As the government’s health insurance benefit for seniors and disabled individuals, Original Medicare covers medically-necessary hospital and medical benefits.
The Medicare program was created to guarantee access to health coverage for American seniors and other younger individuals with disabilities or certain illnesses, such as End-Stage Renal Disease (ESRD). Those who qualify for this national insurance program could then enroll in Original Medicare coverage, which consists of two parts: Medicare Part A and Part B. Although not all-inclusive, this traditional insurance coverage offered by the government does include a variety of medically-necessary health benefits.
What does Medicare Part A cover?
Medicare Part A, also known as hospital insurance, covers inpatient services in hospitals and other health care settings. Services and supplies need to be deemed medically necessary in order to be covered. Additionally, beneficiaries must receive care from health care providers who accept Medicare.
Generally, Medicare Part A covers:
- Inpatient care received during a hospital stay
- Skilled Nursing Facility (SNF) care which occurs after a stay in a hospital
- Nursing home care beyond custodial care
- Home health care including nurses and some therapists for short-term care
- Hospice care, particularly for those who are terminally ill
- Blood transfusions after you pay the first three pints used each calendar year
Part A coverage does not include all costs associated with these benefits. You may be responsible for deductibles, coinsurance, or copayments. Additionally, if you or your spouse did not pay Medicare taxes for 10 or more years while working, you may also be responsible for a monthly Part A premium.
What does Medicare Part B cover?
Medicare Part B, also known as medical insurance, covers outpatient services, durable medical equipment, and doctor’s visits. These services need to be medically necessary in order to be covered; however, as a result of the Affordable Care Act (ACA or Obamacare), Part B now covers several preventive services to help prevent or detect illnesses. Similar to Part A, beneficiaries need to use health care providers who accept Medicare for their services and supplies to be covered.
Generally, Medicare Part B covers:
- Outpatient hospital services, including mental health services and physical therapy
- Durable medical equipment, such as wheelchairs and walkers
- Home health care including nurses and some therapists for part-time care
- Emergency ground ambulance transportation
- Laboratory and radiology services, including X-rays and blood tests
- Preventive services including yearly wellness visits, screenings, and vaccinations such as the flu shot
- A limited amount of outpatient prescription medications including anti-cancer drugs and physician-administered drugs that are not administered by the beneficiaries themselves
Keep in mind that while Part B coverage includes these benefits, it does not cover all associated costs. Before Part B will pay for its part of eligible services, you must pay an annual Part B deductible ($147 in 2013) as well as a monthly premium ($104.90 for newly enrolled individuals in 2013) for Part B coverage. Additionally, you are responsible for 20% of Part B benefits, with the exception of preventive services. Part B only covers 80% of the Medicare-approved amount.
Beyond Original Medicare Coverage
If you are looking for benefits beyond Original Medicare or need coverage for the costs that Part A and Part B do not cover, you should consider enrolling in a private insurance plan, which includes:
Each of these plan types provides additional benefits and coverage for what is not traditionally provided by the government. This may include prescription drug coverage or vision, dental, and hearing benefits. You can enroll in these plans either when you first enroll in the program, during the Annual Election Period (AEP) from October 15 to December 7, or during Special Election Periods (SEP) for which you qualify. To compare costs and benefits for all available plans in your area, visit our free no-obligation plan comparison tool.
For more information on what Medicare pays for, watch this informational video:
Medicare hasn’t approved or endorsed this information.