Medicare is a federal healthcare program to serve people over 65 or those on SSDI. The federal Medicare program has existed since the summer of 1965 when President Lyndon B Johnson signed the bill into law. The original bill that’s now the Medicare we know today outlined rules and regulations both for Medicare and Medicaid.
But if you’re a retired beneficiary who is not permanently disabled or receiving cash assistance, you should probably be more concerned with Medicare than Medicaid.
A brief look at the federal Medicare program
There have been many changes made to the Medicare program over the years. Originally, it was only for people 65 or older and in relatively good health.
It did not provide coverage for people with certain disabilities – such as ESRD – nor did it provide prescription drug coverage.
However, you can opt into prescription drug coverage via the Medicare program under certain circumstances. You can qualify for Medicare even before age 65 if you meet certain requirements.
- Those with an ESRD diagnosis. Once you have been diagnosed and start receiving regular dialysis, or if you’re diagnosed and have received a kidney transplant, your Medicare benefits will usually start three months after that.
- Those with an ALS diagnosis. ALS is short for amyotrophic lateral sclerosis, or Lou Gehrig’s Disease. Your Medicare benefits will start immediately once you start receiving Social Security benefits.
- If you’re already collecting Social Security Disability benefits. However, unlike with ESRD or ALS, you won’t be eligible to enroll in Medicare as quickly. You will have to collect benefits for 24 months before you can enroll. Conversely, suppose you opted not to collect Social Security Disability benefits. In that case, you can enroll and pay for your Medicare Part A and Medicare Part B premiums to purchase Medicare 24 months after qualifying for disability.
The different parts of Medicare
There are four parts to Medicare: Medicare Part A, Medicare Part B, Medicare Part C, and Medicare Part D.
It’s up to you to decide whether you want Original Medicare (Medicare Parts A, B, and the optional Part D prescription drug plan) or a Medicare Advantage plan.
Below, we’ll go into deeper detail on every part of the program so that you can make a better decision.
What Medicare Part A covers
An easy way to remember what Medicare Part A covers is to picture a hospital whenever you think about Medicare Part A.
This part of Original Medicare will largely cover any inpatient care with Medicare Part A. But that’s not all it covers.
Medicare Part A helps you with many expenses, such as inpatient hospital care, SNF care, long-term care hospital services, etc.
Inpatient hospital care
Medicare calculates what they will pay for care at an inpatient hospital based on your benefit period and how many days within that benefit period you receive hospital care.
Your benefit period expires after 60 consecutive days of not receiving hospital care, meaning you can have multiple benefit periods within a year.
Within a single benefit period, your cost breakdown is as follows:
While in the hospital, you can also expect Medicare Part A to pay for:
- Semi-private rooms
- Hospital meals
- General Nursing Care
- Any drugs you need as part of your inpatient treatment (including methadone)
- Other hospital services and supplies, such as your first 3 pints of blood if you require a blood transfusion
Unfortunately, Medicare Part A will not pay for the following if you require inpatient hospital care:
- Personal care items, such as slipper socks or razors
- Luxury items like a TV or a landline phone (if the hospital charges for those)
- Private rooms, unless there’s a medically necessary need for one
- Private duty nursing care
Skilled nursing facility (SNF) care
The main difference between SNF and inpatient hospital care is that the medical professionals tending to your needs are classified as technical personnel.
The benefits which Medicare Part A will pay for under these circumstances include:
- A semi-private room
- Hospital meals
- Skilled nursing care
- Medically necessary physical therapy
- Medically necessary occupational therapy
- Medically necessary speech-language pathology services
- Any medications you require for proper treatment
- Medical supplies and equipment used within the facility
- Medically necessary ambulance transportation
- Dietary counseling
- Swing bed services
- Medical social services
Skilled nursing facility care also works off of the benefit period system. For the first 20 days, you pay a $0 coinsurance fee for each benefit period. You will pay coinsurance for the remaining 80 days of your benefit period. After your first hundred days of SNF treatment on any given benefit period, you will have to pay 100% of all your medical costs.
Long-term care hospital services
Medicare Part A also covers most of the long-term care hospital services costs. The costs associated with these LTCH services are almost identical to inpatient hospital care.
But there are some differences between how the Medicare program charges you for inpatient hospital care versus long-term care hospital services. For one, the $1,600 deductible will be waived if transferred directly from or within 60 days of being discharged from an inpatient hospital.
