Medicare is health insurance for people 65 years or older, under age 65 with certain disabilities, and any age with end-stage renal disease (ESRD) or Lou Gehrig’s disease (ALS).

Medicare has four parts:

• Part A – Hospital insurance
• Part B – Medical/Doctor’s insurance
• Part C – Medicare Advantage Plans
• Part D – Prescription Drug Coverage

Medicare covers certain medical services and supplies in hospitals, doctors’ offices, and other health care settings. Services are either covered under Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance). If you have both Part A and Part B, these services and supplies must be covered as long as they are reasonable and necessary for your health, no matter what type of Medicare plan you have. A list of the covered services is found in the “Medicare and You” handbook.

Deductibles are the amount you must pay each year before Medicare begins paying its portion of your medical bill. There are deductibles for both the Part A (Hospital Insurance) and Part B (Doctor Services) portions of Medicare. Your deductible is taken out of your claims when Medicare receives them. Medicare will not start paying on your claims until you have met your annual deductible. If you have any questions on the status of your deductible, please contact 1-800-MEDICARE (1-800-633-4227).

Medicare offers a variety of coverage options:

The Original Medicare Plan
This is a fee-for-service plan that covers many health care services and certain drugs. You can go to any doctor or hospital that accepts Medicare.

Medicare Part A, or Hospital Insurance, helps pay for care in the following facilities if they are medically necessary based on Medicare requirements and your eligibility for Medicare Part A.

Medicare Part A Covered Facilities

• Inpatient care in hospitals (including critical access hospitals)
• Skilled nursing facilities (SNFs)
• Long Term Care Hospital (LTCH)
• Inpatient Rehabilitation Facility (IRF)
• Hospice care
• Home health care
• Beneficiary access to religious nonmedical health care institution (RNHCI) services Inpatient Mental health/psychiatric care
• Obesity Bariatric Surgery

Medicare Part A helps pay for the following services if they are medically necessary based on Medicare requirements. You must be eligible for Medicare Part A in order to get the following services.

Medicare Part A Covered Services

• Anesthesia
• Chemotherapy
• Room and Board
• All meals and special diets
• General nursing
• Medical social services
• Physical, occupational, and speech-language therapy
• Drugs with the exception of some self-administered drugs
• Blood transfusions
• Other diagnostic and therapeutic items and services
• Medical supplies and use of equipment
• Respite care in hospice
• Transportation services
• Inpatient alcohol or substance abuse treatment
• Part A blood (see the restrictions under non-covered services)
• Clinical Trials (Inpatient)
• Kidney Dialysis (Inpatient)

For more information on what Medicare covers, please visit “Your Medicare Coverage” on the Medicare website.

Medicare Part A DOES NOT cover the following:

• Private duty nursing
• A television or telephone in your room
• Personal care items like razors or slipper socks
• A private room unless medically necessary
• Custodial care, assisted living, adult daycare, or reimbursement for family members
• The first three pints of blood unless the blood deductible has been met
• The doctor services you get while you are in a hospital may be filed under Part B.

Medicare Part B covers medically-necessary services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. Thanks to Healthcare Reform, Medicare Part B also now covers a greater number of preventative services. You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.*

Medicare Part B covers things like:

• Clinical research
• Ambulance services
• Durable medical equipment
• Mental health
• Inpatient services
• Outpatient services
• Partial hospitalization
• Getting a second opinion before surgery
• Limited outpatient prescription drugs

Note: If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Medicare Part B covers certain preventive services, which are listed in the Medicare handbook. The list includes:

• Abdominal Aortic Aneurysm Screening
• Bone Mass Measurement
• Cardiovascular Screenings
• Colorectal Cancer Screenings
• Diabetes Screenings
• Diabetes Self-management Training
• Flu Shots
• Glaucoma Tests
• Hepatitis B Shots
• Mammograms
• Medical Nutrition Therapy Services
• Pap Tests and Pelvic Exams
• Physical Exam (one-time “Welcome to Medicare” physical exam)
• Pneumococcal Shot
• Prostate Cancer Screenings
• Smoking Cessation Counseling

Medicare Part B helps pay for durable medical equipment such as:

• Oxygen equipment
• Wheelchairs and walkers
• Other medically necessary equipment that your doctor prescribes to use in your home

Other items covered by Medicare include:

• Arm, leg, back and neck braces
• Medical supplies such as ostomy bags
• Surgical dressings, splints and casts
• Breast prostheses following a mastectomy
• One pair of eyeglasses with an intraocular lens after cataract surgery

Note: Medicare pays for different kinds of durable medical equipment in different ways. Some equipment must be rented, other equipment must be purchased. 1-800-Medicare can provide more specific information. You can also visit the “Your Medicare Coverage” section of the Medicare website for more information regarding the Original Medicare Plan by clicking here.

Medicare offers a wide range of services and coverage for diabetic individuals, including:

Diabetes Self-Management Training
Diabetes outpatient self-management training is a covered program to teach you to manage your diabetes. It includes education about self-monitoring of blood glucose, diet, exercise, and insulin.

If you’ve been diagnosed with diabetes, Medicare may cover up to ten hours of initial diabetes self-management training. You may also qualify for up to two hours of follow-up training each year if it is provided in a group of 2 to 20 people*, it lasts for at least 30 minutes, it takes place in a calendar year following the year you got your initial training, and your doctor or a qualified non-physician practitioner ordered it as part of your plan of care.

*Some exceptions apply if no group session is available or if your doctors or qualified non-physician practitioner says you have special needs that prevent you from participating in group training.

Yearly Eye Exam
Medicare covers yearly eye exams for diabetic retinopathy.

