Ethan Rhodes
Medicare is a federal health insurance program for individuals aged 65 and above and certain people under 65 with disabilities or specific conditions. It covers a range of hospital services, which vary depending on whether an individual is an inpatient or an outpatient. Medicare Part A covers inpatient hospital services, including semi-private rooms, meals, general nursing services, drugs, supplies, and some blood transfusions. Meanwhile, Medicare Part B covers outpatient hospital services, such as emergency services, laboratory tests, mental health care, radiology services, and preventive care.
| Characteristics | Values |
|---|---|
| Medicare Part A | Covers inpatient care in hospitals, skilled nursing facilities, hospice care, and home health care |
| Medicare Part B | Covers outpatient hospital services, including emergency services, laboratory tests, mental health care, radiology services, medical supplies, and preventive care |
| Medicare Part D | Helps cover the cost of prescription drugs, including shots and vaccines |
| Supplemental Coverage | Medigap or retiree health insurance can cover the Part A deductible and hospital coinsurance, providing additional benefits |
| Medicare Advantage | Medicare-approved bundled plans from private companies, offering an alternative to Original Medicare with potential extra benefits |
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What You'll Learn
Inpatient hospital care
Medicare Part A covers inpatient hospital care. This includes inpatient care in critical access hospitals and skilled nursing facilities. It also covers hospice care and some home health care. If you are admitted as an inpatient to a hospital that accepts Medicare, Part A covers most hospital services, including semi-private rooms, meals, general nursing services, drugs, supplies, and other hospital services that are part of your inpatient treatment. Some blood transfusions and inpatient rehabilitation services are also covered. However, Part A does not cover private rooms unless medically necessary or personal items unless provided to all patients free of charge.
Your costs under Part A depend on the number of days you spend as an inpatient during each benefit period. You pay a portion of the cost, called coinsurance, for each day you are in the hospital beyond 60 days in each benefit period. If you buy a Medicare supplement policy, known as Medigap, or have other coverage, this supplemental policy may cover the Part A deductible, hospital coinsurance, and provide additional lifetime reserve days.
Medicare Advantage is a Medicare-approved plan offered by private companies that includes Part A, Part B, and usually Part D. These plans often have different out-of-pocket costs than Original Medicare or supplemental coverage and may offer some extra benefits. You can use any doctor or hospital that accepts Medicare across the United States.
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Outpatient hospital services
Medicare Part B covers a variety of diagnostic and treatment services provided to outpatients at hospitals that accept Medicare. This includes emergency or observation services, such as an overnight stay or outpatient clinic visit for same-day surgery. It also covers laboratory tests, x-rays, and other radiology services billed directly by the hospital.
In the case of mental health, Medicare Part B covers intensive outpatient programs and partial hospitalization programs for mental health conditions, including substance use disorders. A doctor or qualified mental health professional must certify the necessity of inpatient treatment for the latter.
Additionally, Medicare Part B covers medical supplies, such as splints and casts, as well as preventive and screening services. It may also cover certain drugs and biologicals that are typically administered as part of a procedure, like injectable drugs. However, it generally does not cover prescription or over-the-counter drugs in an outpatient setting, which are typically covered under Medicare Part D.
It is important to note that the specific amount owed for outpatient services may depend on various factors. Your doctor may recommend services that are not covered by Medicare, in which case you may have to pay some or all of the costs. Additionally, you may pay more for outpatient services in a hospital outpatient setting compared to receiving the same care in a doctor's office.
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Prescription drugs
Medicare covers prescription drugs in different ways depending on your care setting and treatment needs. Medicare Part A (Hospital Insurance) covers the drugs you need during a Medicare-covered stay in a hospital or skilled nursing facility (SNF). Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Part B covers drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting. However, Part B does not cover "self-administered drugs" in a hospital outpatient setting.
Medicare Part B covers drugs used with some types of durable medical equipment (DME) if the drug is medically necessary. Some antigen allergy tests and treatments are covered by Medicare if a doctor or other healthcare provider prepares them and they are given by a properly instructed person under appropriate supervision. HIV prevention drugs, injectable osteoporosis drugs, and erythropoiesis-stimulating agents are also covered by Medicare Part B. Oral End-Stage Renal Disease (ESRD) drugs are covered by Medicare, including calcimimetic medications and phosphate binders. Enteral and parenteral nutrition (intravenous and tube feeding) are also covered by Medicare if you cannot absorb nutrition through your intestinal tract or take food by mouth.
Medicare Part D is offered through private companies either as a stand-alone plan or as a set of benefits included with a Medicare Advantage Plan. It covers prescription drugs that are not covered by Part B. Each plan can vary in cost and specific drugs covered, and all plans must cover a wide range of drugs to ensure that people with different medical conditions can access the prescription drugs they need. Plans can include both brand-name drugs and generic drugs, as well as original biological products and biosimilars. Your total costs for Medicare drug coverage will depend on which plan you choose.
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Hospice care
To be eligible for Medicare-covered hospice care, an individual must have a Medicare-assigned doctor certify that they are terminally ill, with a
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Skilled nursing facility care
Skilled nursing facility (SNF) care is covered by Medicare Part A (Hospital Insurance) for a limited time if certain conditions are met. Firstly, you must have Medicare Part A with remaining days in your benefit period. Secondly, you must have had a qualifying inpatient hospital stay, and the SNF care must be for a condition treated during that stay or a new condition that arose during SNF care for an ongoing condition. Additionally, you must enter the SNF within 30 days of leaving the hospital, and your doctor must determine that you require daily skilled care, such as intravenous fluids, medications, or physical therapy. This care must be provided or supervised by skilled nursing or therapy staff in a Medicare-certified SNF.
Medicare Advantage Plans may waive the 3-day minimum inpatient hospital stay requirement, and you should always check with your doctor or hospital staff to confirm if Medicare will cover your SNF stay. If you don't have a 3-day qualifying stay, you may be able to receive care in other settings, such as home healthcare, or explore alternative coverage options like Medicaid or Veterans' benefits.
Medicare-covered services in a skilled nursing facility include a semi-private room, ambulance transportation when necessary for your health, and skilled nursing or therapy care. This skilled care involves treatment, management, observation, and evaluation of your condition by professionals or technical personnel.
It's important to note that if you have a break in skilled care of 60 consecutive days or more, your current benefit period ends, and your SNF benefits are renewed. This means that the maximum coverage available is up to 100 days of SNF benefits per benefit period.
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Frequently asked questions
Medicare Part A helps cover inpatient care in hospitals, skilled nursing facilities, hospice care, and home health care. It covers semi-private rooms, meals, general nursing services, drugs, supplies, and other hospital services that are part of your inpatient treatment.
Medicare Part B covers many diagnostic and treatment services received as an outpatient from a hospital that accepts Medicare. It includes emergency or observation services, laboratory tests, mental health care, radiology services, medical supplies, and preventive and screening services.
Medicare Part B does not typically cover prescription and over-the-counter drugs received in an outpatient setting. However, Medicare Part D specifically helps cover the cost of prescription drugs, including recommended shots or vaccines.
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