The Centers for Medicare & Medicaid Services (CMS) used the events or incidents of health care usage reported by individual people with Medicare from the Medicare Current Beneficiary Survey (MCBS). Each person included in the MCBS self-reported their health status, and health care utilization. We also matched the reported use of health care to the individual claims history to make sure we included Medicare covered services as well as services not covered by Medicare. CMS combined 2005 and 2006 MCBS data to create statistically valid and reliable cost estimates. Data from both years was combined to create a nationally representative cohort of people with Medicare.

We excluded individuals for certain reasons including if they did not participate in both Medicare Parts A & B for the full 12 months of the year or if they were in a long-term care facility for any part of the year. We wanted to focus on people in Original Medicare so that we could link both MCBS survey results and the Medicare claims data for the same period. We also excluded certain categories of individuals whose claims are paid differently or for whom we would not have a full complement of data. We created three health status categories (excellent, good, and poor). We also created three high cost diagnostic conditions: diabetes, congestive heart failure, heart attack.

For each of the three health status categories and three diagnostic conditions we calculated estimated average monthly out-of-pocket costs for health plan. CMS used the actual Medicare claims payment experience and the MCBS self-reported health care utilization to determine total health care utilization for each of the people with Medicare. CMS then computed the out-of-pocket costs based on the benefits covered and co-payments/coinsurance for each health care service. For the Medicare Advantage out-of-pocket costs projections, CMS used the data entered into the Plan Benefit Packages (PBP) to compute out-of-pocket costs. For the Original Medicare Plan and Medigap, CMS applied coinsurance and deductibles to Medicare payment amounts.

CMS made the following basic assumptions related to the out-of-pocket cost estimates for the Original Medicare Plan and Medicare Advantage Plans:  Original Medicare, People with Medicare:

• Do not have any other insurance other than Medicare (no supplemental insurance).
• Enrolled in Part B when first eligible.
• Go to providers who accept Medicare assignment.

Medigap

• People with Medicare have Original Medicare and the selected Medigap policy. Only include the standardized policies at the State level. (Medicare SELECT is not included.) Use exempted State policies offered by Massachusetts, Minnesota, and Wisconsin.
• Using industry representative and most recently available Medigap premiums.

Medicare Advantage Plans

• Use Calendar Year 2011 Plan Benefit Packages to define the out-of-pocket cost estimates.
• Use cost shares for in-network physicians.
• Use minimum co-payments if stated as a minimum/maximum range.
• Use deductibles and plan maximum limits, as applicable.
• Costs for Optional Supplemental benefits are not included.
• Prescription drugs:
  • MCBS drug events are mapped into RXCUI codes to apply a particular plan’s tier-formulary based cost sharing. Use Prescription Drug Event (PDE) claims data (2009) for average drug prices. Relevant deductibles and premiums are also taken into account.
• For Medicare Medical Savings Account Plans (MSA plans)–the CMS annual contribution amount is assumed to be used for Medicare-covered expenses towards meeting the deductible. Any remainder is applied to Medicare eligible expenses (non-covered inpatient or SNF care, dental, and/or prescription drugs). Cost shares are zero once the deductible is met—except for any remaining non-covered expenses.

Medicare and Non-Medicare covered services in the out-of-pocket cost calculations for Original Medicare, Medigap and Medicare Advantage Plans are

• Inpatient Hospital Acute Care,
• Inpatient Psychiatric Hospital/Facility,
• Prescription Drugs,
• Dental, and
• Skilled Nursing Facility.

