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Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.


The steps to take in order to maximize the benefits Medicare provides differ depending on the type of health care provider and situation. We cover the following providers and situations:

Overall health is important to maximizing your ability to fight a health condition. If you are just signing up for Original Medicare, ask your doctor for a free "Welcome To Medicare" physical exam.  Also take advantage of the free other tests and screening for which you are eligible. For instance, you are entitled to periodic cardiovascular screening blood tests and periodic diabetes screening tests.

If you are in a Medicare Advantage plan, speak with your doctor about scheduling other preventive services as well. 

NOTE: If you haven't already, consider signing up for Medicare Part B (non-hospital services) and Part D (medication benefit). Financial assistance is available if needed to help pay premiums and other payments. 

Medicare Hospice Benefits

Custodial care is when you need assistance in your daily activities, and some medication such as for pain, but that you are no longer trying to cure the underlying condition.

The only custodial care that Medicare covers is the Hospice Benefit. Because there have been problems in the past with people remaining on Hospice Benefits for several years, Medicare screens each proposed Hospice claim carefully. The goal of hospice care is to provide symptom and pain reduction care only while the beneficiary is believed to be in the last six months of life.

For Medicare to pay for hospice care, the care must take place in a Medicare-approved hospice.

Before you enter a hospice program, your doctor will speak with you about end-of-life issues and possibly even recommend some counseling. (If you do not have a Living Will and other Advance Directives in place, see Living Wills and Advance Directives.)

Your doctor must be the one to initiate the request for approval of Hospice Care for you, but you should work with him or her in the process.

In order to get the benefit approved, your doctor and the director of the hospice program must both state that they believe your life expectancy is six months or less. If you happen to see this paperwork, don't let it alarm you. It will not be phrased in a pleasant manner. Their goal is to convince Medicare that you are close enough to the end of life to justify granting you the Hospice benefits.

Approval for hospice care is for 90 day periods. You will be approved for hospice care for an additional 90 days if you need it. If you require further hospice care, your doctor can obtain an unlimited number of 60 day extensions after the first two 90 day periods.

If you remain in a hospice for too long, Medicare will look carefully at further extensions to determine whether you should continue to qualify for hospice care. No one is going to complain if you live past six months. No one is going to ask for the money back.

Keep in mind that you always have the right at any time and for any reason to leave the hospice program and go back to regular medical care. Going back to regular medical care will not affect your right to more hospice benefits in the future.

Hospitals: In Patient

Choice of Hospital

Hospital care is not a difficult choice under Medicare. Because the benefit payments by Medicare to hospitals are relatively generous, almost any licensed and accredited acute care hospital is available to you as a Medicare beneficiary.

For advice on which hospital to choose, see Choosing a Hospital.

If you will be admitted to the hospital

During the admission process:

  • Advise the Admissions Clerk that you have Medicare and show your Medicare card.
  • Let the Clerk know that when you leave the hospital you will want an itemized copy of the bill rather than the department total that is usually provided to patients. This will let you review the bill to make sure all charges are for treatment or supplies that you actually received. If you get a hassle, remind the clerk that you  are entitled to the itemized copy under the Federal Balanced Budget Act of 1997.
    • If you want to know more about the Federal Balanced Budget Act of 1997: The Act gives Medicare beneficiaries the right to submit a written request for an itemized statement from their provider/supplier for any Medicare item or service. The law requires that providers/suppliers furnish the itemized statement within thirty (30) days of the request, or they may be subject to a civil monetary penalty for each unfulfilled request.)
  • Ask what items of a "personal comfort" nature will not be covered by Medicare. For example, will you have to pay for any of the following items which Medicare won't pay for:
    • A bedside phone
    •  A rental fee on the television
    •  Reading material
    •  Hair styling
    •  Guest meals
    •  A bed for family members or friends that stay with you

To learn how to maximize your time in a hospital, read: How To Maximize Your Time In A Hospital

Hospitals: Out-patient

If you receive treatments or services in a hospital, but you are not staying in the hospital, you are considered to be an "out-patient." Examples of hospital outpatient services include getting a radiology treatment, chemotherapy, x-ray, getting stitches for a cut, having an angiogram, or a visit to the emergency room.

You can end up owing a lot more money if a procedure is performed on an out-patient basis versus an in-patient.

