Loretta Schoen – Under HIS Wings

Discover the Other Side of Medical Adversity from Being Pressed to Feeling Blessed

Medicare A, B & D

FROM:  Medicare.gov

What does Medicare Part A cover?

What’s covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

In general, Part A covers: 

  • Hospital care
  • Skilled nursing facility care
  • Nursing home care(as long as custodial care isn’t the only care you need)
  • Hospice
  • Home health services

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  2. Go to http”//www.medicare.gov/coverage/ to find out if Medicare covers your item, service or supply.

Medicare coverage is based on 3 main factors 

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

What does Medicare Part B cover?

What’s covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers 2 types of services

  • Medically necessary services:Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive Services:Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Part B covers things like:

  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
    • Inpatient
    • Outpatient
    • Partial hospitalization
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a noticesaying that you may have to pay for the item, service, or supply.
  2. Find out if Medicare covers your item, service, or supply by going to http://www.medicare.gove/coverage/

Medicare coverage is based on 3 main factors

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Drug coverage (Part D)

Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost.

A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:

  • Provide written notice to you at least 60 days prior to the date the change becomes effective.
  • At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.

Note

Starting in early 2016, in most cases, your prescribers need to be enrolled in Medicare or have an “opt-out” request on file with Medicare for your prescriptions to be covered by your Medicare drug plan. If your prescriber isn’t enrolled or has “opted-out,” you’ll still be able to get a 3-month provisional fill of your prescription. This will give your prescriber time to enroll, or you time to find a new prescriber who’s enrolled. Contact your plan or your prescribers for more information.

How to get Medicare prescription drug coverage:

There are 2 ways to get Medicare prescription drug coverage–either through adding a Medicare Prescription Drug Plan (Part D), or getting a Medicare Advantage Plan (Part C) such as an HMO or PPO that offers Medicare prescription drug coverage.