For Original Medicare, Medigap, and Medicare Advantage Plans without prescription drug coverage, full drug costs assuming no insurance, are calculated. The calculations also use PDE coverage prices.
Medicare covered services only included in the out-of-pocket cost calculations for Original Medicare, Medigap and Medicare Advantage Plans are:

• Ambulance,
• Ambulatory Surgical Center,
• Cardiac Rehabilitation,
• Chiropractic,
• Chemotherapy,
• Comprehensive Outpatient Rehabilitation Facility,
• Diagnostic Radiological Service,
• Durable Medical Equipment,
• Emergency Care,
• End-Stage Renal Dialysis,
• Eye Exams,
• Hearing Exams,
• Home Health,
• Inpatient Hospital Services including Acute,
• Inpatient Psychiatric Hospital,
• Mammography Screening,
• Mental Health Specialty – Non-Physician,
• Medicare-Covered Dental,
• Medicare-Covered Part B Prescription Drugs,
• Occupational Therapy,
• Outpatient Diagnostic Tests,
• Outpatient Hospital,
• Outpatient Lab,
• Outpatient X-Ray,
• Other Health Care Professionals,
• Pap Smears and Pelvic Exams Screening,
• Physical Therapy and Speech-Language Pathology,
• Physician Specialist,
• Primary Care Physician Services,
• Podiatry,
• Preventive and Comprehensive Dental,
• Prosthetics, Orthotics, and Other Medical Supplies,
• Psychiatry,
• Skilled Nursing Facility (SNF),
• Therapeutic Radiation,
• Part D Drugs

Some services are excluded from the out-of-pocket cost calculations. For example, some Medigap policies cover additional benefits that were not included in the out-of-pocket cost estimates such as:

• Foreign Travel Emergency to cover emergency medical care when you travel outside the United States (Medigap policies: B, C, D, F, and G).
• Medicare Part B Excess Charges to cover the difference between the doctor’s actual charge and Medicare’s approved amount. This would apply if you go to a doctor who does not accept assignment and bills you more than Medicare’s approved amount. (Medigap policies: F and G).

Medicare Advantage plans offer a wide range of benefits, some of which were not included in the out-of-pocket costs estimates. Some examples of benefits not included in the out-of-pocket cost estimates for Medicare Advantage plans are:

• Foreign Travel Emergency to cover emergency medical care when you travel outside the United States.
• Routine physical exams.
• Acupuncture.
• Hearing services not usually covered by Medicare.
• Vision services not usually covered by Medicare.
• Prevention screening services not covered by Medicare.
• Chiropractic services not usually covered by Medicare.
• Podiatry services not usually covered by Medicare.

Note to Researchers, Medicare providers, and Others: A more in-depth explanation of the exact methodology is available on www.medicare.gov.

I lost (or dropped) my health care coverage. Can I buy a Medicap policy?

Buying a Medigap policy is an important decision. Only you can decide if a Medigap policy is the way for you to supplement Original Medicare coverage and which Medigap policy to choose. Shop carefully. Compare available Medigap policies to see which one meets your needs. As you shop for a Medigap policy, keep in mind that different insurance companies may charge different amounts for exactly the same Medigap policy, and not all insurance companies offer all of the Medigap policies.

Below is a step-by-step guide to help you buy a Medigap policy.

STEP 1: Decide which benefits you want, then decide which of the Medigap Plans A through N meet your needs.
STEP 2: Find out which insurance companies sell Medigap policies in your state.
STEP 3: Call the insurance companies that sell the Medigap policies you’re interested in and compare costs.
STEP 4: Buy the Medigap policy.

Because you may have a guaranteed issue right to buy a Medigap policy, make sure you keep the following: • A copy of any letters, notices, e-mails, and/or claim denials that have your name on them as proof of your coverage being terminated • The postmarked envelope these papers come in as proof of when it was mailed You may need to send a copy of some or all of these papers with your Medigap application to prove you have a guaranteed issue right. You can apply for a Medigap policy while you’re still in your health plan, but your Medigap coverage can only start after your health plan coverage ends.

This will prevent breaks in your health coverage. For more information If you have any questions or want to learn about any additional Medigap rights in your state, you can do the following: • Call your State Health Insurance Assistance Program to make sure that you qualify for these guaranteed issue rights.  • Call your State Insurance Department if you’re denied Medigap coverage in any of these situations.

