medicare guide

The Different Benefits of Traditional Medicare

Medicare is a federally funded program that offers healthcare coverage for individuals aged 65 and older, and for some younger people with disabilities. Traditional Medicare is made up of four parts: A, B, C, and D, each providing distinct types of coverage. Below are the key benefits associated with each part of Medicare:

Medicare Part A: Hospital Insurance

Medicare Part A covers essential hospital services, including:

  • Hospital Stays: This includes inpatient care when you are admitted to a hospital.

  • Home Health Care: Coverage includes necessary health services like skilled nursing care and therapy services at home.

  • Hospice Care: If you're terminally ill, Medicare Part A covers hospice care to provide comfort and palliative care.

Medicare Part B: Medical Insurance

Medicare Part B provides coverage for outpatient services and other medical needs:

  • Physician Visits: This includes doctor visits both in the office and outpatient settings.

  • Laboratory Tests: Medicare Part B covers laboratory services, such as blood tests and screenings.

  • Ambulance Services: Coverage includes emergency transportation to a hospital or healthcare facility.

  • Home Medical Equipment (HME): Medicare Part B covers durable medical equipment that’s needed for home use, such as wheelchairs or walkers.

Medicare Part C: Medicare Advantage Plans

Medicare Part C, also known as Medicare Advantage, is provided by private insurance companies and serves as an alternative to Medicare Part B. These plans offer additional coverage beyond what is included in Original Medicare (Parts A and B), often with added benefits like:

  • Prescription drug coverage (usually included)

  • Vision and dental coverage

  • Additional benefits tailored by the private insurer
    Note: Medicare Part C is an alternative to the standard Medicare Parts A and B and often combines these benefits into a single plan.

Medicare Part D: Prescription Drug Coverage

Medicare Part D offers coverage for prescription drugs, helping beneficiaries manage the cost of their medications. It is optional and provided through private insurance companies.

For more information on coverage options, eligibility, and enrollment periods, visit Medicare.gov.

What Can You Expect to Pay for Medicare Part B Services?

Medicare Part B requires individuals to pay certain out-of-pocket costs for services:

  • Coinsurance: You are typically responsible for 20% of the Medicare-approved amount for most services, provided the healthcare provider agrees to accept Medicare's payment terms.

  • Non-Participating Providers: If the supplier or provider does not accept Medicare assignment, you might be required to pay the full price upfront. However, the provider will file a claim on your behalf for reimbursement.

  • Supplemental Insurance: If you have supplemental insurance (Medigap), it may help cover the 20% coinsurance or deductible costs, once the plan’s deductible is met.

Durable Medical Equipment (DME) Defined

Durable Medical Equipment (DME) is defined by Medicare as medical devices that meet specific criteria, including:

  • Durability: The equipment must be able to withstand repeated use over time.

  • Medical Purpose: The equipment is used to treat a medical condition or improve a person’s health.

  • Home Use: The equipment must be intended for use at home and not in a hospital or skilled nursing facility.

Understanding Assignment (A Claim-by-Claim Contract)

When a supplier accepts Medicare Assignment, they agree to accept Medicare’s approved amount as full payment for a service or product. Here's what this means for you:

  • Coinsurance: You are responsible for paying 20% of the Medicare-approved amount for covered services.

  • Annual Deductible: For 2019, the deductible was $185. You’ll need to meet this deductible before Medicare starts covering your costs for certain services.

  • Medicare Assignment: If the supplier accepts Medicare assignment, they cannot charge more than the Medicare-approved amount.

Medicare's Coverage for DME

Medicare covers Durable Medical Equipment (DME) through the following options:

  • Purchase: Medicare may pay the full price of the equipment upfront, and the equipment becomes yours.

  • Rental: Medicare may cover rental costs for equipment, such as oxygen therapy or mobility aids, until they are no longer needed.

  • Capped Rental: Medicare will pay for the rental of the equipment for up to 13 months, after which you will own the item.

  • Oxygen Therapy: For oxygen equipment, Medicare pays for the rental for up to 36 months, after which a small fee is charged for the gas or liquid contents.

Mandatory Submission of Claims

Medicare requires that suppliers submit claims for reimbursement within one year from the date of service. If an item is not covered under Medicare, the supplier is not obligated to submit the claim on your behalf.

The Role of Physicians in DME

A physician’s order or a Certificate of Medical Necessity (CMN) is required for any DME item billed to Medicare. In order to have a claim covered, your healthcare provider must issue an order confirming that the DME is necessary for your medical condition.

Prescriptions Before Delivery

For certain types of equipment like wheelchairs, oxygen therapy, and TENS units, Medicare requires the following before delivery:

  1. A recent office visit with your healthcare provider.

  2. A written order or prescription for the required equipment.

How Does Medicare Pay for and Allow You to Use the Equipment?

Medicare pays for DME in four main ways:

  1. Purchase: Medicare pays for the item upfront, and you own it.

  2. Rental: Medicare covers the rental cost until the item is no longer needed.

  3. Capped Rental: Medicare covers the rental for 13 months, after which you own the equipment.

  4. Oxygen Therapy: Medicare covers oxygen equipment rental for up to 36 months, after which you pay a small fee for the gas or liquid contents.

Competitive Bidding Program

The Competitive Bidding Program requires you to obtain specific DME from Medicare-contracted suppliers in certain geographic areas. This program helps reduce costs by limiting the number of suppliers eligible to provide equipment. It will become effective starting in 2021.