Understanding Medicare - What's Covered And What's Not

Medicare insures those age 65 or over to help with the cost of medical services. A number of different plans and options exist for those who will enter the Medicare system. To understand your rights and options, it helps to explore Original Medicare, what it does and does not cover, and your out-of-pocket responsibilities even while you're on Medicare.

The Coverage Included in Original Medicare

Medicare health coverage consists of two parts - Part A and Part B ...

Part A

With Medicare Part A, you get coverage for generally for stays in:

*Hospitals
*Skilled nursing facilities, where services such as physical therapy, occupational therapy, and IVs are performed by registered nurses, licensed practical and vocational nurses, audiologists, physical therapists, and occupational therapists
*Hospice centers, in which you have an illness resulting in a life expectancy of no more than six months and you elect care for comfort and other hospice services over treatment of the illness
*Nursing homes, if you receive skilled nursing services and do not intend or need to stay on a long-term basis

Medicare limits the amount of time for which it will pay for hospital stays. Typically, you owe nothing for the first 60 days in the hospital. From 61 days to 90 days, you will have to pay a portion of the hospital cost. That is called coinsurance. Beyond 90 days, you may be responsible under original Medicare for all of the hospital costs.

In addition, you face a deductible. This is the amount of the hospital cost you must pay out of pocket before Medicare Part A takes over.

Part B

Medicare Part B focuses on medical services other than as an inpatient. This encompasses visits to your primary doctor or a specialist. In addition, you enjoy Part B coverage for outpatient services by physical therapists, occupational therapists, and speech therapists. Durable medical equipment for which Medicare will typically pay includes:

*Blood sugar testing items, such as machines, lancets, lancet pens, and test strips
*Hospital beds used in a home
*Wheelchairs
*Scooters
*Walkers
*Canes
*Crutches
*Oxygen tanks, machines, and accessories
*Patient lifts

These devices help you with treating diabetes, breathing or sleep problems, and limitations on your mobility due to degenerative diseases or traumatic injuries.

As with Medicare Part A, you have out-of-pocket costs with Part B. You have the deductible. Once you meet it, you'll have to foot 20 percent of the covered expenses. Medicare pays the remaining 80 percent.

What About Home Health Services?

According to the U.S. Bureau of Labor Statistics, employment of “Home Health and Personal Care Aids” should grow by 33 percent by 2030, with nearly 600,000 openings annually. These and other numbers on the growth of home health reflect the convenience and lower costs of these services.

Original Medicare covers home health care if you require skilled nursing care for an “intermittent” period of time. That means either less than seven days per week or eight hours per day for no more than 21 days. Beyond these thresholds, you do not qualify for home health coverage under Part A or Part B.

Eligible services include physical therapy, occupational therapy, speech therapy, and part-time personal and other medical care in the home if you’re getting skilled nursing care. The skilled care provider must be a registered nurse or a licensed practical nurse working under a registered nurse’s supervision.

What Original Medicare Does Not Cover

Medicare Part A and Part B deal with hospitalization and treatment of illnesses by a physician. The limited scope of Original Medicare excludes many often common types of health services. You don’t get coverage with Original Medicare for:

*Routine eye examinations
*Lenses
*Glasses
*Hearing aids
*Routine hearing tests
*Dentures
*Root canals
*Acupuncture
*Routine teeth cleanings or check-ups
*Cosmetic surgery unless performed because of an accident or traumatic injury
*Removal of calluses from feet
*X-rays and other tests from chiropractors
*Manipulations by a chiropractor, except for a single one to correct a partial dislocation of a spinal vertebra
*Costs of long-term care in a nursing home

Prescription Drugs

You won’t find in Original Medicare benefits for the costs of prescription drugs. These benefits come via enrolling in separate plans approved by Medicare. You can use Medicare plan finder to learn more.

*Part D: When you become eligible for Original Medicare, you may opt for prescription drug coverage under Part D. You must have Medicare Part A and Part B, and you must select it in the month you turn age 65 or in one of the three months before your 65th birthday. Otherwise, you can still enroll in Part D, but it will cost you a penalty each month while you’re on Medicare.

*Part C: Medicare Advantage Plans, also known as Medicare Part C, also provide an avenue to prescription drug coverage. With a Medicare Advantage Plan, you also get benefits for eye exams, routine dental maintenance, dentures, and other services not covered by Original Medicare. To get Part C, you must have both Medicare Part A and Medicare Part B. You cannot carry both Part C and Part D. If you do, Medicare will drop you from Part C.

Understanding Medicare Advantage and Medicare Supplements

Medicare Advantage Plans bring coverage for hospital stays, physician’s services, prescription drugs, and many other benefits into one plan. Medicare Supplement plans fill the gaps in payments left by Original Medicare. These include deductibles, copayments, and your share of the costs of services after Medicare pays.

With the supplement, also known as Medigap, you don’t get payment for prescription drugs or generally for other services not covered by Original Medicare. Medigap plans stopped offering prescription drug coverage after January 1, 2006. In addition, those enrolled in Medicare after January 1, 2020, do not get payment for Medicare B deductibles. As with Medicare Advantage, private insurance companies offer Medicare Supplements.

Choosing Between Medicare Advantage and Medicare Supplements

If you want to go beyond Original Medicare, consider that you’ll generally pay more for a Medicare Supplement Plan than for Medicare Advantage. Although Medigap plans normally do not cover services beyond what Original Medicare covers, you may use Medicare Supplement Plans at any facility or medical practice that accepts Medicare. Medicare Advantage plans restrict you to providers in the particular network of the Medicare Advantage insurer.