Under Medicare, hospitals may bill outpatients for 20% of what they "charge" for the outpatient service whereas Medicare is only obligated to pay 80% of what the service "costs" the hospital.   Because of this you may end up having to pay far more out of your own pocket than you would if you were confined in the very same hospital as an inpatient for the same procedure.

Before you use any outpatient service, contact the hospital admissions office.

  • Let them know you have Medicare coverage.
  • Confirm exactly what procedure(s) will be done.
  • Ask how much it will cost you personally. Although the answer will probably only be an estimate rather than a binding dollar amount, at least you'll have an idea of the cost to you.
  • If the amount sounds too high:
    • Ask your doctor if you can be admitted to the hospital for the procedure. Explain why. While Medicare may not always approve hospital confinement for the same process, your doctor may go to bat for you to get the procedure approved as an inpatient.
    • You can negotiate with the hospital. Particularly if you let the hospital know you are in a financial bind, and offer to pay the amount due right away, you may have a shot at reducing the bill. To help your argument, you can find out what Medicare pays for the procedure in your area by calling Medicare at 800.MEDICARE (800.633.42270


When you consider which doctor to use, think about the factors listed in Choosing A Doctor. In addition, find out whether the doctor is a Participating Physician, a Non-Participating Physician or a Private Contract Physician. The amount of money you will have to pay out-of-pocket depends on which type your doctor is. Fortunately, the vast majority of doctors are Medicare Participating physicians which results in your paying the least out-of-pocket for care. (You may get a list for Medicare participating medical providers from your Medicare Carrier.)

You can save money by sticking with doctors who are Participating Physicians so you don't have to pay more than the Medicare-approved amount.

Participating Physicians

A "Participating Physician" is a doctor who bills Medicare. Participating Physicians must accept the amount Medicare pays (the "Medicare Approved Amount") as full payment for the services the doctor renders to you. 

You will never have to pay more than your coinsurance portion of the Medicare Approved amount, which is usually 20%. The coinsurance portion for mental health services is 50%.

Non-Participating Physician

A "Non-Participating Physician" can bill more than the Medicare Approved Amount, but is not allowed to bill more than 15% above that amount. In some states, Non-Participating Doctors are even more limited in what they can charge.

States in which Non-Participating providers cannot charge people who receive Medicare even a penny more than Medicare Approved Amounts are: Massachusetts, Ohio, Pennsylvania and Rhode Island.
States in which Non-Participating providers can only bill up to 5% above the Medicare Approved Amount are Minnesota and New York.

Like Participating physicians, Non-Participating physicians are required to submit the bill to Medicare.  Instead of paying the physician, Medicare will pay you directly.

As an incentive to encourage physician participation in Medicare, Medicare pays Participating Providers 5% more than it pays to Non-participating Providers.

For example, a physician who does not accept Medicare Assignment bills you for $200. However, Medicare determines the Medicare Approved Amount to be $100. Therefore, the physician cannot collect more than $115 or 15% over the Medicare Approved. Medicare would pay $80 (80% of the Medicare Approved Amount) and you would owe the physician no more than $20 (20% of the Medicare Approved Amount) plus $15 (15% over the Medicare Approved Amount) or $35 total out of your pocket. 

Elective Surgery That Costs $500 Or More By A Non-Participating Doctor

Medicare Part B requires non-participating physicians to provide written notice to Medicare patients before performing, and billing for, any elective (non-emergency) and non-assigned surgical procedure with total charges estimated at $500 or more. At a minimum, this notification must include:

  • The physician's estimated actual charge for the procedure. The actual billed or collected charge may not be greater than Medicare's limiting charge amount for the procedure. You are not liable for, and are entitled to a refund of, any amount billed or collected above the limiting charge.
  • The estimated Medicare approved charges.
  • The excess of the physician's actual charge over the approved charge.
  • The applicable coinsurance amount.

This written notice requirement applies to services furnished by non-participating physicians and assistant surgeons and anesthesia services personally provided by a non-participating surgeon or assistant surgeon. They do not apply to services furnished by non-participating anesthesiologists.

If you are using a non-participating doctor and you do not receive written notice prior to receiving the services, you are entitled to a refund of any money collected in excess of the Medicare payment. If the money is not refunded, the physician may be subject to civil money penalties and/or exclusion from the Medicare program.

