Medicare Basics Medicare covers certain medical services and items in hospitals and other settings. Some are covered under Medicare Part A, and some are covered under Medicare Part B. As long as you have both Part A and Part B, these services and items are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO).

What Is Medicare Part A?
Part A helps cover your inpatient care in hospitals. This includes critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and home health care. You must meet certain conditions to get these benefits.

If you aren’t sure if you have Part A, look on your red, white, and blue Medicare card (see sample card below). If you have Part A, “HOSPITAL (PART A)” is printed on your card. Note: Your card may be slightly different. It’s still valid.

Do you need to replace your Medicare card?
If your Medicare card is lost or damaged, you can order a new card at www.socialsecurity.gov on the web. Or, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772, or visit www.rrb.gov on the web and select “Benefit Online Services.”

Cost: Most people automatically get Part A coverage without having to pay a monthly payment, called a premium. This is because they or a spouse paid Medicare taxes while working.

If you don’t automatically get premium-free Part A, you may be able to buy it

For most people, if you buy Part A coverage, you must also enroll in Part B and pay the Part B premium.

If you have limited income and resources, your state may help you pay for Part A and/or Part B. For more information, visit www.socialsecurity.gov on the web or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

If you have a question or complaint about the quality of a Medicare-covered service, call your local Quality Improvement Organization.Visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get their telephone number. TTY users should call 1-877-486-2048.

 

Medicare Part A Helps Cover Your Medically-Necessary...
Blood		Pints of blood you get at a hospital or skilled nursing facility during a covered stay.
Home Health Services		Limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services, and physical therapy, occupational therapy, and speech-language pathology ordered by your doctor and provided by a Medicare-certified home health agency. Also includes medical social services, other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home.
Hospice Care		For people with a terminal illness (less than six months to live). Includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare (like grief counseling). Hospice care is usually given in your home (may include a nursing facility if this is your home). However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
Hospital Stays		Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes inpatient care you get in critical access hospitals and mental health care. This doesn’t include private-duty nursing or a television or telephone in your room. It also doesn’t include a private room, unless medically necessary. Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
Skilled Nursing Facility Care		Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a three-day inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. Note: Medicare doesn’t cover long-term care.

What is Medicare Part B?
Part B helps cover medical services like doctors’ services, outpatient care, and other medical services that Part A doesn’t cover. Part B is optional. Part B helps pay for covered medical services and items
when they are medically necessary. Part B also covers some preventive services.

Cost: You pay the Part B premium each month. In some cases, this amount may be higher if you didn’t sign up for Part B when you first became eligible. You also pay a Part B deductible each year before Medicare starts to pay its share. You may be able to get help from your state to pay this premium and deductible.

If you don’t take Part B when you are first eligible, the cost of Part B will go up 10% for each full 12-month period that you could have had Part B but didn’t sign up for it, except in special cases.You may have to pay this penalty as long as you have Part B. If you didn’t sign up for Part B when you first became eligible, call Social Security at 1-800-772-1213 to see when you can apply. TTY users should call 1-800-325-0778. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.

Medicare Part B and Group Health Plan Coverage from an Employer or Union
Your Part B enrollment rights can be affected if you have coverage through an employer or union, and you or your spouse are still working, or if you have COBRA coverage. Your decision about when to sign up for Part B can also affect your rights to buy a Medigap (Medicare Supplement Insurance) policy. For more information about enrolling in Part B, call Social Security. You may also visit www.medicare.gov on the web and view the booklet “Enrolling in Medicare” or call 1-800-MEDICARE (1-800-633-4227) to ask questions. TTY users should call 1-877-486-2048.

