on Aging.

Medicare Part A

What Is Part A (Hospital Insurance)?

Ø Part A helps cover:

· Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)

· Inpatient care in a skilled nursing facility (not custodial care)

· Hospice care services

· Home health care services

· Inpatient care in a Religious Non-medical Health Care Institution (Medicare will only cover the non-medical, non-religious health care items and services in this type of facility for people who qualify for hospital or skilled nursing facility care but for whom medical care isn't in agreement with their religious beliefs)

2010 UPDATE – There will be increases in the Medicare Hospital Insurance (Part A) payroll tax on earnings for higher-income taxpayers (more than $200,000/individual and $250,000/couple) by 0.9 percentage points from 1.45 percent to 2.35 percent, beginning in 2013, to be deposited into the Part A Trust Fund.

Entitlement to Benefits

An individual who is 65 years of age or older or a beneficiary of Social Security Disability benefits becomes entitled to Medicare Part A if s/he draws Social Security or Railroad Retirement benefits. A person who is entitled to Medicare Part A coverage usually does not have to pay monthly premiums. Someone who is 65 or older or otherwise qualifies but is not drawing Social Security or Railroad Retirement Benefits can still participate in Medicare Part A, but s/he must pay the monthly premiums. Generally, disabled persons who qualify for Social Security Disability Benefits are also entitled to Medicare Part A. However there is a 24-month waiting period for those disabled persons, beginning the first month that the person is entitled to Social Security Disability Benefits. If the person has amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease) the 24-month waiting period is waived. If the individual has End Stage Renal Disease, s/he is entitled immediately to Part A if s/he needs a transplant or after three months of dialysis.

If the Part A premium is not waived, the premium is $461 per month (2010) for those who have less than 30 quarters of Medicare-covered employment. With 30-39 quarters of Medicare covered employment, the premium drops to $254 per month (2010). A person who failed to enroll in Medicare during the initial enrollment period may have to pay a 10% higher premium for each full year that s/he would have been eligible. These penalties will end after twice the number of months in the penalty period.

Enrollment

People who are drawing Social Security or Railroad Retirement Benefits are usually automatically enrolled in Medicare Part A. If someone wishes to not receive these benefits s/he must fill out a special form at the local Social Security Administration Office. The Social Security Administration Office responsibility is only to enroll people in Medicare, not to administer the Medicare program. All questions not involving enrollment should be directed to the Center for Medicare & Medicaid Services or call 1-800-MEDICARE (1-800-633-4227).

The initial enrollment period begins three months before the individual turns 65 and extends until three months after the month that s/he turns 65. If the individual does not enroll or is not automatically enrolled in Medicare, a penalty may apply.

Benefits

Benefits under Medicare Part A include Inpatient Hospitalization, Skilled Nursing Facility Care, Post Institutional Home Health Care, Hospice Care, and some Blood Unit benefits.

Inpatient Hospitalization (2010)

Covered Services. Medicare Part A only covers hospital stays that are medically necessary. It covers a semi-private room, meals, general nursing, and other hospital services and supplies. This includes mental health care and inpatient care in critical access hospitals (small facilities that provide limited services in rural areas). This does not include private duty nursing, a telephone, or a television in the room. This also does not include a private room unless it is medically necessary as determined by a doctor. Non-covered services will have to be paid for by the individual. Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.

Daily Charges

· Days 1-60: Medicare cover 100% of the charges

· Days 60-90: Beneficiary must pay up to $275 co-insurance per day

· Days 90-150: Beneficiary must pay up to $550 co-insurance per day

· The days between 90 and 150 are called "Lifetime Reserve Days" and can only be used once, but not necessarily at one time. After day 150 or after the Lifetime Reserve Days are exhausted the individual has to pay all expenses.

Deductible

· $1,100 per "spell of illness"

Spell of Illness

· A spell of illness begins when an individual enters a hospital or nursing home, and continues until sixty (60) days after that individual has been discharged.

· On day 61, if the individual reenters the hospital, s/he will have to pay the deductible and co-payment again, but is entitled to the renewed benefits after the new spell of illness begins.

