Medicare is the U.S. government's health insurance program for people age 65 or older.
Some people under age 65 can qualify for Medicare, too. They include those with disabilities, permanent kidney failure, or amyotrophic lateral sclerosis.
Medicare helps with the cost of health care. It does not cover all medical expenses or the cost of most long-term care. The program has four parts:
• Part A is hospital insurance
• Part B helps pay for medical services that Part A doesn't cover
• Part C is called Medicare Advantage. If you have Parts A and B, you can choose this option to receive all of your health care through a provider organization, like an HMO.
• Part D is prescription drug coverage. It helps pay for some medicines.
Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You pay for services as you get them. When you get services, you’ll pay a deductible at the start of each year, and you usually pay 20% of the cost of the Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D).
Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like copayments, coinsurance, and deductibles.
Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when you travel outside the U.S.
Social Security enrolls you in Original Medicare (Part A
and Part B).
Medicare Part A
In general, Medicare Part A covers:
Inpatient care in a hospital: Medicare Part A (Hospital Insurance) covers inpatient hospital care when all of these are true:
- You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury.
- The hospital accepts Medicare.
- In certain cases, the Utilization Review Committee of the hospital approves your stay while you’re in the hospital
Skilled nursing facility care (SNF): Medicare Part A covers skilled nursing care provided in certain conditions for a limited time (on a short-term basis) if all of these conditions are met:
- You have Part A and have days left in your benefit period to use.
- You have a qualifying hospital stay .
- Your doctor has decided that you need daily skilled care. It must be given by, or under the supervision of, skilled nursing or therapy staff.
- You get these skilled services in a SNF that’s certified by Medicare.
- You need these skilled services for a medical condition that’s either: A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it wasn't the reason you were admitted to the hospital. Or a condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you're getting SNF care)
Medicare doesn't cover custodial care, if it's the only care you need. Most nursing home care is custodial care. Custodial care helps you with activities of daily living (like bathing, dressing, using the bathroom, and eating) or personal needs that could be done safely and reasonably without professional skills or training.
Medicare Part A (Hospital Insurance) may cover care in a certified skilled nursing facility (SNF). It must be medically necessary for you to have skilled nursing care (like changing sterile dressings).
Hospice care: If you qualify for hospice care, you and your family will work with the hospice team. Together, you'll set up a plan of care that meets your needs.
Remember that Medicare only covers your hospice care if the hospice provider is Medicare-approved.
Home health care: Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible home health services like these:
- Part-time or "intermittent" skilled nursing care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Part-time or intermittent home health aide services (personal hands-on care)
- Injectible osteoporosis drugs for women
Usually, a home health care agency coordinates the services your doctor orders for you.
Medicare doesn't pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services (like shopping, cleaning, and laundry), when this is the only care you need
- Custodial or personal care (like bathing, dressing, or using the bathroom), when this is the only care you need.
You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
Medicare Part B
Medicare Part B (medical insurance) helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.
Other parts of Medicare are run by private insurance
companies that follow rules set by Medicare.
• Supplemental (Medigap) policies help pay Medicare
out-of-pocket copayment, coinsurance, and deductible
expenses.
• Medicare Advantage Plan (previously known as Part
C) includes all benefits and services covered under
Part A and Part B — prescription drugs and additional
benefits such as vision, hearing, and dental — bundled
together in one plan.
• Medicare Part D (Medicare prescription drug coverage)
helps cover the cost of prescription drugs.
You can sign up for Original Medicare (Part A and Part B)
through Social Security’s online Medicare application.
Visit Medicare’s website, Medicare.gov, to get more
information about Original Medicare, Medicare Advantage,
or Part D coverage.
Sources:
Centers for Medicare and Medicaid Services website. Drug coverage (part D). www.medicare.gov/drug-coverage-part-d. Accessed July 17, 2020.
Centers for Medicare and Medicaid Services website. What Medicare health plans cover. www.medicare.gov/what-medicare-covers/what-medicare-health-plans-cover. Accessed April 30, 2020.