Medicare Basics

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.

Cost

•Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.

•The Part A premium in 2015 is $407.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 40 quarters of Medicare-covered employment.

Medicare Part A Helps Cover Your Medically Necessary Hospital Stays

•Semiprivate room, meals, general nursing, and other hospital services and supplies.

•This includes inpatient care you get in critical access hospitals and mental health care.

•This doesn’t include private duty nursing, or a television or telephone in your room.

•It also doesn’t include a private room, unless medically necessary.

•Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.

•Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (after a related 3-day inpatient hospital stay).

Home Health Care

•Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Hospice Care

•For people with a terminal illness, includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare.

•Hospice care is usually given in your home. However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).

Blood

•Pints of blood you get at a hospital or skilled nursing facility during a covered stay. 

What is Medicare Part B? Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient hospital care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Cost

•You pay the Medicare Part B premium each month*.

•In some cases, this amount may be higher if you didn’t sign up for Part B when you first became eligible.

•The cost of Part B may go up 10% for each 12-month period that you could have had Part B but didn’t sign up for it, except in special cases.

•You will have to pay this extra amount as long as you have Part B.

•For individuals with higher than average retirement income the following surcharges apply:

• Individuals with a MAGI of $85,000 or less Married couples with a MAGI of $170,000 or less
  • 2015 standard premium=$104.90
• Individuals with a MAGI above $85,000 up to $107,000 Married couples with a MAGI above $170,000 up to $214,000
  • Standard premium + $42.00
• Individuals with a MAGI above $107,000 up to $160,000 Married couples with a MAGI above $214,000 up to $320,000
  • Standard premium + $104.90
• Individuals with a MAGI above $160,000 up to $214,000 Married couples with a MAGI above $320,000 up to $428,000
  • Standard premium + $167.80
• Individuals with a MAGI above $214,000 Married couples with a MAGI above $428,000
  • Standard premium + $230.80

Medicare Part B Helps Cover Your Medically Necessary:

Medical and Other Services

•Doctors’ services (not routine physical exams), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers).

•Also covers second surgical opinions, outpatient mental health care, and outpatient occupational and physical therapy including speech-language therapy. (These services are also covered for long-term nursing home residents). Clinical Laboratory Services

•Blood tests, urinalysis, some screening tests, and more. Home Health Care

•Part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

Outpatient Hospital Services

•Hospital services and supplies received as an outpatient as part of a doctor’s care.

Blood

•Pints of blood you get as an outpatient or as part of a Part B covered service.

What is a Medicare Advantage Plan (Part C)?

A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.

If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.

Different Types of Medicare Advantage Plans Health Maintenance Organization (HMO) Plans Preferred Provider Organization (PPO) Plans Private Fee-for-Service (PFFS) Plans Special Needs Plans (SNP)

There are other less common types of Medicare Advantage Plans that may be available: HMO Point of Service (HMOPOS) Plans— An HMO plan that may allow you to get some services out-of-network for a higher cost. Medical Savings Account (MSA) Plans – A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.

How Much Does a Medicare Advantage Plan Cost?

In addition to your Part B premium, you usually pay one monthly premium for the services included. Each Medicare Advantage Plan can charge different out of-pocket costs. Your out-of-pocket costs in a Medicare Advantage Plan depend on: Whether the plan charges a monthly premium. Whether the plan pays any of your monthly Part B premium. Whether the plan has a yearly deductible or any additional deductibles. How much you pay for each visit or service (copayments or coinsurance). The type of health care services you need and how often you get them. Whether you follow the plan’s rules, like using network providers. Whether you need extra benefits and if the plan charges for them. The plan’s yearly limit on your out-of-pocket costs for all medical services.

What Does a Medicare Advantage Plan Cover?

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

How to Join a Medicare Advantage Plan

Not all Medicare Advantage Plans work the same way, so before you join, take the time to find and compare Medicare Health Plans in your area. Once you understand the plan’s rules and costs, you may be able to join by completing a paper application, calling the plan, or enrolling on the plan’s Web site. Medicare also has information on quality to help you compare plans.

A Few Extra Things You Should Know about Medicare Advantage Plans You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year. As with Original Medicare, you still have Medicare rights and protections, including the right to appeal. Check with the plan before you get a service to find out whether they will cover the service and what your costs may be. You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan. You can join a Medicare Advantage Plan even if you have a pre existing condition, except for End-Stage Renal Disease. If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan. If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare.