What Is It?
Original Medicare has two parts. Part A covers hospital visits and Part B covers medical services.
There are several different types of hospital visits covered under Part A: inpatient, nursing facilities, long term care hospital stays, hospice, and home health services.
Inpatient hospital care covers meals, drugs, nursing assistance, semi-private rooms, mental health care, and other necessary services and supplies. These are short-term stays, but you may be transferred to long term nursing facility or specialized hospital if necessary.
If you need long term care (LTC), consider purchasing specialized insurance because Medicare has limitations on LTC services. If you need to be placed in a nursing facility, Medicare will only cover 100% of the costs for the first 20 days. After that, your share of the bill becomes greater: $157.50 per day in coinsurance between days 21 and 100, and all of the costs after day 100. Generally, a longer hospital or nursing home stay is needed for rehabilitation, recovery, and therapy. You need to be placed in a Medicare-approved treatment facility after staying in a hospital as an inpatient for three days and have a hospital-related medical condition which requires additional care.
Your condition may require you to visit a long term care hospital. Medicare will help to cover your stay if you have more than one serious illness, but could recover enough to eventually be returned home with the right hospital care.
Hospice, or end of life care, is also covered under Part A. You will qualify if your doctor has certified that you have fewer than six months or less to live and need palliative care, which is focused on comfort rather than treatment. The services included are pain medications, therapy, counseling for you and your family, short term inpatient or respite care, medical equipment, and nursing or aide support.
The last type of coverage, home health services, are covered under Part A and B. If your condition requires occasional visits from a nurse, aid, physical therapist, or occupational therapist, then you may qualify. You must be certified by your doctor as homebound, meaning you are unable to leave your home to receive the medical services you need.
Part B covers services and supplies that are necessary to treat or diagnose a medical issue. It also covers preventable services, like flu shots. Original Medicare includes services like clinical research, ambulance rides, medical equipment, mental health services, certain prescription drugs, and getting a second doctor’s opinion on prior to surgery.
Sometimes, people with certain ailments or conditions, like dementia or cancer, opt to take part in clinical research trials for new medications. Especially if other forms of treatment have failed in the past, it may be a viable option. Clinical trials are included in Part B, as long as you pay 20% of the Medicare-approved amount for the study. Your insurance will also help to pay for your hospital stay and any treatments you need as a result of the study’s side effects.
Should you experience a severe medical incident which requires an urgent hospital visit, your Part B insurance will help pay for ambulance transportation. If you are in a location that cannot be accessed easily by roads, then a helicopter or airplane ambulance can serve as the replacement. Any non-emergency situations should be handled without ambulance services, as they will not be covered.
Your doctor can prescribe medical equipment for your use at home. As long as it’s a medical necessity and is long lasting, then you will only have to pay 20% of the Medicare-approved amount for medical devices. The list of acceptable equipment includes (but is not limited to) walkers, nebulizers, hospital beds, and blood sugar monitors.
Your physical health and mental health are both equally important. Therefore, Part B covers a variety of counseling and therapy services, in addition to inpatient stays in a psychiatric hospital. Preventative measures are also covered, like annual wellness checks and depression screenings.
In general, you should consider purchasing Medicare Part D if you take regular prescription medications. Certain drugs are covered in Part B. For example, medications required with durable medication equipment like an infusion pump. Preventative vaccinations, like the flu shot, certain cancer drugs, and other drugs that “you wouldn’t usually give to yourself, like those you get at a doctor’s office or hospital outpatient setting” are also covered.
When your doctor recommends surgery for a non-life threatening medical concern, Medicare allows you to seek a second opinion. Of course, certain surgeries, like cosmetic procedures are not covered by Medicare anyway. On the other hand, you should not wait to get a second opinion for emergency procedures like appendicitis, artery blockage, or an aneurysm.
How Much Does It Cost?
Much like the services covered under each part of Original Medicare, the costs are separate.
Under Medicare Part A, you will not have a monthly premium to pay if either you or your spouse contributed to Medicare while still working. Most people receive Part A for free. If you have to buy Part A because you don’t qualify for the exemption, it will cost you up to $407 per month.
The only other costs associated with Part A are for inpatient hospital visits. These are broken down as follows: $1,260 deductible for each benefit period and $0 in coinsurance for the first 60 days of inpatient stay(s). Days 61-90 are $315 per day in coinsurance during the benefit period. After day 90, you pay $630 in coinsurance per “lifetime reserve day”.
The costs of Part B are relatively low. The monthly premium is calculated based on your most recent tax returns. If you made $85,000 or less as an individual or $170,000 or less in a joint tax return in 2013, then your monthly premium in 2015 is $104.90. The highest income bracket pays $335.70 per month.
Additional costs include a deductible of $147 per year and 20% of the amount of Medicare-approved for durable medical equipment, doctor services, and outpatient therapy.
For More Information
To learn more about how to qualify and your healthcare insurance options, call 1-800-MEDICARE, or (TTY) 1-877-486-2048.
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