Medicare Handbook, 2026 Edition

1. AN INTRODUCTION TO MEDICARE COVERAGE AND APPEALS

• History and Overview
• Financing
• Administration
• Enrollment and Eligibility
• Coverage
• Medicare Savings Programs
• The Medicare Appeals Process

2. HOSPITAL COVERAGE

• Introduction to Hospital Coverage
• Eligibility for Medicare Hospital Insurance (Part A)
• Application or Enrollment for Medicare Part A
• Scope of Benefits—Inpatient Hospital Coverage Benefit Periods
• Medicare-Covered Services
• Coverage Criteria Explained
• Limitations on Payment for Services
• The Medical Necessity Standard for Inpatient Hospital Stays
• Hospital Payment
• Utilization Review and Quality of Services
• Appealing Coverage Denials
• Denial and Appeal Process
• How to Develop a Winning Appeal
• Linking Payment to Quality Outcomes Under the Medicare Program

3. SKILLED NURSING FACILITY COVERAGE

• Introduction to Skilled Nursing Facility Coverage
• Coverage
• Qualifying Criteria
• SNF Prospective Payment System
• Pre-Appeals Advocacy
• Appeals

4. HOME HEALTH COVERAGE

• Introduction to Home Health Benefit
• Home Health Coverage and Cost-Sharing
• Requirements for Coverage
• Chronic, Stable, and Maintenance-Level Patients
• Prospective Payment System and Patient-Driven Groupings Model for Home Health Services
• Claims Submission, Determination, and Appeal
• Role of Advocacy
• How to Develop a Winning Appeal

5. HOSPICE COVERAGE

• Introduction to Hospice Coverage
• Eligibility for Hospice Coverage
• Election of the Hospice Benefit
• Who May Make an Election for Hospice Care
• Hospice Admission
• Medicare Advantage
• Patient Rights
• Hospice Revocation
• Hospice Discharge
• Changing Hospice Providers
• Hospice Services
• Hospice Level of Care
• Inpatient Facility Rules
• Hospice Care for Residents of Facilities
• Deductibles and Coinsurance for Nonhospice Care
• Hospice Denials and Appeals

6. MEDICARE PART B: SUPPLEMENTARY MEDICAL INSURANCE BENEFITS FOR THE AGED AND DISABLED

• Introduction to Medicare Part B
• Medicare Part B Enrollment and Payment Requirements
• Covered Medical and Other Health Care Services
• Medicare Part B and Payment
• Filing Medicare Part B Claims
• Information About Coverage
• Appeals
• Appointments of Representatives and Attorneys’ Fees

7. MEDICARE ADVANTAGE: COORDINATED CARE PLANS, PRIVATE FEE-FOR-SERVICE, AND OTHER DELIVERY OF SERVICES OPTIONS

• Introduction to Medicare Advantage
• Choosing Between Traditional Medicare and Medicare Advantage
• Medicare Advantage Basics

8. MEDIGAP SERVICES

• Introduction to Medigap Services
• Standardized Medigap Policies and Benefits
• High Deductible Plans
• Medicare Certification of Policies
• Medicare SELECT
• A History of Medigap’s Evolution Through Legislation
• Consumer Protections
• Required Ratio of Aggregate Benefits to Aggregate Premiums
• Dissemination of Information About Medigap Policy Benefits

9. MEDICARE’S RELATIONSHIP WITH PRIVATE INSURANCE

• Introduction to Medicare’s Relationship to Private Insurance
• Employer Group Health Plans
• Coordination of COBRA Rights and Medicare
• Medicare as Secondary to Liability and No-Fault Insurance
• Medicare as Secondary to Workers’ Compensation Plans
• MSP Coordination and Reporting
• MSP Enforcement
• Beneficiary Rights to Seek Waiver or Appeal the MSP Recovery Claim
• MSP Rules Applicable to Medicare Advantage Plans
• Medical Savings Accounts: HSAs and FSAs
• Medicare and Qualified Health Plans Offered Through the Affordable Care Act Marketplace
• New Special Enrollment Periods

10. DUAL ELIGIBILITY: ISSUES FOR MEDICARE BENEFICIARIES ALSO ELIGIBLE FOR MEDICAID

• Introduction to Dual Eligibility
• Profile of the Dually Eligible
• Summary of Medicaid Eligibility and Medicaid Benefits
• Universe of Dual Eligibility
• Enrollment Issues for Medicare Savings Programs Population
• Access Issues for the Dually Eligible Population
• Managed Care Issues for Dually Eligible Individuals
• Programs of All-Inclusive Care for the Elderly
• Medicare-Medicaid Coordination Office and Center for Medicare and Medicaid Innovation

11. PRESCRIPTION DRUG COVERAGE

• Introduction to Prescription Drug Coverage
• Eligibility for Part D Coverage
• Choice of Drug Plans
• The Part D Drug Benefit
• Enrolling in a Part D Plan
• Premium and Cost-Sharing Subsidies for Part D Prescription Drugs for Low-Income Individuals
• Dual Eligibles
• State Pharmaceutical Assistance Programs
• Grievance, Appeals, and Exceptions Processes