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Medicare Basics


Medicare Insurance Benefits

Original Medicare is sometimes called Medicare fee-for-service or traditional Medicare. You may go to any doctor or hospital that accepts Medicare.

Medicare Part A (hospital coverage) pays for:

  • in-patient hospital services
  • skilled nursing facility care after a hospital stay
  • home health care
  • hospice care
  • all but the first three pints of blood each calendar year

Medicare Part B (medical coverage) pays for:

  • medical expenses
  • clinical laboratory services
  • outpatient hospital treatment
  • preventive health services, including exams, lab tests, health screenings, and shots

In most cases, Medicare pays 80 percent of the Medicare-approved cost of covered medical expenses, including physicians’ services and supplies. Some Medicare Part B services are paid as a specified fixed payment.

Medicare Part D (prescription drug coverage) pays for generic and brand name prescription drugs. You can receive prescription drug coverage by joining a stand-alone prescription drug plan or by purchasing a Medicare Advantage plan that includes the coverage. You may not need Part D coverage if you belong to a group plan that provides prescription drug coverage.
Only private insurance companies approved by Medicare may offer Part D coverage.
The Centers for Medicare and Medicaid Services (CMS) publishes the Medicare & You handbook that describes Medicare coverages and health plan options. CMS mails the handbook to Medicare beneficiaries each year. The handbook is also available online or by calling Medicare


1-800-MEDICARE (633-4227)
1-877-486-2048 (TDD)
www.medicare.gov

 

Services Not Covered by Medicare

  • Long-term care. Medicare only pays for medically necessary care provided in a nursing home or for skilled home health care. Skilled care refers to help for conditions that require a medical professional, such as a nurse or a therapist.
    • Custodial care, such as help walking, getting in and out of bed, dressing, bathing, toileting, shopping, eating, and taking medicine (these are referred to as activities of daily living).
    • More than 100 days of skilled nursing home care during a benefit period following a hospital stay. The Medicare Part A benefit period begins the first day you receive a Medicare-covered service and ends when you have been out of the hospital or a skilled nursing home for 60 consecutive days.
  • Homemaker services
  • Private-duty nursing care
  • Most dental care and dentures
  • Health care received while traveling outside the United States, except under limited circumstances
  • Cosmetic surgery and routine foot care
  • Routine eye care, eyeglasses (except after cataract surgery), and hearing aids.

What You’ll Have to Pay with Medicare

For Medicare parts A and B, you generally have to pay monthly premiums, as well as deductibles, copayments, and coinsurance. You also pay the full cost of services not covered by Medicare.

  • Premiums are amounts you pay regularly to keep your coverage. Most people do not have to pay a Part A premium, but everyone must pay the Part B premium. The premium amounts may change each year in January.
  • A deductible is the amount you must pay for covered medical expenses before Medicare begins to pay.
  • A copayment is a fixed charge for a medical service.
  • Coinsurance is the percentage of the cost of a covered service that you pay after Medicare pays its portion of the cost.

Health care doctors and hospitals who have accepted assignment have agreed to limit their fee to the Medicare-approved amount for a service or supply, although you must still pay any deductibles, coinsurance, and copayments due.

Doctors and hospitals who do not accept Part B assignment may charge as much as 15 percent more than the Medicare-approved amount. You must pay the excess charge. The amount you owe is shown on the Medicare Summary Notice that you receive each quarter. If you were charged more than the 15 percent and paid it, your doctor or hospital must refund the excess charges to you within 30 days. You can also track your Medicare claims online at www.MyMedicare.gov.

If you believe a doctor or hospital has overcharged you, use your Medicare Summary Notice to verify charges and to find the contact information to notify your company. The notice will also tell you about any deadlines to complain or appeal charges and denied services.

Medicare maintains a directory of doctors, hospitals, and suppliers that work with Medicare. The directory lists doctors and hospitals who accept assignment on Medicare claims. For a list of doctors and hospitals who accept assignment in your area, call Medicare or visit its website.

Medicare Advantage Plans

You may have the option to join a Medicare Advantage plan (formerly called Medicare + Choice or Medicare Part C). To be eligible, you must have both Medicare parts A and B and live in an area that has a plan. If you enroll in a Medicare Advantage plan, you are still part of the Medicare program.

Medicare has contracts with insurance companies and managed care plans to offer Medicare Advantage plans in specific geographic areas. Medicare pays the plan a set amount each month, and the plan provides Medicare parts A and B services You pay your monthly Medicare Part B premium, any premium the Medicare Advantage plan charges, and any copayments, deductibles, and coinsurance.

The Medicare Advantage options available in Texas (which vary by ZIP code and county) include

  • managed care plans, such as health maintenance organizations (HMOs), preferred provider plans (PPPs), and provider-sponsored organizations (PSOs).
  • private fee-for-service plans
  • Medicare special needs plans
  • Medicare medical savings account plans (MSAs).

Medicare Advantage plans might offer more benefits than original Medicare, but they’re not right for everyone. Your choice of doctors and hospitals in a Medicare Advantage plan may be limited if you have other insurance, such as a group retirement plan. You should ask your group plan if it works with a Medicare Advantage plan.

Because Medicare negotiates contracts with Medicare Advantage plans each year, the plans available and the benefits they provide can change each year. If your plan discontinues services, you will have to find a new plan in your area or return to original Medicare. To learn what plans are available in your area, call Medicare or visit the Medicare web page and select “Compare Health & Drug Plans.” You may also call the Texas Department of Insurance (TDI)

Consumer Help Line
1-800-252-3439
463-6515
in Austin

 

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