Medicare is a federal government health insurance program that was specially introduced for seniors aged over 65.
It is also known as Title XVIII of the Social Security Act. If you are looking for answers to questions such as what does Medicare cover, and who can benefit from this program, then you are in just the right place.
Here is an extensive guide to Medicare to help you learn all about the program and its medical equipment coverage:
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- 1 Who is Medicare Program for?
- 2 What Does Medicare Cover? – Medicare Parts Explained
- 2.1 Medicare Part A (Hospital Insurance)
- 2.2 Medicare Part B (Medical Insurance)
- 2.3 Medicare Part C (Medicare Advantage)
- 2.4 Medicare Part D (Prescription Drug Coverage)
- 3 What Does Medicare Cover? – Medicare and Medical Equipment
- 4 What Does Medicare Cover? – Types of Senior Aids Covered by Medicare
- 5 How to Enroll in the Medicare Health Insurance Program?
- 6 Bottom Line
Who is Medicare Program for?
This federal health insurance is for:
- Individuals who are 65 or older
- Individuals with End-Stage Renal Disease (sometimes referred to as ESRD). These are people that are suffering from permanent kidney failure and require a transplant or dialysis
- Certain younger disabled individuals
What Does Medicare Cover? – Medicare Parts Explained
There are 4 different parts of Medicare health insurance program and each helps cover some particular types of services.
Medicare Part A (Hospital Insurance)
This Medicare part covers inpatient hospital care. It pays for hospital stays, hospice care, some home health care (only when it is prescribed), and care in a skilled nursing facility.
Hospital insurance is premium-free for 99% of beneficiaries. This is because the individual pays their Medicare taxes while they are still employed.
Medicare Part A ? Hospital Care
If you are a beneficiary of Medicare Part A, you are eligible to receive coverage for any necessary hospital expenses related to your inpatient care.
This might include meals, a semi-private room, medicines that are required in your inpatient treatment, nursing services, and any other essential supplies and services from the hospital.
This coverage includes inpatient care that you receive through:
- Critical access hospitals
- Acute care hospitals
- Long-term care hospitals
- Inpatient rehabilitation facilities
- Involvement in a clinical research study (must be a qualifying one)
- Mental health care
Remember that unless it is medically necessary, Medicare hospital insurance doesn?t cover the expenses of a private room, personal care items such as razors or shampoos, private-duty nursing, and other charges like television or telephone.
Additionally, the expense of blood transfusions is also not covered through Medicare Part A. You don?t need to pay any money if the hospital gets the required blood from a blood bank for free.
However, if the hospital purchases blood for you, you will have to pay for the first 3 units that you receive each calendar year.
Medicare Part A ? Nursing Home Services
Medicare Part A covers skilled nursing facility stays if an individual qualifies a hospital inpatient stay for some related injury or illness.
In order to qualify for this care, it is mandatory for the hospital stay to be of a minimum of 3 days.
The count begins on the day you get admitted formally as an inpatient. This minimum 3-day requirement doesn?t count the day that you are discharged on.
Additionally, the time that you spend under a doctor?s observation as an outpatient doesn?t count.
Medicare Part A only covers skilled nursing care if it is provided at a facility that is certified by Medicare. This coverage includes but isn?t limited to:
- Semi-private room
- Skilled nursing services
- Medical social services
- Rehabilitation services
- Medical equipment and supplies used in SNF
- Medications received
- Dietary counseling
- Ambulance transportation (If SNF fails to provide the required services)
Medicare Part A ? Home Health Care
Home health care is only covered by Medical Part A if the services are ordered by your physician, and are medically necessary. These services may include:
- Physical therapy
- Intermittent or part-time skilled nursing care
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Durable medical equipment
- Intermittent or part-time home health aide services
If durable medical equipment (DME) is ordered by your physician as part of your healthcare, and the medical equipment does meet the requirements for eligibility, then this expense is separately covered under Medicare Part B (medical insurance).
Typically, Medicare covers 80% of the total Medicare-approved amount for the DME ? if you are eligible for coverage.
This part doesn?t cover personal care services like help with dressing and bathing, homemaker services, or meals if they aren?t related to your medical treatment.
Moreover, according to the Medicare health insurance program, you are homebound if the following two statements are true for you:
- You cannot leave your home under normal circumstances and making substantial effort would be required to do so.
- You are medically advised not to leave home without the assistance of transportation, special equipment or another person.
Medicare Part A ? Hospice Care
You might be eligible for coverage of hospice care if your physician has certified that you are suffering from a terminal illness and you have an estimated 6 months or less remaining to live.