Following is a sample notice that you may receive from a physician if the charge is over $500:



Date: ________________


Dear _________________:
(Beneficiary Name)

I am not accepting assignment for your elective surgery. The law requires me to provide the following information to you prior to any elective surgery where assignment is not taken and the charge is $500 or more. These estimates assume that you have met the $100 annual Part B Medicare deductible.


Type of surgery:


Estimated charge: 


Medicare estimated payment:


Your estimated payment: 

$____________ (Includes your Medicare coinsurance)




(Physician Name and Signature)


Acknowledged and Agreed by: ___________________________
(Beneficiary/Legal Representative Name and Signature)

Date: ____________________



Private Contract Physician

 A doctor may "opt out of Medicare" and get around the Medicare billing limits by asking you to sign a "Private Contract." A Private Contract indicates the doctor's intent not to provide services through Medicare and to bill you for the entire charge.

A Private Contract Physician must present you with a written agreement that you sign before any services are provided to help Medicare recipients avoid being treated by such a physician mistakenly. You cannot be asked to sign a Private Contract when you are facing an emergency or urgent health situation.  

Providers who ask for Private Contracts are prohibited from billing Medicare for services or supplies for any Medicare beneficiary for at least two years.

 Under a Private Contract:

  • No payment will be made from Medicare at all will be made for the services you receive.
  • You will have to pay whatever the doctor charges you with no limit on the amount of the charges.
  • Most Medigap policies and many other health insurance plans will not pay anything towards these charges as well. 

Health Care Providers Other Than Hospitals And Doctors

The rules about Participating, Non-Participating and Private Contract apply to some health care providers you may not think about, such as audiologists, chiropractors, dentists, optometrists, physical therapists, podiatrists and speech therapists.

There are some medical providers who must accept Medicare Assignment. In other words, if they treat you they are considered to be Participating and are bound to accept only the Medicare Approved Amount.  These include:

  • Physician Assistants.
  • Nurse Practitioners.
  • Certified Registered Nurse Anesthetists.
  • Clinical Nurse Specialists.
  • Certified Nurse Midwives.
  • Clinical Psychologists.
  • Clinical Social Workers.

You may get a list for Medicare participating medical providers from your Medicare Carrier. See Making Contact.

In those states that have enacted limits for non-participating providers that are more strict than the federal rules, you need to check whether the limitation also applies to these providers. Not all will cover the same types of medical providers as the federal rules.

On your first visit to any medical practitioner, make clear whether or not they accept Medicare assignment and ask for written confirmation. 

Skilled Nursing Facilities

Medicare has strict rules on the coverage of care in a Skilled Nursing Facility and limits on how long they will pay for such care. See Medicare: Schedule of Benefits.  To help determine which skilled nursing facility works best for you, see Choosing a Nursing Home.

There are some things you can do at admission (or even earlier in discussions with your doctor about which Skilled Nursing Facility you will be moved to) that can keep your out-of-pocket costs to a minimum:

  • Make sure the Skilled Nursing Facility has been approved by Medicare for use by Medicare beneficiaries.
  • Ask your doctor to pre-certify your stay. This gives Medicare an advance look at your claim. More importantly, it gives you an advance idea of Medicare's willingness to pay your Skilled Nursing Facility claim.
  • If you don't have written pre-certification from Medicare and there is any doubt about Medicare covering the charges, ask the Skilled Nursing Facility to submit a "demand bill" to Medicare. Medicare will send you a Medicare Summary Notice  explaining what will and won't be covered. If you disagree with Medicare's position, you may appeal by following the instructions on the Medicare Summary Notice. See Medicare: appealing the Claim.
  • Clarify what personal items you will be expected to pay for.

Review the Medicare so you will know how many days Medicare will pay in full and how much you are expected to pay after that. See Medicare: Schedule of Benefits

Home Health Care

To qualify for Medicare Home Health benefits, your doctor must certify your eligibility for the benefit. Then a nurse from the home health agency will visit you to assess your needs.

You will then start receiving home health services based on the assessment from the home health agency. The assessment will not only determine which home health services you will receive, it will also assign a number of hours each week you are authorized to receive the services within the Medicare cap of 8 hours per day and 35 hours per week.

Don't expect to receive the maximum hours of services. The maximum is almost never awarded. Rather, based on what they determine your needs to be, you will likely receive a few hours per week of nursing care, usually to supervise medications and check your progress. You will probably also receive a few hours of home health aide services and some other services.

