Medi­care 101: What do Medi­care A and B cover?

Rappahannock News - - NEWS - BY NANCY B. O’CONNOR

More than 47 mil­lion se­niors age 65 and older, and peo­ple with cer­tain dis­abil­i­ties and med­i­cal con­di­tions, get their health care cov­er­age through Medi­care. While Medi­care cov­ers many health care ser­vices, it does not cover ev­ery­thing. In fact, peo­ple are of­ten sur­prised at the items and ser­vices that Medi­care does not cover.

So what does, and doesn’t, Medi­care cover? For those with orig­i­nal, fee- for- ser­vice Medi­care, the fol­low­ing lists of­fer the high­lights.

Ser­vices Medi­care Part A (“Hospi­tal In­surance”) does cover: •In­pa­tient hospi­tal care. •In­pa­tient care in a skilled nurs­ing fa­cil­ity for a lim­ited num­ber of days, fol­low­ing a qual­i­fy­ing three-day min­i­mum in­pa­tient hospi­tal stay for a re­lated ill­ness or in­jury.

•Home health ser­vices as or­dered by a doc­tor (or other health care provider), in­clud­ing nurs­ing care; phys­i­cal, speech or oc­cu­pa­tional ther­apy; med­i­cal so­cial ser­vices; home health aide ser­vices and med­i­cal sup­plies for use at home.

•Hospice care if you have a ter­mi­nal ill­ness with a life ex­pectancy of six months or less, as cer­ti­fied by a doc­tor, at home or fa­cil­ity where you re­side. Lim­ited cov­er­age for stays in a hospice fa­cil­ity, hospi­tal or skilled nurs­ing fa­cil­ity for pain or symp­tom man­age­ment.

Ser­vices Medi­care Part A does not cover in­clude:

• Cus­to­dial care or longterm care in a skilled nurs­ing fa­cil­ity or nurs­ing home. Cus­to­dial care in­cludes non­skilled per­sonal care, like help with bathing, dress­ing, eat­ing, get­ting in and out of a bed or chair, or toi­let­ing. •Pri­vate duty nurs­ing. Con­fu­sion of­ten ex­ists about Medi­care cov­er­age and nurs­ing homes. Medi­care does not pay for room and board costs or non-skilled per­sonal (cus­to­dial) care in a nurs­ing home, or long term care or as­sisted liv­ing fa­cil­ity. It does cover Medi­care-ap­proved med­i­cal care and ser­vices, or­dered and ren­dered by a Medi­care-en­rolled health care provider, such as a doc­tor or phys­i­cal ther­a­pist, to the ben­e­fi­ciary who is a res­i­dent.

Ser­vices Medi­care Part B (“Med­i­cal In­surance”) does cover:

• Doc­tors’ vis­its, ser­vices and tests; out­pa­tient care and ser­vices; some home health ser­vices not cov­ered un­der Part A; cer­tain durable med­i­cal equip­ment (DME), pros­thet­ics, or­thotics and sup­plies.

•Medi­care-cov­ered ser­vices pro­vided by non- physi­cian health care providers, such as nurse prac­ti­tion­ers, physi­cian as­sis­tants, so­cial work­ers, psy­chol­o­gists, phys­i­cal ther­a­pists and oth­ers.

•Many pre­ven­tive ser­vices and tests.

•Out­pa­tient men­tal health care.

• Kid­ney dial­y­sis ser­vices and sup­plies.

• Am­bu­lance trans­port for med­i­cally-nec­es­sary ser­vices (lim­ited).

• Chi­ro­prac­tic ser­vices (lim­ited).

• Eye­glasses (lim­ited to af­ter-cataract surgery that im­plants an in­traoc­u­lar lens).

• Some pre­scrip­tion drugs (i.e. in­jec­tions in doc­tor’s of­fice, cer­tain oral can­cer drugs).

• Trans­plants and im­muno­sup­pres­sive drugs.

Things that are not cov­ered by Medi­care, un­der ei­ther Parts A or B, in­clude rou­tine dental care, den­tures, hear­ing aids and ex­ams for fit­ting hear­ing aids, cos­metic surgery and acupunc­ture

For those who get cov­er­age through a Medi­care Ad­van­tage Plan (Medi­care Part C), the story is some­what dif­fer­ent. Medi­care Ad­van­tage Plans are of­fered by Medi­care-ap­proved pri­vate in­sur­ers, and must cover all the ser­vices cov­ered un­der orig­i­nal Medi­care, ex­cept hospice care, which con­tin­ues to be cov­ered by orig­i­nal fee-for-ser­vice Medi­care even when a per­son is en­rolled in a Medi­care Ad­van­tage Plan.

Th­ese plans, which may charge a pre­mium, de­ductible and co-in­surance, may in­clude ex­tra ben­e­fits and ser­vices not cov­ered un­der orig­i­nal fee-forser­vice Medi­care, such as dental and vi­sion care, glasses, hear­ing aids and health and/or well­ness pro­grams. Most plans also in­clude pre­scrip­tion drug cov­er­age, avail­able to those in orig­i­nal Medi­care un­der Part D.

In­for­ma­tion about what Medi­care does and doesn’t cover is avail­able in the “Medi­care & You” hand­book, up­dated and mailed an­nu­ally to ev­ery ben­e­fi­ciary in Oc­to­ber, and also avail­able at medi­care.gov. This Medi­care web­site is also a great source of in­for­ma­tion, as is 1800-MEDI­CARE (633-4227) – TTY users call 1-877-486-2048 – where trained cus­tomer ser­vice rep­re­sen­ta­tives can help. In ad­di­tion, VICAP, the Vir­ginia State Health In­surance Pro­gram, can pro­vide per­son­al­ized help in your com­mu­nity; call 1-800-552-3402 to get the help you need.

Nancy B. O’Connor is the Medi­care Re­gional Ad­min­is­tra­tor for the states of Delaware, Mary­land, Penn­syl­va­nia, Vir­ginia, West Vir­ginia and the District of Columbia. You can get al­ways get an­swers to your Medi­care ques­tions by call­ing 1-800MEDICAR­E (1-800-633-4227).

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