Skilled Nursing Facility Services (2010)

Covered Services. After an inpatient hospital stay that is at least 3 days long, a beneficiary can receive a semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies in a Skilled Nursing Facility (SNF), commonly known as a nursing home if the stay in the facility is medically related to the hospital stay. These services include medical social services, ambulance transportation (when other transportation would endanger health) to the nearest provider of services that is not available at the Skilled Nursing Facility, dietary counseling, and some lab tests and X-rays.

Daily Charges

· Days 1-20 in SNF: Medicare pays 100% of approved charges

· Days 21-100 in SNF: Beneficiary pays $137.50 co-insurance per day

· After day 100: The beneficiary has to pay all charges. The day of discharge does not count.

(NOTE: About ½ of all nursing home charges in the United States are paid for by Medicaid).

Certification. A physician must certify that the beneficiary needs skilled care in the SNF on a daily basis.

Benefit Period. The beneficiary can qualify for a stay in a skilled nursing facility every time s/he starts a new spell of illness. The new benefit period starts after 60 continuous days without receiving care in a hospital or a nursing home.

Home Health Care (2010)

Eligibility. To be eligible for home health care, the individual must meet four conditions:

1. A doctor must decide that the individual needs health care in his/her home and must create a plan for home care.

2. The individual must need one of the following:

a. Intermittent (not full time) nursing care

b. Physical therapy

c. Speech/language pathology services

d. Occupational therapy.

3. The individual must be homebound (s/he normally cannot leave the home or leaving home is a major effort). When the individual leaves home, it must be infrequent, for a short time, or to get medical care or attend a religious service. A new regulation allows an individual to attend adult day care and still qualify for home health care.

4. The health agency that provides the care must be approved by Medicare.

Covered Services. Once a beneficiary qualifies for home health care, Medicare covers part-time nursing care, physical therapy, occupational therapy, speech/language therapy, home health aide services, durable medical equipment, certain medical supplies, and medical social services.

Benefit Period. For home health care, Medicare divides the usage into episodes. These episodes are 60 days long and Medicare pays fully for each episode. The amount of episodes allowed is based on the amount of health care an average person in the same situation would need.

Co-Payments.

· Nothing for home health services given by approved Medicare home health agencies

· 20% of the Medicare approved amount for covered durable medical equipment (such as walkers, wheelchairs, or hospital beds)

Additional Benefits. Additional home health benefits are available under Medicare Part B. Please see the Part B Home Health Care Section for details.

For more information call the Mississippi State Health Insurance Assistance Program at 1-888-240-7539. For complaints about quality of care or help filing an appeal or complaint about home health care call 1-800-844-0600.

Hospice Services (2010)

Covered Services. Medicare covers some hospice care for the terminally ill. The purpose of hospice care is to make the patient and the family comfortable rather than providing healing based activity.

Benefit Period

· Two 90-day periods followed by an unlimited number of 60-day periods

· Beneficiary must be certified by his physician and the hospice medical director to be terminally ill (six-month of less prognosis)

· Beneficiary must provide a written election to receive hospice care in lieu of other Medicare benefits

Co-Payments/Deductible

· Beneficiary may pay 5% of the charge for prescription drugs up to $5.00 per prescription and 5% of the cost of respite care up to a maximum equal to the inpatient hospital deductible, $1,100

For more information contact the Mississippi Hospice Organization at (662) 915-7391.

Blood Units

Covered Services. Medicare Part A covers pints of blood received during an inpatient hospital or skilled nursing facility stay.

Co-Payments. The beneficiary pays for the first three pints of blood, unless s/he or someone else donates blood to replace what is used.

v Covered Services Summary Chart

Blood	In most cases, the hospital gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.
Home Health Services	Limited to medically‑necessary part‑time or intermittent skilled nursing care, or physical therapy, speech‑language pathology, or a continuing need for occupational therapy. A doctor must order your care, and a Medicare‑certified home health agency must provide it. Home health services may also include medical social services, part‑time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort.
Hospice Care	For people with a terminal illness. Your doctor must certify that you are expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; and other covered services as well as services Medicare usually doesn't cover, such as grief counseling. A Medicare‑approved hospice usually gives hospice care in your home or other facility like a nursing home. Hospice care doesn't include room and board unless the hospice medical team determines that you need short‑term inpatient stays for pain and symptom management that can't be addressed in the home. These stays must be in a Medicare‑approved facility, such as a hospice facility, hospital, or skilled nursing facility. Medicare also covers inpatient respite care, which is care you get in a Medicare‑approved facility so that your usual caregiver can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren't related to your terminal illness. You can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that you are terminally ill.
Hospital Stays (Inpatient)	Includes semi‑private room, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. Examples include inpatient care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long‑term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care. This doesn't include private‑duty nursing, a television or telephone in your room (if there is a separate charge for these items), or personal care items like razors or slipper socks. It also doesn't include a private room, unless medically necessary. If you have Part B, it covers the doctor's services you get while you are in a hospital.
Skilled Nursing Facility Care	Includes semi‑private room, meals, skilled nursing and rehabilitative services, and other services and supplies after a 3‑day minimum inpatient hospital stay for a related illness or injury. An inpatient stay begins the day you are formally admitted with a doctor's order to a hospital. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn't cover long‑term care or custodial care in this setting.

