Established in 1965, Medicare is a federal medical insurance program managed by the Centers for Medicare and Medicaid Services (CMS). It offers health insurance to Americans over 65, as well as younger people with disabilities approved by the Social Security Administration (SSA), such as people with end-stage renal disease and ALS.
As of 2018, the Medicare Trustees Report states that it provides health coverage to more than 59.9 million people - the majority of whom are 65 or older, and the rest are younger. MedPAC research shows that Medicare covers around half of their medical expenses. The rest is usually covered through additional private insurance or Part C or Part D of the public program.
It can be overwhelming to keep up with the ever-changing landscape of healthcare plans, especially those that apply to seniors. For those on Medicare, it’s important to understand the full range of services covered. Exploring senior services covered by Medicare can help you make informed decisions about your healthcare and save you time, money, and frustration. Knowing what is covered and what isn’t can help you better plan for your healthcare needs and ensure you have access to the services you need.
This article will discuss the various services Medicare covers and how to access them. We’ll also discuss what is not covered, so you can make informed decisions about your healthcare and be prepared for any out-of-pocket costs. With this information, you can feel confident that you are taking advantage of all the services offered through Medicare and are prepared for future changes.
Overview of Medicare services
Medicare is a federal health insurance program available to individuals 65 or older and those under that age who have disabilities. It is divided into four parts: Part A, Part B, Part C, and Part D. Each part provides specific types of coverage to help individuals cover healthcare expenses associated with different medical procedures.
Medicare coverage is available for seniors, but some services are limited to those who are younger than 65. For example, Part A only covers seniors, Part B is available to all individuals, and Part D is only available to individuals over the age of 65 who are enrolled in Medicare. Medicare is a critical resource for many individuals and their families, as it provides coverage for a range of healthcare services.
These services include inpatient and outpatient hospital visits, prescription drugs, skilled nursing care, and more. While Medicare covers a lot of services, there are also some important exceptions, which we will discuss below.
What is covered by Medicare?
Part A - Part A provides coverage for inpatient hospital services and skilled nursing care services. Individuals who qualify for Medicare can receive these services without paying any out-of-pocket costs.
However, out-of-network providers may charge more than the average cost. It’s important to discuss costs with providers before receiving services. Unlike some other parts of Medicare, Part A coverage is not automatic, but rather is a premium that must be paid by most individuals. Premiums vary based on your income, but they are typically only a few hundred dollars per month.
Part B - Part B is voluntary coverage that provides for medically necessary services that are not covered by Part A. Although Part B does not cover inpatient hospital care or skilled nursing care, it does cover a range of other important healthcare services.
Medicare Part B coverage includes lab tests, doctor visits, imaging, and diagnostic tests, outpatient hospital services, and more. Part B coverage is also a premium, but it is typically much less than Part A. Depending on your income, you may qualify for a low-income plan or have the premium paid for entirely by the government.
Part D - Part D provides prescription drug coverage for individuals who have Medicare coverage. It is voluntary coverage that is typically run by private health insurance companies. While many prescription drugs are covered under Part B, Medicare does not cover the cost of the drugs themselves.
Individuals on Medicare are responsible for paying the full cost of their prescriptions, which can add up quickly. This can be particularly challenging for individuals who have chronic diseases and may need to take several drugs each day. Fortunately, Part D has an Annual Open Enrollment Period (AEP), during which individuals can change their prescription coverage plans to get more affordable options.
Medicare coverage for seniors
Although seniors have a range of Medicare coverage options, they do not all have the same level of coverage. Seniors who have paid Medicare taxes for 10 years are considered standard Medicare enrollees who have full coverage. Individuals who have paid Medicare taxes for fewer than 10 years are considered Medicare Advantage enrollees and have less extensive coverage.
When comparing Medicare Advantage plans, it is crucial to pay attention to coverage levels to ensure you have adequate coverage for your healthcare needs. Seniors who have Medicare coverage can take advantage of a number of services, including hospital visits, lab tests and diagnostic screenings, prescription drugs, and more.
