Medicare is a US federal program to meet the medical needs of individuals over 65 years of age. This article contains general information about what is covered under Medicare Parts A and B, including information about coverage for skilled nursing facilities and inpatient rehabilitation facilities.
MEDICARE PART A
Medicare Part A can be considered “hospital insurance.” It helps cover your inpatient care in hospitals, skilled nursing facilities, and inpatient rehab facilities. It also covers hospice care and some home health care.
The program is premium-free if you meet certain conditions; individuals who don’t qualify can still buy in for a monthly premium of up to $407 in 2015.
MEDICARE PART A HELPS COVER
- Hospital Stays
Semi-private room, meals, general nursing, and other hospital services and supplies are covered. This does not include private duty nursing, or a television or telephone in your room. It also does not include a private room, unless medically necessary.
- Skilled Nursing Facility (SNF) Care
Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies are covered, but only after a related three day hospital stay.
Note that medicare does not cover “custodial care.” Custodial care is care that helps you with usual daily activities such as walking, eating, or bathing. This type of care is often given in a nursing home but is not covered by Medicare. Similarly, assisted living care is not covered by Medicare. Alternate methods of paying for custodial care include private pay, Medicaid or long-term insurance.
- Inpatient Rehabilitation Facility (IRF)
Care at Medicare-certified inpatient rehabilitation facilities is covered when a physician has prescribed acute rehabilitation with at least two different types of therapy. To qualify, this therapy must be prescribed for at least three hours per day. A prior hospitilization is not required, although, in practice, inpatient rehabilitation is rarely prescribed or required without the occurence of a hospitalization.
- Home Health Care
Coverage includes part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services. Care must be prescribed by a physician, and unskilled companion care is not covered.
- Hospice Care
Medical and support services from a Medicare-approved hospice for people with a terminal illness are covered. Also covered are drugs for symptom control and pain relief, and other services not otherwise covered by Medicare. Hospice care is given in your home. However, short term hospital and inpatient respite care (care given to a hospice patient by another caregiver so that the usual caregiver can rest) are covered when needed.
Pints of blood you get at a hospital or skilled nursing facility during a covered stay.
MEDICARE PART B
Medicare Part B is “Medical Insurance” and helps cover your doctors’ services, outpatient hospital care, physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. You pay the Medicare Part B premium of $104.90 per month (higher if income is higher than Medicare limits; see www.medicare.gov) in 2015.
MEDICARE PART B HELPS COVER
- 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, outpatient physical and occupational therapy, including speech-language therapy.
- Clinical Laboratory Services
Blood tests, urinalysis, and more.
- Home Health Care
Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers) and medical supplies, and other services.
- Outpatient Hospital Services
Hospital services and supplies received as an outpatient as part of a doctor’s care.
Pints of blood you get as an outpatient or as part of a Part B covered service.
MEDICARE ALSO HELPS COVER
- Ambulance services (when other transportation would endanger your health)
- Artificial eyes
- Artificial limbs that are prosthetic devices, and their replacement parts
- Braces – arm, leg, back, and neck
- Chiropractic services (limited), for manipulation of the spine to correct a subluxation
- Emergency care
- Eyeglasses – one pair of standard frames after cataract surgery with an intraocular lens
- Immunosuppressive drug therapy for transplant patients as long as you are covered by Medicare (transplant must have been paid for by Medicare)
- Kidney dialysis
- Macular degeneration of the eye (“wet” age-related) treatment, using ocular photodynamic therapy with verteporfin
- Medical nutrition therapy services for people with diabetes or kidney disease with a doctor’s referral
- Medical supplies – items such as ostomy bags, surgical dressings, splints, casts, and some diabetic supplies
- Outpatient prescription drugs (very limited). For example, some oral drugs for cancer
- Preventive services
- Prosthetic devices, including breast prosthesis after mastectomy
- Second opinion by a doctor (in some cases)
- Services of practitioners such as clinical social workers, physician assistants, and nurse practitioners
- Telemedicine services in some rural areas
- Therapeutic shoes for people with diabetes (in some cases)
- Transplants – heart, lung, kidney, pancreas, intestine, bone marrow, cornea, and liver (under certain conditions and when performed at approved facilities)
- X-rays, MRIs, CAT scans, EKGs, and some other diagnostic tests
Medicare Health Plans (like an HMO) may include extra benefits such as prescription drugs, dental care, routine physical and vision services.
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