Medicare Parts A & B
Administered by the federal government, Medicare is a health insurance program for people age 65 or older, younger people with certain disabilities and people with end-stage renal disease (ESRD). Medicare is made up of four parts, which are described as Parts A, B, C and D. Each parts covers specific services within the program. Federal and state laws determine Medicare coverage. Medicare pays about 80 percent of health care costs.
Medicare covers lab tests, surgeries, doctor visits and other services. It also covers supplies, such as wheelchairs and walkers that are considered medically necessary to an individual’s treatment. Other rules may apply for Medicare Advantage Plans or other Medicare plans. However, those plans are required to provide at least the same coverage as Original Medicare. Some limitations may apply. When determining if Medicare covers what you need, talk to your doctor or other healthcare provider and ask if Medicare covers the services and supplies you need.
Changes Outlined in the Affordable Care Act
Signed into law by President Barack Obama in 2010, the Affordable Care Act (ACA) launched comprehensive health insurance reforms that have improved access, affordability and quality of health care. Nicknamed “Obamacare,” a key feature of the law makes those with Medicare eligible for key preventive services at no cost. Medicare recipients also receive a 50 percent discount on brand-name drugs in the Medicare “donut hole,” among other benefits.
As a result of changes, more than 12.3 million additional individuals are enrolled in Medicaid and the Children’s Health Insurance Program (CHIP), and 28 states and Washington, D.C. have expanded Medicaid under the ACA.
Medicare Part A – Hospital Coverage
Covers inpatient hospital services including semi-private rooms, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care received in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care.
However, private-duty nursing, private room (unless medically necessary), a television and phone in your room (if there’s a separate charge for these items) and personal care items are not covered.
Skilled nursing facility care
Covers care received in a skilled nursing facility (SNF) under certain conditions and for a limited time. Services include, but are not limited to:
- Semi-private room (a room you share with other patients)
- Skilled nursing care
- Physical and occupational therapy*
- Speech-language pathology services*
- Medical social services
- Medical supplies and equipment used in the facility
- Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF
- Dietary counseling
*Medicare covers these services if they're needed to meet your health goal.
Nursing home care
Covers care given in a certified skilled nursing facility (SNF) that is medically necessary. Most nursing homes provide custodial care, which is NOT covered.
Hospice care is typically given in your home, but it may be covered in a hospice inpatient facility. Once qualified, you and your family will work with the hospice team to determine a plan of care depending on your terminal illness and related conditions.
Services may include doctor services, nursing care, medical equipment, and prescription drugs for symptom control or pain relief, among others.
Home health services
Covers eligible home health services such as intermittent skilled nursing care, physical therapy, and speech-language pathology services, among others. However, 24-hour-a-day home care, delivered meals, homemaker services and personal care are NOT covered.
Medicare Part B – Medical Coverage
Covers two types of services – medically necessary and preventative.
Medically necessary services include services or supplies needed to diagnose or treat medical conditions that meet accepted standards of medical practice.
Preventive services include health care to prevent illness or detect it at an early stage, when treatment is most likely to work best. Most preventive services are provided at no cost if you get the services from a health care provider who accepts assignment.
Part B covers services such as:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health
- Partial hospitalization
- Getting a second opinion before surgery
- Limited outpatient prescription drugs
For more details, contact our office.
For specific benefit cost information, visit www.MyMedicare.gov.
Sources: Official U.S. Government Site for Medicare, www.medicare.gov.