Important: The guaranteed issue rights in this section are from Federal law. These rights are for both Medigap and Medicare SELECT policies. Many states provide additional Medigap rights. There may be times when more than one of the situations. When this happens, you can choose the guaranteed issue right that gives you the best choice. Some of the situations include loss of coverage under Programs of All-Inclusive Care for the Elderly (PACE). PACE combines medical, social, and long-term care services, and prescription drug coverage for frail people. To be eligible for PACE, you must meet certain conditions. PACE may be available in states that have chosen it as an optional Medicaid benefit. If you have Medicaid, an insurance company can sell you a Medigap policy only in certain situations. For more information about PACE, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Section 3: Your Right to Buy a Medigap Policy

In most Medigap policies, when you sign the Medigap insurance contract you agree to have the Medigap insurance company get your Medicare Part B claim information directly from Medicare, and then they pay the doctor directly. Some Medigap insurance companies also provide this service for Medicare Part A claims. If your Medigap insurance company doesn’t provide this service, ask your doctors if they “participate” in Medicare. This means that they “accept assignment” for all Medicare patients. If your doctor participates, the Medigap insurance company is required to pay the doctor directly if you request. If you have any questions about Medigap claim filing, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

As discussed on the previous pages, the cost of Medigap policies can vary widely. There can be big differences in the premiums that different insurance companies charge for exactly the same coverage. As you shop for a Medigap policy, be sure to compare the same type of Medigap policy, and consider the type of pricing used.  For example, compare a Medigap Plan C from one insurance company with a Medigap Plan C from another insurance company. Although this guide can’t give actual costs of Medigap policies, you can get this information by calling insurance companies or your State Health Insurance Assistance Program.

You can also find out which insurance companies sell Medigap policies in your area by visiting www.medicare.gov and selecting “Health & Drug Plans.” The cost of your Medigap policy may also depend on whether the insurance
company does any of the following:

Offers discounts (such as discounts for women, non-smokers, or people who are married; discounts for paying annually; discounts for paying your premiums using electronic funds transfer; or discounts for multiple policies).

Uses medical underwriting, or applies a different premium when you don’t have a guaranteed issue right, or aren’t in a Medigap Open Enrollment period.

• Sells Medicare SELECT policies that may require you to use certain providers. If you buy this type of Medigap policy, your premium may be less. See page 20.

• Offers a “high-deductible option” for Medigap Plan F. If you buy Medigap Plan F with a high-deductible option, you must pay the first $2,000 (in 2011) of deductibles, copayments, and coinsurance not paid by Medicare before the Medigap policy pays anything. You must also pay a separate deductible ($250 per year) for foreign travel emergency services.

• If you bought your Medigap Plan J before January 1, 2006, and it still covers prescription drugs, you would also pay a separate deductible ($250 per year) for prescription drugs covered by the Medigap policy.

Each insurance company decides how it will set the price, or premium, for its Medigap policies. It’s important to ask how an insurance company prices its policies. The way they set the price affects how much you pay now and in the future. Medigap policies can be priced or “rated” in three ways:

1. Community-rated (also called “no-age-rated”)
2. Issue-age-rated (also called “entry-age-rated”)
3. Attained-age-rated

Each of these ways of pricing Medigap policies is described in the chart on the next page. The examples show how your age affects your premiums, and why it’s important to look at how much the Medigap policy will cost you now and in the future. The amounts in the examples aren’t actual costs. Other factors such as geographical rating, medical underwriting, and discounts can also affect the amount of your premiums.

It’s very important to understand your Medigap open enrollment period. Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health. If you apply for Medigap coverage after your open enrollment period, there is no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you’re eligible because of one of the limited situations.

