MedicareMedicare is a government subsidized insurance that covers people over the age of 65 and the disabled. It consists of four different parts: A, B, C, and D.
Medicare Part A covers inpatient services, including nursing homes and skilled nursing facilities. The coverage is substantial, but limited. For hospital inpatient stays, Medicare goes on a 60-30-60 day schedule. There is one deductible amount that covers the first 60 days of a hospital stay, the a daily co-pay amount for the next 30 days, and finally a higher co-pay amount for the next 60 days, known as lifetime reserve days because once these particular days are used, they can never be used again. These amounts change yearly, along with Medicare Part B. For nursing home and skilled nursing facility coverage, Medicare will cover the first 100 days of admission.
For those first 60 days, if you're discharged and then admitted back into the hospital within 90 days, your benefit period picks up from however many days you used the first time. Therefore, if you used five days the first time, you still have 55 days and don't have to pay another deductible. However, if it's more than 90 days, then the first deductible will kick in again.
Medicare Part B covers outpatient services. It's a paid insurance that has a monthly fee. For outpatient services, after a small yearly deductible amount, patients will owe a 20% co-pay for all services. There are a wide range of services covered by Part B.
Medicare Part C refers to what's known as "Medicare Advantage Plans", which is another way of saying an insurance company has contracted with Medicare to offer you insurance benefits. In some cases the benefits offered by these insurances may be better than what Medicare offers, or some things may be moved around, but by law they have to at least match the value of Medicare's coverage.
Medicare Part D was introduced in January 2006 as a way to help control the spiraling costs of medications. Like Medicare B and C, it's an opt-in plan, which means you don't have to have the coverage if you don't wish to pay for it.
Medicare is usually the primary insurance coverage for subscribers unless they are still working or covered under someone else's insurance plan that's still working. If a patient has Tricare, they won't qualify for Medicare coverage. Also, if a person's disability is related to compensation or no fault, that insurance may be primary to Medicare. Most subscribers have some sort of secondary insurance that covers the co-pay or deductible amounts.
One thing that confuses many patients is the 80-20 rule of Medicare's, which supposedly means that Medicare will pay for 80% of a medical bill, and the patient is responsible for the other 20%. This is a misnomer. Medicare pays on different types of fee schedules, based on the types of services being provided, and they pay a percentage of that fee schedule based on a cost accounting process they go through with every hospital in the nation. So, it's possible that the hospital you go to is actually receiving anywhere from 30% to 60% of whatever the fee schedule amount is, not the actual charges. Medicare will pay 80% of its fee schedule amount, minus the percentage, and the hospital has to adjust the rest of the balance off. Patients are responsible for the other 20% of the fee schedule amount. If the hospital, physician, or any other medical entity tries to collect more than that from you, you should report them to Medicare.
Also, Medicare only pays for care as long as a patient has a chance to continue getting better. As an example, if a Medicare patient is receiving physical therapy, they must be showing that they're improving, otherwise Medicare coverage will be discontinued.
Medicare beneficiaries are supposed to be told up front if services they are about to have will not be covered. The form for this is knowns as an advanced beneficiary notice. If you are an inpatient and services are going to be terminated in some fashion, the hospital must provide you with what's known as a "HINN Notice (Hospital Issued Notice of Noncoverage) within 3 days of the end of coverage.
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