[Source: Centers for Medicare & Medicaid Services "Medicare & You" 2010 Handbook;

http://www.medicare.gov/publications/pubs/pdf/10050.pdf]

Medicare Part B

What is Part B?

Medicare Part B is medical insurance that helps cover medically necessary services, including doctors, outpatient care, home health services, and other medical services, as well as some preventive services.

Entitlement

Generally beneficiaries who are entitled to Medicare Part A are also entitled to Medicare Part B.

Enrollment

Enrolling in Part B is optional. A beneficiary of Social Security or Railroad Retirement benefits, is automatically enrolled in Part B starting the first day of the month s/he turns age 65. An individual who is under age 65 and disabled, will be automatically enrolled in Part B after receiving Social Security or Railroad Retirement benefits for 24 months. An individual who does not wish to enroll in Medicare Part B, should follow the instructions that come with his/her Medicare card, which will be mailed to the individual approximately three months before s/he becomes eligible.

Most people who choose to enroll in Part B, will have the premium deducted from their monthly Social Security, Railroad Retirement, or Office of Personnel Management Retirement payment. There are three enrollment periods for Medicare Part B:

1. Initial Enrollment Period;

2. General Enrollment Period; and

3. Special Enrollment Period.

The Initial Enrollment Period begins three months before the month an individual turns age 65 and ends three months after the month s/he turns age 65.

The General Enrollment Period applies when an individual did not enroll during the Initial Enrollment Period. The General Enrollment Period runs from January 1 through March 31 of each year. Medicare Part B coverage begins on July 1 of the year of enrollment. Unfortunately, the cost will increase 10% for each 12-month period that an individual was entitled to Medicare Part B but didn't take it. This penalty will apply as long as a beneficiary has Part B.

The Special Enrollment Period applies when an individual was eligible to enroll, but did not because s/he or his/her spouse was working and had group health plan coverage through an employer or union based upon the current employment. If this is the case, an individual may enroll any time s/he is still covered by the health plan through the employment or during the eight months following the month that the employer or union group health plan coverage ends, or when the employment ends (whichever is first).

If an individual is disabled and working (or has health insurance from a working family member), then the Medicare Special Enrollment Period rules may also apply.

Those who are entitled to enroll and do so during the Special Enrollment Period do not have higher premiums. A potential enrollee who may enroll during the Special Enrollment Period who does not enroll will only be able to enroll during the General Enrollment Period, resulting in the 10% penalty.

If a beneficiary enrolls in Part B and then later drops coverage because the individual, spouse, or a family member is working and has health coverage through the employer or union, s/he can enroll in Part B again during a Special Enrollment Period. Individuals who drop Part B before their other health insurance coverage begins may be left without coverage.

Under COBRA (Consolidated Omnibus Budget Reconciliation Act), some people keep their employer group health plan coverage when they stop working. An individual who is eligible for COBRA, should still consider enrolling in Medicare Part B since a Special Enrollment Period does not apply when COBRA coverage ends.

Premiums

In some cases the premium may be higher if the beneficiary did not sign up for Part B when s/he first became eligible. The premiums may go up 10% for each 12-month period that s/he could have had Part B coverage but did not enroll. Except in special cases, the beneficiary must pay this extra amount as long as s/he has Part B coverage.

The Part B premium is $96.40 per month (individual with income less than or equal to $85,000 or a couple with income less than or equal to $85,000) for beneficiaries who were or are already receiving Part B prior to 2010.