Services available through Medicare's Home Health Benefit include:

Skilled Services. Skilled services must be reasonable and necessary and so inherently complex that a skilled nurse or therapist must perform or supervise them in order to be safe and effective. If a home health aide or other person could perform the service, it is not considered skilled.

Skilled Nursing. The skilled care of a registered nurse must be reasonable and necessary to the diagnosis and treatment of your illness or injury. Examples of such services include:

  • Administration of medications
  • Tube feedings, catheter changes and wound care
  • Teaching and training activities
  • Observation and assessment of a patient's condition
  • Management and evaluation of a patient's care plan

Skilled Therapy. Physical, speech and occupational therapy services are covered up to the limits described in Medicare -- Schedule of Benefits. To receive coverage for occupational therapy, you must need it initially in conjunction with physical or speech therapy.

Home Health Aide Services. Aide services include personal care such as bathing, feeding, dressing and toileting.

Medicare does not cover housekeeping services, such as cleaning and cooking.

Medical Social Services. Social services help patients and families deal with the logistics and emotional issues related to the illness.

Medical Supplies. The home health agency will provide whatever supplies (other than medications) that are required to perform their duties. For example, if an I.V. drip is needed, the agency will supply the pole, the bottle, the tube, and, if needed, the regulator. It will not supply the medication to go into the drip. Durable medical equipment is covered at 80% of the Medicare Approved Amount. (See Obtaining Durable Medical Equipment.)

To assure you receive all the home care benefits you need and for which you are eligible:

  • Make a list of what you believe you may need. For example:
  • What care do you need?
  • How frequently do you need care?
  • How long do you need care each time?
  • Do you need a Registered Nurse to provide care, and if so, for how many hours and for how many days a week?
  • Do you need a Home Health Aide to help with housekeeping?
  • Remember, don't expect to receive all the care you ask for. Still, it is worthwhile spending some time thinking about what you believe you need and why.
  • Review the list with your doctor. Work with him or her to develop the final list of what services (including the frequency and duration) the doctor will put in letter certifying your eligibility for benefits.
  • When the person from the home health agency comes to assess your needs:
  • Advocate for yourself by clearly listing all the needs you and your doctor have come up with. This is frequently somewhat of a bargaining situation so it won't hurt to ask for more than you expect in the hope of "compromising" and settling for what you do need. If you're not up to the discussion, have a friend or family member with you at the interview to raise the issues and do the negotiation.
  • Confirm with the assessment nurse that you are a Medicare patient and their services will be paid by Medicare.
  • Know what is authorized for your care and how many hours are supposed to be provided so you can monitor your care to make sure you receive everything that is authorized. If you're not up to it, ask a family member or friend to take on the responsibility of doing the monitoring for you.
  • Read the paperwork you are provided during the assessment. Included in it will be the procedures for making grievances and complaints about the care.
  • Generally, you first raise the issue with the nurse providing your care.
  • Next, contact the administrator of the home health agency. The more specific you are with examples and specific dates and times, the more weight your complaint will have.
  • Involve your doctor if you have trouble getting the issues resolved.
  • If your doctor can't resolve the situation, contact the numbers provided in Medicare -- Making Contact.
  • If you continue to be unable to resolve your problems with the agency, you have the right to change and receive your care from another Medicare Certified Home Health Agency.
If You Need Home Health Care, But The Home Health Agency Doesn't Believe Medicare Will Pay For It

If a Home Health Agency does not believe that Medicare will cover your Home Health Services -- or that your care will be terminated -- you must be notified before services are delivered. You must then either agree to postpone start of the services or to pay for services while Medicare is reviewing your case.

The notice an agency must give is known as a Home Health Agency Beneficiary Notice (HHABN).

  • An HHABN must identify the specific home health services that are being denied, reduced, or terminated.
  • The notice must be hand-delivered where possible.
  • The notice must state why the agency expects Medicare to deny care. Possible reasons:
    • The care is "not medically necessary and reasonable."
    • The care is custodial in nature.
    • You, the beneficiary, is not really homebound.
    • You, the beneficiary, does not require part-time or intermittent services.
  • The notice must contain a "return page" on which you can indicate either that you agree to the termination, reduction, or denial of care, or that you wish to pay for the services at issue and have the home health agency submit a demand bill for an initial Medicare decision.
  • The Home Health Agency must provide you assistance in understanding the HHABN.

The Home Health Agency must implement your choice of either to terminate services or pay for the continuation of services while the demand bill is being processed by Medicare.