Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Medicare is run by a federal agency called The Centers for Medicare & Medicaid Services (CMS). Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) that are considered medically necessary to treat a disease or condition.
Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) that are considered medically necessary to treat a disease or condition. Medicare only pays for long term care if you require skilled services or rehabilitative care. It does not pay for non-skilled assistance with Activities of Daily Living (ADL), which make up the majority of long-term care services.
Insurance that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
How much does Part A cost?
Premium-free Part A
Most people usually don't pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called "premium-free Part A."
Most people get premium-free Part A.
You can get premium-free Part A at 65 if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You're eligible to get Social Security or Railroad benefits but haven't filed for them yet.
- You or your spouse had Medicare-covered government employment.
If you're under 65, you can get premium-free Part A if:
- You got Social Security or Railroad Retirement Board disability benefits for 24 months.
- You have End-Stage Renal Disease (ESRD) and meet certain requirements.
What if I am not eligible for Premium Free Part A?
If you do not have a sufficient work history or did not pay Medicare taxes you will need to pay a premium for Medicare Part A.
If you must buy Part A, you'll pay up to $422 each month in 2018. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $422. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $232 in 2018.
In most cases, if you choose to buy Part A, you must also have Medicare Part B (Medical Insurance) and pay monthly premiums for both. Contact Social Security for more information about the Part A premium.
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services
Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.
Some services may only be covered in certain settings or for patients with certain conditions.
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.
You pay nothing for most preventive services if you get the services from an approved health care provider
Part B covers things like:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health
- Getting a second opinion before surgery
- Limited outpatient prescription drugs
How much does Part B cost?
Part B premiums
You pay a premium each month for Part B. Most people will pay the standard premium amount.
The standard Part B premium amount in 2017 is $134 (or higher depending on your income). However, most people who get Social Security benefits pay less than this amount. This is because the Part B premium increased more than the cost-of-living increase for 2017 Social Security benefits. If you pay your Part B premium through your monthly Social Security benefit, you’ll pay less ($109 on average). Social Security will tell you the exact amount you'll pay for Part B in 2017.
Part B deductible & coinsurance
- Most doctor services (including most doctor services while you're a hospital inpatient)
- Outpatient therapy
- Durable medical equipment
(Link to “what is medicare part c or medicare advantage” page. It will be a duplicate)
What is Medicare Part D?
Medicare’s drug benefit (Part D) offers outpatient prescription drug coverage for anyone with Medicare. If you have Medicare, you don’t automatically get Medicare Part D prescription drug coverage. This Medicare Part D coverage is optional, but can be valuable if you take medications.
To get Medicare drug coverage, you must join a plan through an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.
2 ways to get drug coverage
- Medicare Prescription Drug Plan (Part D). These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
- Medicare Advantage Plan (Part C) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. You must have Part A and Part B to join a Medicare Advantage Plan.
What are the costs?
Most drug plans charge a monthly fee that varies by plan. You pay this in addition to the part B premium. If you have higher income, you might have to pay more for your Part D Coverage. If you don’t sign up for Medicare Part D Coverage when you’re first eligible, you might have to pay a late-enrollment penalty if you decide to enroll later.
When considering a Medicare Part D plan, you should take into account the coverage you currently have, and all options you are eligible for to see which is the best fit. The number of prescriptions you take, as well as your current plan will both play a role in choosing the best plan. If you are currently enrolled in a Medicare Advantage plan with prescription coverage, you will be disenrolled and return to Original Medicare if you opt in to a Part D plan.
Prescription Coverage Gap
Most Medicare prescription plans have a coverage gap, or a temporary limit on what the plan will cover. Currently, after you and your plan have spent $3,700 on covered drugs, you have reached the coverage gap. Once you reach the coverage gap, you will pay no more than 40% of the price for name brand prescriptions. The amount paid, plus any manufacturer discount will count as your out of pocket expense for name brand drugs. For generic drugs, Medicare will pay 49% of the cost of the drug during the coverage gap. Only the amount paid for generic drugs count towards out of pocket expense to get you out of the coverage gap. For those who receive extra help paying for Part D coverage will not enter the coverage gap.
The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2017, once you and your plan have spent $3,700 on covered drugs, you're in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.
Getting an appeal while in the hospital
If you believe you're being discharged from a hospital too soon, you have the right to an immediate review of your case. The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your area will conduct the review.
Within 2 days of your admission and prior to your discharge, you should get a notice called "An Important Message from Medicare about Your Rights." This notice is sometimes called the Important Message from Medicare or the IM. If you don't get this notice, ask for it. This notice lists the BFCC-QIO's contact information and explains:
- Your right to get all medically necessary hospital services
- Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and to know who will pay for them
- Your right to get the services you need after you leave the hospital
- Your right to appeal a discharge decision and the steps for appealing the decision
- The circumstances under which you will or won’t have to pay for charges for continuing to stay in the hospital
- Information on your right to get a detailed notice about why your covered services are ending
If the hospital gives you the IM more than 2 days before your discharge day, it must do one of these before you're discharged:
- Give you a copy of your original, signed IM
- Provide you with a new one (that you must sign)
How do I ask for a fast appeal?