It’s also important to understand that your Medigap rights may depend on when you choose to enroll in Medicare Part B. If you’re 65 or older, your Medigap open enrollment period begins when you enroll in Part B and can’t be changed or repeated. In most cases, it makes sense to enroll in Part B when you’re first eligible, because you might otherwise have to pay a Part B late enrollment penalty. However, if you have group health coverage through an employer or union, because either you or your spouse is currently working, you may want to wait to enroll in Part B. This is because employer plans often provide coverage similar to Medigap, so you don’t need a Medigap policy. When your employer coverage ends, you will get a chance to enroll in Part B without a late enrollment penalty which means your Medigap open enrollment period will start when you’re ready to take advantage of it. If you enrolled in Part B while you still had the employer coverage, your Medigap open enrollment period would start, and unless you bought a Medigap policy before you needed it, you would miss your open enrollment period entirely.

The best time to buy a Medigap policy is during your Medigap open enrollment period. This period lasts for 6 months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B. Some states have additional open enrollment periods including those for people under 65. During this period, an insurance company can’t use medical underwriting.

This means the insurance company can’t do any of the following because of your health problems: • Refuse to sell you any Medigap policy it sells • Make you wait for coverage to start (except as explained below) • Charge you more for a Medigap policy While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage if you have a pre-existing condition. A preexisting condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months. This is called a “pre-existing condition waiting period.” After 6 months, the Medigap policy will cover the pre-existing condition. Coverage for a pre-existing condition can only be excluded in a Medigap policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medigap policy. After this 6-month period, the Medigap policy will cover the condition that was excluded. Remember, for Medicare-covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t cover your out-of-pocket costs, but you’re responsible for the coinsurance or copayment.

If you have a pre-existing condition and you buy a Medigap policy during your Medigap open enrollment period and you are replacing certain kinds of health coverage that counts as “creditable coverage,” it’s possible to avoid or shorten waiting periods for pre-existing conditions. Prior creditable coverage is generally any other health coverage you recently had before applying for a Medigap policy. If you have had at least 6 months of continuous prior creditable coverage, the Medigap insurance company can’t make you wait before it covers your pre-existing conditions. There are many types of health care coverage that may count as creditable coverage for Medigap policies, but they will only count if you didn’t have a break in coverage for more than 63 days. Talk to your Medigap insurance company. It will be able to tell you if your previous coverage will count as creditable coverage for this purpose. You can also call your State Health Insurance Assistance Program.

If you buy a Medigap policy when you have a guaranteed issue right (also called “Medigap protection”), the insurance company can’t use a pre-existing condition waiting period. Note: If you’re a person with Medicare under 65 and have a disability or ESRD, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. See page 39 for more information.

• You must have Medicare Part A and Part B to buy a Medigap policy. • If you have a Medicare Advantage Plan, you can apply for a Medigap policy, but make sure you can leave the Medicare Advantage Plan before your Medigap policy begins. • Plans E, H, I, and J are no longer for sale, but you can keep these plans if you already have one. • You pay the private insurance company a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare. • A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you each will have to buy separate Medigap policies. • You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one. •  If you want to drop your Medigap policy, contact your insurance company to cancel the policy. • Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.

Although some Medigap policies sold in the past cover prescription drugs, Medigap policies sold after January 1, 2006, aren’t allowed to include prescription drug coverage. • If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D) offered by private companies approved by Medicare. To learn about Medicare prescription drug coverage, visit http://go.usa.gov/3GG to view the booklet “Your Guide to Medicare Prescription Drug Coverage,” or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

• Medicare Advantage Plans (Part C), like an HMO, PPO, or Private Fee-for-Service Plan • Medicare Prescription Drug Plans (Part D) • Medicaid • Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP) • TRICARE • Veterans’ benefits • Long-term care insurance policies • Indian Health Service, Tribal, and Urban Indian Health plans

Insurance companies selling Medigap policies are required to make Plan A available. If they offer any other Medigap plan, they must also offer either Medigap Plan C or Plan F. Not all types of Medigap policies may be available in your state. See pages 42–44 if you live in Massachusetts, Minnesota, or Wisconsin. If you need more information, call your State Insurance Department or State Health Insurance Assistance Program. • Plans D and G —Plans D and G effective on or after June 1, 2010, have different benefits than D or G Plans bought before June 1, 2010. • Plans No Longer for Sale —Plans E, H, I, and J are no longer sold, but, if you already have one, you can keep it.

