Overview: What Medicare Insurance Covers

Wrapping your head around what Medicare is and what it’s for should include one important concept: Medicare coverage. Services are covered under the different Medicare parts depending on policies, providers, and networks. This type of health insurance can cover everything from hospital bills and vision exams to hearing aids and prescription drugs, depending on which parts one opts to get and how the different components interact. It can be a complex thing to understand, but the HealthPlusLife team is here to make this easy and help you figure out what you need to know about Medicare coverage services.

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The Structure of Medicare Coverage Services

Before we dive into the specifics of Medicare health coverage, let’s start by defining the basic Medicare parts to understand what each is designed to do — and what it doesn’t do.

Medicare Part A is your hospital insurance, covering inpatient hospital stays, skilled nursing facility care, hospice care, and some home healthcare services. Medicare Part B is medical insurance that covers services and supplies that aren’t in Part A (things like doctor visits, preventive services, and outpatient care). Together, Parts A and B make up Original Medicare.

Medicare Part C often is referred to as Medicare Advantage, and it’s an alternative to Original Medicare offered by a private insurer that provides all the benefits of Parts A and B and often includes additional coverage like vision or dental services.

Medicare Part D is another private insurer product, this time adding prescription drug coverage to Original Medicare or a Medicare Advantage plan that doesn’t include drug coverage.

Understanding Original Medicare Insurance

Original Medicare combines Medicare Parts A and B, making this the foundational government health insurance program primarily for people 65 and older. Younger people can qualify as well if they meet specific requirements and disabilities. Let’s explore what these important Medicare parts cover in more detail.

Medicare Part A is your hospital insurance, covering things like:

• Hospital Stays: Original Medicare Part A covers inpatient care in hospitals. This includes critical access hospitals and, in some cases, long-term care hospitals.
• Skilled Nursing Facility Care: After a qualifying hospital stay, Medicare Part A may cover skilled nursing facility (SNF) care. However, it’s important to note that this doesn’t equate to long-term or custodial care. Instead, it’s for medically necessary services like physical therapy or intravenous injections that can only be given in an SNF.
• Hospice Care: For those with a terminal illness and a life expectancy of six months or less, Part A can cover hospice care, which includes pain relief, symptom management, and support services.
• Home Healthcare: In specific conditions, if you’re confined to your home, Medicare Part A might cover home healthcare services. This can include part-time skilled nursing care, physical therapy, and other services.

Medicare Part B is your medical insurance, and it covers:

• Outpatient Care: Part B covers outpatient care, including doctor visits, outpatient surgeries, lab tests, and preventive services.
• Durable Medical Equipment (DME): Equipment that a doctor prescribes for home use, like walkers, wheelchairs, or oxygen equipment, is typically covered under Part B.
• Preventive Services: Part B covers a range of preventive services, aiming to detect and address health conditions early. Examples include cardiovascular screenings, mammograms, and certain immunizations like flu shots.
• Mental Health Services: This includes outpatient counseling, therapy services, and partial hospitalization for those who require more intensive care but aren’t in a full inpatient setting.
• Ambulance Services: If it’s deemed a medical necessity and other transportation could endanger one’s health, Part B may cover ambulance services.

Medicare Advantage (Part C): An All-In-One Plan

Comprehensive healthcare solutions are possible with a Medicare Advantage, or Medicare Part C, plan. Often referred to as the “all-in-one” option, Medicare Advantage wraps up the services of Parts A and B, with the added benefit of typically including even more in terms of Medicare service coverage.

Medicare Advantage provides coverage for everything that Original Medicare does — from hospital stays to outpatient care — but it distinguishes itself with the additional services covered by Medicare that it can offer:

• Prescription Drug Coverage: Many Medicare Advantage plans come bundled with prescription drug coverage (Part D). This inclusion eliminates the need for beneficiaries to sign up for a separate Part D plan, simplifying medication management and potentially reducing costs.
• Vision and Dental Care: Vision tests, eyeglasses, routine dental care, and even hearing aids — services not typically covered under Original Medicare — can be a part of a Medicare Advantage plan’s offering. This comprehensive approach ensures beneficiaries receive holistic care, encompassing all aspects of their health.
• Wellness Programs: Recognizing the shift towards preventive health, many Medicare Advantage plans incorporate wellness programs. These could range from fitness memberships to nutrition counseling, further enhancing the Medicare service coverage spectrum.
• Specialized Plans: Some Medicare Advantage plans cater to specific health needs. For instance, plans are tailored for people with chronic conditions or those requiring institutional care, ensuring that specialized care is available for those who need it.

Another notable aspect of Medicare Advantage is the flexibility it offers. Beneficiaries can choose from Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and other plan types, depending on their preferences and needs.

However, while the Medicare Advantage plans broaden the scope of Medicare service coverage, remember to brush up on network restrictions. Many of these plans operate within specific networks of healthcare providers, and going out-of-network might lead to higher out-of-pocket costs.

Consolidating various services into one plan simplifies healthcare management while offering broader Medicare service coverage. Reach out to the HealthPlusLife team to learn more about how a Medicare Advantage plan can benefit you and explore the full range of services covered under HealthPlusLife’s offerings.

