Understanding Medicare

Karl’s Free Report on How to Avoid the Biggest Medicare Mistakes

Choosing a MediGap Policy

Medicare & You Handbook

How to understand Medicare coverage

Don’t see what you need? Send me an email, Karl@TheBig65.com. Tell me what you are looking for and I will do my best to help.

Medicare Part A, Hospital Insurance

What’s covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

In general, Part A covers:

• Hospital care
• Skilled nursing facility care
• Nursing home care (as long as custodial care isn’t the only care you need)
• Hospice
• Home health services

Two ways to find out if Medicare covers what you need

Talk to your doctor or other health care providers about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a notice saying that you may have to pay for the item, service, or supply.

Find out if Medicare covers your item, service, or supply.

---

Medicare coverage is based on 3 main factors

1. Federal and state laws.
2. National coverage decisions made by Medicare about whether something is covered.
3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Medicare Part B, Physician Services

What’s covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers 2 types of services

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.

Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Part B covers things like:

• Clinical research
• Ambulance services
• Durable medical equipment (DME)
• Mental health
• Inpatient
• Outpatient
• Partial hospitalization
• Getting a second opinion before surgery
• Limited outpatient prescription drugs

There are 2 ways to find out if Medicare covers what you need.

Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a notice saying that you may have to pay for the item, service, or supply.

Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

1. Federal and state laws.
2. National coverage decisions made by Medicare about whether something is covered.
3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Questions about how Medicare works? Give me a call at 877-850-0211, or book a time on my calendar.