Medicare doesn't cover everything. Some of the items and services Medicare doesn't cover include:

• Long-term care (also called custodial care )
• Most dental care
• Eye exams related to prescribing glasses
• Dentures
• Cosmetic surgery
• Acupuncture
• Hearing aids and exams for fitting them
• Routine foot care

If you need services Medicare doesn't cover, you'll have to pay for them yourself unless you have other insurance or a Medicare health plan that covers them.

How does Medicare work?

With Medicare, you are given different options on how you will want to be covered. Once you enroll, you will decide on how you will get your Medicare coverage.

There are two ways:

Original Medicare

Original Medicare comes with Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You will pay for the services as you require them. When you get these services, you’ll pay a deductible at the start of each year, and you usually pay 20% of the cost of the

Medicare-approved service, called coinsurance. If you would like drug coverage, you have the option to add a separate drug plan (Part D).

Original Medicare pays a good portion of the amount, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the few remaining health care costs, such as copayments, coinsurance, and deductibles. Some

Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U.S.

Medicare Advantage

Medicare Advantage is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D. Most plans do come with extra benefits that Original Medicare does not come with— such as dental, vision, hearing and more. Medicare Advantage Plans do have a yearly contract with them and have follow Medicare coverage rules . This plan does have to notify you of any changes in the plan before the start of the next enrollment year.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services.

Medicare prescription drug coverage (Part D)

Medicare drug coverage assists you on payments for prescription drugs you need. In order to get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage (this includes Medicare drug plans and Medicare Advantage Plans with drug coverage).

Each plan can have differences in prices and different specific drugs covered, but must give at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies.

Plans have different monthly premiums. You’ll also have other costs throughout the year in a Medicare drug plan. How much you pay for each drug depends on which plan you choose.

Medicare prescription drug coverage is a benefit offered to anyone that has Medicare. It is optional to these people. Below explains how to get prescription drug coverage and we also offer tips for making the right choices for you.

If you decide not to get Medicare drug coverage when you're first eligible, you'll likely pay a late enrollment penalty if you join later, unless one of these applies:

• You have other creditable prescription drug coverage
• You get Extra Help

Generally, you'll pay this penalty for as long as you have Medicare prescription drug coverage.

To get Medicare drug coverage, you have to join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.

2 ways to get prescription drug coverage

1. Medicare Prescription Drug Plan (Part D) . These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private
   Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
2. Medicare Advantage Plan (Part C) like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.

How to join a drug plan

Here's how to get prescription drug coverage, only once you choose a prescription drug plan.

• Enroll on the Medicare Plan Finder or on the plan's website.
• Complete a paper enrollment form.
• Call the plan.
• Call us at (209)723-2000

When you join a Medicare drug plan, you'll give your Medicare Number and the date your Part A and/or Part B coverage will start. This information is also located on your Medicare card.

Consider all your drug coverage choices

Before you make a decision, learn how prescription drug coverage works with your other drug coverage. For example, you may have drug coverage from an employer or union, TRICARE, the Department of Veterans Affairs (VA), the Indian Health Service, or a Medicare Supplement Insurance (Medigap) policy. Compare your current coverage to Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options.

If you have (or are eligible for) other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefits administrator, insurer, or plan provider before you
make any changes to your current coverage.

Joining a Medicare drug plan may affect your Medicare Advantage Plan

Generally, you need to join a Medicare Advantage Plan that includes drug coverage. If you join a separate Medicare Prescription Drug Plan (Part D), in most cases but not all, you will lose your current Medicare Advantage Plan (Part C) and go back to Original Medicare for your health coverage.

Although you can only join a different Medicare Prescription Drug Plan without losing your health coverage that you currently have if you are in a:

• Private Fee-for-Service Plan
• Medical Savings Account Plan
• Cost Plan
• Certain employer-sponsored Medicare health plans

Talk to your current plan if you have questions about what will happen to your current health coverage.

Employer or union health coverage

Employer or union health coverage will be referring to health coverage from you, your spouse's, or other family member's current or former employer or union. If you have prescription drug coverage from your previous employment or current, your employer or union will notify you annually to tell you that your prescription drug coverage is creditable. Be sure to keep the information you acquire from them for any future references.

Call your benefits administrator for more information before making any changes to your coverage.

