While most people assume that Medicare pays for more costs of long term care than it does, its coverage of hospital, doctor, and prescription bills can be essential help.
Who Is Eligible
Medicare is a federal health insurance program for people who are:
- Age 65 and older who have contributed to Social Security at least 10 years of their worklives
- Age 65 and older whose spouses have contributed to Social Security
- Under 65 and disabled and collecting Social Security disability benefits for 24 months
- Diagnosed with permanent kidney failure
- Diagnosed with Lou Gehrig’s disease
To get a quick determination of Medicare eligibility online, along with an estimate of premiums, use the Medicare Eligibility & Premium Calculator.
How It Works
Medicare pays for limited therapy and nursing visits that qualify as home health care or hospice care at the end of life.It also covers care received in Medicare-certified facilities for a short time, which may give patients and their families some breathing room to find a facility and to finance a stay if extended care is needed.
Coverage includes daily skilled nursing or rehabilitation services provided by a registered nurse, or physical, speech, or occupational therapist following a hospital stay of at least three days. It does not cover dental or eye care, acupuncture, or hearing aids.
Coverage is limited to 100 days per illness. The first 20 days are covered in full; the additional 80 days require a copayment. The 100 days are not guaranteed, and Medicare must approve the length of stay in the facility.
There are four parts to Medicare.
Part A Hospital Insurance, free for most people — although copayments, co-insurance, or deductibles may be required — pays for:
- Most inpatient care in a hospital or religious nonmedical health care institution
- Some inpatient skilled nursing home care
- Some home health care
- Hospice care
The IRS has determined that Part A coverage meets the Affordable Care Act’s mandate of adequate insurance, so those enrolled in premium-free Part A need not look for more. Federal law prohibits selling coverage that duplicates what Medicare already provides.
Those who must pay a premium for Part A coverage and are not yet enrolled in Medicare may shop for a policy under the state’s online insurance coverage marketplace, Covered California.
Until the government clarifies the issues involved, those qualified for Medicare who wish to cancel or buy any type of policy should consider consulting:
- An insurance specialist at Covered California, 800.300.1506
- The Health Insurance Counseling and Advocacy (HICAP) office, 800.434.0222
Part B Medical Insurance, generally available for a monthly premium of about $100, pays for:
- Services from doctors and other healthcare providers, including physical therapists, social workers, and psychologists
- Hospital care, mental healthcare, and physical and speech therapy received as an outpatient
- Some chiropractic services
- Some home health care
- Ambulance services
- Some medical equipment and supplies, such as oxygen, wheelchairs, and walkers
- Some preventive services, including an annual wellness visit, flu shots, and screenings for abdominal aneurysms, alcohol misuse, bone density, breast cancer, colorectal cancer, cardiovascular disease, and diabetes
For a comprehensive list of tests, services, and items covered, see the guide published annually by the Centers for Medicare & Medicaid Services, “Medicare & You.”
Parts A and B together, known as “Original Medicare,” are managed by the federal government and available through the Social Security Administration.
Part C Medicare Advantage Plans allow the option of getting Parts A and B coverage from private companies that are approved and reimbursed by Medicare.
Four plans are offered; most include coverage for prescription drugs:
- Health maintenance organization (HMO) plans, which limit medical care to doctors, other health care providers, or hospitals on the plan’s list except in an emergency
- Preferred provider organization (PPO) plans, which offer the flexibility of using medical providers that aren’t on the plan’s network — although outside providers will usually cost more than those in network
- Private fee-for-service (FFS) plans, which cover care by any medical provider that agrees to accept the plan’s payment terms
- Special needs plans (SNPs), which cover those with specific chronic conditions including dementia, those who require nursing care at home or in a nursing home, and those who have both Medicare and Medi-Cal; generally, insureds must get care from network providers — which include specialists in their diseases
Part D Prescription Drug Plans help pay for medications that doctors prescribe for treatment; most charge a monthly fee that varies by plan, type of prescriptions used, and pharmacy — and require prior authorization before the plan will pay.
Medicare Savings Programs
A number of programs offer help paying Medicare Part A and B costs for those in financial need. Each has its own caps on income and resources a person may have to qualify. The caps change slightly every year. Resources that don’t count in the tally generally include a primary home, car, household items, burial plot, $1,500 for burial expenses per person, and life insurance policies. Four Medicare Savings Programs are currently offered.
