The Scope of Coverage of Medicare

What services does Medicare cover?

Medicare Part A and Part B cover certain medical services and supplies in hospitals, doctor's offices and other health care settings. Prescription drug coverage is provided by Medicare  Part D. 

If you have both Part A and Part B, you can get all of the Medicare-covered services listed in this section.

PART A COVERAGE

Part A or Hospital Insurance helps cover;

• Inpatient care in hospital
• Inpatient care in skilled nursing facility
• Hospice care
• Inpatient care in a religious non-medical health care institution

You can find out if you have Part A by looking at your red, white and blue Medicare card. If you have it, it will be listed as HOSPITAL and will have an effective date.

Part A-covered services

Blood - If the hospital gets blood from a blood bank at no charge, you won't ave to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

Home health services Hospice Care -  To qualify, a hospice doctor and your doctor must certify that you're terminally ill (you have a life expectancy of 6 months or less). When you agree to hospice care, you agree to palliative care rather than care to cure your illness. You must also sign a statement choosing hospice care  instead of other Medicare-covered treatments. Coverage includes: 

• All items and services needed for pain relief and symptom management
• Medical, Nursing and social services
• Drugs
• Durable medical equipment
• Aide and homemaker services
• Other covered services, as well as services not usually covered by Medicare (spiritual and grief counseling)

Hospital Care (inpatient care) -  Medicare covers semi-private rooms, meal, general nursing and drugs as part of your inpatient treatment and other hospital services and supplies. 

This includes care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long term care hospitals, inpatient care, inpatient mental healthcare given in a psychiatric hospitals and others. 

This doesn't include private-duty nursing, television or phone in your room or personal care items like razors or slipper socks, private room, unless medically necessary. If you have Part B, it generally covers 80% of the Medicare-approved amount for doctor's services you get while you're in a hospital.

Am I an inpatient or outpatient?

Staying overnight in a hospital doesn't always mean you're an inpatient. Your doctor must order your hospital admission and the hospital must formally admit you for you to be an inpatient. Without the formal inpatient admission you're still an outpatient.

You or your caregiver should always ask the hospital and/or your doctor if you're an inpatient or an outpatient each day during your stay since it affects what you pay and can affect whether you'll qualify for Part A coverage or not. 

Medicare Outpatient Observation Notice (MOON)

It is a document that let's you know you're an outpatient in a hospital. You must receive this notice if you're getting observation services as an outpatient for more than 24 hours.  It will also let you know how this may affect what you pay while in a hospital and for care you get after leaving the hospital.

Skilled Nursing Facility Care

Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services and supplies furnished in a skilled nursing facility. These services are only covered after a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury. 

To qualify, your doctor must certify that you need daily skilled care, which as a practical matter, can only be provided to you as an inpatient for  skilled nursing facility. 

YOU PAY:

• Nothing for the first 20 days of each benefit period
• A coinsurance amount of $176 per day for days 21-200 of each benefit  period
• All costs for each day after day 100 in a benefit period

PART B COVERAGE:

Medicare Part B helps cover medically necessary doctor' services, outpatient care, home health services, durable medical equipment, mental health services and preventive services.

PART B-covered Services

Here are the list of the services covered by Medicare Part B.

• Abdominal aortic aneurysm screening

• Advance care planning

• Alcohol misuse screening and counseling

• Ambulance Services

• Ambulatory surgical centers

• Behavioral health integration services

• Blood

• Bone mass measurement

• Breast cancer screening (mammogram)

• Cardiac rehabilitation

• Cardiovascular disease (behavioral therapy)

• Cardiovascular disease screenings

• Cervical and Vaginal cancer screenings

• Chemotherapy

• Chiropractic services (limited coverage)

• Chronic care management services

• Clinical research studies

• Colorectal cancer screenings

• Continuous Positive Airway Pressure therapy

• Defibrillator

• Depression screening

• Diabetes screenings

• Diabetes self-management training

• Diabetes equipment and supplies and therapeutic shoes

• Doctor and other health care provider services

• Durable Medical Equipment (DME)

• EKG or ECG (electrocardiogram) screening

• Emergency department services

• Eyeglass (after cataract surgery)

• Federally Qualified Health Center Services

• Flu shots

• Foot exams and treatment

• Glaucoma tests

• Hearing and balance exams

• Hepatitis B shots

• Hepatitis B Virus infection screening

• Hepatitis C screening test

• HIV (Human immunodeficiency Virus) screening

• Home health services

• Kidney Dialysis services and supplies

• Kidney Disease Education services

• laboratory services

• Lung cancer screening

• Medical nutrition therapy services

• Mental Health Care (outpatient)

• Obesity screening and counseling

• Occupational therapy

• Opioid use disorder treatment services

• Outpatient hospital services

• Outpatient medical and surgical services and supplies

• Physical therapy

• Pneumococcal shots

• Prescription drugs (limited)

• Prostate Cancer screenings

• Prosthetic/Orthotic items

• Pulmonary rehabilitation

• Rural Health Clinic (RHC) services

• Second surgical opinions

• Sexually transmitted infection screening and counseling

• Shots / Vaccines

• Smoking and tobacco-use cessation 

• Speech-language pathology services

• Surgical dressing services

• Telehealth

• Tests (other than lab tests)

• Transitional care management services

• Transplants and immunosuppressive drugs

• Travel ( health care needed when traveling outside the U.S)

• Urgently needed care

• Yearly wellness visit

What's NOT covered by Part A and Part B?

Not everything is covered by Medicare. If you need certain services that aren't covered, you'll have to pay for it unless:

• You have other coverage to cover the costs
• You're in a Medicare Advantage Plan that covers these services.

Some of the items not covered by Original Medicare:

1. Most Dental Care
2. Eye exams related to prescribing glasses
3. Dentures
4. Cosmetic surgery
5. Massage therapy
6. Routine physical exams
7. Acupuncture
8. Hearing aids and exams for fitting them
9. Long-term care
10. Concierge care

Thorough descriptions about each services covered by Medicare Part B will be discussed on the next blog. :)