The premium will stay this amount, even though the 2010 standard monthly premium is $110.50 because of the "hold harmless" provision of the Social Security Act, which does not allow a decrease from one year to the next in Social Security Benefits due to an increase in the Part B premiums.

People who will pay the new premium include:

· New enrollees or those who get Part B beginning January 1, 2010,

· Those with incomes above certain amounts (see table)

· Those who have Part B but do not receive Social Security benefits

· States that pay the Part B premium through Medicaid

Medicare Part B Premiums Based on Incomes for 2008

*Individual Income*	*Joint Income*	*Premium Price*
*$85,001-$107,000*	*$170,000-$214,000*	*$154.70*
*$107,001-$160,000*	*$214,001-$320,000*	*$221.00*
*$160,000-$214,000*	*$320,001-$428,000*	*$287.30*
*Above $214,000*	*Above $428,000*	*$353.60*

(Source: Centers for Medicare and Medicaid Services; http://www.medicare.gov/Publications/Pubs/pdf/11444.pdf)

The premiums are usually taken out of the beneficiary's Social Security, Railroad Retirement, or Civil Service Retirement payment. If the individual does not receive one of these payments, Medicare will send a bill for the premium every three months.

Deductible

The Part B deductible is $155 per year. The co-payment (out-of-pocket expense) once the deductible has been met is 20%, but it may depend on the services rendered. There is no limit on the number of physician visits and other services received. Medicare pays an amount determined to be a reasonable charge. Physicians who accept Medicare can impose excess charges above the reasonable charge. The current limitation on the excess charges is 115% of the Medicare reasonable charge. These limits do not apply to physicians who opt out of Medicare.

Assignment

Some doctors accept the Medicare approved charge as payment in full. This is called accepting assignment. Those doctors who accept assignment from Medicare for all of their Medicare patients are called participating physicians. Some doctors who are not participating physicians accept assignment on a case-by-case basis.

There are some cases where the physician must accept assignment. For example, they must accept assignment for lab tests covered by Medicare or for patients who are eligible for Medicaid. Some health care providers who are not medical doctors, such as medical social workers, must also accept assignment for their services.

Occasionally there are doctors who choose to opt out of Medicare and enter into private contracts with patients to provide Medicare-covered services at a rate set by the doctor. In exchange for being able to set their own rate schedules, doctors must agree to give up Medicare payments for all patients for two years after entering into the private fee arrangement. Medicare or a supplemental policy will not reimburse the individual for the services received under the private contract, even though Medicare covers the services.

Benefits

Medicare Part B covers medical services, clinical laboratory services, home health care, outpatient hospital services, blood, preventive services, ambulance services, and other services. It covers doctor services (excluding routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, durable medical equipment (wheelchairs, hospital beds, oxygen, walkers, etc.), second surgical opinions, outpatient mental health care, and outpatient physical and occupational therapy, including speech/language therapy. In limited circumstances, some drugs may be covered by Part B.

v Covered Services Summary Chart

Bone Mass

Measurement

(Bone Density)

Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a co-payment.

NEW

Cardiac

Rehabilitation

Medicare covers comprehensive programs that include

exercise, education, and counseling for patients who meet certain conditions with a doctor's referral. Medicare also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. You pay 20% of the Medicare‑approved amount if you get the services in a doctor's office. In a hospital outpatient

setting, you pay a co-payment.

Cardiovascular

Screenings

Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the test, but you generally have to pay 20% of the Medicare‑approved amount for the doctor's visit.

Chiropractic

Services (limited)

Helps correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. Note: You pay all costs for any

services or tests ordered by a chiropractor.

Clinical Laboratory

Services

Includes certain blood tests, urinalysis, some screening tests, and more. No cost to you.

Clinical Research

Studies

Clinical research studies test different types of medical care, like how well a cancer drug works. They help doctors and researchers see if the new care works and if it's safe. Medicare covers some costs, like doctor visits and tests, in qualifying clinical research studies. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Colorectal

Cancer

Screenings

To help find precancerous growths and help prevent or find cancer early, when treatment is most effective. One or more of the following tests may be covered. Talk to your doctor.

■ Fecal Occult Blood Test—Once every 12 months if age 50 or older. No cost for the test, but you generally have to pay 20% of the Medicare‑approved amount for the doctor's visit.

