Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant.)
The following is a breakdown of Medicare Benefits, Covered Services, Eligibility Requirements and Patient Financial Responsibility:
Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals. Part A also helps cover skilled nursing facility, hospice, and home health care if you meet certain conditions.
Medicare Part B (Medical Insurance) helps cover medically-necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse.
Medicare Part C (Medicare Advantage Plans) is another way to get your Medicare benefits. It combines Part A, Part B, and, sometimes, Part D (prescription drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare (Compare Medicare Plans). These plans must cover medically-necessary services. However, plans can charge different co-payments, coinsurance, or deductibles for these services.
Medicare Part D (Medicare Prescription Drug Coverage) helps cover prescription drugs. This coverage may help lower your prescription drug costs and help protect against higher costs in the future.
Medicare and You 2010.pdf- A complete guide of Medicare Benefits.
Medicare Part A
Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals. Part A also helps cover skilled nursing facility, hospice, and home health care if you meet certain conditions.
People with Medicare should visit Medicare.gov or the Center for Medicare & Medicaid Services for the latest on Medicare programs enrollment benefits and other helpful tools
The following is a breakdown of Medicare Part A Benefits, Covered Services, Eligibility Requirements and Patient Financial Responsibility:
Inpatient Hospital Care (Medicare Part A)
Skilled Nursing Care (Medicare Part A)
Home Health Care (Medicare Part A)
Hospice Care (Medicare Part A)
Residential Care (a.k.a. Long Term Care)
Inpatient Hospital Care (Medicare Part A)
Type of Facility(s):
-
Hospital
-
Long Term Acute Care Hospital (LTACH)
-
Acute Rehab
-
Mental Health
Premium:
$ 254 (30-39 quarters worked)
$ 461 (less than 30 quarters worked)
Benefit & Covered Services:
90 days per benefit period, plus 60 day lifetime reserve days.
Covered Services Include:
-
Semi-private room
-
Meals
-
Routine nursing care
-
Lab tests and x-rays billed by hospital
-
Medical supplies & equipment
-
Rehabilitation therapies
Patient Responsibility:
Deductible: $1,100
Co-Pay:
-
Medicare Pays 100% for days 1-60.
-
Patient pays $275/day for days 61-90.
-
Patient pays $550/day for 60 lifetime reserve days after 90 days.
Services Not Covered:
-
Expenses beyond 90 days (unless you choose to use reserve days)
-
Personal convenience items (i.e. TV)
-
Private Duty Nurses
-
Extra charges for private room.
Skilled Nursing Care (Medicare Part A)
Type of Facility(s):
Skilled Nursing and Rehabilitation
Premium:
$ 254 (30-39 quarters worked)
$ 461 (less than 30 quarters worked)
Benefit & Covered Services:
100 days per benefit period (based on your need for daily skilled care)
Eligibility Requirements:
- Three consecutive days in hospital, (Physician must confirm a need for daily skilled nursing and/or rehabilitative care)
- Must enter a facility within 30 days of leaving the hospital and require services related to your hospital stay.
Covered Services Include:
-
Semi-private room
-
Meals
-
outline nursing care
-
Lab tests and x-rays billed by facility
-
Medical supplies & equipment
-
Rehabilitation therapies & equipment
-
Rehabilitation therapies & services
-
Drugs furnished by the facility
Patient Responsibility:
Deductible: $0
Co-Pay:
-
Medicare Pays 100% for days 1-20.
-
Patient Pays $137.50/day for days 21-100.
Services Not Covered:
-
Expenses beyond 100 days
-
Personal convenience items (i.e. TV)
-
Private Duty Nurses
-
Extra charges for private room.
-
Custodial nursing home care.
Nursing Home Compare: www.medicare.gov/NHCompare
Type of Facility(s):
Home Health
Premium:
$ 254 (30-39 quarters worked)
$ 461 (less than 30 quarters worked)
Benefit & Covered Services:
Unlimited Benefits as long as you meet the following:
Eligibility Requirements:
-
Your doctor decides you need medical care in your home, and makes a plan for your care at home
-
You need at least one of the following: intermittent (and not full time) skilled nursing care, or physical therapy or speech language pathology services, or a continued need for occupational therapy
-
You are homebound. This means you are normally unable to leave home and that leaving home is a major effort. When you leave home, it must be infrequent, for a short time. You may attend religious services. You may leave the house to get medical treatment, including therapeutic or psychosocial care.
Patient Responsibility:
-
Medicare pays 100%, if requirements for home health care are met.
