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  • Medicare Experience

What Does Medicare Cover?

Learn which services and care are covered by Part A and Part B coverage.

Medicare consists of Parts A and B, otherwise known as hospital and medical coverage.


Part A hospital insurance covers inpatient care, skilled nursing facility, home health care, surgery, lab tests, and hospice.


Part B medical insurance covers doctor services and outpatient care, as well as home health care, medical equipment, and a variety of preventive services.


What Medicare Covers: Part A and Part B

Here, we’ll go through the covered services and care provided under Medicare (Parts A and B), so that you have a good understanding of what Medicare covers and how it might apply to your health care.



Medicare Part A Hospital Coverage

Part A is known as your hospital insurance. It is one of two parts that make up Original Medicare, which is the basic coverage provided through enrollment.

Part A helps to cover costs for in-patient care in a hospital and skilled nursing facility, as well as home health care and hospice care services.


Most individuals are eligible for Part A once they reach the age of 65. Some are eligible for Medicare before turning 65, such as in the case of disability or End-Stage Renal Disease.

Most commonly, people do not have to pay a monthly premium for Part A.

If you sign up for Medicare Part A, you will receive coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. We’ll take an in-depth look at each of these options.



Inpatient Hospital Care

1. Inpatient Hospital Care

For those admitted to a hospital by a physician, Part A covers certain services during your stay. This coverage extends for up to 90 days during each benefit period.


You also have an additional 60 lifetime reserve days. For inpatient care at a psychiatric hospital, Part A covers up to 190 lifetime reserve days.


Covered Inpatient Hospital Care Services Include:

  • Semi-private rooms

  • General nursing

  • Drug treatment

  • Meals

  • Hospital services and supplies

Inpatient Hospital Care Includes: inpatient care you receive in acute care hospitals, critical access hospitals, rehabilitation facilities, long-term care hospitals, qualifying clinical research studies, and psychiatric hospitals (limited to 190 days in a lifetime).


How to Qualify for Inpatient Hospital Care:

  • Inpatient stay must be in a Medicare-covered hospital or psychiatric hospital.

  • A doctor must determine that hospital care is necessary for treatment.


Your Costs (2022):

Your deductible for each benefit period is $1,556.

Once this deductible amount is met:

Days 1 – 60: Your coinsurance costs are $0.

Days 61 – 90: Your coinsurance costs are $389 per day.

Days 91 – 150: Your coinsurance costs are $778 per day.

From day 151 and on you will have used up your lifetime reserve days. Once you have exhausted your lifetime reserve days you are responsible for all costs.


Medicare only pays for these lifetime reserve days once. So, if a new benefit period begins, you will begin paying for all costs after the 90th day.



Long-Term Care Hospital Services:


Part A also covers the cost of care in a long-term care hospital. These are hospitals that specialize in treating patients hospitalized for 25+ days.


This might be a patient using a ventilator for an extended period or a patient with a severe wound or injury.


After discharge from a long-term care hospital, many patients move on to care in a Skilled Nursing Facility or custodial care in a long-term facility.

The cost structure is the same as listed above for inpatient hospital care. However, you do not have to pay an additional deductible if you were already charged one for prior hospitalization in the same benefit period.


Your benefit period starts on the first day of your initial hospital stay and counts toward this deductible. This is common if you have been transferred to long-term care from an acute care hospital or have been admitted to long-term care within 60 days of being discharged from a hospital.


Inpatient Mental Health Care Services:

Part A covers mental health care services received in a hospital that requires inpatient admittance. These services help patients with conditions like depression and anxiety.

The cost structure is the same as listed above for inpatient hospital care. However, for inpatient mental health care your costs will include 20% of the Medicare-approved services you receive while a hospital inpatient.

You can receive this care in a general hospital or a psychiatric hospital that cares specifically for people with mental health conditions. There is no limit to your number of benefit periods when receiving mental health care in a general hospital.


However, if you are an inpatient in a psychiatric hospital, Part A has a lifetime limit of 190 days. Also note that Medicare does not cover private duty nursing, personal items, a private room (unless medically necessary), or a phone or TV in your room.



Skilled Nursing Facility Care

2. Skilled Nursing Facility Care

Part A covers a range of services provided in a Skilled Nursing Facility by a skilled nurse of therapist. Typically, this care is for when you require skilled nursing or therapy to treat, manage, and observe your condition.