Hospice care doesn?t focus on curing your disease. It focuses on providing palliative care. The objective is to relieve the patient?s pain and make them as comfortable as possible.
Following are the conditions you need to meet to qualify for Medicare Part A hospice coverage:
- Your health provider or doctor must certify that you are suffering from a terminal illness and have an estimated 6 months or less to live
- The facility you choose to receive hospice care from must be Medicare-approved
- While Medicare will continue to cover palliative care for your terminal illness, you must agree to give up on receiving curative treatments
- You must be enrolled in Medicare Part A
Hospice care covered through Medicare Part A is usually received by the patient in their home. The coverage might include but isn?t limited to:
- Nursing care
- Doctor services
- Social services
- Pain relief medications
- Medical supplies
- Durable medical equipment
- Homemaker services
- Hospice aid services
- Dietary counseling
- Occupational and physical therapy
- Short-term respite care
- Short-term inpatient care (if medically necessary)
When a patient receives hospice care coverage under Medicare Part A, some other costs such as grief and spiritual counseling expenses might also get covered.
In case you decide to go back to receiving curative treatments, you have the right to stop hospice care at any time.
Medicare Part B (Medical Insurance)
This Medicare part covers medical supplies, certain doctor?s services, hospital services, outpatient care, durable medical equipment, preventive services, and some home health services.
For most elderly individuals, medical insurance costs around $136/month (2019).
Medicare Part B ? Clinical Research
Clinical trials, commonly referred to as clinical research studies, test the safety of different types of medical care and how well they work.
Medicare Part B covers some expenses such as tests and office visits in certain qualifying clinical research studies.
Medicare approves a certain amount and you might have to pay 20% of it, depending on the type of treatment you receive. Additionally, the Part B deductible might also apply.
Medicare Part B ? Ambulance Services
Ambulance transportation is covered through Medicare Part B when you need to be transported to a skilled nursing facility or critical access hospital for urgent medical concerns.
Medicare may also pay for emergency ambulance transportation in a helicopter or an airplane if you require rapid and immediate treatment.
In some scenarios, Medicare might also pay for nonemergency ambulance transportation if you have a doctor?s note that explicitly states that ambulance transportation is medically required.
Medicare Part B ? Durable Medical Equipment (DME)
Durable medical equipment, or DME, is an apparatus that you require to accomplish daily activities.
We will discuss DME coverage further in this article.
Medicare Part B ? Mental Health
Medicare offers coverage for health services that help with conditions like anxiety and depression.
You can benefit from the following care from either a psychiatric hospital or a general hospital:
- Partial Hospitalization
Limited Outpatient Prescription Drugs
Here are some types of drugs that are covered by Medicare Part B:
Injectable Osteoporosis Drugs
If you are a female with osteoporosis, eligible for Medicare home health benefit and have a bone fracture that a physician certifies to be related to post-menopausal osteoporosis then Medicare may help you pay for an injectable drug.
Medicare health insurance program helps pay for antigens that are prepared by a doctor and a properly instructed person (can be you) is willing to give it to you under appropriate supervision.
Drugs Used In Conjunction with Durable Medical Equipment:
Medicare helps pay for drugs that are to be used with durable medical equipment such as a nebulizer or an infusion pump.
Blood Clotting Factors
If you have hemophilia, Medicare helps pay for blood clotting factors.
If you have ESRD or need erythropoietin to treat anemia related conditions, Medicare helps pay for them.
Oral End-Stage Renal Disease Drugs
If oral ESRD drugs are available in injectable form and are covered under the Medicare Part B ESRD benefit then Medicare helps pay for some of those drugs.
Infused and Injectable Drugs
Most infused and injectable drugs that are given by a licensed medical provider are covered by Medicare Part B.
Medicare Part C (Medicare Advantage)
This part allows private companies such as PPOs and HMOs to offer health insurance that offers at least the same benefits as Medicare Part A and Part B.
Sometimes additional benefits are included such as vision and dental.
Moreover, some Medical Advantage plans now also offer community-based and long-term home services such as in-home personal care assistance, adult day care, respite care and more under specific conditions.
Additionally, most Part C plans cover prescription drugs as well.
It is always recommended to study the Medicare Part C plan options for your particular location as Medicare Advantage coverage details can vary with different insurance companies.
Following are four common types of Medicare Advantage plans available in most locations:
Health Maintenance Organization (HMO) Plans
These Medicare plans offer a network of hospitals and doctors that are Medicare-approved and generally required to use by patients in order to be covered.
Therefore, HMOs plans have strict guidelines. They require any prescriptions and visits to be pre-approved.