Services Not Covered:
-
24 hour a day nursing care at home
-
Drugs and biologicals
-
Meals delivered to the patient’s home
-
Homemaker services
-
Blood transfusions
Home Health Compare: www.medicare.gov/HHCompare
Hospice Care (Medicare Part A)
Type of Facility(s):
-
Hospital
-
Long Term Acute Care Hospital (LTACH)
-
Skilled Nursing and Rehabilitation
-
Hospice
-
Home
Premium:
$ 254 (30-39 quarters worked)
$ 461 (less than 30 quarters worked)
Benefit & Covered Services:
Eligibility Requirements:
-
Your doctor and the hospice medical director certify that you are terminally ill and probably have less than six months to live
-
You sign a statement choosing hospice care instead of routine Medicare covered benefits for your terminal illness
-
Unlimited Coverage for services include:
-
Nursing Care
-
Physician Care
-
Drugs
-
Rehabilitation therapies & services
-
Home health aide
-
Homemaker services
-
Medical supplies & equipment
-
Respite Care
-
Counseling
Patient Responsibility:
- Medicare Pays 100%, if requirements for hospice care are met. Patients should contact their local hospice agency to determine specific Medicare availability.
Residential Care (a.k.a. Long Term Care)
Type of Facility(s):
-
Adult Day Care
-
Adult Foster/Board Homes
-
Assisted Living
-
Continuing Care Retirement Center (CCRC)
-
Nursing Homes
-
Adult Day Care
Premium:
N/A
Benefit & Covered Services:
Medicare generally doesn’t pay for long-term care. Medicare also doesn’t pay for help with activities of daily living. Some examples of activities of daily living include eating, bathing, dressing, and using the bathroom. Medicare will help pay for skilled nursing or home health care if you meet certain conditions.
Patient Responsibility:
N/A
Medicare Part B
Medicare Part B (Medical Insurance) helps cover medically-necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse.
People with Medicare should visit Medicare.gov or the Center for Medicare & Medicaid Services for the latest on Medicare programs enrollment benefits and other helpful tools.
The following is a breakdown of Medicare Part B Benefits, Covered Services, Eligibility Requirements and Patient Financial Responsibility:
Outpatient Rehabilitation Services (Medicare Part B)
Outpatient Hospital Service (Medicare Part B)
Dialysis Services (Medicare Part B)
Outpatient Mental Health (Medicare Part B)
Doctor’s Services (Medicare Part B)
Outpatient Rehabilitation Services (Medicare Part B)
Type of Facility(s):
-
Comprehensive Outpatient Rehabilitation Facility (CORF)
-
Outpatient Rehabilitation Clinics
-
Hospital Outpatient Therapy Department
-
Physician’s Office
-
Skilled Nursing Facility
Premium:
| Annual Individual Income | Annual Married Income |
Monthly Premium |
| $0-$85,000 | Up to $170,000 |
*$110.50 (base rate) |
| $85,001-$107,000 | $170,001 to $214,000 |
$154.70 |
| $107,001-$160,000 | $214,001 to $320,000 | $221.00 |
| $160,001-$214,000 | $320,001 to $428,000 | $287.30 |
| over $214,000 | Over $428,000 | $353.60 |
*$110.50 monthly premium reflects any newly enrolled members into the Medicare program in 2010. Most Medicare members enrolled since 2009 will continue to pay $96.40 for Part B coverage.
Benefit & Covered Services:
Medicare helps pay for medically necessary outpatient physical and occupational therapy and speech-language pathology services.
Eligibility Requirements:
-
Your doctor or therapist sets up the plan of treatment
-
Your doctor periodically reviews the plan to see how long you will get therapy.
-
You can get outpatient services from a participating hospital or skilled nursing facility, or from a participating home health agency, rehabilitation agency, or public health agency. Also, you can get services from a Medicare-approved physical or occupational therapist in private practice, while in his or her office or in your home. Medicare doesn’t pay for services given by a speech pathologist in private practice.
-
You can get these services from any Medicare-approved outpatient provider.
Patient Responsibility:
Deductible: $155
Co-Pay:
-
Your Medicare benefit for outpatient physical therapy and speech-language pathology services (combined) is limited to $1,860 per year. There is a separate yearly benefit limit of $1,860 for outpatient occupational therapy. After you have reached the $1,860 cap, you will be responsible for 100% of the charges, unless you have other insurance coverage.
-
There is NO CAP if you go to a hospital outpatient therapy department.
Once you pay $155 medical deductible for covered services in 2010, the Part B deductible does not apply to any further covered services you receive the rest of the year.
