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What Benefits Does Medicare Provide

The Parts Of Medicare

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Social Security enrolls you in Original Medicare .

  • Medicare Part A helps pay for inpatient care in a hospital or limited time at a skilled nursing facility . Part A also pays for some home health care and hospice care.
  • Medicare Part B helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.

Other parts of Medicare are run by private insurance companies that follow rules set by Medicare.

  • Supplemental policies help pay Medicare out-of-pocket copayments, coinsurance, and deductible expenses.
  • Medicare Advantage Plan includes all benefits and services covered under Part A and Part B prescription drugs and additional benefits such as vision, hearing, and dental bundled together in one plan.
  • Medicare Part D helps cover the cost of prescription drugs.

Most people age 65 or older are eligible for free Medical hospital insurance if they have worked and paid Medicare taxes long enough. You can enroll in Medicare medical insurance by paying a monthly premium. Some beneficiaries with higher incomes will pay a higher monthly Part B premium. To learn more, read .

Do Medicare Supplement Plans Cover Transportation

Medicare Supplement Insurance plans are sold by private insurance companies to work alongside your Original Medicare coverage.

A Medigap plan won’t typically cover transportation, but a Medigap plan can help cover the out-of-pocket Medicare costs that you may face if Medicare covers your transportation.

For example, if your ambulance ride to the hospital is covered by Medicare Part B, some types of Medicare Supplement plans will cover your Part B deductible, and all Medigap plans provide at least some coverage for your Part B coinsurance costs.

Medicare Supplement plans and Medicare Advantage plans are very different things, and you cannot have a Medigap plan and a Medicare Advantage plan at the same time.

What Benefits Does Medicare Provide

If you are eligible for Medicare, you can choose from a range of health plans. The Original Medicare Plan is available in all locations. However, not all of the other choices may be available in your area. A Medicare Personal Plan Finder is available online at www.medicare.gov to help you choose the plan in your area thats best for you.

Medicare’s publication “Medicare & You” explains the rules about which health care services and supplies Medicare covers, what specific benefits you can get, and when you can get them. It also explains how much Medicare pays for each service, and how much you pay.

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Things You Might Not Know About Medicare

There are four parts to the Medicare plan: A, B, C, and D. Each part covers different aspects of healthcare. You can enroll in one or more parts of Medicare, but the most common parts people enroll in are parts A and B, known as original Medicare. These parts cover the majority of services. People usually have to pay a monthly premium, but this varies widely based on income.

Part A also provides limited coverage for skilled nursing facilities if you have a qualifying inpatient hospital stay three consecutive days resulting from a formal inpatient admission order written by your doctor.

How Long Does Medicare Coverage Last For Home Health Care

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Medicare coverage for home health care is designed for those who need intermittent skilled nursing care for a short period. It isnt meant for an extended period.

Intermittent is defined as care thats needed for:

  • Fewer than 8 hours each day
  • Fewer than 7 days a week
  • Up to 21 days

The 21-day limit for Medicare-covered home health care may be extended if your doctor can predict how much longer youll need skilled nursing care.

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Types Of Services Provided

Different kinds of home health care professionals deliver different services.

Registered nurses or licensed practical nurses under the supervision of a registered nurse deliver skilled nursing care.

This includes:

  • Giving injections, intravenous drugs or tube feedings
  • Teaching about prescription drugs and diabetes care

Some of the tasks home health aides do include:

  • Assessing pain
  • Checking blood pressure, breathing, heart rate and temperature
  • Checking the safety of the home
  • Ensuring medications are being taken correctly
  • Monitoring food and drink intake
  • Teaching patients and caregivers about the plan of care and how to carry it out

Professional therapists provide specific kinds of services, including physical therapy, speech therapy and occupational therapy.

Social workers provide medical social services.

“Your doctor or other health care provider may recommend you get services more often than Medicare covers,” Medicare’s website says. Or they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Medicare home health benefits do not cover full-time skilled nursing care. They also do not cover drugs, housekeeping, meal delivery or transportation.

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Proposals For Reforming Medicare

As legislators continue to seek new ways to control the cost of Medicare, a number of new proposals to reform Medicare have been introduced in recent years.