Preferred Provider Organization (PPO) Plans
These plans again offer a network of hospitals and doctors that beneficiaries can choose from.
Unlike HMO plans, these plans allow you to receive care from healthcare providers that are not within the plan?s network.
You don?t need to have referrals for specialist care or a primary care physician to be eligible for Medicare Advantage PPO plans.
Private Fee-for-Service (PFFs) Plans
These plans allow you to visit any hospital or doctor that is Medicare-approved, as long as the provider accepts the PFF plan?s terms and conditions related to payments.
Remember that every time you receive treatments, you will have to find providers that contract with the Medicare Advantage PFF plan.
Special Needs Plans (SNPs)
The Special Needs Plans limit enrollment to those beneficiaries who are institutionalized, suffering from chronic conditions or qualify for both state Medicaid and Medicare.
Prescription drugs, provider options, and benefits are specially tailored to meet the requirements of the SNP?s enrollees.
Medicare Part D (Prescription Drug Coverage)
This part offers prescription drug coverage through private insurance companies that are approved by Medicare.
However, it does so at the cost of additional monthly premiums which can range from $12 – $100 (2019). The Medicare Prescription Drug Plan is added to:
- Some Medicare Cost Plans
- Medicare Medical Savings Account Plans
- Some Medicare Private-Fee-for-Service Plans
- Original Medicare
What Does Medicare Cover? – Medicare and Medical Equipment
Durable medical equipment (DME) includes equipment that provides assistance in accomplishing day-to-day activities.
It might include a wide variety of items like oxygen tanks, wheelchairs and walkers. Medicare typically offers DME coverage if the equipment:
- Serves a medical purpose
- Is durable i.e. capable of withstanding repeated use
- Is likely to last for 3 years or more
- Is appropriate for home usage
DME that Medicare covers includes but isn?t limited to the following senior aids:
- Blood sugar monitors
- Commode chairs
- Blood sugar test strips
- Continuous passive motion devices
- Continuous Positive Airway Pressure (CPAP) devices
- Hospital beds
- Lancet devices & lancets
- Infusion pumps & supplies
- Nebulizers & nebulizer medications
- Patient lifts
- Oxygen equipment & accessories
- Mattress overlays, mattresses and pressure-reducing beds
- Traction equipment
- Suction pumps
- Wheelchairs & scooters
What Does Medicare Cover? – Types of Senior Aids Covered by Medicare
Here is a detailed guide to help you learn about different types of senior aids and if Medicare covers them or not:
Devices that assist seniors or disabled individuals in walking are known as mobility aids.
They can significantly improve their ability to perform day-to-day activities. These mobility aids not only cater to a wide range of senior needs but they also come in various models and sizes.
Wheelchairs, walkers and power-operated scooters are covered by Medicare Part B (medical insurance) as durable medical equipment. These mobility aids are covered by Medicare Part B if:
- The physician treating you for your medical condition gives an order in writing, stating that you medically need a scooter or a wheelchair to move around in your house.
- Your mobility is limited and all the following conditions apply to your situation:
- You are incapable of performing daily activities such as dressing, bathing, using the bathroom or getting in and out of a chair or bed, even with the help of a walker, crutch or cane.
- You are suffering from a medical condition that makes it difficult for you to move around easily in your home.
- Your supplier and the doctor treating you for your condition are both enrolled in the Medicare health insurance program.
- You are able to safely get on and off and operate the scooter or the wheelchair or have someone available at all times who can help you use the device safely.
- You can easily operate the equipment within your home premises. For instance, it should pass through your doorways with ease.
With this plan, you need to pay 20% of the Medicare-approved amount along with your Medicare Part B deductible. Medicare pays the remaining 80%.
If you are enrolled in a Medicare Advantage Plan (Medicare Part C) like a PPO or an HMO, contact your provider to find out more about which DME suppliers you can use and the costs.
Following are some types of mobility aids covered by Medicare:
If you are incapable of using a walker or a cane safely but you have someone to assist you or you have enough strength in your upper body then you may qualify for this option.
However, you might have to rent a manual wheelchair that is most appropriate for you prior to purchasing it.
Power-Operated Scooter / Vehicle
You may be eligible for receiving a power-operated vehicle if you are incapable of using a walker or a cane, or operating a manual wheelchair. In order to qualify, it is mandatory for you to be able to get in and out of the scooter safely.
Moreover, you should be strong enough to sit up and operate the controls of the vehicle safely.
If you don?t require a power-operated vehicle on a long-term basis, Medicare enables you to rent the equipment and lower your expenses. You can learn more about this option from your supplier.