Outpatient Hospital Service (Medicare Part B)
(ER, X-Ray, Radiology, Same Day Surgery, Labs, Ambulance)
Type of Facility(s):
Hospital
Premium:
| Annual Individual Income | Annual Married Income |
Monthly Premium |
| $0-$85,000 | Up to $170,000 |
*$110.50 (base rate) |
| $85,001-$107,000 | $170,001 to $214,000 |
$154.70 |
| $107,001-$160,000 | $214,001 to $320,000 | $221.00 |
| $160,001-$214,000 | $320,001 to $428,000 | $287.30 |
| over $214,000 | Over $428,000 | $353.60 |
*$110.50 monthly premium reflects any newly enrolled members into the Medicare program in 2010. Most Medicare members enrolled since 2009 will continue to pay $96.40 for Part B coverage.
Benefit & Covered Services:
Medicare Part B covers medically necessary services you get as an outpatient from a Medicare-participating hospital for diagnosis or treatment of an illness or injury.
Patient Responsibility:
Deductible: $155
Co-Pay:
-
Medicare Pays 80% of allowed charges.
-
Patient pays 20% of Medicare approved amount.
Once you pay $155 medical deductible for covered services in 2010, the Part B deductible does not apply to any further covered services you receive the rest of the year.
Dialysis Services (Medicare Part B)
Type of Facility(s):
Dialysis Center
Premium:
| Annual Individual Income | Annual Married Income |
Monthly Premium |
| $0-$85,000 | Up to $170,000 |
*$110.50 (base rate) |
| $85,001-$107,000 | $170,001 to $214,000 |
$154.70 |
| $107,001-$160,000 | $214,001 to $320,000 | $221.00 |
| $160,001-$214,000 | $320,001 to $428,000 | $287.30 |
| over $214,000 | Over $428,000 | $353.60 |
*$110.50 monthly premium reflects any newly enrolled members into the Medicare program in 2010. Most Medicare members enrolled since 2009 will continue to pay $96.40 for Part B coverage.
Benefit & Covered Services:
Medicare covers outpatient maintenance dialysis treatments (when you get treatments in any Medicare-approved dialysis facility).
Patient Responsibility:
Deductible: $155
Co-Pay:
-
Medicare Pays 80% of allowed charges.
-
Patient pays 20% of Medicare approved amount.
Once you pay $155 medical deductible for covered services in 2010, the Part B deductible does not apply to any further covered services you receive the rest of the year.
Outpatient Mental Health/Substance Abuse Services (Medicare Part B)
Type of Facility(s):
-
Mental Health Program
-
Substance Abuse Program
Premium:
| Annual Individual Income | Annual Married Income |
Monthly Premium |
| $0-$85,000 | Up to $170,000 |
*$110.50 (base rate) |
| $85,001-$107,000 | $170,001 to $214,000 |
$154.70 |
| $107,001-$160,000 | $214,001 to $320,000 | $221.00 |
| $160,001-$214,000 | $320,001 to $428,000 | $287.30 |
| over $214,000 | Over $428,000 | $353.60 |
*$110.50 monthly premium reflects any newly enrolled members into the Medicare program in 2010. Most Medicare members enrolled since 2009 will continue to pay $96.40 for Part B coverage.
Benefit & Covered Services:
-
Medicare covers mental health services on an outpatient basis by either a doctor, clinical psychologist, clinical social worker, clinical nurse specialist, or physician assistant in an office setting, clinic, or hospital outpatient department.
-
Medicare covers substance abuse treatment in an outpatient treatment center if they have agreed to participate in the Medicare program.
Patient Responsibility:
Deductible: $155
Co-Pay:
- * 45% for Mental Health or Substance Abuse services plus separate co-payment for facility service
* Once you pay $155 medical deductible for covered services in 2010, the Part B deductible does not apply to any further covered services you receive the rest of the year.
Doctor’s Services (Medicare Part B)
Type of Facility(s):
Doctor’s Office's
Premium:
| Annual Individual Income | Annual Married Income |
Monthly Premium |
| $0-$85,000 | Up to $170,000 |
*$110.50 (base rate) |
| $85,001-$107,000 | $170,001 to $214,000 |
$154.70 |
| $107,001-$160,000 | $214,001 to $320,000 | $221.00 |
| $160,001-$214,000 | $320,001 to $428,000 | $287.30 |
| over $214,000 | Over $428,000 | $353.60 |
*$110.50 monthly premium reflects any newly enrolled members into the Medicare program in 2010. Most Medicare members enrolled since 2009 will continue to pay $96.40 for Part B coverage.
Benefit & Covered Services:
Medicare covers medically necessary services you get from your doctor in his or her office, in a hospital, in a skilled nursing facility, in your home, or any other location. Routine annual physicals and gynecological (GYN) exams are not covered.
Patient Responsibility:
Deductible: $155
Co-Pay:
-
Medicare Pays 80% of allowed charges.
-
Patient pays 20% of Medicare approved amount.
Once you pay $155 medical deductible for covered services in 2010, the Part B deductible does not apply to any further covered services you receive the rest of the year.
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