This coverage extends for up to 100 days each benefit period and also covers your room and board in the facility. It does not, however, include custodial or long-term care.

Covered Skilled Nursing Facility Services:

  • Tube feedings

  • Wound care

  • Medications

  • Medication administration

  • Medical supplies and equipment used in the facility

  • Dietary counseling

  • Medical social services

  • Swing bed services

  • Semi-private room

  • Meals

  • Ambulance transportation (when your health requires it) to nearest supplier of needed services.


The following services are also covered if required to meet your health goal:

  • Physical therapy

  • Occupational therapy

  • Speech-language pathology services

How to Qualify for Skilled Nursing Facility Care:

  • You have spent 3 consecutive days as an inpatient at a hospital.

  • You receive your skilled nursing care within 30 days of your inpatient stay.

  • A doctor has determined you require skilled care on a daily basis.

  • You need skilled services for a medical condition that is hospital-related or started while receiving care for such a medical condition.

Your Costs (2022):

Days 1 – 20: Your costs are $0 for each benefit period.

Days 21 – 100: Your coinsurance costs are $194.50 per day.

Day 101 and on: You are responsible for all costs associated with this care.



Hospice Care

3. Hospice Care

For those that are terminally ill, Part A will cover necessary care to manage symptoms and control your pain. Part A also covers respite care and some medical equipment for use at your home.


This coverage is extended for as long as your healthcare provider determines you need the care. You will find that once you choose hospice care, Part A will generally cover all of your needs.


Covered Hospice Care:

  • Any items or services needed for pain relief and symptom management

  • Prescription drugs for pain relief or symptom control

  • Any medical, nursing, and social services

  • Durable medical equipment

  • Short-term inpatient care for pain and symptom management

  • Short-term respite care up to 5 days at a time

  • Hospice aide and homemaker services

  • Physical therapy services

  • Occupational therapy services

  • Speech-language pathology services

  • Dietary counseling

  • Grief and loss counseling for you and your family

Important Hospice Care Note: Your Part A hospice care does not pay for your stay in a facility unless a short-term stay is determined necessary for pain or symptom management. If this is the case, the facility must be Medicare-approved.

How to Qualify for Hospice:

  • Both your regular doctor and hospice doctor have certified you are terminally ill with a life expectancy of 6 months or less.

  • You accept palliative care (aimed at comfort) rather than care aimed at curing your illness.

  • You choose hospice care through a signed statement rather than other Medicare benefits that treat your terminal illness and other conditions.

Important Note: Once your hospice care begins, Medicare won’t cover the following:

  • Room and board for hospice care in your home, nursing home, or hospice inpatient facility.

  • Treatment aimed at curing your terminal illness or related conditions.

  • Prescription drugs aimed at curing your illness.

  • Care from a hospice provider not designated by the hospice medical team.

  • Hospital outpatient care, hospital inpatient care, or ambulance transportation (unless arranged by your hospice team or unrelated to your terminal illness).

Your Costs:

Your cost for hospice care is $0.

Note, however, that Medicare does not cover room and board for hospice care in your home, nursing home, or similar facility. Two other potential costs to be aware of are:

  • In the case of respite care, you may need to pay 5% of the Medicare-approved amount.

  • For prescription drugs and other pain relief products, you may need to pay a copayment of no more than $5.



Home Health Care

4. Home Health Care

For those that are homebound and in need of skilled care, Part A will cover part-time skilled care in your home.


For daily care, this coverage lasts for up to 100 days. For intermittent care, your coverage is unlimited.


Home Health Care Covers:

  • Part-time or intermittent skilled nursing care

  • Part-time or intermittent home health aide services

  • Medical social services

  • Physical therapy

  • Occupational therapy

  • Speech-language pathology services

Home Health Care May Also Include:

  • Medical supplies for use at home

  • Injectable osteoporosis drugs

  • Durable medical equipment

Important Home Health Care Note: Medicare does not cover personal care such as help bathing, dressing, or using the bathroom when this is the only care that you require.


Additionally, Medicare does not cover 24-hour at home care, meals delivered to your home, or homemaker services.

How to Qualify for Home Health Care:

  • You are under the care of a doctor, which includes receiving services under a plan created and reviewed by the doctor.

  • A doctor has certified that you are homebound.

  • A doctor has certified that you need one or more of the following: Intermittent skilled nursing care (not including drawing blood), physical therapy, occupational therapy, or speech-language pathology.

  • These services must be specific and determined safe and effective treatment for your condition.

