- Medicare is a Federal health insurance program for individuals who are aged (65 years or over) and younger individuals who are disabled.
- Original Medicare consists of Medicare Part A for hospital coverage and Medicare Part B for outpatient medical services.
- Original Medicare only covers 80% of approved medical services and does not cover outpatient prescription medications. Additional insurance is important, otherwise you will have to pay the 20% difference, unless you qualify for Medi-Cal with no share-of-cost.
- Additional Medicare insurance is important to pay the 20% difference or gap that Original Medicare does not , unless you qualify for Medi-Cal with no share-of-cost.
- Sign-up and stay on Original Medicare Part A and Part B when eligible. Then buy a Medicare Supplement plan also known as MediGap, which covers the 20% difference. Unfortunately, this option does not include Part D, which is also required. You will have to enroll in a Part D Plan to cover your prescription medications. Medicare Supplement plans have a monthly premium as do Part D plans; these premiums are in addition to your Part B monthly premium.
- Or, after signing up for Part A and B, you can replace Original Medicare by enrolling in a Medicare Advantage plan (Part C). Medicare Advantage plans cover the same services as Medicare Parts A and B, plus include extra benefits at no extra cost. There are many Medicare Advantage plans that include Part D for prescription drug coverage. Note that the Part B premium will still have to be paid, depending on your income level.
What Does Medicare Part A Cover?
Medicare Part A is hospital insurance that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. It covers inpatient hospital care when:
- You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury;
- The hospital accepts Medicare; and
- In certain cases, the Utilization Review Committee of the hospital approves your stay while you’re in the hospital.
Skilled Nursing Facility (SNF) care is also covered by Medicare Part A in certain conditions for a limited time (on a short-term basis) if all of these conditions are met:
- You have Part A and have days left in your benefit period to use;
- You have a qualifying hospital stay;
- Your doctor has decided that you need daily skilled care. It must be given by, or under the supervision of, skilled nursing or therapy staff;
- You get these skilled services in a SNF that’s certified by Medicare; and
- You need these skilled services for a medical condition that’s either:
- A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay (not including the day you leave the hospital), even if it wasn’t the reason you were admitted to the hospital; or
- A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you’re getting SNF care)
Also covered by Medicare Part A is the cost of long-term care in a long-term care hospital. A long-term care hospital is an acute care hospital that provides treatment for patients who stay, on average, more than 25 days. Most patients are transferred from an intensive or critical care unit. Services provided include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management. You would pay the following for each benefit period:
- Days 1-60: $1,556 Deductible.*
- Days 61-90: $389 Coinsurance each day.
- Days 91 and beyond: $778 Coinsurance for each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime).
- Each day after the lifetime reserve days: All costs.
*You don’t have to pay a deductible for care you get in the long-term care hospital if you were already charged a deductible for care you got in a prior hospitalization within the same benefit period. This is because your benefit period starts on day one of your prior hospital stay, and that stay counts towards your deductible. For example:
- You’re transferred to a long-term care hospital directly from an acute care hospital.
- You’re admitted to a long-term care hospital within 60 days of being discharged from a hospital.
What Does Medicare Part B Cover?
With original Medicare, You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment. Part B covers 2 types of services:
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
Examples of services covered by Part B:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health
- Limited outpatient prescription drugs