COBRA

There may be reasons why you should take Medicare Part B instead of, or in addition to, COBRA. If you take COBRA and it includes creditable prescription drug coverage, you'll have a special enrollment period to join a Medicare Prescription Drug Plan without a penalty when COBRA ends.

Talk with your State Health Insurance Assistance Program (SHIP) to see if COBRA is a good choice for you.

Medicare Supplement Insurance (Medigap) policy with prescription drug coverage

It may be to your advantage to join a Medicare Prescription Drug Plan because most Medigap drug coverage isn't credible. You may pay more if you join a drug plan later.

Medigap policies can no longer be sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. If you join a Medicare drug plan, your Medigap insurance company must remove the prescription drug coverage under your Medigap policy and adjust your premiums. Call your Medigap insurance company for more information.

Medicaid

Your drug costs are covered by Medicare. You'll need to join a Medicare Prescription Drug Plan for Medicare to pay for your drugs.

In most cases, you'll pay a small amount for your covered drugs. If you have full coverage from Medicaid and live in a nursing home, you pay nothing for covered prescription drugs.

If you have full coverage from Medicaid and live in an assisted living or adult living facility, or a residential home, you'll pay a small copayment for each drug.

If you don't join a drug plan, Medicare will enroll you in one to make sure you don't miss a day of coverage. If you decide you want another plan, you can switch to another plan at any time.

Supplemental Security Income Benefits

If you get benefits or help from your state Medicaid program paying your Medicare premiums, you need to join a Medicare Prescription Drug Plan for Medicare to cover your drugs. You automatically qualify for Extra Help with your prescription drug costs. If you don't join a plan, Medicare will enroll you in one to make sure you don't miss a day of coverage.

State Pharmaceutical Assistance Program

Each state decides how its State Pharmaceutical Assistance Program (SPAP) works with Medicare prescription drug coverage. Some states give extra coverage when you join a Medicare Prescription Drug Plan. Some states have a separate state program that helps with prescriptions. Contact your SPAP to get more information.

Long-term care facility

Long-term care pharmacies contract with Medicare Prescription Drug Plans to provide drug coverage to their residents. If you're entering, living in, or leaving a nursing home, you'll have the opportunity to choose or switch your Medicare drug plan. This allows you to choose a plan that contracts with your nursing home's pharmacy.

HUD housing assistance

If you get housing assistance from the Department of Housing and Urban Development (HUD), you may want to join a Medicare Prescription Drug Plan.

If you qualify for Extra Help, you won't lose your housing assistance. However, your housing assistance may be reduced as your prescription drug spending decreases. The value of the Extra Help paying your drug costs will make up for any decrease in your housing assistance.

Food stamps

If you get food stamps, you may want to join a Medicare Prescription Drug Plan. If you qualify for Extra Help, your food stamp benefits may decline, but that decline will be offset by Extra Help.

If you're near the food stamps eligibility cutoff, you may lose your minimum food stamp benefits because you’ll be paying less for your prescription drugs. The value of the Extra Help paying your drug costs will make up for any decrease in food stamp benefits.

Health Insurance Marketplace

A service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces.

The Health Insurance Marketplace (also known as the “Marketplace” or “exchange”) provides health plan shopping and enrollment services through websites, call centers, and in-person help.

The types of insurance listed below are all considered creditable prescription drug coverage. If you have one of these types of insurance, in most cases, it will be to your advantage to keep your current coverage.

The Federal Employee Health Benefits (FEHB) Program plans usually include prescription drug coverage, so you don’t need to join a Medicare drug plan. However, if you decide to join a Medicare drug plan, you can keep your FEHB plan, and your plan will let you know who pays first.

For more information, contact the U.S. Office of Personnel Management (OPM). You can also call your plan if you have questions.

You may be able to get prescription drug coverage through the Veterans Affairs (VA) program. You may join a Medicare Prescription Drug Plan, but if you do, you can't use both types of coverage for the same prescription at the same time. For more information, contact the VA.

TRICARE (military health benefits)

Most people with TRICARE who are entitled to Medicare Part A must have Medicare Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you don’t need to join a Medicare Prescription Drug Plan.

For active-duty military enrolled in Medicare, TRICARE pays first. For inactive-duty military, your Medicare Prescription Drug Plan pays first.

If you join a Medicare Advantage Prescription Drug (MA-PD) Plan with drug coverage, the plan and TRICARE may coordinate their benefits if your MA plan network pharmacy is also a TRICARE network pharmacy. For more information, contact the TRICARE Pharmacy Program.

