Medicare coverage options can be confusing, to say the least. To make it easier to understand, the program has been broken down into four distinct sections: Medicare Part A, Part B, Part C, and Part D. In most cases, the different parts of Medicare help cover specific services.
Most beneficiaries choose to receive their Parts A and B benefits through Original Medicare. This is the traditional fee-for-service program offered directly through the federal government. With Original Medicare, the government pays for the health care services you receive. You are able to see any doctor and visit any hospital that takes Medicare anywhere in the country.
Instead of Original Medicare, you can choose to get your benefits from a Medicare Advantage Plan, also known as Part C. Each Medicare Advantage Plan must provide all Part A and Part B services offered by Original Medicare, but the plans can have different rules and restrictions.
It’s important to understand your Medicare coverage options and to pick your coverage carefully. The way you choose to get your benefits can affect where you can get your care and how much you’ll have to pay out of pocket.
This guide breaks down the different parts of Medicare so that you can have a better understanding of your coverage options.
Part A — Hospital Coverage
Medicare Part A helps pay for hospital and facility costs. When you apply for Medicare, you’ll automatically be enrolled in Part A. Most people don’t have to pay a premium for Part A as you’ve already paid into the system in the form of the Medicare tax deductions taken from your paychecks.
Part A covers the following services:
- Inpatient hospital care: This is care you receive after being formally admitted into a hospital by a physician. You’re covered for up to 90 days each benefit period in a general hospital, along with 60 lifetime reserve days. Medicare Part A also covers up to 190 lifetime days in a Medicare-certified psychiatric hospital.
- Home health care: Medicare covers services performed in your home if you’re homebound and need skilled care. You can receive coverage for up to 100 days of daily care or an unlimited amount of intermittent care. To qualify for this Part A coverage, you must have spent a minimum of three consecutive days as a hospital inpatient within 14 days of receiving home health care. If you don’t meet all the requirements for Part A coverage you can receive home health care through Medicare Part B.
- Skilled nursing facility (SNF) care: Medicare covers, room, board, and a range of services provided in an SNF. Some of these services include administration of medications, wound care, and tube feedings. If you qualify for coverage, you’re covered for up to 100 days each benefit period. To qualify you must need skilled nursing or therapy services and have spent at least three consecutive days as a hospital inpatient within 30 days of admission to the SNF.
- Hospice care: This is care you can choose to receive if a provider deems you to be terminally ill. You’re covered for as long as your provider certifies that you need care.
Be aware that Medicare does not usually pay the full cost of your care so you’ll likely be responsible for part of the cost-sharing for Medicare-covered services. This can be in the form of deductibles, coinsurances, or copayments.
Part B — Doctor And Outpatient Services
Medicare Part B provides coverage for outpatient medical services. Here is a summary of the services and coverage rules under Part B:
- Provider services: Necessary medical services you receive from a licensed health professional.
- Home health services: Services covered if you’re homebound and in need of skilled nursing or therapy care.
- Durable medical equipment (DME): This is equipment that serves a medical purpose, is appropriate for use in the home and is able to withstand regular use. Examples of DME include wheelchairs, walkers, and oxygen tanks. You can rent or purchase DME from a Medicare-approved supplier after your provider verifies you need it.
- Preventative services: These are counseling and screenings intended to detect conditions, prevent illness, and keep you healthy. Preventative care is usually covered by Medicare without coinsurance.
- Ambulance services: This is emergency transportation, usually to and from hospitals. Coverage for non-emergency ambulance transportation is limited to situations where transportation is medically necessary and there is no other safe transportation available.
- Select prescription drugs: This includes immunosuppressant drugs, antiemetic drugs, anti-cancer drugs, and certain dialysis drugs. It also includes drugs normally administered by a physician.
- Therapy services: This includes outpatient physical, speech, and occupational therapy services provided by a Medicare-certified therapist.
- Chiropractic care: This is covered when chiropractic services are medically necessary to fix a subluxation of the spine.
This list includes the most common covered services but is not exhaustive of all the services covered under Medicare Part B. Similar to Part A, you’ll likely have to pay deductibles, coinsurances, or copayments for services
Part C — Medicare Advantage
While most people with Medicare get their health coverage from Original Medicare, some elect to get their benefits from a Medicare Advantage Plan, also known as Part C or as a Medicare private health plan.
The most common types of Medicare Advantage Plans are:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Private Fee-For-Service (PFFS)
You can join a Medicare Advantage Plan if you:
- Have Medicare Parts A and B
- Live in the plan’s service area
- Do not have End-Stage Renal Disease (except in limited circumstances)
You’ll still have Medicare if you enroll in a Medicare Advantage plan. This means you’ll likely pay a monthly premium for Part B, and a premium for Part A if you have one. If you’re enrolled in a Medicare Advantage Plan you will receive the same benefits offered by Original Medicare. Be aware that your Medicare Advantage Plan may have different rules, costs, and restrictions, which can affect when and how you receive care.
These plans may also offer certain benefits that Medicare doesn’t cover such as dental and vision care, some in-home support like housekeeping, as well as caregiver counseling and training. Not all Medicare Advantage plans cover additional benefits, so you’ll want to check specific plans to learn what benefits are covered.
Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and Part B services. For instance, the maximum out-of-pocket cost for HMO plans in 2020 is $6,700.
These plans cannot charge higher copayments or coinsurances than Original Medicare for certain services such as chemotherapy and dialysis but they can charge higher cost-sharing for other services.
Part D — Prescription Drugs
Medicare Part D helps pay for outpatient prescription drugs. It is offered through private companies as either a stand-alone plan for those enrolled in Original Medicare or as a set of benefits included with your Medicare Advantage Plan.
You should enroll in Part D when you first get Medicare unless you have creditable drug coverage and will have a Special Enrollment Period. You could have enrollment penalties and gaps in your coverage if you delay your enrollment.
Every Part D plan has a list of covered drugs called a formulary. If your drug isn’t on the formulary, you may need to request an exception, file an appeal, or pay out of pocket for the drug.
A drug category is a group of drugs that have similar effects on the body or treat the same symptoms. All Part D plans must include at least two drugs from most categories. Plans must cover all available drugs in the following categories:
- Anticancer drugs (unless covered by Part B)
- Antipsychotic medications
- HIV/AIDS treatments
- Anticonvulsive treatments for seizure disorders
- Immunosuppressant drugs
Part D plans must also cover most vaccines, except for those covered by Part B.
By law, some drugs are excluded from Medicare coverage. This includes drugs used to treat weight gain or loss and over the counter drugs.
With so many options available, Medicare coverage can be confusing. Coverage2Care wants to eliminate the confusion and help you find coverage that meets your unique needs. Our agents can make the enrollment process easier and help you save time and money by doing all the research for you based on your doctors and medications. Contact one of our agents today to get the benefits you deserve!