Medicare is a federal healthcare program designed to serve people over the age of 65, or those on SSDI.
A Brief Look at the Federal Medicare Program
The federal Medicare program has been around since the summer of 1965 when then President Lyndon B Johnson signed the bill into law. The original bill that is 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.
Who Is Medicare Meant For?
There have been many changes made to the Medicare program over the years. Originally, it was only for people who were 65 years old 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.
Today, however, you can opt into prescription drug coverage via the Medicare program under certain circumstances. You can also qualify for Medicare even before the age of 65 if you meet certain requirements.
- If you have an ESRD diagnosis. Once you have been diagnosed and start receiving regular dialysis, or if you are diagnosed and you have received a kidney transplant, your Medicare benefits will usually start three months thereafter
- If you have an ALS diagnosis. ALS is short for amyotrophic lateral sclerosis, also known as 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, if you opted not to collect Social Security Disability benefits, you can enroll and pay for your Medicare Part A and Medicare Part B premiums in order 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 (also referred to as Medicare Advantage) 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 individual 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. Any inpatient care you get with Medicare Part A will largely be covered by this part of Original Medicare. 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, and more.
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 that you can have multiple benefit periods within a single 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 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 care 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 required 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 $0 coinsurance fee for each benefit period. For the remaining 80 days of your benefit period, you will pay a coinsurance. 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 cost of long-term care hospital Services. 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 $1,556 deductible will be waived if you’re 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, another type of severe wound, or who have recently been removed from a ventilator that they were on for an extended period of time.
Nursing Home Care and Custodial Care
There’s a very specific difference between nursing home care received in a skilled nursing facility (SNF) and custodial care. More often than not, custodial care (helping a person with personal hygiene, bathroom needs, and staying well-fed) can be provided at home either by a family member or nurse.
But when a beneficiary needs care beyond simple custodial care, such as being administered IV medication or regular changing of sterile dressings, that’s when Medicare will step in and help you cover those costs. Costs are often determined on a case-by-case basis between the SNF that you received nursing home care from and the Medicare program.
Hospice care costs you virtually nothing; Medicare foots a substantially 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/or 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 for palliative care – meaning that you only receive care to keep you comfortable in your final days instead of any treatment meant to cure you or prolong your life. Hospice 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 required to relieve pain and manage symptoms
- Add and Homemaker services
- Spiritual grief counseling for you and your loved ones, along with any other services deemed medically necessary to manage pain and other symptoms
Hospice care costs you virtually nothing; Medicare foots a substantially 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 / or 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
- rescription drugs meant to cure your illness or related conditions
- Care provided outside of your hospice medical team
- Hospital outpatient care which has not been arranged by your hospice Team
- Room and board
Home Health Services
The thing about home health services is that, depending on the service end of the care you need, it could be covered by either Part A, or a mix of Medicare Part A and Medicare Part B.
If you are 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 this 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 for all of the following to apply to you before they will 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 either intermittent skilled nursing care (other than having blood drawn), physical therapy, speech language pathology, or continued occupational therapy services
- You must have a doctor-certified designation that you are homebound
- For beneficiaries in Florida, Illinois, Massachusetts, Texas, or Michigan, you may have to undergo a Medicare demonstration program. 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 that are 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 the vast majority of preventive services as long as the healthcare provider who takes care of you also accepts Medicare assignment. Be sure to ask your healthcare provider in advance whether or not they accept Medicare assignment 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 is classified as outpatient care. The vast majority of outpatient and inpatient care is practically identical, but the only important difference is whether or not a doctor wrote an order to admit you to the facility
While you are receiving outpatient care, if possible, stay on top of your health situation and keep asking your doctors and nurses to update you on the status of whether or not you are an inpatient or an outpatient.
Also, make sure to closely coordinate with your local Medicare office and any other relevant entities (such as your Medicare Advantage or Medigap insurance agent) to make sure you know what services are being charged as outpatient care, as well as who is paying for what.
Home Health Care
Unlike hospice care, outpatient hospital treatment, or skilled nursing facility healthcare, 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 examples of 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 different factors are involved in the final calculation. Much of it largely depends on whether you are on Original Medicare, purchased a Medicare Advantage plan, or have paired your Medicare Part B benefits with a Medigap policy.
Be sure to contact your local Medicare office as well as any other relevant parties (such as your Medicare Advantage or Medigap insurance agent) for more information on how to estimate and manage your home health care costs.
Durable Medical Equipment
Durable medical equipment (DME) is defined as any type of 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”.
Medicare Part B provides durable medical equipment coverage for 18 different types of DME, including blood sugar testing supplies, walking assistance implements, hospital beds, and more. This link will take you to a list of durable medical equipment that Part B will cover. But there are some associated costs attached to that coverage.
First of all, 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, along with 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 live up to medicare’s expectations so that you get the best quality care possible from the equipment you are provided
Many Preventative Services
Medicare Part B pays for 27 different 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.