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

CHAMPVA is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. You may join a Medicare Prescription Drug Plan, but if you do, you won’t be able to use the Meds by Mail program, which can give your maintenance medications at no charge to you (no premiums, no deductibles and no co-payments). For more information, visit va.gov/communitycare/programs/dependents/champva/ or call CHAMPVA at 800-733-8387.

Indian Health Services

Many Indian health facilities participate in the Medicare prescription drug program. If you get prescription drugs through an Indian health facility, you'll continue to get drugs at no cost to you, and your coverage won’t be interrupted.

Joining a Medicare Prescription Drug Plan may help your Indian health facility because the drug plan pays the Indian health facility for the cost of your prescriptions. Talk to your local Indian health benefits coordinator who can tell you how Medicare works with the Indian health care system.

What's covered?

If you're in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

In general, Part A covers:

• Inpatient care in a hospital
• Skilled nursing facility care
• Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
• Hospice care
• Home health care

There are 2 ways to find out if Medicare covers what you need

1. Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will be covering them. You may need something that's usually covered but your provider thinks that Medicare won't cover it in your situation. If so, you'll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

1. The first is federal and state laws.
2. The second is national coverage decisions made by Medicare about whether something is covered.
3. Third is local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

What's covered?

If you're in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers 2 types of services

• Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
• Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

If you get the services from a health care provider who accepts assignment, you will pay nothing for most preventive services.

Part B covers things like:

• Clinical research
• Ambulance services
• Durable medical equipment (DME)
• Mental health
• Inpatient
• Outpatient
• Partial hospitalization
• Limited outpatient prescription drugs

There are 2 ways to find out if Medicare covers what you need

1. Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something that's usually covered but your provider thinks that Medicare won't cover it in your situation. If so, you'll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

1. The first is federal and state laws.
2. Second is national coverage decisions made by Medicare about whether something is covered.

Third is local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

It’s important to understand how your current coverage works with Medicare. If you have questions about your current insurance, the best source of information is your benefits administrator, insurer, or plan provider.

I have employer coverage and:

I'm turning 65

If you are not getting benefits from Social Security (or the RRB) at least 4 months before you turn 65, you will need to sign up with Social Security to get Parts A and B. However, depending on the size of the employer, you can possibly be able to delay Part A and Part B without having to pay another penalty if you enroll later. Learn more about whether you should get Parts A and B. Call our office at (209)723-2000.

I'm over 65

In most cases, you don't need to do anything until you (or your spouse) retire or you lose the employer coverage. If you didn’t enroll when you were first eligible, the size of the employer determines if you have to pay a penalty if you enroll later. Learn more about whether you should get Parts A and B and what happens when your employment or coverage ends.

I'm under 65 and have a disability

In most cases, you don't need to do anything until you (or your spouse) retire or you lose the employer coverage. If you didn’t enroll when you were first eligible, the size of the employer determines if you have to pay a penalty if you enroll later. Learn more about whether you should get Parts A and B and what happens when your employment or coverage ends.

Medicaid is a joint federal and state program that:

• If you get help with medical costs for some people with limited income and resources
• Offers benefits not normally covered by Medicare, like nursing home care and personal care services

How do I apply for Medicaid?

When it comes to each state they all have different rules about eligibility and applying for Medicaid. Call your state Medicaid program to see if you qualify and learn how to apply.

Medicaid spend down

Even if you have too much income to qualify, some states let you "spend down" to become eligible for Medicaid. The "spend down" process allows you to subtract your medical expenses from your income to be able to qualify for Medicaid. In this case, you're eligible for Medicaid because you're considered "medically needy."

To be eligible as "medically needy," your measurable resources must also be under the resource amount allowed in your state. Call your state Medicaid program to see if you qualify and learn how to apply.

Dual eligibility

If you have Medicare and full Medicaid coverage, most of the health care costs are likely covered.

You can also get your Medicare coverage through Original Medicare or a Medicare Advantage Plan (Part C). If you have Medicare and full Medicaid, you'll get your Part D prescription drugs through

Medicare. And, you'll automatically qualify for Extra Help paying for your Medicare prescription drug coverage (Part D). Medicaid may still cover some drugs and other care that Medicare doesn’t cover.

Who pays first—Medicaid or Medicare?