Premium support

Since the mid-1990s, there have been a number of proposals to change Medicare from a publicly run social insurance program with a defined benefit, for which there is no limit to the government’s expenses, into a publicly run health plan program that offers “premium support” for enrollees. The basic concept behind the proposals is that the government would make a defined contribution, that is a premium support, to the health plan of a Medicare enrollee’s choice. Sponsors would compete to provide Medicare benefits and this competition would set the level of fixed contribution. Additionally, enrollees would be able to purchase greater coverage by paying more in addition to the fixed government contribution. Conversely, enrollees could choose lower cost coverage and keep the difference between their coverage costs and the fixed government contribution. The goal of premium Medicare plans is for greater cost-effectiveness if such a proposal worked as planned, the financial incentive would be greatest for Medicare plans that offer the best care at the lowest cost.

Currently, public Part C Medicare health plans avoid this issue with an indexed risk formula that provides lower per capita payments to sponsors for relatively healthy plan members and higher per capita payments for less healthy members.


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Care Cant Be Full Time

These services are limited to fewer than seven days a week or less than eight hours a day for up to 21 days.

Medicare also covers medical supplies and up to 80 percent of the cost of medical equipment, such as a wheelchair or walker, if a doctor certifies that it is medically necessary.

Home health care has many benefits: It is usually less expensive and more convenient for patients and can shorten their stay in a hospital or skilled nursing facility. It also can help them recuperate faster. Medicare beneficiaries have no copayments for approved services.

“Not only can home health care help to avoid accidents and falls, but it can increase your loved one’s happiness, says Gretchen Jacobson, associate director at the Kaiser Family Foundation.

It’s a popular benefit: From 2002 to 2019, the number of Medicare beneficiaries using home health grew by more than 30 percent, according to a Commonwealth Fund report. There was a 6 percent decline in 2020 as the COVID-19 pandemic took hold, but even that year, there were nearly 2.9 million home health users among beneficiaries, and about 8.9 million home health claims.

Does Medicare Cover Dental Care

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When it comes to Medicare, you have two main options. You can either enroll in Original Medicare or a Medicare Advantage plan. You cannot have both. Understanding the difference is important when it comes to dental care.

Original Medicare is Medicare Part A and Part B. It is referred to as original because these parts of Medicare came into existence when the Social Security Amendments were first passed in 1965.

In 1997, Medicare Part C was created. It was initially called Medicare+Choice, but its name was changed to Medicare Advantage in 2003.

These plans cover everything Original Medicare does, but they are overseen by insurance companies rather than the federal government. The insurance companies are allowed to offer additional services, known as supplemental benefits, above and beyond what Original Medicare covers.

Original Medicare covers dental care, but in limited circumstances. Medicare Advantage plans, on the other hand, can offer dental care as a supplemental benefit.

Depending on the plan you choose, this can include a wider range of services, including but not limited to routine dental cleanings, bridges, crowns, dentures, fillings, root canals, tooth extractions, and X-rays. Most plans set a cap on how much they would pay for dental care annually.

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Reimbursement For Part A Services

For institutional care, such as hospital and nursing home care, Medicare uses prospective payment systems. In a prospective payment system, the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care. The actual allotment of funds is based on a list of diagnosis-related groups . The actual amount depends on the primary diagnosis that is actually made at the hospital. There are some issues surrounding Medicare’s use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of “upcoding”, when a physician makes a more severe diagnosis to hedge against accidental costs.

Medicare Prescription Drug Coverage

Medicare drug coverage helps pay for prescription drugs you need. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage .

Learn more about how to get Medicare drug coverage.

Each plan can vary in cost and specific drugs covered, but must give at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover and how they place drugs into different “tiers” on their formularies.

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How Do Medicare And Social Security Work Together

Youll get Medicare automatically if youre already receiving Social Security retirement or SSDI benefits. For example, if you took retirement benefits starting at age 62, youll be enrolled in Medicare three months before your 65th birthday. Youll also be automatically enrolled once youve been receiving SSDI for 24 months.

Youll need to enroll in Medicare if you turn 65 but havent taken your Social Security benefits yet. The Social Security Administration and Medicare will send you a Welcome to Medicare packet when youre eligible to enroll. The packet will walk you through your Medicare choices and help you enroll.

SSA will also determine the amount you need to pay for Medicare coverage. You wont pay premiums for Part A unless you dont meet the coverage rules discussed above, but most people will pay a premium for Part B.

In 2020, the standard premium amount is $144.60. This amount will be higher if you have a large income. Social Security uses your tax records to determine the rates you need to pay.

If you make more than $87,000 a year, SSA will send you an Income-Related Monthly Adjustment Amount . Your IRMAA notification will tell you the amount above the standard premium you need to pay. Youll also be responsible for an IRMAA if you choose to buy a separate Part D plan and you make over $87,000.