Medicare Part B Helps Cover...
Ambulance Services		When you need to be transported to a hospital or skilled nursing facility, and transportation in any other vehicle would endanger your health.
Ambulatory Surgery Center		Facility fees are covered for approved services.
Blood		Pints of blood you get as an outpatient or as part of a Part B-covered service.
Bone Mass Measurement		To help see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people with Medicare who meet certain medical conditions.
Cardiovascular Screenings		Every five years to test your cholesterol, lipid, and triglyceride levels to help prevent a heart attack or stroke.
Chiropractic Services (limited)		To correct a subluxation (when one or more of the bones of your spine moves out of position) using manipulation of the spine.
Clinical Laboratory Services		Including blood tests, urinalysis, some screening tests, and more.
Clinical Trials		To help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care, like how well a new cancer drug works. Routine costs are covered if you take part in a qualifying clinical trial (may not cover the costs of experimental care, such as the drugs or devices being tested in a clinical trial).
Colorectal Cancer Screenings		To help find precancerous growths, and help prevent or find cancer early, when treatment is most effective. One or more of the following tests may be covered. Talk to your doctor. Fecal Occult Blood Test—Once every 12 months if age 50 or older. You pay nothing for the test, but usually have to pay for the doctor visit. Flexible Sigmoidoscopy—Generally, once every 48 months if age 50 or older, or every 120 months when used instead of a colonoscopy for those not at high risk. Screening Colonoscopy—Once every 120 months (high risk every 24 months). No minimum age. Barium Enema—Once every 48 months if age 50 or older (high risk every 24 months) when used instead of sigmoidoscopy or colonoscopy. Your risk for colorectal cancer increases if you or a close relative have had colorectal polyps or cancer, or if you have inflammatory bowel disease (like Crohn’s disease). In 2007, Medicare covers its share of these costs even if you haven’t met the yearly Part B deductible.
Diabetes Screenings		To check for diabetes. These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a history of high blood sugar. Tests are covered if you answer yes to two or more of the following questions. Are you age 65 or older? Are you overweight? Do you have a family history of diabetes (parents, brothers, sisters)? Do you have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds? Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.
Diabetic Self-management Training		For people with diabetes. Your doctor or other health care provider must provide a written order.
Diabetic Supplies		Including glucose testing monitors, blood glucose test strips, lancet devices and lancets, glucose control solutions, and therapeutic shoes (in some cases). Syringes and insulin are only covered if used with an insulin pump or if you have Medicare prescription drug coverage.
Doctor Services		Doesn’t cover routine physical exams except for the one-time “Welcome to Medicare” Physical Exam.
Durable Medical Equipment		Items such as oxygen, wheelchairs, walkers, and hospital beds needed for use in the home.
Emergency Room Services		When you believe your health is in serious danger, when every second counts. You may have a bad injury, sudden illness, or an illness that quickly gets much worse.
Eye Exams		For people with diabetes to check for diabetic retinopathy once every 12 months.
Eyeglasses (limited)		One pair of eyeglasses with standard frames after cataract surgery that implants an intraocular lens.
Flu Shots		To help prevent influenza or flu virus. This is covered once a flu season in the fall or winter. The flu is a serious illness. You need a flu shot for the current virus each year.
Foot Exams and Treatment		If you have diabetes-related nerve damage and/or meet certain conditions.
Glaucoma Tests		To help find the eye disease glaucoma. This is covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African American and age 50 or older, or are Hispanic and age 65 or older. Tests must be done by an eye doctor legally authorized to perform service in your state
Hearing and Balance Exam		If your doctor orders it to see if medical treatment is needed. Hearing aids and exams for fitting hearing aids aren’t covered.
Hepatitis B Shots		To help protect people from getting Hepatitis B. This is covered (three shots) for people with Medicare at high or medium (intermediate) risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant), or a condition that lowers your resistance to infection. Other factors may increase your risk for Hepatitis B. Check with your doctor to see if you are at high or medium risk for Hepatitis B.
Home Health Services		Limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy, and speech-language pathology that are ordered by your doctor and provided by a Medicare-certified home health agency. Also includes medical social services, other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home.
Kidney Dialysis Services and Supplies		Either in a facility or at home.