Medicaid never pays first for services covered by Medicare. It only pays after Medicare, employer group health plans, and/or Medicare Supplement (Medigap) Insurance have paid.

There are specific times when you can sign up for a Medicare Advantage Plan (Part C) and/or Medicare prescription drug coverage (Part D), or make changes to coverage you already have.

When you first get Medicare (Initial Enrollment Periods for Part C & Part D)

I'm newly eligible for Medicare because I turned 65.

What can I do?

Sign up for a Medicare Advantage Plan and/or a Medicare Prescription Drug Plan.

When?

During the 7-month period that:

• Starts 3 months before the month you turn 65
• Includes the month you turn 65
• Ends 3 months after the month you turn 65

I'm newly eligible for Medicare because I have a disability (under 65).

What can I do?

Sign up for a Medicare Advantage Plan or a Medicare Prescription Drug Plan. Your Medicare coverage begins 24 months after you get Social Security or Railroad Retirement Board (RRB) disability benefits.

When?

During the 7-month period that:

• Starts 3 months before your 25th month of getting Social Security or RRB disability benefits
• Includes your 25th month of getting disability benefits
• Ends 3 months after your 25th month of getting disability benefits

I'm already eligible for Medicare because of a disability, and I turned 65.

What can I do?

• Sign up for a Medicare Advantage Plan and/or a Medicare Prescription Drug Plan.
• Switch from your current Medicare Advantage Plan or Medicare Prescription Drug Plan to another plan.
• Drop a Medicare Advantage Plan or a Medicare Prescription Drug Plan completely.

When?

During the 7-month period that:

• Starts 3 months before the month you turn 65
• Includes the month you turn 65
• Ends 3 months after the month you turn 65

If you sign up for a Medicare Advantage Plan during this time, you can drop that plan any time during the next 12 months and go back to Original Medicare.

I don't have Medicare Part A, and I enrolled in Medicare Part B during the Part B General Enrollment Period (January 1–March 31).

What can I do?

Sign up for a Medicare Prescription Drug Plan.

When?

April 1–June 30

I have Medicare Part A coverage, and I enrolled in Medicare Part B during the Part B General Enrollment Period (January 1–March 31).

What can I do?

Sign up for a Medicare Advantage Plan (with or without drug coverage).

When?

April 1–June 30

During certain times each year (yearly enrollment periods for Part C & Part D)

Each year, you can make changes to your Medicare Advantage or Medicare prescription drug coverage for the following year. There are 2 separate enrollment periods each year:

Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage.

What can I do?

• Change from Original Medicare to a Medicare Advantage Plan.


• Change from a Medicare Advantage Plan back to Original Medicare.


• Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.


• Switch from a Medicare Advantage Plan that doesn't offer drug coverage to a Medicare Advantage Plan that offers drug coverage.


• Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn't offer drug coverage.


• Join a Medicare Prescription Drug Plan.


• Switch from one Medicare drug plan to another Medicare drug plan.


• Drop your Medicare prescription drug coverage completely.

Enrollment Period

Medicare Advantage Open Enrollment Period

What can I do?

• If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage).


• You can drop your Medicare Advantage Plan and return to Original Medicare. You'll also be able to join a Medicare Prescription Drug Plan.

• You can not switch from Original Medicare to a Medicare Advantage Plan.


• Join a Medicare Prescription Drug Plan if you're in Original Medicare.


• Switch from one Medicare Prescription Drug Plan to another if you're in Original Medicare.

What you pay in a Medicare Advantage Plan

What you pay in Medicare Advantage Plan (plan C) all depends on:

• If the plan charges a monthly premium. There are plans that have no premium as well.
  
• If the plan pays any of your monthly Medicare Part B premium which would also be your Medical Insurance. Some plans pay all or partial of your Part B premium.
  
• If the plan has a yearly deductible or if there are any other deductibles.
  
• How much you pay for each visit or service ( copayment or coinsurance ). For example, the plan may charge a copayment, between $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare .
  
• How often you require health care services and how many times you need them.
  
• If you go to a doctor or supplier who accepts assignment if:
  
  • You're in a PPO, PFFS, or MSA plan.
    
  • You go out-of-network .
    
• Whether you follow the plan's rules, like using network providers.
  
• If you require additional benefits and if the plan you choose charges for it.
  
• The plan's yearly limit on your out-of-pocket costs for all medical services.
  
• We also look if you have Medicaid or get help from your state.