Paul Sanchez
Medicare is a federal health insurance program for individuals aged 65 and older, as well as certain individuals under 65 with disabilities or specific conditions. It consists of two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare covers a range of services, including inpatient hospital care, doctors' services, tests, and preventive services. However, it's important to note that Medicare coverage may vary depending on your location and specific plan chosen. To understand what services are covered by Medicare in your specific situation, it is recommended to consult official Medicare resources or seek advice from a healthcare provider or insurance professional.
| Characteristics | Values |
|---|---|
| Type | Federal health insurance |
| Eligibility | Anyone 65 and older, and some people under 65 with certain disabilities or conditions |
| Parts | Part A (Hospital Insurance), Part B (Medical Insurance) and Part D (drug coverage) |
| Coverage | Inpatient hospital care, doctors' services and tests, preventive services, prescription drugs, vaccines |
| Cost | You pay for services as you get them and Medicare pays part of the cost |
| Supplemental coverage | Medicare Supplement Insurance (Medigap), coverage from a former employer or union, or Medicaid |
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What You'll Learn
Medicare Part A and Part B
- Anyone aged 65 and older
- Certain individuals under 65 with disabilities or specific conditions
Medicare Part A is also known as Hospital Insurance. It covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care. Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The exact number of QCs required depends on whether the person is filing for Part A on the basis of age, disability, or End-Stage Renal Disease (ESRD).
Medicare Part B is also known as Medical Insurance. It covers doctors' services and tests, and preventive services. You pay for services and items as you get them. You must be lawfully present in the U.S. for Medicare to pay for Part B covered services. To be eligible for premium-free Part B, the same requirements as Part A must be met.
Medicare Advantage (Part C) is an alternative to Parts A and B that bundles several coverage types, including Parts A, B, and usually D (prescription drugs). You must sign up for Part A or Part B before enrolling in a Medicare Advantage plan.
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Supplemental coverage
Medicare Supplement Insurance, also known as Medigap, is an additional insurance policy that can be purchased from a private health insurance company to supplement Original Medicare coverage. It is important to note that Medigap can only be used in conjunction with an Original Medicare plan (consisting of Part A and Part B) and does not cover prescription drug costs (Part D) or any extra benefits.
Medigap helps cover the "gaps" in Original Medicare by paying for out-of-pocket expenses such as deductibles, copays, and coinsurance. It is designed to help individuals manage their finances and provide peace of mind by reducing the financial burden of leftover bills after Medicare has been applied. However, it is important to plan accordingly as Medigap will only contribute after Medicare has made a payment towards the covered services.
There are different Medigap plans available, each offering varying levels of coverage. Some plans cover 100% of certain benefits, while others cover a percentage, leaving the individual responsible for the remaining amount. It is important to review the specific benefits and limitations of each Medigap plan to determine which one best suits your needs.
Medigap policies also have certain restrictions. For example, Plans C and F are not available for individuals who turned 65 years or older on or after January 1, 2020, or for certain people under the age of 65. Additionally, Medigap plans do not cover prescription drug costs, so individuals seeking drug coverage may need to consider a separate Medicare drug plan or a Medicare Advantage Plan, which often includes Part D coverage.
In summary, Medicare Supplemental Insurance, or Medigap, is a valuable option for individuals seeking to reduce their out-of-pocket expenses and manage their finances more effectively. By understanding the coverage options, limitations, and restrictions of Medigap plans, individuals can make informed decisions about their healthcare coverage and choose the plan that best meets their unique needs.
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Medicare Advantage Plans
Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). Part A covers inpatient hospital care, while Part B covers doctors' services and tests, as well as preventive services. However, Original Medicare does not cover long-term care, dentures, or routine physical exams.
It is important to note that Medicare Advantage Plans can disenroll you under certain circumstances, such as moving outside the plan's service area or losing Medicare eligibility. Additionally, joining a Medicare Advantage Plan might impact your employer or union coverage, which could extend to your spouse and dependents.
Before enrolling in a Medicare Advantage Plan, it is recommended to consult with your employer, union, or benefits administrator to understand the potential implications on your existing coverage.
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Prescription drugs
Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Part B covers drugs that are not typically self-administered, like those you would receive at a doctor's office or in a hospital outpatient setting. Doctors, other healthcare providers, and pharmacies must accept assignment for Part B-covered drugs, so they should never ask for more than the coinsurance or copayment for the drug itself. In most cases, after meeting the Part B deductible, you pay up to 20% of the Medicare-approved amount for covered Part B prescription drugs. Your coinsurance amount may change depending on the price of your prescription drug.
Part B does not cover self-administered drugs in a hospital outpatient setting. If you receive non-covered prescription drugs in a hospital outpatient setting, you pay 100% of the cost of the drugs unless you have other drug coverage. If you have other coverage, like Part D, what you pay depends on whether your drug plan covers the drug and if the hospital is in your plan's network.
Some of the drugs covered by Medicare Part B include:
- Drugs used with some 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 to check for allergies and their treatment if prepared by a doctor or other healthcare provider and given under appropriate supervision.
- HIV prevention drugs.
- Injectable osteoporosis drugs.
- Erythropoiesis-stimulating agents: Medicare covers erythropoietin by injection if you have End-Stage Renal Disease (ESRD) or need this drug to treat anemia related to certain other conditions.
You can also join a Medicare Advantage Plan (Part C) or other Medicare health plan with drug coverage. To join a separate Medicare drug plan, you must have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance).
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Coverage outside the US
Original Medicare, a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities, does not provide coverage for healthcare outside the United States. This includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
However, there are some specific exceptions where Original Medicare may cover healthcare expenses outside the United States:
- If you are in the United States, but the nearest hospital that can best treat your condition is located in a foreign country.
- If you are travelling in Canada and are closer to a Canadian hospital than a US hospital. Specific criteria may be used to determine your eligibility based on where you are travelling in Canada.
- If you live in the United States but your home is closer to a foreign hospital than a US hospital. In this case, you may be able to receive general and emergency medical care at the foreign hospital, which may be covered by Medicare.
- If you experience a medical emergency while travelling between Alaska and another state, and a Canadian hospital is the closest.
- If you are in the United States or one of its territories and face a medical emergency, but the nearest hospital is across the border, for example in Canada or Mexico.
- If you need medical attention and you are on a ship within six hours of a US port.
Medicare Supplement Insurance (Medigap), which is purchased in addition to Original Medicare, may also provide coverage for foreign travel emergencies. Medigap plans C, D, F, G, M, and N cover emergency healthcare while travelling outside the country. However, plans C and F are no longer available to new Medicare beneficiaries. These plans pay 80% of billed charges for specific medically necessary emergency care outside the US, but a $250 deductible for the year must be paid first. Medigap's foreign travel emergency coverage has a lifetime limit of $50,000.
Some private Medicare Advantage (Part C) plans may also offer foreign coverage, but the details vary, and coverage is limited.
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