Who Qualifies For Free Medicare Part A

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According to the Centers for Medicare & Medicaid Services, most people do not pay a monthly premium for Medicare Part A coverage. People in the following categories qualify for free Medicare Part A:

  • people already getting retirement benefits from the RRB or Social Security
  • a person who is eligible for retirement benefits from the above agencies but has not filed yet
  • an individual who has Medicare-covered government employment, or their spouse
  • a person with ESRD who meets specific requirements
  • an individual who receives disability benefits for 24 months

Although a person may qualify for premium-free Medicare Part A, they will still have to pay certain deductibles for some services.

Medicare Part A coverage for 2021 includes inpatient hospital stays, which may take place in:

  • acute care hospitals
  • medical equipment that a doctor uses during the inpatient stay
  • rehabilitation services, such as physical therapy

People who use their Medicare Part A coverage for inpatient hospital stays still have to meet their deductible before Medicare funds any treatment. In 2021, this deductible is $1,484.

Once Medicare covers costs, there are often still copayments that depend on the length of stay. For example, Medicare Part A covers the first 60 days of an inpatient stay. However, an individual will have to pay $371 for each additional day between 61 and 90 days.

If an inpatient stay extends beyond 90 days, Medicare provides 60 reserve days that will cost a person $742 a day.

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What Is The Difference Between Medicaid And Medicare

Medicare and Medicaid are different programs. Medicaid is not part of Medicare.

Heres how Medicaid works for people who are age 65 and older:

Its a federal and state program that helps pay for health care for people with limited income and assets. A basic difference is that Medicaid covers some benefits or services that Medicare doesnt like nursing home care or transportation to medical appointments .

Visit your states Medicaid/Medical Assistance website or medicare.gov for more information. Learn more in the article, Can I get help paying my Medicare costs?

Medicare Part A And Part B Leave Some Pretty Significant Gaps In Your Health

Medicare Part A and Part B, also known as Original Medicare or Traditional Medicare, cover a large portion of your medical expenses after you turn age 65. Part A helps pay for inpatient hospital stays, stays in skilled nursing facilities, surgery, hospice care and even some home health care. Part B helps pay for doctors’ visits, outpatient care, some preventive services, and some medical equipment and supplies. Most folks can start signing up for Medicare three months before the month they turn 65.

It’s important to understand that Medicare Part A and Part B leave some pretty significant gaps in your health-care coverage. This is why increasing numbers of Medicare beneficiaries choose to go with Medicare Advantage, which purports to fill some of those gaps.

A private plan through Medicare Advantage can offer more benefits and lower premiums. But a recent report from the Office of Inspector General found that some beneficiaries of Medicare Advantage are denied necessary care.

Here’s a closer look at what isn’t covered by traditional Medicare, plus information about supplemental insurance policies, Medicare Advantage and strategies that can help cover the additional costs, so you don’t end up with unexpected medical bills in retirement.

You can also get a long-term care rider on an annuity, which could help defray the cost of long-term care.

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Should I Sign Up For Medical Insurance

With our online application, you can sign up for Medicare Part A and Part B . Because you must pay a premium for Part B coverage, you can turn it down.

If youre eligible at age 65, your initial enrollment period begins three months before your 65th birthday, includes the month you turn age 65, and ends three months after that birthday.

If you choose not to enroll in Medicare Part B and then decide to do so later, your coverage could be delayed and you may have to pay a higher monthly premium for as long as you have Part B. Your monthly premium will go up 10 percent for each 12-month period you were eligible for Part B, but didnt sign up for it, unless you qualify for a “” .

If you dont enroll in Medicare Part B during your initial enrollment period, you have another chance each year to sign up during a general enrollment period from January 1 through March 31. Your coverage begins on July 1 of the year you enroll. Read our publication for more information.

Late Enrollment Penalties For Medicare Part A And Part B

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Both Medicare Part A and Part B can have late enrollment premium penalties.

The Part A Late Enrollment Penalty

If you must pay a Part A premium and enroll late, you could pay a penalty. The Part A late enrollment penalty is 10% of the Part A premium. You pay the penalty in addition to your Part A premium for twice the number of years you delay enrollment.

Example: If you delay 2 years, you will pay an additional 10% of the Part A premium for 4 years .

The Part B Late Enrollment Penalty

The Part B penalty is 10% of the monthly premium amount for each full 12-month period enrollment is delayed. You pay the Part B premium penalty in addition to your Part B premium for as long as you have Medicare Part B.

Example: You delayed Part B 3 years. To calculate how much your penalty will cost, you’ll multiply x . In this case, x . Thus, your Part B premium penalty will be 30% of the Part B premium.

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