Prescription Drug Coverage (Part D)

While hospital bills and out-of-pocket costs for doctor appointments rightfully get the majority of attention when considering Medicare health coverage, don’t forget about another potentially expense part of your healthcare: prescription drugs. For people with Original Medicare, or a Medicare Advantage plan that doesn’t include coverage for medications, a Medicare Part D plan could be a good option.

Medicare Part D primarily serves to cover the cost of prescription drugs. The specifics of what drugs are covered can vary between plans, but each plan must provide a standard level of coverage set by Medicare. This often includes a broad range of generic and brand-name drugs, categorized in a list called a formulary. Beneficiaries should review this formulary to understand which drugs are covered and at what cost.

And don’t forget that while Part D benefits can help make prescription drugs more affordable and give people a financial safety net, there’s a cost to get this kind of coverage as well. Beneficiaries should be prepared for monthly premiums, deductibles, and co-payments or coinsurance.

After you and your drug plan have spent a certain amount on covered drugs, you may enter a coverage gap, often called the “donut hole.” During this phase, you might pay higher out-of-pocket costs for your drugs. However, recent reforms have aimed to reduce the costs associated with this gap, providing significant relief to beneficiaries.

Additional Services Covered by Medicare

Basic medical needs aren’t the only services covered by Medicare, and many beneficiaries might not even realize everything else that may fall under Medicare coverage services.

Preventive services, for example, are often covered at no additional cost to the beneficiary — things like diagnostic tests and screenings, vaccinations, and annual wellness visits.

Home healthcare may also be among the services covered by Medicare, such as temporary part-time skilled nursing care, physical or occupational therapy, speech-language pathology, and home health aides.

Hospice care, including medical services, counseling, medication, and respite care, can also be covered for those diagnosed with a terminal illness and a life expectancy of six months or less.

What Medicare Insurance Doesn’t Cover

Understanding Medicare coverage requires knowledge of what Medicare covers, obviously — but just as important are those things that it won’t cover. There are certain limitations to Medicare coverage services, as with all insurance policies, and getting to know these exclusions can help you prepare medically and financially.

Routine vision, hearing, and dental care, for example, typically aren’t covered. Dental care procedures and cleanings, fillings, or dentures won’t be covered, just like routine eye exams for glasses or contact lenses or standard hearing aids and routine hearing tests.

The range of what Medicare covers also typically won’t include long-term care — things like assistance with bathing, dressing, eating, or other long-term custodial care. Because of this, beneficiaries who need prolonged assistance in a nursing home or another long-term care facility would need to look beyond Medicare for coverage. Medicaid or a private long-term care insurance policy might be the best option in these cases.

Other things generally not covered by Medicare include cosmetic surgery, overseas medical care, and alternative therapies like acupuncture or most chiropractic services. And don’t forget that Original Medicare won’t cover outpatient prescription drugs, though a Medicare Part D plan or a Medicare Advantage plan can offer this coverage.

While Medicare health coverage is comprehensive for many health needs, it has its limitations, and being informed about what is included among the various Medicare coverage services is a crucial part of making educated decisions. Sometimes, switching to a Medicare Advantage plan, adding a Medicare Part D plan, or adding supplementary insurance can be a great way to prepare for out-of-pocket expenses. For those looking to bridge the coverage gap, HealthPlusLife offers a range of insurance solutions tailored to ensure complete peace of mind. Give our team a call today at 888-828-5064 or contact us online to get started.

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Frequently Asked Questions About Medicare Coverage Services

What services are covered under Medicare?

Medicare typically covers many services, including hospital stays (inpatient), skilled nursing facility care, lab tests, surgeries, doctor visits (outpatient), home health care, and preventive services.

How does the coverage differ between Original Medicare and Medicare Advantage?

Original Medicare comprises Part A (hospital insurance) and Part B (medical insurance). Medicare Advantage (Part C) is an alternative to Original Medicare offered by private companies approved by Medicare. While it covers all services that Original Medicare provides, most Medicare Advantage Plans also offer prescription drug coverage, and some offer additional benefits like vision, dental, and hearing care.

Does Medicare cover prescription drugs?

Original Medicare doesn’t automatically cover prescription drugs. However, you can add this coverage by joining a Medicare Prescription Drug Plan (Part D). On the other hand, most Medicare Advantage Plans (Part C) include prescription drug coverage.

Are preventive services covered by Medicare?

Yes, Medicare covers many preventive services, including flu shots, cardiovascular screenings, mammograms, and colorectal cancer screenings. Some preventive services are available without out-of-pocket costs if specific criteria are met.

What are some services that Medicare does not cover?

While Medicare provides comprehensive coverage, it doesn’t cover everything. Some services not covered include long-term care, most dental care, eye exams related to prescription glasses, cosmetic surgery, acupuncture, and hearing aids.

Can I get additional coverage for services not included in Medicare?

Absolutely. You can purchase supplemental insurance, often referred to as Medigap, from private companies. Medigap can help pay for costs not covered by Original Medicare, such as deductibles, copayments, and services outside the U.S.

How can I find out if my Medicare plan covers a specific service?

It’s always recommended to check your plan’s official documentation or contact your plan provider directly. HealthPlusLife representatives can also assist in navigating your coverage details and answering specific questions related to Medicare.

Are there costs associated with services covered by Medicare?

Yes, even if Medicare covers a service or item, you might have to pay deductibles, coinsurance, or copayments. The exact cost can vary depending on the service, whether you have additional insurance, the type of Medicare plan, and several other factors.

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