If you are enrolled in Medicare – or you are about to be – it is important to have a good understanding of what will and will not be covered. That way, there will be no surprises when you go to use your Medicare benefits for either hospitalization and/or doctors’ services.
While Medicare Parts A and B – which are also commonly referred to as Original Medicare – do provide coverage for a wide range of services, they can also be fraught with many out-of-pocket expenses that are your responsibility. These can include deductibles, copayments, and/or coinsurance charges.
If you are enrolled in Original Medicare, and you want to help ensure that you don’t have to pay out large sums when you obtain your services, you could consider a Medicare Supplement insurance plan (or Medigap) that can help with filling in some of the “gaps” in Medicare’s coverage.
Alternatively, you could opt to receive your A and B services from Medicare Advantage. Medicare Advantage, Part C, offers a different way of obtaining your Medicare benefits. These Advantage plans may also provide you with additional coverage outside of Original Medicare, such as benefits for vision, dental, hearing, and/or wellness.
What Is Medicare And How Does It Work?
Medicare is a federal health insurance program for those who are age 65 and over, as well as specific people who are under the age of 65 and qualify for this program due to having certain disabilities (such as End Stage Renal Disease, a permanent type of kidney failure that requires either a kidney transplant or kidney dialysis).
This program was originally formed in the year 1965, when President Lyndon Johnson signed the Social Security Act to provide health insurance for those who are age 65 and over, regardless of their income or their medical history.
What Are The Different Parts Of Medicare?
While Medicare originally began by offering Part A for hospital services and Part B for medical / doctors’ services, today this program has four different parts or components. These include the following:
Medicare Part A
Hospital Insurance – Medicare Part A offers coverage for hospital stays, as well as offers some benefits for receiving care in a skilled nursing home facility, some hospice care benefits, and some benefits for home health care.
Medicare Part B
Medical / Doctors’ Services – Medicare Part B offers coverage for various doctors’ services, as well as for outpatient care, preventive services, and for medical supplies that are needed and prescribed by a doctor.
Medicare Part C (Medicare Advantage)
Medicare Part C is also known as Medicare Advantage. A Medicare Advantage plan can offer an alternate way of receiving Medicare Part A and B benefits, while also providing additional coverage that is not provided by Original Medicare. Many Medicare Advantage plans are set up in a similar manner to HMOs (Health Maintenance Organizations) or PPOs (Preferred Provider Organizations). Medicare Advantage is not offered through Medicare itself, but rather via private insurance carriers. Because of that, these plans can differ from one to another, as well as by one insurance carrier to another. Also, the premium that is charged for Medicare Advantage coverage can differ, based on the specific plan that is chosen. You cannot have both Original Medicare (Medicare Part A and Part B) and a Medicare Advantage plan at the same time. Some Medicare Advantage plans also include Medicare Part D prescription drug benefits.
Medicare Part D
Prescription Drug Coverage – Medicare Part D offers prescription drug benefits. These plans are also offered by private insurers that have been approved by Medicare. If you have Medicare Part A and Part B, and you also want to have prescription drug coverage, then you can purchase a stand-alone Medicare Part D plan. Because prescription drug plans are sold separately from Medicare itself, the coverage and the amount of the premium can differ. If you purchase a Medicare Part D plan, it is important to ensure that the specific medications that you take will be covered under the plan.
What Specific Services Does Medicare Part B Cover?
Medicare Part B covers various services that relate to outpatient hospital coverage, doctors’ services, and certain other needs. For example, Part B of Medicare will typically provide coverage for the following items:
Medically Necessary Services
Medically necessary services and/or supplies that are needed to diagnose or to treat a medical condition – and that also meet accepted standards of medical practice – are covered under Part B of Medicare.
Medicare Part B also offers coverage for health care that is needed in order to prevent certain types of illnesses, such as the flu, and also for services that can help with detecting conditions at an early stage when the treatment can be most likely to work.
Some of the specific items that are covered if you have Medicare Part B can include:
Medicare will provide coverage for various types of clinical research studies, which test different medical care and treatment options, such as how well a particular drug for cancer may work. (These clinical research studies can also be helpful for medical professionals in determining whether or not a new type of treatment may work, as well as whether or not they are safe). It may be necessary for a Medicare enrollee to pay a copayment of 20 percent of the Medicare-approved amount for these studies, depending on the type of treatment that is received. The Medicare Part B deductible may also apply.
Part B of Medicare may also cover ambulance services to the nearest appropriate medical facility that is able to give the Medicare enrollee the care that is required. Service may be covered if you are going to or from a hospital, a critical access hospital, or a skilled nursing facility. It is important to note that this type of service is only covered by Medicare Part B if other types of transportation could endanger your health.