■ Flexible Sigmoidoscopy—Generally, once every 48 months if age 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. You pay 20% of the Medicare‑approved amount for the doctor's services. In a hospital outpatient setting, you pay a co-payment.

■ Colonoscopy—Generally once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. No minimum age. You pay 20% of the Medicare‑approved amount for the doctor's services. In a hospital outpatient setting, you pay a co-payment.

■ Barium Enema—Once every 48 months if age 50 or older (high-risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare‑approved amount for the doctor's services. In a hospital outpatient setting, you pay a co-payment.

Note: If you get a screening flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare‑approved amount.

Defibrillator

(Implantable

Automatic)

For some people diagnosed with heart failure. You pay 20% of the Medicare‑approved amount for the doctor's services. You pay a co-payment but no more than the Part A hospital stay deductible (see page 120) if you get the device as a hospital outpatient. The Part B deductible applies.

Diabetes

Screenings

Checks for diabetes. Medicare covers these screenings

if you have any of the following risk factors: high blood

pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests are also covered if you answer yes to two or more of the following questions:

■ Are you age 65 or older?

■ Are you overweight?

■ Do you have a family history of diabetes (parents, siblings)?

■ Do you have a history of gestational diabetes (diabetes

during pregnancy), or did you deliver a baby weighing

more than 9 pounds?

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare‑approved amount for the doctor's visit.

Diabetes

Self‑Management

Training

For people with diabetes. Your doctor or other health care provider must provide a written order. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Diabetes Supplies

Including blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes (in some cases). Insulin is covered only if used with an insulin pump. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Note: Insulin and certain medical supplies used to inject

insulin, such as syringes, may be covered by Medicare

prescription drug coverage (Part D).

Doctor

Services

Services that are medically necessary (includes outpatient and some doctor services you get when you are a hospital inpatient) or covered preventive services. Doesn't cover routine physicals except for the one‑time "Welcome to Medicare" physical exam. See "Physical Exam." You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Durable

Medical

Equipment

(like walkers)

Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds your doctor orders for use in the home. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. You must get your covered equipment or supplies from a supplier enrolled in Medicare. You should also check if the supplier is a participating supplier. Participating suppliers must accept assignment (see page 47), and your out‑of‑pocket costs may be less.

NEW

EKG Screening

Medicare covers a one‑time screening EKG if you get a referral for it as a result of your one‑time "Welcome to Medicare" physical exam. See "Physical Exam." You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. An EKG is also covered as a diagnostic test. See page 37.

Emergency

Department

Services

When you believe your health is in serious danger. You may have a bad injury, a sudden illness, or an illness that quickly gets much worse. You pay a specified co-payment for the hospital emergency department visit, and you pay 20% of the Medicare‑approved amount for the doctor's services. The Part B deductible applies.

Eye Exams for

People with

Diabetes

Checks for diabetic retinopathy once every 12 months by an eye doctor who is legally allowed by the state to do the test. You pay 20% of the Medicare‑approved amount for the doctor's services, and the Part B deductible applies. In a hospital outpatient setting, you pay a co-payment.

Eyeglasses

(limited)

One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Federally‑

Qualified Health

Center Services

Includes many outpatient primary care and preventive services you get through certain community‑based organizations. You pay 20% of the Medicare‑approved amount.

Flu Shots

Helps prevent influenza or flu virus. Covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor accepts assignment for giving the shot.

Foot Exams and

Treatment

If you have diabetes‑related nerve damage and/or meet certain conditions. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a co-payment.

Glaucoma Tests

Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African‑American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare‑approved amount, and the Part B

deductible applies for the doctor's visit. In a hospital outpatient setting, you pay a co-payment.

Hearing and

Balance Exams

If your doctor orders it to see if you need medical treatment. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a co-payment.

Note: Medicare doesn't cover hearing aids and exams for fitting hearing aids.

Hepatitis B

Shots

Helps protect people from getting Hepatitis B. This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End‑Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare‑approved amount for shots given in a doctor's office, and the Part B deductible applies. You pay a co-payment for a Hepatitis B shot given in a hospital outpatient setting.

NEW

HIV Screening

Starting December 8, 2009, Medicare covers HIV screening for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. There is no cost for the test, but you generally have to pay 20% of the Medicare‑approved amount for the doctor's visit.