You might qualify for a Medicare-covered power wheelchair if the following statements are true for you:
- You cannot operate a manual wheelchair in your home
- You aren?t strong enough to work the controls of a power-operated scooter safely and therefore you don?t qualify for receiving one
Hearing aids are small devices that help seniors who have weak hearing due to age or have lost their hearing entirely.
The Medicare health insurance program doesn?t cover hearing aids or pay for any exams for fitting hearing aids.
Therefore, you have to pay 100% of the cost of any medical bills of hearing aids and related exams.
Medicare doesn’t offer coverage for routine version service.
However, it does pay for treatments of injuries to or illnesses of the eye. Here are some ways you can receive vision coverage through Medicare:
As mentioned earlier, your Original Medicare offers benefits that include hospital insurance (Medicare Part A) and outpatient insurance (Medicare Part B).
Just like any other medical condition, Part B covers treatment for injuries or health conditions affecting the eye.
If you require treatment for conditions such as macular degeneration, cataracts, glaucoma or even minor eye-related problems like pink-eye, 80% of the total cost of these treatments is covered by Medicare Part B.
You are, however, required to pay the Part B deductible.
Yearly diagnostics and preventive exams that screen for health conditions such as macular degeneration or glaucoma are also covered by Medicare Part B.
If you need to have eye surgery for cataracts, the cost for a pair of basic eyeglasses that are needed after the operation is also covered by Medicare Part B.
Remember, Medicare Part B only covers standard basic lenses.
In case you decide to purchase designer frames or upgrade the lenses with tinting or anti-scratch coating, you will have to pay the additional amount from your pocket to make up for the difference.
Medicare doesn’t cover routine eye exams. These exams are conducted for the purpose of getting eye spectacles and are known as eye refractions.
Medicare also doesn’t pay for the expenses of a low vision exam (low vision refraction) aids, procedures, and devices that help patients maximize their existing vision.
Any sort of treatment you get at a low vision clinic will have to be paid for by you.
When it comes to the Medicare coverage rule for routine eye exams, there is one little exception.
When the patient is diabetic or has a disease related to diabetes that requires routine eye examinations, then, Medicare pays for those exams.
Every twelve months, glaucoma screenings are covered by Medicare for people at high-risk. This includes diabetics, Hispanics, and African Americans (65 years of age and older) and people that have a family history of glaucoma.
How to Enroll in the Medicare Health Insurance Program?
While some individuals are automatically enrolled in Medicare, for others it might depend on their eligibility. You can use one of the following methods to enroll in Medicare Part A and/or Part B:
- Call Social Security at 1-800-772-1213. Monday – Friday, 7AM-7PM
- Enrolling in the Medicare program online is generally quick and easy. In this modern digital world, more and more individuals are signing up for Medicare online. Visit www.socialsecurity.gov for online enrollment
- Visit your local Social Security office
- Railroad workers can enroll in this program by simply contacting the Railroad Retirement Board at 1-877-772-5772 (RRB) or 1-312-751-4701 (TTY users). Monday – Friday, 9AM – 3:30PM
Automatic Medicare Enrollment
Following are some situations where you might get enrolled in the Medicare program automatically:
When You Are Collecting Retirement Benefits
If you are already receiving retirement benefits through Social Security or Railroad Retirement Board, you will be enrolled automatically in Medicare Part A i.e. hospital insurance and Medicare Part B i.e. medical insurance when you turn 65.
This happens if you sign up for your retirement benefits and Medicare Part B at the same time.
If you reside outside any of the 50 US states or D.C. then you will be automatically enrolled in Medicare Part A (hospital insurance) but will be required to enroll manually in Medicare Part B (medical insurance).
When You’re Receiving Certain Disability Benefits
Individuals under the age of 65 receiving disability benefits from the Railroad Retirement Board or Social Security are enrolled automatically in Medicare Part A, Medicare Part B, and Original Medicare.
The disabled individual gets enrolled after 24 months of receiving disability benefits.
One exception to this scenario is that if the individual is suffering from end-stage renal diseases (ESRD). In such a case, the individual might require regular kidney dialysis or a kidney transplant and thus, they can apply for Medicare.
Lastly, if the individual has amyotrophic lateral sclerosis (Lou Gehrig’s disease or ALS), they get enrolled automatically in Original Medicare and that too in the same month that they start receiving disability benefits.
When it comes to healthcare, it is essential to understand what is covered by the programs or plans you are signing up for.
With all the aforementioned answers to questions such as what does Medicare cover, and how to enroll in the program, we hope that we have made the process a little easier for you!