Medicare in Plain English (page 2)

What does Part A of government Medicare cover?

Here is all that Part A will cover:

1. Hospital care (inpatient care)

Medicare covers semi-private rooms, meals, 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 as part of a qualifying clinical research study, and mental health care. This doesn’t include private-duty nursing, a television or phone in your room (if there’s a separate charge for these items), or personal care items, like razors or slipper socks. It also doesn’t include a 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.

■ You pay a deductible and no coinsurance for days 1–60 of each benefit period.

■ You pay coinsurance for days 61–90 of each benefit period.

■ You pay coinsurance per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime).

■ You pay all costs for each day after you use all the lifetime reserve days.

■ Inpatient psychiatric care in a freestanding psychiatric hospital is limited to 190 days in a lifetime.

Note: In some cases, the hospital or a Medicare contractor may determine you should’ve gotten services in an outpatient setting. The hospital may submit a Part B claim for your services, and the amount you owe may change. You’ll pay your part for Part B services, but you may be able to get a refund for any money you paid for Part A services.

2. Skilled nursing facility care

Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services and supplies after a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day the hospital formally admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged. You may get coverage of skilled nursing care or skilled therapy care if it’s necessary to:

■ Help improve your condition or

■ Maintain your current condition or prevent or delay it from getting worse

To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy.

You pay:

■ Nothing for the first 20 days of each benefit period

■ A coinsurance per day for days 21–100 of each benefit period

■ All costs for each day after day 100 in a benefit period

Note: Medicare doesn’t cover long-term care or custodial care.

3. Home health services

Medicare covers medically necessary part-time or intermittent skilled nursing care, and/or physical therapy, speech-language pathology services, and/or services for people with a continuing need for occupational therapy. A doctor, or certain health care professionals who work with a doctor, must see you face-to-face before a doctor can certify that you need home health services. A doctor must order your care, and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part-time or intermittent home health aide services, and medical supplies for use at home.

You must be homebound, which means both of these are true:

1. You’re normally unable to leave home and doing so requires a considerable and taxing effort.

2. Because of an illness or injury, leaving home isn’t medically advisable or isn’t possible without the aid of supportive devices, use of special transportation, or the assistance of another person.

You pay nothing for covered home health care services and 20% of the Medicare-approved amount for durable medical equipment.

4. Blood

If the hospital gets blood from a blood bank at no charge, you won’t have 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

5. Hospice care

To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. If you’re already getting hospice care, a hospice doctor or nurse practitioner will need to see you about 6 months after your hospice care started to certify that you’re still terminally ill. Coverage includes:

■ All items and services needed for pain relief and symptom management

■ Medical, nursing, and social services

■ Drugs

■ Certain durable medical equipment

■ Aide and homemaker services

■ Other covered services, as well as services Medicare usually doesn’t cover, like spiritual and grief counseling

A Medicare-approved hospice usually gives hospice care in your home or other facility where you live, like a nursing home.

Hospice care doesn’t pay for your stay in a facility (room and board) unless the hospice medical team determines that you need short-term inpatient stays for pain and symptom management that can’t be addressed at home. These stays must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility that contracts with the hospice. Medicare also covers inpatient respite care, which is care you get in a Medicare-approved facility so that your usual caregiver (family member or friend) can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness or related conditions. You can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that you’re terminally ill.

■ You pay nothing for hospice care.

■ You pay a copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Part D.

■ You pay 5% of the Medicare-approved amount for inpatient respite care.

For detailed answers to your questions, a licensed agent at the private Medicare Helpline can assist you and guide you thru comparing benefits and costs of available plans in your area at 1-855-MEDICARE or contact us via the web: