Medicare Coverage

Medicare Part A: Hospital Coverage (Inpatient)

  1. Hospital Inpatient Care
  2. Skilled Nursing Facility/Rehab and Recovery Care
  3. Hospice Care
  4. Home Health Care

        Part A of Medicare is free for most people

Medicare Part B: Medical Insurance (Outpatient)

Part B of Medicare provides Outpatient medical services. You can receive these outpatient medical services and treatments at a doctor’s office, hospital, or clinic. There is an annual deductible of $226 for Part B medical services, and after the deductible is met,  Medicare only covers 80% of Part B medical expenses. Medicare Supplements cover the other 20%. The following is a list of outpatient medical services and treatments where Medicare covers only 80% of the cost.

  • Doctor office visits
  • Diagnostic testing and Lab tests
  • Outpatient surgery
  • Radiation and Chemotherapy treatments
  • Kidney dialysis
  • Physical, speech, and occupational therapy
  • Durable medical equipment
  • Prosthetics
  • Drugs administered in a doctor’s office
  • Mental health services
  • Ambulance services
  • Emergency Room

You pay a monthly premium to the government for your Part B coverage. The standard Part B premium for 2023 is $164.90. If your income exceeds a certain amount, your premium could be higher than the standard premium.

Medicare Part C: Private Health Insurance Plans

Part C of Medicare refers to private health insurance plans. Insurance companies approved by the Center for Medicare and Medicaid Services offer what insurance companies refer to as Medicare Advantage plans. These private health plans are not considered supplemental Medicare coverage. These plans must provide the same benefits as Original Medicare (those covered under Parts A and B); however, each plan can charge different out-of-pocket costs and have different rules for getting services. If you enroll in one of these plans,  you must continue to pay the Medicare Part B premium of $164.90.

The Disadvantages of Medicare Part C Plans

  • You leave Medicare, and your primary coverage is with an insurance company.
  • The insurance company, not Medicare, approves your claims and pays all claims.
  • Private health insurance plans have networks (HMO or PPO).
  • If you want to go to a doctor or hospital not in the plan’s network, you’d have to pay all or a significant portion of the cost.
  • Private health insurance plans require pre-authorization for many medical services and treatments, which could mean delay or denial of medical care.
  • When faced with a severe illness, you could be out-of-pocket as much as $7,500 in a calendar year.

Medicare Part D: Prescription Drug Coverage

Part D of Medicare is the prescription drug benefit that covers outpatient prescription drugs. Insurance companies with government contracts offer Part D 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 it’s 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. It would be best to enroll in a Part D prescription drug plan when you first go on Medicare or lose your employer coverage. If you delay enrollment, you will have to pay a late enrollment penalty and have gaps in your coverage.

Drug Coverage Gap (Donut Hole)

When the total retail cost of your drug purchases exceeds $4,660, you enter the Drug Coverage Gap. The $4,660 is not what you paid for your drugs but the retail cost of your medications. When you enter the Drug Coverage Gap, you pay 25% of the price for brand-name and generic drugs.

How To Save Money On your Prescriptions

  • GoodRx.com and Rxgo.com offer coupons that may lower the cost of some of your medications.
  • Needymeds.org will help you find financial assistance for brand-name drugs.
  • You may consider getting some of your expensive medications from Canada.

Uncomplicate Medicare, Call Steve Today at 205-290-8648