The biggest difference between an inpatient care hospital and an LTCH is that these specialized facilities are designed to care for patients who need at least 25 days of serious hospital care.
Examples of such patients include people who have suffered a severe head injury or another type of severe wound or who have recently been removed from a ventilator that they were on for an extended period.
Nursing home care and custodial care
There’s a specific difference between nursing home care received in a skilled nursing facility (SNF) and custodial care. Often, custodial care (helping a person with personal hygiene, bathroom needs, and staying well-fed) can be provided at home by a family member or nurse.
But when a beneficiary needs care beyond simple custodial care, such as being administered IV medication or regularly changing sterile dressings, Medicare will help you cover those costs.
Costs are often determined case-by-case between the SNF from which you received nursing home care and the Medicare program.
Hospice care costs you virtually nothing; Medicare foots a large chunk of the medical bill. Under some circumstances, prescription drugs and pain relief products may require a $5 copay.
Conversely, you may want to check and see if Medicare Part D will cover the drugs and pain relief products for you.
Hospice care is a special type of medical care that recipients are eligible for if a doctor has determined that they are terminally ill with a life expectancy of six months or less.
Hospice care only provides palliative care – meaning that you only receive care to keep you comfortable in your final days instead of any treatment meant to cure or prolong your life.
This type of care requires you to sign an official document stating that you choose hospice care over any other medical intervention.
While in hospice care, Medicare will pay for:
- Items and services necessary to relieve pain and manage symptoms
- Nursing, medical, and Social Services
- Durable medical equipment is required to relieve pain and manage symptoms
- Add and Homemaker services
- Spiritual grief counseling for you, your loved ones, and any other services deemed medically necessary to manage pain and other symptoms.
Hospice care costs you virtually nothing; Medicare foots a large chunk of the medical bill. Under some circumstances, prescription drugs and Pain Relief products may require a $5 copay. Conversely, you may want to check and see if Medicare Part D will cover those drugs and pain relief products for you.
While under hospice care, Medicare will not pay for:
- Treatment that could potentially cure your terminal illness or related conditions P
- prescription drugs meant to cure your illness or related conditions
- Care provided outside of your hospice medical team
- Hospital outpatient care which your hospice Team has not arranged
- Room and board
Home health services
Home health services could be covered by either Part A or a mix of Medicare Part A and Medicare Part B, depending on the service end of the care you need.
If you’re deemed eligible for Medicare home health services, your total cost will be:
- $0 for the home health services themselves
- 20% of the cost of the Medicare-approved amount of any durable medical equipment (DME) that you may require
Here’s what Medicare will pay for if you qualify for these medical benefits:
- Part-time/intermittent skilled nursing care
- Occupational therapy
- Physical therapy
- Injectable osteoporosis drugs for women
- Speech-language pathology services
- Medical social services
The following medical benefits and services are excluded from home health services paid for by Medicare:
- Any homemaker services such as shopping, cleaning, laundry, etc., if Medicare determines that homemaker services are the only surfaces that the patient needs
- Custodial or personal care (dressing, bathing, using the bathroom, etc.) if this is the only care the patient needs
- 24/7 care at home
- Delivered meals
If you think you might be eligible or if you would like to request home health services for Medicare, you will need all of the following to apply to you before they grant your request:
- You must be under a doctor’s care with a care plan that has been created and regularly reviewed by your doctor
- Your doctor must certify that you need intermittent skilled nursing care (other than blood drawn), physical therapy, speech-language pathology, or continued occupational therapy services.
- You must have a doctor-certified designation that you’re homebound
- You may have to undergo a Medicare demonstration program for beneficiaries in Florida, Illinois, Massachusetts, Texas, or Michigan. If you live in any of these states, call 1-800-Medicare for more information on how the pre-claim review process works.
What Medicare Part B covers
Services from doctors and other healthcare providers
Specifically, medically necessary services provided by doctors and other health care providers. The definition of medically necessary services is “any services or supplies needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.”
You also have affordable access to preventive services, which are healthcare services designed to prevent an illness or detect illness in its early stages when treatment is most likely to work best.
Best of all, you pay nothing for most preventive services as long as the healthcare provider who takes care of you also accepts Medicare. Be sure to ask your healthcare provider whether or not they accept Medicare assignments before you seek treatment.