Home Health

Services

Limited to medically‑necessary part‑time or intermittent skilled nursing care, or physical therapy, speech‑language pathology, or a continuing need for occupational therapy. A doctor must order it, and a Medicare‑certified home health agency must provide it. Home health services may also include medical social services, part‑time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort. No cost to you for home health services. For Medicare‑covered durable medical equipment, you pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Kidney Dialysis

Services and

Supplies

For people with End‑Stage Renal Disease (ESRD). Medicare covers dialysis either in a facility or at home when your doctor orders it. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

NEW

Kidney Disease

Education

Services

Medicare may cover kidney disease education services if you have kidney disease, and your doctor refers you for the service. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Mammograms

(screening)

A type of X‑ray to check women for breast cancer before they or their doctor may be able to find it. Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35–39. You pay 20% of the Medicare‑approved amount.

Medical

Nutrition

Therapy

Services

Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Mental

Health Care

(outpatient)

To get help with mental health conditions such as depression, anxiety, or substance abuse. Includes services generally given outside a hospital or in a hospital outpatient setting, including visits with a doctor, psychiatrist, clinical psychologist, or clinical social worker, and lab tests. Certain limits and conditions apply. What you pay will depend on whether you are being diagnosed and monitored or whether you are getting treatment.

■ For visits to a doctor or other health care provider to diagnose your condition, or to monitor or change your prescriptions, you pay 20% of the Medicare‑approved amount.

■ For outpatient treatment of your condition (such as counseling or psychotherapy), you pay 45% in 2010 (which is lower than in 2009) of the Medicare‑approved amount. This coinsurance amount will continue to decrease over the next 4 years. In a hospital outpatient setting, you pay a co-payment.

The Part B deductible applies for both visits to diagnose or monitor your condition as well as treatment.

Note: Inpatient mental health care is covered under Part A hospital stays. See page 20.

Talk to your doctor if you feel sad, have little interest in things you used to enjoy, feel dependent on drugs or alcohol, or have thoughts about ending your life.

Non‑doctor

Services

Medicare covers services provided by non‑doctors, such as physician assistants and nurse practitioners. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Occupational

Therapy

Evaluation and treatment to help you return to usual activities (such as dressing or bathing) after an illness or accident when your doctor certifies you need it. There may be limits on physical therapy, occupational therapy, and speech‑language pathology services and exceptions to these limits. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Outpatient

Hospital

Services

Services you get as an outpatient as part of a doctor's care. You pay 20% of the Medicare‑approved amount for the doctor's services. You may pay more for a doctor's care in a hospital outpatient setting than you will pay for the same care in a doctor's office. You pay a specified co-payment for each service you get in an outpatient hospital setting. The co-payment can't be more than the Part A hospital stay deductible.

The Part B deductible applies.

Outpatient

Medical and

Surgical

Services and

Supplies

For approved procedures (like X‑rays, a cast, or stitches). You pay 20% of the Medicare‑approved amount for the doctor's services. You pay a co-payment for each service you get in an outpatient hospital setting. For each service, this amount can't be more than the Part A hospital stay deductible. See page 120. The Part B deductible applies, and you pay all charges for items or services that Medicare doesn't cover.

Pap Tests and

Pelvic Exams

(includes clinical

breast exam)

Checks for cervical, vaginal, and breast cancers. Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child‑bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. You pay 20% of the Medicare‑approved amount for Pap test specimen collection, and pelvic and breast exams. If the pelvic exam was provided in a hospital outpatient setting, you pay a co-payment.

Physical Exam

(one‑time

“Welcome

to Medicare”

physical exam)

A one‑time review of your health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months you have Part B. You pay 20% of the Medicare‑approved amount. In a hospital outpatient setting, you pay a co-payment. When you make your appointment, let your doctor's office know that you would like to schedule your "Welcome to Medicare" physical exam.

Physical

Therapy

Evaluation and treatment for injuries and diseases that change your ability to function when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Pneumococcal

Shot

Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot.

Prescription

Drugs (limited)

Includes a limited number of drugs such as injections you get in a doctor's office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or infusion pump) and under very limited circumstances, certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare‑ approved amount for these covered drugs. If the covered drugs you get in a hospital outpatient setting are part of the service you get, you pay the co-payment for the services. However, if you get other types of drugs in a hospital outpatient setting, what you pay depends on whether you have Part D or other prescription drug coverage, whether your drug plan covers the drug, and whether the hospital is in your drug plan's network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting. Keep in mind that under Part B, you pay 100% for most prescription drugs, unless you have Part D or other drug coverage.