Durable Medicare Equipment (DME)
Medicare Part B will also cover the cost of durable medical equipment, or DME, provides that it is medically necessary and that it is prescribed by a doctor for use in the Medicare enrollee’s home. Just some of the durable medical equipment that may be covered by Medicare Part B include canes, blood sugar test strips, crutches, hospital beds, manual wheelchairs, and power mobility devices.
(Inpatient, Outpatient, and / or that requires Partial Hospitalization) – Certain mental health services may also be covered by Medicare Part B, such as those that require a Medicare enrollee to be admitted as a hospital inpatient, as well as services that are required with certain types of mental health professionals, such as a psychiatrist or other doctor, a clinical psychologist, a clinical social worker, a clinical nurse specialist, a nurse practitioner, and / or a physician’s assistant. It is necessary that the care provider also accepts Medicare assignment.
Getting a second opinion before undergoing surgery may also be covered under Medicare Part B. This entails getting another medical option from a doctor who is other than your regular doctor, and he or she provides their view about your health condition as well as how it may be treated. Getting a second opinion can help individuals to make more informed decisions regarding their care.
Limited Outpatient Prescription Medication
In some cases, Medicare Part B may also provide coverage for outpatient prescription medication. These can include drugs that you would not typically give to yourself, such as those in a hospital outpatient setting and/or those that are given at a doctor’s office. Some examples of covered drugs can include injectable osteoporosis medication, some antigens, and drugs that are used with an item of durable medical equipment such as medication that is given via a nebulizer and through an infusion pump.
What Costs May Be Associated With Medicare Part B Coverage?
If you are enrolled in Medicare Part B, there are certain costs that you will be responsible for paying out-of-pocket. These include your regular Medicare Part B premium amount. For most people, this cost is $134 per month – which is typically taken directly out of your Social Security retirement income.
However, if you are considered to be in a higher income bracket, the amount of your Medicare Part B premium may be more. For example, if your modified adjusted gross income (MAGI) as reported on your IRS tax return for two years prior (for instance, in 2016) was over a certain amount, then depending on how you file your income tax return, the amount that you pay would be based on the following factors (in 2018):
|File individual tax return:||File joint tax return:||File as married and separate tax return:||You pay each month in 2018 for Medicare Part B:|
|$85,000 or less||$170,000 or less||$85,000 or less||$134|
|Above $85,000 up to $107,000||Above $170,000 up to $214,000||Not applicable||$187.50|
|Above $107,000 up to $160,000||Above $214,000 up to $320,000||Not applicable||$267.90|
|Above $160,000 up to $214,000||Above $320,000 up to $428,000||Above $85,000 and up to $129,000||$328.30|
|Above $214,000||Above $428,000||Above $129,000||$428.60|
There are also other costs that are associated with Medicare Part B. These can include:
- Part B Yearly Deductible – In 2018, the Medicare Part B annual deductible is $183
- 20 percent for services – Once you have met your yearly deductible amount, you will then typically be required to pay 20 percent of the Medicare-approved amount for the following services:
- Most doctors’ services – including those doctors’ services that are received if you are an inpatient in a hospital
- Outpatient therapy
- Durable medical equipment
Are There Ways To Help With Medicare’s Out-of-Pocket Expenses?
In some cases, depending on the amount of health care services that you use, your out-of-pocket expenses can be high. But there are ways to help ensure that some or all of these costs are covered as well. One way is through the purchase of a Medicare Supplement insurance plan.
With Medicare Supplement insurance – depending on the plan that you choose – you could have your Medicare Part B deductible covered, as well as some of the additional expenses that are required, such as your Medicare Part A deductible, the coinsurance that is required if you are admitted to a skilled nursing facility, and even certain expenses that you incur if you have a healthcare need while traveling in a foreign country.
How To Get The Best Rates On Medicare Supplement And Medicare Advantage Plans
When looking for the lowest monthly premiums for your MA or MedSup plan we suggest finding an independent insurance agency to help you through the process. Most independent advisors have contracts with multiple carriers which gives you a wide array of options and plans to choose from.
If you are ready to see the Medicare related plans, benefits, and premium costs that are available to you, let us help! Our aim is to find the plan that is right for you and in your budget, and we believe we have the tools to accomplish this.
We can also be reached via phone, toll-free, by calling us at 864-332-4209. Working with our experts can bring you closer to the Medicare plan that you need. So, contact us today – we’re here to help.