What Medicare Covers

Medicare Parts A, B, C & D

Medicare is a Federal health insurance program covering millions of Americans aged 65 and older, people under the age of 65 with certain disabilities, and people with End-Stage Renal Disease (ESRD). The Centers for Medicare and Medicaid Services (CMS) is the federal agency that oversees Medicare.

Medicare Part A: Hospital Insurance (Inpatient)

  1.  Inpatient care in a Hospital:  Medicare Part A will pay for all medically necessary services for your inpatient care.
  2.  Inpatient care in a Skilled Nursing Facility (Rehab not custodial or long-term care) To qualify for care in a Skilled Nursing Facility, you must have been an inpatient in a hospital for three consecutive days.
  3.  Hospice Care:  The doctor has certified that his patient has a terminal illness with six months or less to live. The goal of hospice care is not to cure the illness but to make the patient as comfortable as possible until death occurs.
  4.  Home Health Care:  These are medically necessary services that have to be ordered by a doctor (physical, occupational and speech therapy). Medicare will only pay for these services if the patient’s condition is expected to improve in a reasonable amount of time, and if the patient needs a skilled therapist to treat the injury or illness. Medicare will not cover custodial care (eating, dressing, bathing, toileting, cooking, cleaning, or shopping). Medicare does not cover personal care services.

Part A of Medicare is free for most people, and you become eligible for Part A coverage at age 65, even if an employer group medical plan still covers you.

Medicare Part B: Medical Insurance (Outpatient)

Part B of Medicare provides Outpatient medical coverage to examine, diagnose, and treat your health conditions. You can receive these outpatient medical services and treatments at a doctor’s office, hospital, or clinic. There is an annual deductible of $198 for Part B medical services, and after the deductible is met,  Medicare only covers 80% of Part B medical expenses.

  • Doctor’s office exam
  • Preventive services and screenings
  • Diagnostic and Lab tests (MRI, CT Scan, EKG, X-rays, Blood work, Urinalysis)
  • Same day hospital visit
  • Outpatient surgery
  • Chemotherapy and Radiation treatments
  • Kidney dialysis
  • Physical, speech, and occupational therapy
  • Durable medical equipment and Prosthetics
  • Ambulance services
  • Emergency Room

*This is not a complete list of Part B medical services and treatments

You pay a monthly premium to Medicare (the government) for your Part B coverage. The standard Part B premium for 2020 is $144.60, but you may pay more if your income is above a certain amount. If you want to apply for a Medicare Supplement, you must be enrolled in Part A and Part B of Medicare.

Medicare Part C: Medicare Advantage

Part C of Medicare refers to Medicare Advantage Plans (MA Plans). These plans (HMO or PPO) are offered by private insurance companies approved by Medicare. When you enroll in an MA Plan you receive your health care from the insurance company, not Medicare. The MA Plan will provide all of your Part A and Part B coverage. The Insurance company, not Medicare has to authorize inpatient hospital care, diagnostic tests, and surgeries. Advantage Plans offer the same benefits as Original Medicare Part A and Part B but they can apply different rules, costs, and restrictions than Medicare does. For example, they can require you to get a referral before seeing a specialist and only go to the doctors and hospitals that are in their network.

Medicare Advantage plans have provider networks for doctors and hospitals (HMO or PPO).  If you want to go to a doctor or hospital that is not in their network, you could be responsible for all costs unless it is an emergency. When you travel out of state, you may be out of network.  Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and Part B services. The maximum out-of-pocket cost for HMO plans in 2020 is $6,700. If you use out of network providers, your out of pocket cost may be higher.

Most Medicare Advantage plans include Part D prescription drug coverage. These plans can offer additional benefits that Medicare does not cover, such as dental, vision, and hearing.  The benefit levels for these extra benefits can vary among MA plans, and benefits for each plan are state-specific. It is crucial to understand how your medical expenses are covered, and which doctors and hospitals are in their network before you decide to enroll. The devil is always in the details. Many people have found out that there are substantial financial gaps in their MA plan when faced with a severe or life-threatening illness. Keep in mind that as you get older, you will utilize more and more medical services. My advice is to enroll in a Medicare health plan that will provide you with excellent coverage in good or bad health. When you enroll in a Medicare Advantage Plan, you must continue to pay your Medicare Part B premium.

Medicare Part D: Prescription Drug Coverage

Part D of Medicare is the prescription drug benefit that covers outpatient prescription drugs. Part D is offered by private companies that have contracts with the government to offer this coverage. You pay a monthly premium to an insurance company for your Part D plan. You will have an annual deductible to meet and have to pay a copay or a percentage of the drug’s cost. Each Medicare prescription drug plan has a list of covered drugs, called its formulary.  Medicare drug plans place medications in their formulary that are placed in Tiers 1-5. The lower the tier, the less you pay for the medication. Brand name medications that are not available in generic can be expensive with a Medicare drug plan and could add substantially to your out-of-pocket costs when you go on Medicare.

Unless you have creditable drug coverage, you should enroll in a Part D prescription drug plan when you first go on Medicare. If you delay enrollment, you will have to pay a late enrollment penalty and have gaps in your coverage. There are 32 prescription drug plans offered in Alabama for 2020. My advice is not to choose a Medicare drug plan because it has a low premium. Base your decision on how well the drug plan covers your medications at the pharmacy you want to use. It is important to shop for your Part D drug plan each year. Your drug plan’s benefits, formulary, pharmacy network, premium, co-payments, or co-insurance may change on January 1 of each year. Medicare gives you an annual election period (October 15-December 7), during which you can change your plan if you desire to do so. If you do not make a change by December 7, your plan will automatically renew. If you are happy with your drug plan, that’s fine, but if you’re not, you are stuck with it for another year.