What Does Medicare Cover? In July 1965, during President Lyndon Johnson’s administration, Medicare was enacted under Title XVIII of the Social Security Act. It was set up to provide health insurance to citizens 65 and older, regardless of income.
Medicare pays benefits for three categories of medical treatment. These include emergencies and surgeries in the hospital, doctors and treatments, and prescriptions. There are two main parts to Medicare: Part A and Part B and a Part D drug coverage policy.
Part A covers:
- Inpatient services and care in the hospital
- End-of-life or Hospice care
- Skilled nursing facility care
- Nursing home care if it is not long-term or custodial care
- Home Health Care
Medicaid coverage is also based on three main issues: federal and state laws, Medicare’s national decisions about what is covered, and local coverage decisions. These decisions are made by companies that process Medicare claims. These companies can decide if medical treatment is necessary and is covered in their area. You can learn more about from sites like www.medicareusa.com
Part B covers:
Part B Medicare covers two types of services:
- Services that are medically necessary or services of supplies needed to treat or diagnose your medical needs. These needs must meet accepted medical practice guidelines.
- Preventive services that prevent illness or find a disease in early stages when treatment may be successful.
If you get your preventive care from a health care provider who accepts Medicare, you will pay little to nothing out of pocket.
Plan B covers clinical research, ambulance services, medical equipment (DME), mental health needs in inpatient or outpatient, or partial hospitalization. Part B also pays for limited outpatient prescription drugs and needed medical supplies.
Part D – Drug Coverage
All insurance plans listed with Medicare must have a wide range of prescriptions that those on Medicare take. Prescriptions include drugs in protected classes or drugs that treat cancer or HIV/AIDS. Each plan has its formula for the drugs they carry and the prices they charge.
Many drug plans place prescription drugs in tiers or “donut holes.” Each tier has specific drugs listed and at different prices. If you have a drug you regularly take in a lower tier, you will pay less than a prescription in a higher tier.
Medicare drug plans and Medicare Advantage Plan have a specific list of prescriptions they cover. This list is called a formulary. Insurance plans must include brand name drugs and generic drugs. The formulary must have at least two drugs in the commonly prescribed categories. This requirement is to ensure that those with different medical conditions get the prescriptions they need. Plans can choose which drugs they will offer. If your drug is not on the list, you can ask for an exception.
Plans can change drug lists during the year since new drug therapies are introduced and different medical information is available.
If the FDA considers a drug unsafe or if the manufacturer removes them from the market, Medicare under Part D often immediately removes these prescriptions from the list. Insurance plans can take away brand name drugs from their lists or coverage and switch them to generic drugs. Plans can also increase the cost of brand name drugs if there is a generic drug available.
An insurance plan can change their drug Part D coverages. Insurance plans must give you written notice 30 days before the date the change takes place. They must also allow you at least a month’s supply of your current drug.
Using prescriptions on your Plan’s D formulary will provide cost savings. However, if you use a drug that is not on your plan’s list, you will need to pay full price. No copayment or insurance coverage will be offered. Save money by using generic drugs instead of asking for brand name prescriptions.
If you are taking a prescription that Medicare Part D does not cover, talk to the drug manufacturer for discounts.
Medicare Advantage Plans
Medicare Advantage Plans are an alternative way to get Medicare Part A and Part B coverage. Private companies oversee Medicare Advantage Plans, or Part C or MA plans. Companies must follow Medicare rules.
Many Medicare Advantage Plans include Part D or drug coverage. However, you will be required to use providers signed up in the plan’s network to take advantage of the Medicare Advantage Plan. Advantage Plans require providers to provide service for the lowest costs.
Medicare Advantage Plans provide a limit on out-of-pocket costs. These limits change each year for covered services and protect you from unforeseen costs. Some plans offer out-of-network coverage, but usually at a higher cost. Medicare Advantage Plans include Preferred Provider Organization or PPO Plans, Health Maintenance Organization or HMO Plans, Special Needs Plans or SNPs, and Private Fee for Service or PFFS Plans.
Sign Up for Medicare
Signing up for Medicare can be confusing. Some people, when they turn 65 and on Social Security, are automatically signed up. Those who do not receive Social Security will need to sign up on their own. During certain times of the year, October to December, you can change your coverage or sign up. You should sign up for Medicare Part B as soon as you are eligible for Medicare. By signing up for Plan B quickly, you will avoid paying the penalty. You can always choose how you get your Medicare coverage, and there may be help with Medicare costs.
Do not forget to sign up for Plan D or prescription coverage. Prescriptions are expensive, and Medicare help will be a lifesaver.
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