Seniors can also contact their state’s medicare assistance program (MAP) to find local healthcare providers who accept Medicare coverage. MAP programs can also help individuals find a plan that best suits their healthcare needs based on their personal situation and expected healthcare costs.
Medicare Part C and Part D coverage
There are two Medicare parts, Part C and Part D, that are not available to seniors but are available to other groups covered by Medicare.
Part C is a Medicare Advantage plan that provides standard Medicare coverage. Most Medicare Advantage plans also have lower out-of-pocket costs than standard Medicare, which can make them a more affordable choice for some individuals.
Part D provides prescription drug coverage for individuals with Medicare coverage. Unlike standard Medicare, Part D plans will cover the cost of prescription drugs, meaning individuals will not have to pay anything out-of-pocket. However, it is essential to note that these plans do not cover every drug and may have a list of preferred drugs, meaning an individual may need to pay the full cost for a drug not on the preferred list.
Part C and Part D plans are standardized plans that are offered by private health insurance companies. This means individuals should compare plans to find one that best suits their healthcare needs based on personal situations and expected healthcare costs. It is important to note that these plans are not available to seniors.
Additional Medicare services
- Medicare Advantage Plans - Medicare Advantage Plans are standardized plans that are offered by private health insurance companies. While these plans are not available to seniors, they are available to other groups covered by Medicare and may have lower out-of-pocket costs than regular Medicare.
- Medicare Cost Plans - Medicare cost plans are not standardized plans like Medicare Advantage plans. As a result, they are not required to provide the same level of coverage and may not comply with government regulations.
- Medicare Supplement Insurance - Medicare Supplement Insurance, or Medigap, provides additional coverage for Medicare services. For example, Medigap plans cover the cost of prescription drugs that are not covered by Part D.
Medicare coverage exceptions
- Out-of-network providers - Out-of-network providers are healthcare providers who are not part of the Medicare network. While Medicare will cover a portion of the cost of care with an in-network provider, there is no guarantee that the out-of-network provider will accept Medicare’s terms.
- Hospitalization - While Medicare covers inpatient hospitalization, it does not cover skilled nursing care services. This can create a significant financial burden for individuals who require care after a hospital stay.
- Emergency care - Medicare does not cover emergency care, so individuals may be responsible for paying the full cost of any treatment or services in an emergency room setting. - Medical equipment and supplies
- Medicare does not cover the cost of medical equipment and supplies. This can include items such as wheelchairs, hospital beds, and more.
- Prescription drug coverage - Medicare does not cover the cost of prescription drugs, meaning individuals on Medicare are responsible for paying for all medication costs out of pocket.
- Vision and dental coverage - While Medicare covers some vision and dental care, it does not cover the full cost of these services, and they are not included in Medicare Advantage plans.
Accessing Medicare services
When individuals first enroll in Medicare, they are assigned a Health Insurance Claim Number (HICN) and can begin accessing Medicare services. To access Medicare services, individuals can visit their local Medicare office, call the Medicare hotline to speak with a representative or submit a request online.
It is important to keep accurate records of all medical visits, including dates, times, and the services provided, and to clearly document the services that Medicare covered. This can help individuals avoid confusion and ensure they receive the benefits they are entitled to.
Similarly, individuals can contact their state’s medicare assistance program (MAP) to find local healthcare providers accepting Medicare coverage. MAP programs can also help individuals find a plan that best suits their healthcare needs based on their personal situation and expected healthcare costs.
How to save money on healthcare services
- Stay informed - It can be overwhelming to keep up with all the changes in Medicare and healthcare services, but staying informed can help you make decisions based on up-to-date information.
- Negotiate costs - The costs of healthcare services are not set in stone, so it is important for individuals to shop around and negotiate the best deal.
- Ask about payment options - Some providers offer flexible payment options, including payment.
Ask friends or family which Parts of Medicare A, B, C, or D work for them and how to take advantage of negotiated costs and payment options. Check with your local carrier or Medicare agent in your State for a plan that would benefit you and how to minimize your out-of-pocket costs for healthcare.
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