MEDICARE: WHAT YOU NEED TO KNOW
Medicare is health insurance for Americans who are 65 and older, under 65 with certain disabilities and of any age with end-stage renal disease (ESRD - permanent kidney failure requiring dialysis or a kidney transplant).
What Are the Different Parts of Medicare?
Medicare Part A (“Original Medicare”, hospital insurance) helps cover: inpatient care at hospitals, skilled nursing facility care (including rehabilitation), home health care and hospice care.
Medicare Part B (“Original Medicare”, medical insurance) helps cover: services from primary care physicians and other health care providers, outpatient care, home health care, durable medical equipment and some preventive services.
Medicare Part C (Medicare Advantage plans - HMO, PPO): managed by Medicare-approved private insurance companies, includes all benefits and services covered under Part A and Part B, usually includes Medicare prescription drug coverage (Part D) and may include additional benefits and services at an extra cost.
Medicare Part D (Prescription drug coverage): managed by Medicare-approved private insurance companies, helps to cover the cost of prescription drugs and may help lower prescription drug costs and protect against future higher costs.
Medigap (optional Medicare supplement insurance): supplemental insurance plans sold by private insurance companies to fill gaps in Original Medicare coverage.
Hospitalization: Inpatient or Outpatient?
This is a critical question to ask each day during your stay. You are not admitted as an INPATIENT unless a doctor orders it. As OUTPATIENT, you may still benefit from receiving emergency department services, OBSERVATION services, outpatient surgery, lab tests, x-rays, etc with an overnight stay. However, your status will determine what you pay and can affect Part A coverage in a skilled nursing/rehabilitation facility at time of discharge.
Following a 3-day minimum INPATIENT hospital stay, you may qualify for skilled nursing/rehabilitative services that are deemed “medically necessary" by a physician and Medicare. Medicare covers 100% of the first 20 days of each benefit period, from days 21-100, you pay $167.50 per day for each benefit period and 100% of costs each day after day 100 of each benefit period. A common but incorrect assumption is that patients are eligible for a 100-day stay. However, the length of stay is determined by Medicare based on your progress during your stay. An average stay is less than 100 days and you should plan accordingly.
What’s NOT covered by Original Medicare Part A and Part B?
Most dental care, eye exams (prescription glasses), dentures, cosmetic surgery, acupuncture, hearing aids & exams, concierge medicine (fee-based primary care) and long-term care.
WHAT IS LONG-TERM CARE?
Non-medical care for chronic illnesses and disabilities that includes personal care (a.k.a. custodial care) assistance with “activities of daily living” or “ADL’s” such as bathing, dressing, grooming, medication management, toileting and transferring. This type of care can be provided in the home, in the community or in a licensed assisted living/memory care or skilled nursing facility (a.k.a. nursing home).
Medicare and most health insurance plans, including Medigap, DO NOT pay for this type of care. Long-term care can be paid for with private financial resources, long-term care insurance policies, VA Aid & Attendance pension benefit for veterans and surviving spouses and Medicaid (see MEDICAID: What You Need to Know).
Source - “Medicare & You 2018”, Centers for Medicare & Medicaid Services
Arizona State Health Insurance Assistance Program (SHIP) / 1-800-432-4040 /
For help with questions about appeals, buying other insurance, choosing a health plan, buying a Medigap policy, and Medicare rights and protections.