Millions of Americans rely on Medicare for their health care coverage. Medical services are becoming increasingly complex and expensive. Many Medicare recipients are already on a fixed income, so paying for medical treatments can be a financial burden in many cases.
How do you know what Medicare will cover and pay for and what it won’t? We will run through all the details of Medicare coverage and tell you what it covers and some things it won’t cover.
We’ll also discuss your options in cases where your policy doesn’t cover things you feel it should. Keep reading for all the details.
The Basics Of Medicare Coverage
Medicare coverage is available to many people, although those options vary a little based on your situation. Retirees receiving Social Security benefits will automatically enroll in Original Medicare.
This includes both Medicare Part A and Medicare Part B. If you or your spouse receive Social Security or Railroad retirement benefits, you qualify for premium-free Medicare Part A.
- This means that Part A coverage will not cost you anything. You must have paid into the Medicare insurance system long enough during your working years to qualify for free coverage.
- If you do not qualify for premium-free coverage, then you can choose to pay for Part A coverage. The amount you must pay is related to how long you worked and paid Medicare taxes.
In addition to retirees, you can also be eligible for Medicare if you receive Social Security disability benefits.
- Once you receive benefits for 24 months, then you will automatically be enrolled in Medicare. If you elect to pay for Part A, you are generally required to obtain Part B coverage.
- Part B always includes a premium even if you qualify for premium-free coverage under Part A.
In the next section, we will discuss in more detail what is covered under each part of Medicare, but here are the basics.
- Medicare Part A is hospital coverage that covers most inpatient care.
- Medicare Part B is similar to basic health insurance that covers doctor visits and outpatient procedures.
- Medicare Part C is also referred to as a Medicare Advantage Plan. These plans are administered by private insurance companies that contract with Medicare. They allow you to manage all your Medicare coverage under a single plan to make things simpler than working all the separate parts.
- These plans might even include vision and dental coverage if you elect to purchase those.
- Medicare Part D is your prescription drug coverage.
KEY TAKEAWAYS
- There are several parts to Medicare coverage; each part covers different healthcare-related conditions; you can select specific parts or bundle your coverage.
- Medicare Part A – Hospital Insurance is free for a lot of retirees who have paid into the Medicare Insurance system for a extented period during their working years.
- There are costs associated with the different Medicare plans, which include premiums, deductibles, and out-of-pocket expenses.
What Medicare Covers
Now that you know the basics of Medicare health plans, let’s discuss in more detail what each part of Medicare will cover. Here is what you need to know.
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Cost Of Medicare
The costs associated with Medicare are divided into the premiums you pay to keep your coverage active and the out-of-pocket expenses for any services you receive.
- Regarding premiums, you might be eligible to receive Part A at no cost. Part A should cost nothing if you or your spouse qualify for or receive Social Security retirement benefits. However, if you do not qualify, you will pay $278 or $505 per month, depending on how much you have paid into the Medicare system while working.
- Part B coverage always requires the payment of a premium, and the Part B premium will cost you $175 in most cases. Your premium might also be adjusted upward if your income is higher than average.
- There are also deductibles associated with Part A and B. Part A’s deductible is $1,632 per benefit period, and Part B’s deductible is $240. You must pay these amounts before Medicare makes any payments to your healthcare providers.
- Parts C and D also come at a cost, but the price varies by provider. Since each company can set its rates, you must check with a specific company to determine their plan details and costs. Part D costs are usually on somewhat of a sliding scale. The higher your income, the more you must pay for Part D premiums.
In addition to the above, some people also choose to enroll in a Medigap plan. These plans are like secondary insurance or Medicare supplements that can help with out-of-pocket expenses like copayments, deductibles, and services that your Medicare plan does not pay for. The cost of these Medigap plans varies by provider.
TIP
You may find it beneficial to explore Medicare Advantage plans, which often include dental and vision care. Secondary insurance plans, such as “Medigap” plans, may also benefit you, especially if you have consistently high annual medical costs.
What Medicare Does Not Cover
While Medicare covers quite an extensive list of items and healthcare services, some things are not covered under a Medicare plan. So, what does Medicare not cover?
- In general, Medicare does not provide dental or vision coverage. While you can choose to add these coverages to a Medicare Advantage plan, they do not come as part of Original Medicare.
- In addition, coverage is not provided for cosmetic surgery or routine foot care.
- Neither Medicare nor Medicaid covers assisted living facility costs.
- Finally, some things that you might think are medical equipment are not covered. For example, dentures are not covered, and neither are hearing aids or services for their fitment.
If you have a question about whether or not an item or service is covered, you should check with your plan provider or contact Medicare.
Appealing A Medicare Coverage Decision
There might be instances where Medicare denies coverage, but you believe that coverage was denied improperly. It could even be an instance where you have already paid for the service, but Medicare refuses to reimburse you.
In those cases, you can appeal Medicare’s coverage decision. There are five levels to the Medicare appeals process.
- The first level is a redetermination, which simply asks Medicare to reconsider whether the denial was made in error.
- Next is the reconsideration stage. This allows an independent party to reconsider the entire claim along with the documentation and evidence provided.
- Hearing with an Administrative Law Judge
- Appeal to the Medicare Appeals Council
- Lastly, an appeal to the Federal Court.
Very few claims end up in Federal Court. However, claimants are often very successful with the Medicare appeals process, as many denials are overturned, and Medicare provides coverage.
The Bottom Line
Medicare covers a large list of medical items and services, but the specifics depend on your plan.
If you have Original Medicare, then it will cover most hospital services and routine doctor visits. However, if you have opted for a Medicare Advantage Plan, you might also have dental and vision coverage.
You should check your plan specifics for details of what is covered.
Frequently Asked Questions
Many people ask, “What does Medicare pay for?” It is generally a good idea to check with Medicare before any medical services are performed to determine whether they will provide coverage.
You can access the Medicare coverage details to determine whether your plan covers the item or service.
In most cases, if it is medically necessary, it is generally covered by Medicare.
Original Medicare does not cover prescription drugs in most cases unless they are used in a limited situation as part of outpatient care.
However, you can enroll in a Medicare Part D prescription drug plan. Many Medicare beneficiaries choose to enroll in one of these plans so that their prescription drugs will be covered. The details and costs of these plans vary by insurance provider.
Medicare does not pay for long-term care in a nursing home. However, it does pay for care in a skilled nursing facility. Most stays in these facilities are temporary; the distinction comes from the care received.
Nursing home care will not be covered if you only need custodial care, such as help with daily living activities like dressing, bathing, and eating.
However, if you require skilled nursing care, such as sterile wound care or other services that require specialized skills and training, then Medicare will usually provide coverage.
You can find a Social Security Administration office near you by using our SSA office locator and searching for your closest location.
