What services does Medicare cover??

Medicare Part A and Part B cover certain medical services and supplies in hospitals, doctors’ offices, and other health care settings. Prescription drug coverage is provided through Medicare Part D.

Solving the Mysteries of Medicare

Lesson 3: Part A – Hospital Insurance

Part A-covered services

Blood

If the hospital gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

Home health services

You can use your home health benefits under Part A and/or Part B.

Hospice care
To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. You must accept palliative care (for comfort) instead of care to cure your illness. You also must sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions. Coverage includes:
• All items and services needed for pain relief and symptom management
• Medical, nursing, and social services
• Drugs
• Certain durable medical equipment
• Aide and homemaker services
• Other covered services, as well as services Medicare usually doesn’t cover,
like spiritual and grief counseling

A Medicare-certified hospice usually gives hospice care in your home or other facility where you live, like a nursing home.
Hospice care doesn’t pay for your stay in a facility (room and board) unless the hospice medical team determines that you need short-term inpatient stays for pain and symptom management that can’t be addressed at home. These stays must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility that contracts with the hospice. Medicare also covers inpatient respite care, which is care you get in a Medicare-approved facility so that your usual caregiver (family member or friend) can
rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness or related conditions. After 6 months, you can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies (at a face-to-face meeting) that you’re terminally ill.
• You pay nothing for hospice care.
• You pay a copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Part D.
• You pay 5% of the Medicare-approved amount for inpatient respite care.

Original Medicare will cover your hospice care, even if you’re in a Medicare Advantage Plan.

Hospital care (inpatient care)
Medicare covers semi-private rooms, meals, general nursing, and drugs as part of your inpatient treatment, and other hospital services and supplies. This includes care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and inpatient mental health care given in a psychiatric hospital or other hospital. This doesn’t include private-duty nursing, a television or phone in your room (if there’s a separate charge for these items), or personal care items, like razors or slipper socks. It also doesn’t include a private room, unless medically necessary. If you have Part B, it generally covers 80% of the Medicare-approved amount for doctor’s
services you get while you’re in a hospital.
• You pay a deductible of $1,364 and no coinsurance for days 1– 60 of each benefit period.
• You pay coinsurance amount of $341 per day for days 61– 90 of each benefit period.
• You pay a coinsurance amount of $682 per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime).
• You pay all costs for each day after you use all the lifetime reserve days.
• Inpatient psychiatric care in a freestanding psychiatric hospital is limited to 190 days in a lifetime.

Am I an inpatient or outpatient?
Staying overnight in a hospital doesn’t always mean you’re an inpatient. Your doctor must order your hospital admission and the hospital must formally admit you for you to be inpatient. Without the formal inpatient admission, you’re still an outpatient, even if you stay overnight in a regular hospital bed, and/or you’re getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays. You or a family member should always ask the hospital and/or your doctor if you’re an inpatient or an
outpatient each day during your stay, since it affects what you pay and can affect whether you’ll qualify for Part A coverage in a skilled nursing facility.

A “Medicare Outpatient Observation Notice” (MOON) is a document that lets you know you’re an outpatient in a hospital or critical access hospital. You must receive this notice if you’re getting observation services as an outpatient for more than 24 hours. The MOON will tell you why you’re an outpatient receiving observation services, rather than an inpatient. It will also let you know how this may affect what you pay while in the hospital, and for care you get after leaving the hospital.

Religious non-medical health care institution (inpatient care)
In these facilities, religious beliefs prohibit conventional and unconventional medical care. If you qualify for hospital or skilled nursing facility care, Medicare will only cover the inpatient, non-religious, non-medical items and services. Examples are room and board, or any items and services that don’t require a doctor’s order or prescription, like unmedicated wound dressings or use of a simple walker.

Skilled nursing facility care
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services and supplies furnished in a skilled nursing facility after a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day the hospital formally admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged. You may get coverage of skilled nursing care or skilled therapy care if it’s necessary to help improve or maintain your current condition.

To qualify for skilled nursing facility care coverage, your doctor must certify that you need daily skilled care (like intravenous injections or physical therapy) which, as a practical matter, can only be provided in a skilled nursing facility if you’re an inpatient.

You pay:
• Nothing for the first 20 days of each benefit period
• A coinsurance amount of $170.50 per day for days 21–100 of each benefit period
• All costs for each day after day 100 in a benefit period

Note: Medicare doesn’t cover long-term care or custodial care.

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