Medicare Part A
Otherwise known as hospital insurance, Part A covers inpatient hospital care, care in skilled nursing care facilities (following a hospital stay), hospice care, and some home health care services.
How much does it cost, and who is eligible?
Most people who qualify for Medicare also qualify for Part A. Part A is funded through federal payroll taxes paid into the Medicare system. As such, most beneficiaries covered under Part A do not have to pay a monthly premium if you or your spouse have paid Medicare taxes for 10 years or 40 quarters to receive coverage at no cost.
What Does Part A Cover?
Inpatient hospital care is covered for all emergency and non-emergency care following admission to the hospital, generally up to 90 days per benefit period in a hospital. It also provides 60 lifetime reserve days and 190 total days of coverage in approved psychiatric hospitals.
Skilled nursing care provides coverage for some services, medications, wound care, and tube feeding received at a skilled nursing facility (SNF). It also requires that the individual was first admitted to a hospital for a minimum of three days. Beneficiaries receive 100 days of SNF care per benefit period provided the care is medically necessary and other requirements are met.
Home health care is usually covered under Medicare Part B. Part A may cover you if it follows a qualifying inpatient hospital stay of at least three days, and coverage continues as long as you meet eligibility and medical necessity criteria.
Hospice care coverage will cover you if you are terminally ill and expected to live six months or less. Medicare will cover hospice care if you continue to meet eligibility requirements and your provider recertifies the need for hospice care. Coverage is structured in benefit periods (initially 90 days) with ongoing recertification requirements.
Medicare Part B
Otherwise known as medical coverage, Part B covers medically necessary outpatient services, procedures, treatments, and preventative services.
How much does it cost, and who is eligible?
Unlike Part A, Part B requires a monthly premium. Part B is paid for by the federal government, monthly premiums, copays, and deductibles.
The premium is determined based on the beneficiary’s yearly gross income reported to the IRS. Those receiving social security benefits will find the premium automatically deducted from their Social Security benefit payment; those who do not will receive a bill. As for coinsurance, you are generally expected to pay 20% of the approved amount after the deductible.
During the Initial Enrollment Period, you are not required to enroll in Part B Medicare coverage. However, it is generally recommended as later enrollment can come with hefty fees.
What Does Part B Cover?
Doctor’s services covered by Part B includes treatment considered medically necessary.
Ambulance services are covered for any ambulance services needed during an emergency. For non-emergent care, ambulance services are covered if there is no alternative transportation and it is medically necessary.
Home health care coverage if medically necessary and ordered by a doctor, residence including part-time or intermittent skilled nursing care, physical therapy, and occupational therapy.
Covered if prescribed for medical reasons and used in the home, Durable medical equipment used repeatedly and serves a medical purpose is covered under Part B. Examples include wheelchairs, hospital beds, crutches, and blood test strips.
Part B covers certain drugs administered in a doctor’s office or hospital outpatient setting, Limited prescription drugs, such as cancer medications, immunosuppressants, dialysis medications, and antiemetic drugs, are covered under part B. Other, more common prescription drugs are covered under part D.
Some early-stage preventative services are covered under Part B. Examples include physical therapy, speech therapy, yearly health screenings, vaccines, and lab work.
Part B may cover some costs for qualifying clinical research studies. Clinical research that is covered could involve diagnostic tests, surgical treatments, testing new treatments, and new medicine.
Mental health services covered include outpatient services, such as individual and group therapy, psychiatric evaluation, and partial hospitalization necessary for diagnosing and treating mental health issues.
What's Not Covered by Parts A & B?
As expected, Medicare Part A & B do not cover everything. In some cases, the services they do not cover will be covered by Parts C, D, and Supplements. However, a basic list of things that Medicare Parts A & B will not cover includes:
- Majority of Dental Care, including dentures
- Eye Exams
- Cosmetic surgery
- Massage Therapy
- Hearing aids and fitting exams
- Any care provided by an opt-out doctor
- Concierge Care
- Long-Term Care
- Out-of-Country Visits
