Medicare is a federal health insurance program for people age 65 and older, people of any age with permanent kidney failure, and certain disabled people under age 65. Medicare is managed by the Health Care Financing Administration, which is part of the Department of Health and Human Services. This article summarizes Medicare covered services.
Medicare Has More to Offer
Medicare allows you to choose the way you receive your benefits. Newly eligible seniors are enrolled automatically in the Original Medicare Plan, which is the traditional payment-per-service arrangement. If you want to stay with the Original Medicare Plan, you don't have to do anything. The basic benefits of this plan are described below.
Starting in 1999, Medicare offers more ways to receive your benefits through other health plan choices. Choices that may be available in your area include Medicare Managed Care Plans, such as Health Maintenance Organizations, Preferred Provider Organizations, or Provider Sponsored Organizations. In addition, Private Fee-For-Service Plans and Medicare Medical Savings Account Plans may be available in your area. One of the new health plan choices might be right for you. The choice is yours. No matter what you decide, you are still in the Medicare program.
Your copy of Medicare & You will explain the Original Medicare Plan and other Medicare health plans in detail. It also will explain how to enroll in other health plan options, if you are interested. If you don't have a computer, your local public library or senior center may be able to help you find this information.
All Medicare health plans must provide at least the basic Medicare covered services.
Medicare Covered Services
Hospital Insurance (Part A)
Medicare hospital insurance helps pay for necessary medical care and services furnished by Medicare-certified hospitals, skilled nursing facilities, home health agencies, and hospices.
The number of days that Medicare covers care in hospitals and skilled nursing facilities is measured in benefit periods. A benefit period begins on the first day you receive services as a patient in a hospital or skilled nursing facility and ends after you have been out of the hospital or skilled nursing facility and have not received skilled care in any other facility for 60 days in a row. There is no limit to the number of benefit periods you can have.
Inpatient Hospital Care
Medicare Part A helps pay for up to 90 days of inpatient hospital care in each benefit period. Covered services include your semi-private room and meals, general nursing services, operating and recovery room costs, intensive care, drugs, laboratory tests, X-rays, and all other necessary medical services and supplies.
Skilled Nursing Facility Care
You may need inpatient skilled nursing or rehabilitation services after a hospital stay. If you meet certain conditions, Part A helps pay for up to 100 days in a participating skilled nursing facility in each benefit period. Medicare pays all approved charges for the first 20 days; you pay a coinsurance amount for days 21 through 100. Covered services include your semi-private room and meals, skilled nursing services, rehabilitation services, drugs, and medical supplies.
Home Health Care
If you meet certain conditions, Medicare pays the full approved cost of covered home health care services. This includes part-time or intermittent skilled nursing services prescribed by a physician for treatment or rehabilitation of homebound patients. The only amount you pay for home health care is a 20 percent coinsurance charge for medical equipment such as a wheelchair or walker.
Medicare helps pay for hospice care for terminally ill beneficiaries who select the hospice care benefit. There are no deductibles, but you pay limited costs for drugs and inpatient respite care. For more information, consult the article Hospice Benefits from Medicare.
Medical Insurance (Part B)
Medicare Part B helps pay for doctor's services, outpatient hospital services (including emergency room visits), ambulance transportation, diagnostic tests, laboratory services, some preventive care like mammography and Pap smear screening, outpatient therapy services, durable medical equipment and supplies, and a variety of other health services. Part B also pays for home health care services for which Part A does not pay.
Medicare Part B pays 80 percent of approved charges for most covered services. You are responsible for paying a $100 deductible per calendar year and the remaining 20 percent of the Medicare approved charge. You will have to pay limited additional charges if the doctor who cares for you does not accept assignment. This means the doctor does not agree to accept the Medicare approved charge for services.
Services Medicare Does Not Cover
Medicare Part A does not pay for convenience items such as telephones and televisions provided by hospitals or skilled nursing facilities, private rooms (unless medically necessary), or private duty nurses.
The only type of nursing home care Medicare pays for is skilled nursing facility care for rehabilitation, such as recovery time after a hospital discharge. Medicare does not pay if you need only custodial services (help with daily living activities like bathing, eating or getting dressed).
Medicare Part B usually does not pay for most prescription drugs, routine physical examinations, or services not related to treatment of illness or injury. Part B does not pay for dental care or dentures, cosmetic surgery, routine foot care, hearing aids, eye examinations, or eyeglasses.
Except for certain limited cases in Canada and Mexico, Medicare does not pay for treatment outside the United States.
The Original Medicare Plan
This is the traditional payment-per-service arrangement. Newly eligible seniors are enrolled automatically in this option. This plan includes all Medicare covered services listed above.
Carriers and Fiscal Intermediaries
Private insurance organizations called Medicare carriers and fiscal intermediaries handle claims under the Original Medicare Plan. Carriers handle medical insurance (Part B) claims. Fiscal intermediaries handle all hospital insurance (Part A) claims. Medicare & You gives more information about how to contact your carrier or fiscal intermediary. The Social Security Administration does not handle claims for Medicare payment.
The Original Medicare Plan with a Supplemental Policy
Many private insurance companies sell Medicare Supplemental Insurance Policies (Medigap or Medicare SELECT) to help fill the coverage gaps in the Original Medicare Plan. If you remain in the Original Medicare Plan, you may want to consider buying one of these 10 standard policies for extra benefits. These policies help pay Medicare's coinsurance amounts and deductibles, and other out-of-pocket costs for health care.
