What is Medicare?
Medicare is the federal health insurance program for:
- People 65 years of age and older.
- Some people under age 65 who have disabilities.
- People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare has several parts, including:
- Part A (Hospital Insurance)
- Part B (Medical Insurance)
- Part D (Prescription Drug Coverage)
What does Medicare Part A cover?
Medicare Part A helps pay for:
- Care in hospitals as an inpatient
- Critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas)
- Skilled nursing facilities
- Hospice care
- Some home health care
What does Medicare Part B cover?
Medicare Part B (Medical Insurance) helps pay for:
- Doctors’ services
- Outpatient hospital care
- Certain medically necessary services, such as physical and occupational therapists and some home health care
What is Medicare Prescription Drug Coverage?
Medicare Prescription Drug Coverage (also known as Medicare Part D) helps cover your prescription drug costs. Medicare created the new prescription drug plan to help people with Medicare afford prescription drug coverage. It went into effect January 1, 2006. Medicare beneficiaries can only enroll in an organization that has a contract with Medicare, such as Elderplan.
Plus, with Elderplan, there’s no need to enroll in a separate prescription drug plan. That’s because Elderplan is a Medicare Advantage Part D (MA-PD) plan, which includes the Medicare Prescription Drug coverage.
Where can I find out if Medicare covers a service or supply I need?
Answers about what Medicare covers can be found in the “Find Out What Medicare Covers” section on the Medicare website: English | Español. This section of the website provides information about your health care benefits in the Original Medicare plan (sometimes referred to as “fee-for-service”). By searching this database, you will find:
- Some of the services and supplies the Original Medicare plan covers;
- The conditions that must be met for some services or supplies to be covered;
- How often services or supplies are covered (limits);
- How much you pay;
- Who you can contact if you have additional questions;
- Some of the services and supplies the Original Medicare plan does not currently cover.
Please note that some services and supplies are statutorily excluded from Medicare coverage. Congress would need to change Medicare in order for current excluded services and supplies to be covered.
What is the difference between Medicare and Medicaid?
Medicare is an insurance program. Medical bills are paid from trust funds that Medicare beneficiaries have paid into. Medicare primarily serves people over age 65, whatever their income. It also serves younger disabled people and individuals with End-Stage Renal Disease. Patients pay part of costs through deductibles for hospital and other costs. Monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services (CMS), an agency of the federal government.
Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. Medicaid serves low-income people of every age. Patients usually pay 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. It is run by state and local governments within federal guidelines.
What will Medicare cost me?
Premium Amounts (for 2019, may change for 2020):
Depending on your eligibility, there are three possible premiums for Medicare Part A Hospital Insurance.
- Most people do not pay a monthly Part A premium because they or a spouse have 40 or more quarters of Medicare-covered employment.
- The Part A premium is $240 per month for people having 30 – 39 quarters of Medicare-covered employment.
- The Part A premium is $437 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
Part B: (Medical Insurance) Premium:
- $135.50 (in 2019) per month
Medicare Deductible and Co-insurance Amounts:
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible during the first 60 days and co-insurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay:
- $1,364 deductible
- A total of $0 for a hospital stay of 1 – 60 days.
- $341 per day for days 61 – 90 of a hospital stay.
- $682 per day for days 91 – 150 of a hospital stay (Lifetime Reserve Days).
- All costs for each day beyond 150 days.
Skilled Nursing Facility Co-insurance
- A total of $0 for a hospital stay of 1 – 20 days.
- $170.50 per day for days 21 – 100 each benefit period.
- Days 101 and beyond you pay all costs.
Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)
- $185 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $185 deductible).
What are my options for other coverage?
If you have both Medicare Part A and Part B, you can sign up for Medigap insurance or a Medicare Advantage plan from a private provider. These options may offer coverage beyond what Medicare covers. You may also sign up with a Special Needs Plan like Elderplan Medicare for Medicaid Beneficiaries (HMO SNP), Elderplan Medicare for Nursing Home Residents (HMO), or Elderplan Medicare Plus Managed Long-Term Care (HMO SNP) to receive more coverage than Original Medicare. While there are several options to consider, one place to begin a search would be with the Medicare Options Compare on the Medicare website: English | Español. Or, call 1-800-MEDICARE (1-800-633-4227). TTY users can call TTY, 24 hours a day, 7 days a week.