Foot Exam
A foot exam is covered every six months for people with diabetic peripheral neuropathy and loss of protective sensations, as long as you haven’t seen a foot care professional for another reason between visits.

Glaucoma Screening
Medicare covers glaucoma screening every 12 months for people with diabetes or a family history of glaucoma, African Americans age 50 and older, or Hispanics age 65 and older.

Medical Nutrition Therapy Services
Medical nutrition therapy services are covered for people with diabetes or kidney disease when referred by a doctor. These services can be given by a registered dietitian or Medicare-approved nutrition professional and include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.

Diabetes Screening (Fasting Plasma Glucose Test)
Medicare covers tests to check for diabetes. These tests are available if you have any of the following risk factors: high blood pressure, dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a history of high blood sugar. Medicare also covers these tests if you have two or more of the following characteristics:

• age 65 or older
• overweight
• family history of diabetes (parents, brothers, sisters)
• a history of gestational diabetes (diabetes during pregnancy)
• or delivery of a baby weighing more than 9 pounds

 

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.

For more information about diabetes outpatient self-management training from a Medicare-certified program, routine foot care, glaucoma screening, eye exam for diabetic retinopathy, medical nutrition therapy services, or diabetes screening (Fasting Plasma Glucose Test) call your Medicare Carrier. For more information about diabetes outpatient self-management training in an outpatient facility, call your Fiscal Intermediary. To get their telephone number, call 1-800-MEDICARE (1-800-633-4227).

Usually, no. Most nursing home care is custodial care (help with bathing, dressing, using a bathroom, and eating). This care is not covered by Medicare. Medicare Part A only covers skilled care given in a certified skilled nursing facility. You must meet certain conditions and coverage is limited. For more information about Medicare skilled nursing care, please see “Medicare Coverage of Skilled Nursing Facility Care” on the Medicare website by clicking here.

If you have limited income and resources, Medicaid may help cover nursing home costs. For more information about Medicaid, call your State medical assistance office.

Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. In rare cases, Medicare Part B will pay for certain dental services. In addition, Medicare Part A will pay for certain dental services that you get when you are in the hospital. Some Medicare Advantage plans may include dental benefits.

You can file for Medicare online using the Social Security website when you file for retirement or disability. You also can file for just Medicare if you do not wish to start receiving your retirement benefits.

If you do not wish to apply online you can make an appointment by calling 1-800-772-1213. People who are deaf or hard of hearing may call the Medicare “TTY” number, 1-800-325-0778, between 7 a.m. and 7 p.m. on business days.

If you are already receiving Social Security benefits, you will automatically be enrolled in Medicare Parts A and B. However, because you must pay a premium for Part B coverage, you have the option of turning it down. You will be contacted by mail a few months before you become eligible and given all the information you need. (Note: Residents of Puerto Rico or foreign countries will not receive Part B automatically. They must elect this benefit.)

Social Security website

Some people don’t need Medicare Part B because they are still covered by an employer group plan or their spouse’s health plan. However, if you do not join Part B right away and you are not covered under another health care plan, the Part B premium will increase 10 percent each year after you were first eligible to purchase it. Call 1-800-MEDICARE (1-800-633-4227) for more information, 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

Most people sign up for and buy Medicare Part B. If you want to join a Medicare Supplement or Medicare Advantage plan, you will need to have both Medicare Parts A and B. Call the Social Security Administration at 1-800-772-1213 or visit their website for more information or to enroll.

Social Security website

Even if you keep working after you turn 65, you should sign up for Medicare Part A. If you have health coverage through your employer or union, Part A may still help pay some of the costs not covered by your group health plan. Call the Social Security Administration at 1-800-772-1213 to sign up. However, you may want to wait to sign up for Medicare Part B if you or your spouse are working and have group health coverage through you or your spouse’s employer or union. (See note below if you work for a small company.) You would have to pay the monthly Medicare Part B premium, and the Medicare Part B benefits may be of limited value to you as long as the group health plan is the primary payer of your medical bills. In addition, you would start your 6-month Medigap open enrollment period during a time when it will not be of most use to you. For more information on your Medigap open enrollment period, please click here.

Note: If you are age 65 or older and working for a small company (less than 20 employees), you should talk to your employee health benefits administrator before making any decision not to take Medicare Part B. If your employer has less than 20 employees, Medicare is the primary payer and your group health insurance would be the secondary payer. To learn more, please click here.

If you are disabled and working (or you have coverage from a working family member), the Special Enrollment Period rules also apply. Call the Social Security Administration at 1-800-772-1213 or visit their website for more information.

There are many factors to consider before choosing Medicare coverage, such as:

• Cost — What will you pay out-of-pocket, including premiums?
• Doctor and hospital choice — Can you see the doctor(s) you want to see? Do you need a referral to see a specialist? Can you go to the hospital you want?
• Convenience — Where are the doctor’s offices? What are their hours? Is there paperwork? Are they accepting new patients? Do you spend part of each year in another state?
• Prescription drugs — Are they covered? Are your prescription drugs on the plan’s list of covered drugs (formulary)?
• Pharmacy choice — Can you use the pharmacy you want? Are the pharmacies convenient?
• Quality of care — How is the quality of the plans in your area? Information about quality is available at on the Medicare.gov.
• Benefits — Are extra benefits and services, like additional drug coverage, eye exams or hearing aids covered? (These may be covered by some plans.)

A list of participating physicians in your area can be found on the Medicare.gov website here.

Medicaid is a joint Federal and State program that helps pay medical costs for some people with limited incomes and resources. To qualify for Medicaid, you must have a low income and few savings or other assets. Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not paid for by Medicare. Medicaid has programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have a low income.