You may have the right to ask the BFCC-QIO for a fast appeal. Follow the directions on the IM to request a fast appeal if you think your Medicare-covered hospital services are ending too soon. You must ask for a fast appeal no later than the day you're scheduled to be discharged from the hospital. If you ask for your appeal within this time frame, you can stay in the hospital while you wait to get the BFCC-QIO's decision. You won't have to pay for your stay (except for applicable coinsurance or deductibles).
If you miss the deadline for a fast appeal, you can still ask the BFCC-QIO to review your case, but different rules and time frames apply.
What will happen during the BFCC-QIO's review?
When the BFCC-QIO gets your request within the fast appeal time frame, it will notify the plan and the hospital. Once your plan and the hospital are notified by the BFCC-QIO, your plan or the hospital will provide you a "Detailed Notice of Discharge." Your plan or the hospital will provide this notice by noon of the day after the BFCC-QIO notifies the hospital. The notice will include:
- Why your services are no longer reasonable and necessary or are no longer covered
- The applicable Medicare coverage rule or policy, including a citation to the applicable Medicare policy, or information on how you can get a copy of the policy
- How the applicable coverage rule or policy applies to your specific situation
You can also ask your plan for copies of any of the materials that your plan sent to the BFCC-QIO about your hospital discharge. The BFCC-QIO will look at your medical information provided by the hospital and will also ask you for your opinion. The BFCC-QIO will decide if you're ready to be discharged within one day of getting the requested information.
If the BFCC-QIO decides that you're being discharged too soon: Medicare will continue to cover your hospital stay as long as medically necessary (except for applicable coinsurance or deductibles) if one of these applies:
- Your plan previously authorized coverage of the inpatient admission
- The inpatient admission was for emergency or urgently needed care
You may need to appeal the denial of coverage for your plan to pay if:
- Your plan never authorized the inpatient admission
- The inpatient admission wasn’t for emergency or urgently needed care
If the BFCC-QIO decides that you're ready to be discharged and you met the deadline for requesting a fast appeal:You won't be responsible for paying the hospital charges (except for applicable coinsurance or deductibles) incurred through noon of the day after the BFCC-QIO gives you its decision. If you get any inpatient hospital services after noon of that day, you may have to pay for them.
When does Medicare pay for healthcare services or post acute care?
Medicare Part A (Hospital Insurance) covers hospital services, including semi-private rooms, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care you get in these facilities:
- Acute care hospitals
- Inpatient rehabilitation facilities
- Long-term acute care hospitals
All people with Part A are covered when all of these are true:
- A doctor makes an official order which says you need 2 or more midnights of medically necessary care to treat your illness or injury and the hospital formally admits you.
- You need the kind of care that can be given only in a hospital.
- The hospital accepts Medicare.
- The Utilization Review Committee of the hospital approves your stay while you're in a hospital.
Your costs in Original Medicare for 2018
- $1,340 deductible for each benefit period.
- Days 1–60: $0 coinsurance for each benefit period.
- Days 61–90: $335 coinsurance per day of each benefit period.
- Days 91 and beyond: $670 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).
- Beyond lifetime reserve days: all costs.
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Medicare Part A (Hospital Insurance) covers skilled nursing care provided in a skilled nursing facility (SNF) under certain conditions for a limited time.
People with Medicare are covered if they meet all of these conditions:
- You have Part A and have days left in your benefit period.
- You have a qualifying hospital stay, which means an inpatient hospital stay of 3 consecutive days or more. This starts the day you are formally admitted (not getting observation services), but does not include the day you leave the hospital. This is sometimes called the “3-midnight rule,” because being admitted through 3 consecutive midnights in a hospital qualifies you for a SNF admission.
- Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. If you're in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they're offered.
- You get these skilled services in a SNF that's certified by Medicare.
- You need these skilled services for a medical condition that was either:
- A hospital-related medical condition.
- A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.
Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you're getting observation services in the hospital, you're considered an outpatient. Keep in mind, this time does not count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay until you are officially admitted.
Your costs in Original Medicare for 2018
- Days 1–20: $0 for each benefit period.
- Days 21–100: $167.50 coinsurance per day of each benefit period.
- Days 101 and beyond: all costs.
If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.
If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.
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Medicare Part A (Hospital Insurance) may cover care in a certified skilled nursing facility (SNF) if it's medically necessary for you to have skilled nursing care (like changing sterile dressings) following a hospitalization. However, most long term nursing home care is considered custodial care. Medicare doesn't cover custodial care if that's the only care you need.