  • The amount, frequency, and duration of services must be reasonable and require a qualified therapist to perform.

  • The home health agency caring for you is Medicare-approved.

Important Home Health Care Eligibility Notes:

  • You are not eligible for home health care if you require more than part-time or intermittent skilled nursing care.

  • You can leave home under certain conditions, such as for medical treatment, short or infrequent non-medical absences (ex: religious services), and adult day care.

Your Costs:

Your cost for home health care services is $0.

Note, however, that if you require any durable medical equipment, you will be responsible for 20% of its Medicare-approved amount.

Home Health Care Costs Note: Before starting your home health care, your home health agency should detail for you how much of your costs Medicare will pay.


If there are any items or services of your care that Medicare doesn’t cover, your agency should inform you of this too, along with how much you will be required to pay. This notice required of your home health agency is called the Advance Beneficiary Notice.


Medicare Part B Medical Coverage:

Part B is known as your medical insurance. It is the second part of Original Medicare coverage. Part B helps to cover costs for medical services that extend beyond inpatient treatment, such as medically necessary services and preventive services.

While it is part of Original Medicare, enrollment in Part B is optional. Some individuals choose to defer enrollment if they are working past 65, though Part B can be used in coordination with employer coverage, as well.

If you are eligible for Medicare Part A, then you are also eligible to enroll in Part B coverage.

Part B covers both medically necessary services and preventive services. This includes some of the more expensive services you might experience during a hospital stay, procedures like surgery, radiation, and chemotherapy.


It also covers a number of preventive care measures such as flu shots, colonoscopies, and mammograms.



Medically Necessary Services

5. Medically Necessary Services

Medically necessary services include any services and supplies used for diagnosis and treatment of medical conditions.


These services and supplies must meet the accepted standards of medical practice. This includes the use of durable medical equipment like wheelchairs, hospital beds, and oxygen equipment.



Medically Necessary Services Cover:

  • Wheelchairs

  • Scooters

  • Canes

  • Walkers

  • Crutches

  • Patient lifts

  • Traction equipment

  • Hospital beds

  • Pressure-reducing beds and mattresses

  • Commode chairs

  • Suction pumps

  • Oxygen equipment

  • CPAP devices

  • Blood sugar monitors and test strips

  • Infusion pumps and supplies

  • Lancets and lancet devices

  • Nebulizers and nebulizer medications

  • Continuous passive motion devices

Your Costs:

Your costs will depend on a few factors. For starters, does your durable medical equipment supplier accept assignment? If yes, then you pay 20% of the Medicare-approved amount. Also, in this case, the Medicare Part B deductible applies ($233 for 2022).

Another factor is that Medicare may cover the costs in different ways, depending on the type of equipment you require and your qualifying diagnosis. For example: Whether you need to rent or buy the equipment will impact your costs.

Note: Medicare only provides coverage for durable medical equipment if your doctors and equipment suppliers are enrolled in Medicare and meet all of their standards. Also, note that if your suppliers participate in Medicare, they must accept assignment.


However, if your supplier is enrolled in Medicare but not participating, they can choose whether or not to accept assignment.



Preventive Services

6. Preventive Services:

Preventive services cover healthcare to prevent illness or detect it early enough for optimal treatment. This includes diagnostic tests like MRIs, EKGs, CT scans, and X-rays.


It also applies to covered screenings such as pap tests, HIV screening, glaucoma tests, hearing tests, diabetes screening, and colorectal cancer screenings.


If your healthcare provider accepts assignment, you often don’t have to pay anything for these preventive services.



Preventive Services Cover:

  • Abdominal aortic aneurysm screening

  • Cardiovascular disease screening

  • Cervical and vaginal cancer screening

  • Depression screening

  • Diabetes screening

  • HBV infection screening

  • Hepatitis C screening

  • HIV screening

  • Lung cancer screening

  • Prostate cancer screening

  • Colorectal cancer screening (multi-target stool DNA tests, screening barium enemas, screening colonoscopies, screening fecal occult blood tests, screening flexible sigmoidoscopies)

  • Mammograms

  • Alcohol misuse screening and counseling

  • Obesity screening and counseling

  • Sexually transmitted infections screening and counseling

  • Tobacco use cessation counseling

  • Bone mass measurements

  • Cardiovascular disease behavioral therapy

  • Diabetes self-management training

  • Glaucoma tests

  • Nutrition therapy services