Medicare and other health insurance plans can be a hassle to figure out. Knowing what plans cover what, how much they cost, and what their limitations are can make it difficult to decide what is right for you or your loved ones, especially since there seem to be so many different ways of stacking services together under various names (HMO, Original Medicare, Advanced Medicare, etc.).
Fortunately, the basic coverage provided by Medicare is split into four different parts for ease of reference.
Medicare Part A covers inpatient services, which include such items as hospitalization expenses, skilled nursing and hospice care, and some other health care costs. For seniors 65 and older and a few other qualifying individuals, this coverage is provided free of monthly premiums. It covers costs for the hospital and SNF services listed below.
If in a hospital, Part A covers:
- A semi-private room (or a private room if medically necessary)
- Normal nursing
- Medical social services
If you are in a skilled nursing facility such as Senior Care Centers:
- Rehabilitative services, including physical, speech, and occupational therapy
- Supplies used during stay
- Skilled nursing services
- Medical social services
- If after a three-day hospital stay, other services
- Blood purchased beyond the first three pints in a calendar year
Part A will also cover some home and hospice care. In addition, psychiatric care in a facility for up to 190 days can also be covered.
Unlike Part A, which is free in many cases, Medicare Part B requires a monthly premium. The premium is calculated based on your annual income, with the minimum payment being just over $100. While it is not strictly necessary to enroll in Part B, it does come with a small fee for late enrollment. Part B covers medical services outside of a hospital, or outpatient expenses. These include both medically necessary services and preventative measures, which may involve the following:
- Clinical research
- Mental health services
- DME, or durable medical equipment, such as wheelchairs
- Limited prescription drugs
The precise coverage you get depends on federal and state laws as well as local and national coverage decisions made by Medicare.
Medicare Advantage plans, or Medicare Part C, is any coverage provided through a private company that includes Part A and Part B benefits. They may also offer coverage to fill in whatever Parts A and B lack. Some types of Medicare Advantage (MA) plans include:
- HMO: Requires that you get your care from physicians in the plan’s specific network, with the exception of emergencies.
- PPO: You may go to any doctor you choose, but you pay less for those within a certain network.
- SNPs: These plans focus on patients with specific medical needs, such as heart disease, and are eligible for those who are diagnosed with a chronic condition or who have been institutionalized.
Each MA plan comes with its own premiums depending on who is providing it.
Medicare Part D includes prescription drug coverage and may be included with other plans.