Millions of Americans rely on Medicare for their health care coverage. Medical services are getting more and more complex as well as more 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 exactly 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 as well as some things that it won’t cover. We’ll also discuss your options in cases where they won’t cover things that you feel like they should. Keep reading to get all the details.
The Basics Of Medicare Coverage
Medicare coverage is available to a wide range of people, although those coverage options vary a little based on your situation. Retirees who are receiving Social Security benefits will automatically get enrolled in Original Medicare. This includes both Medicare Part A and Medicare Part B. If you or your spouse are receiving Social Security or Railroad retirement benefits, then 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, then you are generally required to obtain Part B coverage as well. Part B always includes a premium even if you qualify for premium-free coverage under Part A.
We will discuss in more detail in the next section what is covered under each part of Medicare, but here are the basics. Part A is hospital coverage that covers most inpatient care. 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 are plans that are administered by private insurance companies who contract with Medicare. They allow you to manage all your Medicare coverage under a single plan to make things simpler than managing all the separate parts. These plans might even include vision and dental coverage if you elect to purchase those. Finally, Medicare Part D is your prescription drug coverage.
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.
— Medicare Part A
What does Medicare Part A cover? Medicare Part A is often called hospital insurance. It would be similar to medical insurance that you would use for hospital care. It covers things like hospital stays for inpatient care, hospice care, and home health care. Part A will also pay for care in a skilled nursing facility or nursing home care. However, the facility must be a skilled nursing facility as Medicare will not pay for long term care in a nursing home.
— Medicare Part B
So, what does Medicare Part B cover? Medicare Part B is similar to your basic health insurance. It pays for things like outpatient care, preventive services and medically necessary services. These are things like regular doctor office visits. Part B also pays for items that you might not normally think of like durable medical equipment, ambulance services, clinical research, or dialysis treatments. In addition, Part B covers mental health services as well. While Part B is generally limited to outpatient services, it will cover inpatient, outpatient, and partial hospitalization for mental health care. Most preventive care like health screenings and vaccines are covered at no charge for Part B beneficiaries.
— Medicare Part C
Part C refers to the Medicare Advantage plans available from private insurance companies. The things that these plans cover vary by plan provider. However, at a minimum, the plans must cover at least the same items that Medicare itself covers. Each insurance company can set their own monthly premium amounts, copayments, deductibles, coinsurance, and other out of pocket costs related to the plan. Some people choose to add other coverages like dental care and vision plans.
— Medicare Part D
Part D is essentially your prescription drug plan. These plans are also administered by private insurance companies, and you will need to join as soon as your Medicare eligibility begins or you might pay a penalty for joining late. If you miss the deadline, you might need to wait until the open enrollment period next year. These Medicare benefits will pay for your prescription medication. However, each plan provider decides which drugs and medicines that they will cover. You should thoroughly research the Part D plan that you are considering before enrolling to make sure that it meets your needs.
Cost Of Medicare
Costs associated with Medicare come in two parts. First is the premiums that you pay to keep your coverage active, and the other cost is the out of pocket expenses for any services that you receive. When it comes to premiums, you might be eligible to receive Part A at no cost. If you or your spouse qualify for or already receive Social Security retirement benefits, then Part A should cost you nothing. However, if you do not qualify, then you will pay either $259 or $471 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 $148.50 in most cases. If your income is higher than average, then your premium might be adjusted upward as well. There are also deductibles associated with both Part A and B. For Part A, the deductible is $1,484 per benefit period, and Part B has a deductible of $203. This means that you must pay these amounts before Medicare will make any payments to your health care providers.
Parts C and D also come at a cost, but the cost varies by provider. Since each company can set their own rates, then you would need to 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 usually must pay for Part D premiums.
In addition to the parts mentioned 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. You can find more information on Medicare costs at Medicare.gov.
What Medicare Does Not Cover
While Medicare covers quite an extensive list of items and health care services, there are some things that 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 cover assisted living facility costs.
Finally, some things are not covered that you might think are considered medical equipment. 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, then 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 is refusing 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. This is simply asking Medicare to take a second look at 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.
The final steps in the appeals process involve a hearing with an administrative law judge, the Medicare Appeals Council, and finally Federal Court. Very few claims make it all the way to Federal court. However, claimants are often very successful with the Medicare appeals process as many denials are overturned and Medicare ends up providing coverage.
The Bottom Line
Medicare covers a large list of medical items and services, but the specifics depend on exactly which plan you have. 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, then you might also have dental and vision coverage. You should check your plan specifics for details of what is covered.
Frequently Asked Questions
How do I know if a product is covered by Medicare?
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 on Medicare.gov to determine whether the item or service is covered by your plan. In most cases, if it is medically necessary, then it is generally covered by Medicare.
Does Medicare cover prescription drugs?
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.
What does Medicare cover for people in nursing homes?
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, and the distinction comes in the type of care received at the facility. If you only need custodial care, then the nursing home care will not be covered. These are situations where you might only need help with daily living activities like dressing, bathing, and eating. However, if you require skilled nursing care like sterile wound care or other services that require specialized skills and training, then Medicare will usually provide coverage.