Prostate Cancer

Screenings

Helps detect prostate cancer. Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies for the doctor's visit. In a hospital outpatient setting, you pay a co-payment. You pay nothing for the PSA test.

Prosthetic/

Orthotic Items

Including arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); some types of breast prostheses (after mastectomy); and prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and parenteral and enteral nutrition therapy) when your doctor orders it. For Medicare to cover your prosthetic or orthotic, you must go to a supplier that is enrolled in Medicare. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

NEW

Pulmonary

Rehabilitation

Medicare covers a comprehensive program of pulmonary rehabilitation if you have moderate to very severe chronic obstructive pulmonary disease (COPD) and have a referral for pulmonary rehabilitation from the doctor treating your chronic respiratory disease. You pay 20% of the Medicare‑approved amount if you get the service in a doctor's office. You pay a co-payment per session if you get the service in a hospital outpatient setting.

Rural Health

Clinic Services

Includes many outpatient primary care services. You pay 20% of the amount charged, and the Part B deductible applies.

Second Surgical

Opinions

Covered in some cases for surgery that isn't an emergency. In some cases, Medicare covers third surgical opinions. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Smoking

Cessation

(counseling to

stop smoking)

Includes up to 8 face‑to‑face visits in a 12‑month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. In a hospital outpatient setting, you pay a co-payment.

Speech‑Language

Pathology

Services

Evaluation and treatment given to regain and strengthen speech and language skills including cognitive and swallowing skills when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Surgical Dressing

Services

For treatment of a surgical or surgically‑treated wound. You pay 20% of the Medicare‑approved amount for the doctor's services. You pay a fixed co-payment for these services when you get them in a hospital outpatient setting. You pay nothing for the supplies. The Part B deductible applies.

Telehealth

Includes a limited number of medical or other health services, like office visits and consultations provided using an interactive two‑way telecommunications system (like real‑time audio and video) by an eligible provider who is at a location different from the patient's. Available in some rural areas, under certain conditions, and only if the patient is located at one of the following places: a doctor's office, hospital, rural health clinic, federally‑qualified health center, hospital‑based dialysis facility, skilled nursing facility, or community mental health center. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Tests

Including X‑rays, MRIs, CT scans, EKGs, and some other diagnostic tests. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. See "Clinical Laboratory Services" on page 27 for other Part B‑covered tests. If you get the test at a hospital as an outpatient, you pay a co-payment that may be more than 20% of the Medicare‑approved amount, but it can't be more than the Part A hospital stay deductible.

Transplants and

Immunosuppressive

Drugs

Including doctor services for heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and only in a Medicare‑certified facility. Medicare covers bone marrow and cornea transplants under certain conditions. Immunosuppressive drugs are covered if Medicare paid for the transplant, or an employer or union group health plan that was required to pay before Medicare paid for the transplant. You must have been entitled to Part A at the time of the transplant, and you must be entitled to Part B at the time you get immunosuppressive drugs. You pay 20% of the Medicare‑approved amount, and the Part B deductible applies. If you are thinking about joining a Medicare Advantage Plan and are on a transplant waiting list or believe you need a transplant, check with the plan before you join to make sure your doctors and hospitals are in the plan's network. Also, check the plan's coverage rules for prior authorization.

Note: Medicare drug plans (Part D) may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn't pay for the transplant.

Travel (health

care needed

when traveling

outside the

United States)

(limited)

Medicare generally doesn't cover health care while you are traveling outside the U.S. (the "U.S." includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). There are some exceptions including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. In rare cases, Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following situations:

1) If an emergency arose within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition

2) If you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency

3) If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists

You pay 20% of the Medicare‑approved amount, and the Part B deductible applies.

Urgently‑

Needed Care

To treat a sudden illness or injury that isn't a medical emergency. You pay 20% of the Medicare‑approved amount for the doctor's services, and the Part B deductible applies.

[Source: Centers for Medicare & Medicaid Services "Medicare & You" 2010 Handbook; http://www.medicare.gov/publications/pubs/pdf/10050.pdf]