Jane Dotson
Medicare is a form of health insurance for individuals in the United States. It is comprised of several parts, including Original Medicare (Part A and Part B), Medicare Advantage (Part C), and Medicare Supplement Insurance (Medigap). Original Medicare covers inpatient hospital care, doctors' services and tests, and preventive services. Medicare Advantage is an alternative to Original Medicare, bundling Part A, Part B, and usually Part D (drug coverage) into a single plan. Medigap is extra insurance that can be purchased to help pay for costs not covered by Original Medicare, such as long-term care, vision, dental, and hearing services.
| Characteristics | Values |
|---|---|
| Medicare Part | A (Hospital Insurance) and B (Medical Insurance) |
| What it covers | Inpatient hospital care, doctors' services and tests, and preventive services |
| What it doesn't cover | Long-term care, dentures, routine physical exams, vision, hearing, dental services, prescription drugs |
| Supplemental coverage | Medicare Supplement Insurance (Medigap), coverage from a former employer or union, or Medicaid |
| Medicare Advantage | Part C, an alternative to Parts A and B that bundles several coverage types, including Parts A, B, and usually D |
| Medicare Advantage extra benefits | Vision, hearing, and dental services |
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What You'll Learn
Inpatient hospital care
Medicare Part A (Hospital Insurance) helps pay for inpatient care in hospitals, critical access hospitals, skilled nursing facilities, and inpatient rehabilitation facilities. Inpatient rehabilitation care includes rehabilitation services such as physical therapy, occupational therapy, and speech-language pathology, as well as personal items like toothpaste, socks, or razors.
Medicare Part A covers inpatient hospital services, including semi-private rooms and meals. It also covers skilled nursing facility (SNF) care, hospice care, and some home health care. However, it's important to note that your doctor may recommend services that Medicare doesn't cover, in which case you may have to pay some or all of the costs. Hospitals are required to share the standard charges for their items and services, including those negotiated by Medicare Advantage Plans, to help you make informed decisions about your care.
Your hospital status as an inpatient or outpatient affects how much you pay for hospital services. You are considered an inpatient when formally admitted to the hospital with a doctor's order, and your inpatient status ends on the day before you are discharged. On the other hand, if you are receiving emergency department services, observation services, outpatient surgery, or other hospital services without a doctor's order for admission, you are considered an outpatient, even if you spend the night in the hospital. It's important to ask the hospital or your doctor about your status, as it impacts your deductible, coinsurance, and copayment.
Medicare Part B (Medical Insurance) covers doctors' services received while in an inpatient rehabilitation facility. It also covers many diagnostic and treatment services received as an outpatient from a hospital that accepts Medicare, including emergency or observation services, laboratory tests, mental health care, radiology services, medical supplies, preventive and screening services, and certain drugs. However, it generally does not cover prescription and over-the-counter drugs received in an outpatient setting.
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Doctors' services
Medicare Part B (Medical Insurance) helps cover two types of services: medically necessary services and preventive services.
Medically necessary services are services or supplies that meet accepted standards of medical practice to diagnose or treat your medical condition. Preventive services are a type of healthcare that prevents illness (like the flu) or detects it at an early stage when treatment is likely to work best. You pay nothing for most preventive services if you get the services from a healthcare provider who accepts assignment.
If you go to a doctor or other healthcare provider that accepts the Medicare-approved amount, your share of costs may be less. If you get a service that Medicare doesn’t cover, you pay the full cost. You can go to any doctor or hospital that takes Medicare, anywhere in the US. In many cases, you can only use doctors who are in the plan's network. Plans must cover all emergency and urgent care, and almost all medically necessary services that Original Medicare covers. For non-emergency or non-urgent care, you may need to use doctors who are in the plan's network.
Medicare is federal health insurance for anyone aged 65 or older, and some people under 65 with certain disabilities or conditions.
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Prescription drugs
Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Part B typically covers drugs administered in a doctor's office or hospital outpatient setting that you wouldn't usually give to yourself. Here are some examples of prescription drugs covered by Medicare Part B:
- Drugs used with certain types of durable medical equipment (DME): Medicare covers drugs infused through DME, such as an infusion pump or nebulizer, if they are medically necessary.
- Some antigen allergy tests and treatments: Medicare covers antigen tests for allergies and their treatment if prepared by a healthcare provider and administered under appropriate supervision.