ShareofCost.com offers low-cost dental care.  The National Institutes of Dental and Craniofacial Research (NIDCR) sometimes seeks volunteers with specific dental, oral, and craniofacial conditions to participate in research studies, also known as clinical trials. Researchers may provide study participants with limited free or low-cost dental treatment for the particular condition they are studying. To find out if there are any NIDCR clinical trials that you might fit into, go to “NIDCR Studies Seeking Patients.” For a complete list of all federally funded clinical trials, visit ClinicalTrials.gov. To see if you qualify for any clinical trials being conducted at our Bethesda, Maryland, campus, you can call the Clinical Center’s Patient Recruitment and Public Liaison Office at 1-800-411-1222.

Dental schools (American Dental Association) can be a good source of quality, reduced-cost dental treatment. Most of these teaching facilities have clinics that allow dental students to gain experience treating patients while providing care at a reduced cost. Experienced, licensed dentists closely supervise the students. Post-graduate and faculty clinics are also available at most schools.

Dental hygiene schools (American Dental Hygienists’ Association) may also offer supervised, low-cost preventive dental care as part of the training experience for dental hygienists.

The Bureau of Primary Health Care, a service of the Health Resources and Services Administration  (1-888-Ask-HRSA), supports federally-funded community health centers across the country that provide free or reduced-cost health services, including dental care.

The Centers for Medicare & Medicaid Services (CMS) administers three important federally-funded programs: Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

Medicare is a health insurance program for people who are 65 years and older or for people with specific disabilities. Medicare dental coverage is limited; it does not cover most routine dental care or dentures.
Medicaid is a state-run program that provides medical benefits, and in some cases dental benefits, to eligible individuals and families. States set their own guidelines regarding who is eligible and what services are covered. Most states provide limited emergency dental services for people age 21 or over, while some offer comprehensive services. For most individuals under the age of 21, dental services are provided under Medicaid.
CHIP helps children up to age 19 who are without health insurance. CHIP provides medical coverage and, in most cases, dental services to children who qualify. Dental services covered under this program vary from state to state.
CMS (1-800-MEDICARE) can provide detailed information about each of these programs and refer you to state programs where applicable.

Your state or local health department may know of programs in your area that offer free or reduced-cost dental care. Call your local or state health department to learn more about their financial assistance programs. Check your local telephone book for the number to call.

The United Way may be able to direct you to free or reduced-cost dental services in your community. Local United Way chapters can be located on the United Way website.

Dental services are a required service for most Medicaid-eligible individuals under the age of 21, as a required component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

Individuals under Age 21

EPSDT is Medicaid’s comprehensive child health program. The program’s focus is on prevention, early diagnosis,  and treatment of medical conditions. EPSDT is a mandatory service required to be provided under a state’s Medicaid program.

Dental services must be provided at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental organizations involved in child health, and at such other intervals, as indicated by medical necessity, to determine the existence of a suspected illness or condition. Services must include at a minimum, relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services for EPSDT recipients.

Oral screening may be part of a physical exam, but does not substitute for a dental examination performed by a dentist as a result of a direct referral to a dentist. A direct dental referral is required for every child in accordance with the periodicity schedule set by the state. The Centers for Medicare & Medicaid Services does not further define what specific dental services must be provided, however, EPSDT requires that all services coverable under the Medicaid program must be provided to EPSDT recipients if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity.

If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in the state’s Medicaid plan.

Individuals Age 21 and older

States may elect to provide dental services to their adult Medicaid-eligible population or, elect not to provide dental services at all, as part of its Medicaid program. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.

Reuters examines how the efforts of “budget-minded lawmakers [in the new U.S. Congress who will] seek to curb costs without undercutting military operations” could impact U.S.-backed aid programs, including those in Afghanistan.

An expert panel sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, has issued comprehensive U.S. guidelines to assist health care professionals in diagnosing food allergy and managing the care of people with the disease.