Medicare FAQs

Medicare is an expansive topic that can sometimes seem confusing to understand. These Medicare FAQs introduce the basics of what Medicare is and how it works. You can read the Medicare FAQs as an article or jump to a specific question or topic.

Medicare FAQs: What is Medicare and who qualifies?

Medicare is a health insurance program administered by the United States government. It provides coverage to people 65 years of age or older, people under 65 with certain disabilities, and people with end-stage renal disease. The plan is divided into different parts according to what is covered:

  • Part A covers overnight hospital stays, including room, food, tests, and doctor's fees.
  • Part B helps pay for some services and products not covered by Part A. These are typically outpatient costs.
  • Part C plans give those eligible for Medicare the option of receiving their benefits via private health insurance plans, making the benefits usually acquired through Parts A and B more attractive.
  • Part D covers certain prescription medicines.

Medicare FAQs: Am I eligible for Medicare Part A?

If you are 65 years old or older, yes, you are eligible for Part A. Depending on your and your spouses work records, this coverage is free for you. If you are not eligible for Medicare Part A, you can still enroll in it and receive the same coverage by paying a monthly premium. Your monthly premium is calculated according to the number of work credits you have accumulated. If you dont enroll immediately when you turn 65, your premium increases by 10% each year after you turn 65. Note that if you want Part As paid hospital insurance, you must also enroll in Medicare Part B and pay the premium for it, too.

Medicare FAQs: What will Medicare Part A cover?

  • Overnight hospital stays, including room, tests, meals, general nursing, doctor's fees, and miscellaneous hospital services and supplies.
  • Critical access hospital stays and mental health care. Hospital stays must be at least 3 midnights.
  • Reasonably necessary medical in-home services such as skilled nursing care, physical and occupational therapy, speech therapy, and medical social services.
  • Home-use equipment such as wheelchairs, hospital beds, walkers, oxygen, and other certain medical supplies.
  • Hospice, if you are terminally ill and have six months or less to live. The following is a list of hospice services that are covered by Medicare:
    • Doctor and nursing care
    • Medical equipment and supplies
    • Medicine for pain and symptom management
    • Home health aide and homemaker services
    • Physical and occupational therapy
    • Speech therapy
    • Social worker services
    • Grief counseling for you and your family
  • Brief nursing home visits if
    • You were previously required to stay at least three midnights in the hospital
    • Your nursing home stay is due to something diagnosed during that previous hospital stay
    • You are not receiving rehabilitation, but have another issue requiring skilled nurses care
    • Your nursing home care is skilled care and not merely custodial, non-skilled or long-term care
  • 100 days is the maximum length of nursing home stay that Medicare Part A will cover. Your first 20 days are paid in full, while the other 80 require a co-payment.
  • Your maximum-days-covered clock for inpatient treatments (hospital and nursing home) is reset after 60 days of not using facility-based service coverage.

Medicare FAQs: Am I eligible for Medicare Part B?

You are eligible for Medicare Part B benefits if

  • You are 65 years or older; AND
  • You are a United States citizen

You do not have to be eligible for Medicare Part A to be eligible for Medicare Part B.

Medicare FAQs: What will Medicare Part B cover?

Not only is Medicare Part B easier to qualify for than Part A, but it also covers many things, such as outpatient care, that Part A does not:

  • Doctors care at a hospital, doctors office, or at home
  • Services of nurses, technicians, and medical assistants
  • Laboratory tests (100%)
  • Periodic exams such as mammograms, bone density tests, and pelvic exams for women
  • Annual flu shots (100% coverage)
  • Pneumonia vaccines (100% coverage)
  • Wellness exam, if done within six months of your enrollment
  • Outpatient treatment, such as ER and clinic visits, X-rays, tests, and shots
  • Ambulatory service
  • Medicines given while in the hospital or at your doctors office
  • Medical equipment and supplies
  • Certain oral and maxillofacial surgeries
  • Some outpatient therapy
  • Some podiatrist and optometrist services
  • Some counseling services
  • Some preventive services
  • Chiropractic manipulation if done manually to alleviate a misplaced vertebrae
  • Some Alzheimers-related care
  • Medically proven and necessary treatments for obesity
  • In-home (100% coverage), part-time skilled nursing care, physical therapy, and speech therapy

Medicare FAQs: How much of my bill will Medicare Part B pay?

When added all together, Medicare really only ends up paying for about half of your total medical expenses. This is due to a few different factors:

  • You will likely have routine exams, medicines, glasses, hearing aids, dentistry, etc., that Medicare does not cover. You bear these costs on your own.
  • Medicare decides on its own what the appropriate amounts, or approved charges are for each of your services.
  • These approved charges may seem like sufficient amounts to Medicare, but they are usually far less than what doctors are actually charging. Your health care providers do not have to accept what Medicare says are the appropriate amounts. They can charge whatever they typically charge anyone else, and you are responsible for the difference.
  • Although there are several services which are 100% covered by Medicare Part B, it only pays about 80% of the approved charges of other services.

Medicare FAQs: What is Plan C coverage and what does it cover?

Medicare Part C is a private health insurance plan. Anyone who is eligible for Parts A and B are also eligible for Part C. Beneficiaries pay monthly premiums and receive a more attractive plan than Plan A and Plan B, mainly because of the vast coverage of prescription drugs. Beneficiaries also pay a monthly premium to receive Medicare Part B coverage. The following is a list of benefits that various Plan C plans offer:

  • Medically necessary services from any hospital or doctor in the country
  • Prescription drugs
  • Dental care
  • Vision care
  • Gym and health care memberships
  • Various plans save you out-of-pocket costs and cap the amount of out-of-pocket expenses you will pay (for example, guaranteeing that you wont pay more than $5,000 in expenses)

Medicare FAQs: Who is eligible for Medicare Part D coverage?

You are eligible for Medicare Part D coverage if you are

  • Eligible for Medicare Part A (even if youre not enrolled); OR
  • Enrolled in Medicare Part B

Medicare Part D helps beneficiaries pay for prescription drugs. You dont have to enroll, unless you also receive Medicaid, in which case, the government enrolls you in Medicare Part D automatically.

Medicare FAQs: How much does Medicare Part D cost?

Medicare Part D requires you to pay premiums, deductibles, and copayments, and also has a coverage gap during which you pay full price for all of your prescription costs. This gap begins once Medicare has paid a certain dollar amount of your prescriptions. Then, once youve paid an out-of-pocket required amount, the coverage gap ends, and you then are only responsible for the co-payments for the rest of that calendar year. This is to ensure that your out-of-pocket expense isnt too debilitating (usually capped at around $5,000). Part D plans pick and choose what types of drugs and brands they want to cover and can choose to deny coverage altogether. You should review the different Part D plans carefully to choose the one that is best fitted for your needs.

Medicare FAQS: Can I get any of Medicare Part D's costs waived?

Maybe. If your income is below a certain amount, you may qualify for supplemental assistance from Social Security. In certain situations, your copayments may be significantly reduced or even waived. You may qualify for this copayment assistance if you

  • Are eligible for Medicaid
  • Have an income level that does not reach above 149% of the federal poverty level; or
  • Live in a long-term nursing home, are enrolled in Medicaid, and are enrolled in Medicare Part D

You also may qualify for assistance through pharmacies and drug companies if you

  • Take certain types of medications, like generic brands
  • Use a pharmacy who waives copayments for those under a certain income. Ask your pharmacy if it participates in this program

Next Steps

Contact a qualified health care attorney to help navigate legal issues around your health care.

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