Covered By Medicare?

Medicare Part A will not cover every hospital procedure you may need. You can check the procedure or test you need on the Medicare website to make sure it is covered before you have it done. Click here to check.

If you need certain care that Medicare doesn’t cover, you will have to pay for those procedures or services out-of-pocket unless you have supplemental insurance.

Some things that are not covered under Medicare Parts A and B are:

Whenever a patient needs a procedure which is not covered, providers are required to inform patients of this and have them sign a release prior to receiving treatment. This allows patients to opt to pay for the service out-of-pocket or refuse the care.

Remember that Medicare also doesn’t cover your deductible, co-insurance, or copayments. See the chart below to understand these costs better.

Beginning in 2017, in general, these are the costs of inpatient care for those who have Medicare Part A:

Keep in mind that you have to be admitted to the hospital and approved for these services. Additionally, to qualify for Medicare coverage you have to be in a Medicare-approved facility.

Again, Part B will not cover all the services you may require. The important part to remember is that any care you receive must be considered “medically necessary.” You should always confirm your coverage before having any tests, services, or procedures performed.

It is important to note that the outpatient services that are covered by Part B, require you to meet your deductible and pay any co-insurance or co-payments required.

You will have to pay a premium for PART B. This is what you can expect to pay in premiums:

The deductible and coinsurance associated with Part B are as follows:

Also, keep in mind that neither Part A nor Part B gives you prescription drug coverage, so if you are going to opt to enroll in Original Medicare you will also need to pay a premium for Part D coverage or pay for your prescription drugs out-of-pocket. We will cover the coverages and costs associated with part D later in this article.

That should give you a good summary of what is and is not covered in under Original Medicare.

By law, Medicare Part C plans must cover all the same things as Medicare Part A and B.

But as opposed to Original Medicare, they do cover some services that Original Medicare does not pay for.

For example, most Part C plans include a prescription drug benefit. Another example might be that some Part C plans include eye exams, a pair of eyeglasses each year, or a hearing exam. These difference will vary from plan to plan so please evaluate your needs as you determine the policy you want.

However, Part C will not cover medical services outside your service area. Generally, these plans require you to use specific providers. These are the doctors, hospitals, drug stores and other healthcare providers that the Medicare Advantage plans have contracts with. These are called in-network providers.

It’s important to know that if you use providers outside your plan’s network, it may cost you more money. In certain cases, it may also mean that you the carrier won’t provide any Medicare coverage at all for that service.

Also, be aware that each Part C plan has different rules for how you get services like whether you need a referral to see a specialist, etc. so make sure you understand these rules so that your procedures and services are covered.

Just like with Original Medicare, you are required to pay a premium for Part C coverage. Because these plans are offered by private insurance companies, we cannot give you the exact amount of your expected premium, but the following may be helpful as you estimate your costs:

Additionally, just like with Original Medicare you will pay an annual deductible for your healthcare services, in addition to the standard Part B deductible. Some plans that include prescription drug coverage may charge another deductible for drug coverage.

Instead of having to pay a co-insurance percentage, most Part C plans charge a copayment which is a flat fee for services and remember that some types of plans charge higher copays to see providers out of your network.

Each year plans establish the amounts they charge for premiums, deductibles and services.

For your information and estimating purposes, the maximum out-of-pocket spending limit is $6,700 in 2019 for all Medicare beneficiaries, though if you use out-of-network providers, that limit may be higher. Also, some Part C plans offer an out-of-pocket limit below the $6,700 maximum.

Part D only covers a certain number of drugs. Every day new drugs are researched, developed, and manufactured and it takes time for these new drugs to appear on the Part D coverage lists.

Part D does not cover experimental drugs.

Just like Part C plans, Part D plans vary in cost from plan to plan and from carrier to carrier. However, the following information may help you understand and estimate your costs of having a Part D plan.

In addition to a premium, many plans require a separate prescription drug deductible. Remember these kinds of policies will not pay for your prescriptions until you pay the deductible amount out-of-pocket.

Just like your other healthcare coverage, you will have the cost of a copayment or coinsurance with your prescriptions. Remember that a copay is a fixed dollar amount for your prescriptions.

For example, you might have to pay $5 for a generic drug, $40 for a “preferred” brand name drug and $75 for a non-preferred brand name drug.

Coinsurance is a percentage of the price of your prescription. Typically plans require coinsurance for drugs listed in higher tiers like tier 4 and tier 5 drugs. For example, if your prescription costs $400, and your coinsurance is 25%, you will pay $100.

Note that it is possible that some of your medications require a fixed copayment and others a coinsurance.

At this point, you should have a very good understanding of what is covered and not covered under each part of the Medicare program and the costs associated with each.