- HIV prevention drugs and injectable osteoporosis drugs.
- Erythropoiesis-stimulating agents: Medicare covers erythropoietin injections for patients with End-Stage Renal Disease (ESRD) or those needing treatment for anemia related to specific conditions.
It's important to note that doctors, healthcare providers, and pharmacies must accept assignment for Part B-covered drugs. After meeting the Part B deductible, individuals typically pay up to 20% of the Medicare-approved amount for covered Part B prescription drugs, with the coinsurance amount potentially varying based on the drug's price.
Medicare Part D specifically relates to drug coverage. Pharmaceutical Assistance Programs (PAPs) are available to help pay for medications for those enrolled in Medicare drug coverage (Part D). Each company has different eligibility requirements for their PAPs. Additionally, the Medicare Prescription Payment Plan helps manage out-of-pocket costs by spreading them across the calendar year, although it doesn't reduce overall drug costs.
There are two main ways to obtain Medicare drug coverage:
- Enroll in a Medicare Advantage Plan (Part C) or another Medicare health plan that includes drug coverage.
- Join a separate Medicare drug plan (Part D) while maintaining Part A and/or Part B coverage.
Those with Medicare drug coverage will receive an Explanation of Benefits (EOB) detailing prescriptions filled, payments, and out-of-pocket costs. It's worth noting that there may be a late enrollment penalty for Part D, resulting in an additional amount permanently added to the premium.
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Supplemental coverage
Medicare Supplement Insurance, also known as Medigap, is extra insurance that you can buy from a private company to help pay your share of costs in Original Medicare. Generally, you need to have Part A and Part B to buy a Medigap policy. Some Medigap policies offer coverage when you travel outside the U.S. However, they generally do not cover long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs. If you are under 65, you may not be able to buy a Medigap policy, or you may have to pay more.
Medigap policies are standardized, and in most states, they are named by letters, like Plan G or Plan K. The benefits in each lettered plan are the same, regardless of the insurance company. The price is the only difference between policies with the same letter sold by different companies.
You may also have other supplemental coverage, such as coverage from a former employer or union, military benefits, or veterans' benefits. You can also join a Medicare Advantage Plan, which is an alternative to Original Medicare that bundles Part A, Part B, and usually Part D into one plan. Medicare Advantage Plans may offer some extra benefits that Original Medicare doesn't cover, like vision, hearing, and dental services.
It's important to note that you must have both Part A and Part B to join a Medicare Advantage Plan. When you have Medicare and other health insurance, one will be the primary payer, and the other will be the secondary payer. The primary payer depends on various factors, such as your work status, the type of insurance you have, and your specific situation.
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Dental, vision, and hearing
Dental
Medicare does not typically cover dental services such as routine cleanings, fillings, tooth extractions, dentures, or implants. However, there are certain inpatient or outpatient dental services that are covered by Medicare if they are directly related to specific medical treatments. For example, dental services are covered if they are required before getting a heart valve replacement, organ transplant, or cancer treatment. Dental or oral exams are also covered before and during dialysis treatment for end-stage renal disease (ESRD) to eliminate oral or dental infections.
Vision
Medicare Part B covers preventive screenings for specific conditions, such as glaucoma, cataracts, and macular degeneration, and diagnosing tests for vision problems. However, routine eye exams are not typically covered, and beneficiaries are responsible for paying for glasses or contact lenses unless they have a Medicare Advantage plan with vision coverage. This plan may include annual exams and prescription eyewear.
Hearing
Medicare Part B covers diagnostic hearing and balance exams if they are ordered by a doctor or healthcare provider to determine the need for medical treatment. Beneficiaries can also visit an audiologist once a year without a referral for non-acute hearing conditions and diagnostic services related to hearing loss treated with surgically implanted devices. However, Medicare does not cover hearing aids or exams for fitting them, and beneficiaries are responsible for paying for these costs.
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Frequently asked questions
Part A of Medicare, also known as Hospital Insurance, covers inpatient hospital care, doctors' services and tests, and preventive services.
Part B of Medicare, also known as Medical Insurance, covers doctors' services and tests, and preventive services. You must pay for Part B, and the price depends on your income level.
Medicare Advantage, or Part C, is an alternative to Parts A and B that bundles several coverage types, including Parts A, B, and usually Part D. It may also include additional benefits that Original Medicare doesn't cover, like vision, hearing, and dental services.