- The Qualified Medicare Beneficiary (QMB) program helps pay for Part A and B premiums, deductibles, and coinsurance for hospital stays and doctor visits and is subject to these maximums: annual income of $11,490 (individual) or $15,510 (couple); and resources of $7,080 (individual) or $10,620 (couple).
- The Specified Low-Income Medicare Beneficiary (SLMB) program helps pay for Part B premiums that would ordinarily be deducted from a monthly Social Security check and is subject to these maximums: annual income of $13,404 (individual) or $18,156 (couple); and resources of $7,080 (individual) or $10,620 (couple).
- The Qualified Individual (QI) program helps pay for Part B premiums for those with slightly higher incomes and is subject to these maximums: annual income of $15,512 (individual) or $20,939 (couple); and resources of $7,080 (individual) or $10,620 (couple).
- The Qualified Disabled Working Individual (QDWI) program pays for Medicare Part A for those who had Social Security and Medicare benefits because of a disability, but lost them after returning to work and earning above the income limits. Coverage is subject to these maximums: annual income of $22,980 (individual) or $31,020 (couple); and resources of $4,000 (individual) or $6,000 (couple).
For more information on these programs, call the Medi-Cal office at 800.541.5555 and ask for information on Medicare Savings Programs.
Help with Prescription Coverage
The Extra Help or Low-Income Subsidy (LIS) pays for part or all of Medicare Part D’s prescription drug coverage: premiums, yearly deductibles, co-insurance, and copayments. Those who qualify for the QMB, SLMB, or QI programs outlined above automatically qualify to get Extra Help paying for Medicare prescription drug coverage.
The full subsidy is available to individuals and married couples subject to these maximums: annual incomes of $17,235 (individual) or $23,265 (couple); and resources of $13,300 (individual) or $26,580 (couple).
For more information on this Medicare program, see “Extra Help.”
How to Apply
How and where to apply for Medicare Parts A and B varies depending on the applicant’s age, medical condition, and benefits already being received.
- Those who receive benefits from Social Security or the Railroad Retirement Board are automatically enrolled in Medicare Part A and Part B the month they turn 65.
- Those under 65 and disabled will be automatically enrolled in Parts A and B after getting disability benefits from Social Security or the Railroad Retirement Board for 24 months.
- Those with Lou Gehrig’s disease are automatically enrolled in Parts A and B the month Social Security disability benefits begin.
- Those with permanent kidney failure must apply through the local office of the Social Security Administration.
- Those who wish to apply for Medicare alone can apply online through Social Security.
For More Information
Many people fret that they will be denied Medicare benefits by applying for them incorrectly — or get questions about their benefits once they receive them. Much personalized help is available online and by telephone from government and independent agencies.
- For information on Medicare coverage, contact the main Medicare office at 800.633.4227 or 877.486.2048 (TTY) or visit the Medicare website
- To compare costs of Medicare plans available in your area, use the Medicare Plan Finder
- For more information on Medicare costs, including free individual counseling, contact the local office of the Health Insurance Counseling and Advocacy Program (HICAP)
- To monitor your Medicare claims, create an online Medicare account
- To learn how to spot Medicare fraud, contact the Senior Medicare Patrol
- To report problems or complaints with Medicare, contact the Medicare Beneficiary Ombudsman
- For Medicare advocacy and education, visit the California Health Advocates
Medicare supplemental insurance, popularly called Medigap, is available only to those with Parts A and B Original Medicare, since as the name implies, it’s intended to cover the “gaps” between what Medicare pays and does not pay, such as copayments, co-insurance, and deductibles. It’s illegal to sell such policies to those covered by a Medicare Advantage Plan.
In California, 10 standard Medigap plans are sold by private insurance companies regulated by state and federal law, and must be clearly labeled as Medicare supplements and identified by letter: A, B, C, D, F, G, K, L, M, or N.
Plan A, the basic benefit package, covers:
- Medicare Part A co-insurance, plus coverage for 365 additional days of hospitalization after Medicare benefits end
- Medicare Part B co-insurance or copayment
- The first three pints of blood each year
- Medicare Part A hospice care co-insurance or copayment
The other packages contain various combinations of additional benefits, which may include:
- Skilled nursing facility care co-insurance
- Medicare Part A deductible
- Medicare Part B deductible
- Medicare Part B excess charges
- Foreign travel emergency coverage
For information on buying Medigap policies, see Choosing a Medigap Policy:A Guide to Health Insurance for People with Medicare.