You can get hospice care if you have Medicare Part A (Hospital Insurance) AND meet all of these conditions:
- Your hospice doctor and your regular doctor or nurse practitioner (if you have one) certify that you’re terminally ill (you're expected to live 6 months or less).
- You accept palliative care (for comfort) instead of care to cure your illness.
- You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.
Only your hospice doctor and your regular doctor or nurse practitioner (if you have one) can certify that you’re terminally ill and have a life expectancy of 6 months or less.
Your costs in Original Medicare
- $0 for hospice care.
- You may need to pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you're at home. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it's covered under Part D.
- You may need to pay 5% of the Medicare-approved amount for inpatient respite care.
- Medicare doesn't cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).
Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) covers eligible home health services like these:
- Intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- Continued occupational services, and more
Usually, a home health care agency coordinates the services your doctor orders for you.
Medicare doesn't pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services
- Personal care
All people with Part A and/or Part B who meet all of these conditions are covered:
- You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of these:
- Intermittent skilled nursing care (other than just drawing blood)
- Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally-predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.
- The home health agency caring for you must be Medicare-certified.
- You must be homebound, and a doctor must certify that you're homebound.
You're not eligible for the home health benefit if you need more than part-time or "intermittent" skilled nursing care.
You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.
Note: Home health services may also include medical social services, part-time or intermittent home health aide services, medical supplies for use at home, durable medical equipment, or injectable osteoporosis drugs.
Your costs in Original Medicare
- $0 for home health care services.
- 20% of the Medicare-approved amount for durable medical equipment.
Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren't covered by Medicare, and how much you'll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the "Home Health Advance Beneficiary Notice" (HHABN) before giving you services and supplies that Medicare doesn't cover.
All Assisted Living and Private Duty Home Care is paid privately or out of pocket by an individual. There is no Medicare benefit for these services.
Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical and occupational therapy, and speech-language pathology services. There are limits on these services when you get them from most outpatient providers. These limits are called “therapy caps” or "therapy cap limits."
The therapy cap limits for 2018 are:
- $2,010 for physical therapy (PT) and speech-language pathology (SLP) services combined
- $2,010 for occupational therapy (OT) services
You may qualify for an exception to the therapy cap limits. If so, Medicare will continue to pay its share for your therapy services after you reach the therapy cap limits. Your therapist or therapy provider must:
- Establish your need for medically reasonable and necessary services and document this in your medical record
- Indicate on your Medicare claim for services above the therapy cap that your outpatient therapy services are medically reasonable and necessary
As part of the exceptions process, there are additional limits (called “thresholds”). If you get outpatient therapy services higher than the threshold amounts, a Medicare contractor may review your medical records to check for medical necessity. The threshold amounts for 2017 are:
- $3,700 for PT and SLP combined
- $3,700 for OT
In general (when an exceptions process is in effect), Medicare will continue to cover its share above the $2,010 therapy cap limits if these apply:
- Your therapist or therapy provider provides documentation to show that your services were medically reasonable and necessary
- Your therapist or therapy provider that your services were medically reasonable and necessary on your claim
Your therapist or therapy provider must give you a written notice before providing generally covered therapy services that aren't medically reasonable and necessary for you at the time. This notice is called an "Advance Beneficiary Notice of Noncoverage" (ABN). In this situation, your therapist or therapy provider must give you the ABN because Medicare doesn't pay for therapy services that aren't medically necessary. The ABN lets you choose whether or not you want the therapy services. If you choose to get the medically unnecessary services, you agree to pay for them.
All people with Part B are covered if Medicare finds that the services are medically reasonable and necessary. Medicare will pay its share for therapy services until the total amounts paid by both you and Medicare reaches either one of the therapy cap limits. Amounts paid by you may include costs like the deductible and coinsurance.
Your costs in Original Medicare
You pay 20% of the Medicare-approved amount, and the Part B deductible applies
Information for this tab is included here: https://www.dropbox.com/s/41brxc57dvzgk2l/When%20does%20Medicare%20pay%20for%20healthcare%20services%20or%20post%20acute%20care%20UPDATED.docx?dl=0
Additional Medicare Information
(Link to “what is medicare part c or medicare advantage” page. It will be a duplicate)
What is the difference between Medicare and Medicaid?
Medicare is an insurance program. Medical bills are paid from trust funds, which were paid into by those who are covered. It primarily serves people over 65, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of their healthcare costs through deductibles for hospital and other copays. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program and is basically the same everywhere in the United States. It is run by the Centers for Medicare & Medicaid Services, an agency of the federal government
Medicaid is an assistance program. It serves low-income people of every age. Patients usually pay little to no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state and is run by state and local governments within federal guidelines. To see if you qualify for your state's Medicaid (or Children's Health Insurance) program, see https://www.healthcare.gov/medicaid-chip/eligibility/
For more information on Medicaid, please go to http://www.medicare.gov/