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Medicare
FAQ
by Nolo.com
From
the Nolo.com Retirement & Elder Care Center
Answers
to frequently asked questions about who is eligible for Medicare and what medical
expenses Medicare covers.
What's Below:
At present, the Medicare
system provides some healthcare coverage for almost 40 million people, most
of them seniors. Medicare pays for most of the cost of hospitalization and much
other medical care for older Americans -- about half of all medical costs for
people over 65.
Despite its broad coverage,
Medicare does not pay for many types of medical services, and pays only a portion
of the costs of other services. To take maximum advantage of the benefits Medicare
does provide, to protect yourself against the gaps in Medicare coverage and
to understand the current political debate about the program's future, you must
become well-informed about how the Medicare system works.
What is Medicare?
Medicare is a federal government
program that helps older and some disabled people pay their medical bills. The
program is divided into two parts: Part A and Part B. Part A is called hospital
insurance and covers most hospital stay costs, as well as some follow-up costs.
Part B, medical insurance, pays some doctor and outpatient medical care costs.
Who is eligible for Medicare
Part A coverage?
There are two types of eligibility
for Medicare Part A hospital insurance. Most people age 65 and over are covered
for free, based on their work records or on their spouse's work records. People
over 65 who are not eligible for free Medicare Part A coverage can enroll in it
and pay a monthly fee for the same coverage. The premium increases by 10% for
each year after your 65th birthday during which you are not enrolled.
If you enroll in paid Part
A hospital insurance, you must also enroll in Part B medical insurance, for
which you pay an additional monthly premium.
How much of my bill will
Medicare Part A pay?
All rules about how much Medicare
Part A pays depend on how many days of inpatient care you have during what is
called a benefit period or spell of illness. The benefit period begins the day
you enter the hospital or skilled nursing facility as an inpatient and continues
until you have been out for 60 consecutive days. If you are in and out of the
hospital or nursing facility several times but have not stayed out completely
for 60 consecutive days, all your inpatient bills for that time will be figured
as part of the same benefit period. Medicare Part A pays only certain amounts
of a hospital bill for any one benefit period -- and the rules are slightly different
depending on whether the care facility is a hospital, psychiatric hospital, skilled
nursing facility or care received at home or through a hospice.
All those covered by Medicare
Part A must pay an initial amount before Medicare will pay anything. This is
called the hospital insurance deductible. The deductible is increased every
January 1.
What kinds of costs does
Medicare Part B cover?
Part B is medical insurance.
It is intended to help pay doctor bills for treatment in or out of the hospital.
It also covers many other medical expenses you incur when you are not in the hospital,
such as the costs of necessary medical equipment and tests.
The rules of eligibility
for Part B medical insurance are much simpler than for Part A: If you are age
65 or over and a citizen of the United States, or you are a resident of the
United States who has been here lawfully for five consecutive years, you are
eligible to enroll in Medicare Part B medical insurance. This is true whether
or not you are eligible for Part A hospital insurance.
Part B medical insurance
is intended to cover basic medical services provided by doctors, clinics and
laboratories. The lists of services specifically covered and not covered are
long, and do not always make a lot of common sense. Making the effort to learn
what is and is not covered can be important. You may get the most benefits by
fitting your medical treatments into the covered categories whenever possible.
Part B insurance pays for:
- doctor services (including
surgery) provided at a hospital, doctor's office or your home
- mammograms, pelvic exams,
bone density tests and PAP smears for women
- medical services provided
by nurses, surgical assistants, or laboratory or X-ray technicians
- outpatient hospital treatment,
such as emergency room or clinic charges, X-rays and injections
- an ambulance, if required
for a trip to or from a hospital or skilled nursing facility
- drugs or other medicine
administered to you at a hospital or doctor's office
- medical equipment and
supplies, such as splints, casts, prosthetic devices, body braces, heart pacemakers,
corrective lenses after a cataract operation, glucose monitoring equipment
and therapeutic shoes for diabetics and equipment such as ventilators, wheelchairs
and hospital beds
- some kinds of oral surgery
- some of the cost of outpatient
physical and speech therapy
- a limited number of services
by podiatrists and optometrists
- some care and counseling
by psychologists, social workers and daycare personnel
- some preventative cancer
screening exams
- manual manipulation of
out-of-place vertebrae by a chiropractor, and
- part-time skilled nursing
care, physical therapy and speech therapy provided in your home.
How much of my bill will
Medicare Part B pay?
When all your medical bills
are added up, you will see that Medicare pays, on average, only about half the
total. There are three major reasons why Part B medical insurance pays for so
little.
First, Medicare does not
cover a number of major medical expenses, such as routine physical examinations,
medications, glasses, hearing aids, dentures and a number of other costly medical
services.
Second, Medicare only pays
a portion of what it decides is the proper amount -- called the approved charges
-- for medical services. When Medicare decides that a particular service is
covered and determines the approved charges for it, Part B medical insurance
usually pays only 80% of those approved charges; you are responsible for the
remaining 20%.
Note, however, that there
are now several types of treatments and medical providers for which Medicare
Part B pays 100% of the approved charges rather than the usual 80%. These categories
of care include: home health care, clinical laboratory services and flu and
pneumonia vaccines.
Finally, the approved amount
may seem reasonable to Medicare, but it is often considerably less than what
doctors actually charge. If your doctor or other medical provider does not accept
assignment of the Medicare charges, you are personally responsible for the difference.
©
2001 Nolo.com.
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