If you receive care at a hospital or a skilled nursing facility – but without getting a written order for admittance from a doctor – it’s classified as outpatient care.
The vast majority of outpatient and inpatient care is practically identical. Still, the only important difference is whether or not a doctor wrote an order to admit you to the facility.
While receiving outpatient care, stay on top of your health situation. Keep asking your doctors and nurses to update you on whether you’re an inpatient or an outpatient.
Also, coordinate closely with your local Medicare office and any other relevant entities (such as your Medicare Advantage or Medigap insurance agent) to ensure you know what services are being charged as outpatient care and who is paying for what.
Home health care
Home health care is an overarching term for less expensive services designed to help you get better, regain independence, become or maintain your current level of self-sufficiency, or slow the decline of your health.
Monitoring your illness, injections, intravenous or nutrition therapy, patient and caregiver education, and wound care are some home health care services Medicare Part B can provide for you at a greatly reduced cost.
It’s hard to estimate exactly which services will be provided and how much they will cost because of how many factors are involved in the final calculation. It largely depends on whether you’re on Original Medicare, purchased a Medicare Advantage plan, or have paired your Medicare Part B benefits with a Medicare Supplement policy.
Contact your local Medicare office and other relevant parties (such as your Medicare Advantage or Medigap insurance agent) for more information on estimating and managing your home healthcare costs.
Durable medical equipment
Durable medical equipment (DME) is any medical equipment that “is durable, used in your home, used for a medical reason, not particularly useful for someone who isn’t sick or injured, and generally has an expected lifetime of at least three years.”
First, the doctor, facility, or organization providing you the DME must accept Medicare assignment. If they do, you pay 20% coinsurance on the Medicare-approved amount and any applicable Part B deductible. This is true whether you choose to rent or buy the equipment.
Additionally, the equipment suppliers have to be enrolled in Medicare as well. This is because they must maintain strict standards that meet Medicare’s expectations. This is to ensure you get the best quality care possible from the equipment you’re provided
Many preventative services
Medicare Part B pays for 27 services and screenings related to medically necessary and preventative treatment. These can range from colorectal cancer screenings to annual flu shots to yearly wellness visits and more.
Guide to Medicare FAQs
When are you eligible for Medicare?
You will become Medicare-eligible upon turning 65. Individuals under 65 can start Medicare after 24 months of disability or if they have specific qualifying chronic health conditions. When you first become eligible, you’ll enter your Initial Enrollment Period.
What are my Medicare plan options?
Once enrolled in Medicare you have a few different plan options.
- Stay with Original Medicare only (Not Recommended)
- Stay with Original Medicare only and enroll in a Part D prescription drug plan (Not Recommended)
- Stay with Original Medicare, enroll in a Medicare Supplement Plan, and enroll in a Part D drug plan (Best coverage options – most expensive)
- Enroll in a Medicare Advantage plan (Lower cost alternative in most cases, combines Medicare benefits into one plan)
Private insurance companies contracted with the Centers for Medicare & Medicaid Services administer Medicare Advantage, Medicare Supplement, and Part D plans.
What’s the difference between Original Medicare and Medicare Advantage?
Medicare Advantage plans allow an alternative to receiving your Medicare benefits. They must cover everything that’s provided under Original Medicare. However, they can provide additional benefits not covered by traditional Medicare.
What’s the difference between Medigap and Medicare Advantage?
Medicare Supplements (Medigap plans) help fill in the gaps in the Original Medicare cost share that you’d typically be responsible for. A Medicare Advantage plan is an all-in-one coverage option that provides all the Medicare benefits in one plan. These plans have outlined costs different from those of Original Medicare and a maximum out-of-pocket limit. Comparing these two coverage options is like comparing apples to oranges.
Do Medicare Supplement plans include prescription drug coverage?
Medicare Supplement plans don’t include drug coverage. To get coverage for prescription medications, you’ll want to enroll in a stand-alone Part D prescription drug plan in addition to your Medicare Supplement.
How to get help finding a Medicare plan in your area
When you first start Medicare, it can be very confusing, and you need help navigating the Medicare system. Finding a good licensed insurance broker is vital. Fill out our online rate form or give us a call. We can help connect you with a licensed professional that can help make the process simpler.