The federal government does not sell these types of policies. You should read the publication called Guide to Health Insurance for People With Medicare before you buy a supplemental policy. For a free copy, call the Medicare hotline at 1-800-638-6833. Your state insurance department (See the Neighborhood Networks) also has information available to help you. ElderCare Online’s Insurance Coverage Channel includes several informative articles on the range of insurance coverage options.
Do not delay. When you first enroll in Part B at age 65 or older, you have a 6-month Medigap open enrollment period. During that time your health status cannot be used as a reason either to refuse you a policy or to charge you more than all other open enrollment applicants. (The insurer may make you wait up to 6 months for coverage of a pre-existing condition.) If you try to enroll later, you may be denied a policy or charged a higher rate.
At age 65, Medigap open enrollment is available to beneficiaries who are enrolled in Part B. If you are under age 65, contact your state insurance department for information about open enrollment.
Other Medicare Health Plan Choices
In addition to the plans explained above, you may have other Medicare health plan choices available to you. To be eligible for these other health plan choices, you must:
- Have both Part A (hospital insurance) and Part B (medical insurance).
- Continue to pay the monthly Part B premium.
- Live in the plan's service area (the counties in which the plan is offered).
- Not have permanent kidney failure (End-Stage Renal Disease).
The following types of plans may be options for you:
Medicare Managed Care Plans
You may choose to get your Medicare coverage through a managed care plan. Medicare Managed Care Plans may include Health Maintenance Organizations (HMOs), HMOs with a Point-of-Service option (POS), Provider Sponsored Organizations (PSOs), and Preferred Provider Organizations (PPOs). These types of plans involve a specific group of doctors, hospitals and other providers who provide your care as a member of the plan.
Medicare Managed Care Plans provide all services covered by both Part A and Part B. Most offer a variety of additional benefits, like preventive care, prescription drugs, dental care, hearing aids, eyeglasses and other items not covered by the Original Medicare Plan. Costs for these extra benefits vary among plans.
In addition to the Original Medicare Plan and Medicare Managed Care Plans, other Medicare health plan choices may be available in your area. These include Private Fee-for-Service Plans, Medicare Medical Savings Account (MSA) Plans, and Religious Fraternal Benefit Plans. These plans provide all services covered by both Part A and Part B. Some offer a variety of additional benefits.
For information about which ones are available in your area, look on the Internet at www.medicare.gov.
Other Insurance Sometimes Pays Before Medicare
Some people who have Medicare have other insurance (not including Medigap policies) that must pay before Medicare pays its share of your bill. Your other insurance pays first if:
- (a) You are 65 or older; (b) you or your spouse are currently working at an employer with 20 or more employees; and (c) you have group health insurance based on that employment.
- (a) You are under age 65 and are disabled; (b) you or any member of your family is currently working at an employer with 100 or more employees; and (c) you have group health insurance based on that employment.
- You have Medicare because of permanent kidney failure.
You have an illness or injury that is covered under workers' compensation, the federal black lung program, no-fault insurance, or any liability insurance.
If you match any of these descriptions and you have other insurance along with Medicare, your other insurance will often be the first payer on your health claims. Tell your doctor, hospital, and all other providers of services about your other insurance. Your claims can then be sent to the right insurer first.
Assistance for Low-Income Beneficiaries
If you have a low income and limited resources, your State may pay your Medicare costs, including premiums, deductibles, and coinsurance. Please review detailed guidelines on the government website. To qualify:
- You must be entitled to Medicare hospital insurance (Part A).
- Your annual income level must be at or below the national poverty guidelines.
- and You cannot have resources such as bank accounts or stocks and bonds worth more than $4,000 for one person or $6,000 for a couple (your home and first car don't count).
If your income is just above the poverty guidelines, you may qualify for help with paying your Part B premiums. If you think you qualify, contact your state or local welfare, social service, or Medicaid agency. The contact number is available on the Internet at www.medicare.gov.
For More Information
Up-to-date information about Medicare is available on the Internet at the web site http://www.medicare.gov. If you don't have a computer, your local public library or senior center may be able to help you find this information.
If you have questions about how to enroll in Medicare, call Social Security's toll-free number, 1-800-772-1213, any business day from 7:00 a.m. to 7:00 p.m. The lines are busiest early in the week and early in the month, so it is best to call at other times. People who are deaf or hard of hearing may call a toll-free TTY number, 1-800-325-0778, between 7:00 a.m. and 7:00 p.m. on business days. When you call, have your Social Security number handy.
These calls are all treated confidentially. Some calls may be monitored by a second customer representative to make sure you are receiving accurate information and courteous service.
If you have any questions about what Medicare covers, call the Medicare carrier that processes Medicare claims in your area. The name and number are listed in Medicare & You.
If you want to order free publications, like the Guide to Health Insurance for People With Medicare, call the Medicare hotline at 1-800-638-6833. Audio-tapes in English and Spanish, and Spanish copies of Medicare & You are also available by calling this number.
If you believe you have been discriminated against because of your race, color, sex, national origin, disability or age, call the DHHS Office for Civil Rights at 1-800-368-1019 or 1-800-537-7697 (TTY/TDD).