Mammograms (screening)		To check women for breast cancer before they or their doctor may be able to feel it. Preventive (screening) mammograms are covered once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between age 35 and 39.
Medical Nutrition Therapy Services		Medicare may cover medical nutrition therapy if you have diabetes or kidney disease and you are referred for the service by your doctor.
Mental Health Care (outpatient)		Certain limits and conditions apply.
Occupational Therapy		Services given to help you return to usual activities (such as bathing) after an illness.
Outpatient Hospital Services		Received as an outpatient as part of a doctor’s care.
Outpatient Medical and Surgical Services and Supplies		For approved procedures.
Pap Test and Pelvic Exam (includes clinical breast exam)		To check for cervical and vaginal cancers. Medicare covers these exams for women at low risk for cervical cancer every 24 months. These exams are covered once every 12 months for women at high risk for cervical and vaginal cancer, and those of child bearing age who have had an exam that indicated cancer or other abnormalities in the past three years. Your risk of developing breast cancer increases if you had breast cancer in the past, have a family history of breast cancer (like a mother, sister, daughter, or two or more close relatives who have had breast cancer), had your first baby after age 30, or have never had a baby.
Physical Exam (one-time“Welcome to Medicare” Physical Exam)		A one-time review of your health, and education and counseling about preventive services, including certain screenings and shots. Getting referrals for other care, if you need it, are also covered.
Physical Therapy		Treatment of injuries and disease by mechanical means, such as heat, light, exercise, and massage.
Pneumococcal Shot		To help prevent pneumococcal infections. Most people only need this preventive shot once in their lifetime. Talk with your doctor.
Practitioner Services		Such as those provided by clinical social workers, physician assistants, and nurse practitioners.
Prescription Drugs		Limited, like certain injectable cancer drugs.
Prostate Cancer Screening		These tests help find prostate cancer. Medicare covers a preventive digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50.
Prosthetic/ Orthotic Items		Including arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); breast prostheses(after mastectomy); prosthetic devices needed to replace an internal body part or function (including ostomy supplies and parenteral and enteral nutrition therapy).
Second Surgical Opinions		Covered in some cases (and some third surgical opinions are covered) for surgery that isn’t an emergency.
Smoking Cessation (counseling to stop smoking)		Provided at any provider site if ordered by your doctor. It includes up to eight face-to-face visits during a 12-month period if you are diagnosed with a smoking-related illness or are taking medicine that may be affected by tobacco.
Speech-language Pathology Services		Treatment given to regain and strengthen speech skills.
Surgical Dressings		For treatment of a surgical or surgically treated wound.
Telemedicine		Services in some rural areas, under certain conditions in a practitioner’s office, a hospital, or a federally-qualified health center.
Tests		Including X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests.
Transplant Services		Including heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and in a Medicare-certified facility only. Bone marrow and cornea transplants (under certain conditions). Immunosuppressive drugs are covered if the transplant was paid for by Medicare, or paid by an employer or union group health plan that was required to pay before Medicare (you must have been entitled to Medicare Part A at the time of the transplant and entitled to Medicare Part B at the time you get immunosuppressive drugs, and the transplant must have been performed in a Medicare-certified facility). Note: Medicare drug plans may cover immunosuppressive drugs, even if the transplant wasn’t paid for by Medicare or an employer or union group health plan.
Travel (health care needed when traveling outside the United States)		Limited to medical services provided in Canada when you travel on the most direct route through Canada between Alaska and another state. Medicare also covers hospital, ambulance, and doctor services if you are in the United States, but the nearest hospital that can treat you isn’t in the United States (the “United States” means the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). In some cases, Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the United States.
Urgently Needed Care		To treat a sudden illness or injury that isn’t a medical emergency.

 

What isn’t covered by Medicare Part A and Part B?
Medicare doesn’t cover everything. Items and services that aren’t covered include, but aren’t limited to the following:

Buying a Medigap (Medicare Supplement Insurance) Policy
The Original Medicare Plan pays for many health care services and supplies, but there are many costs it doesn’t cover. To help cover extra health care costs, you might want to buy a Medigap policy. Medicare doesn’t pay any of the costs for a Medigap policy.

What is a Medigap policy?
A Medigap policy is health insurance sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. Medigap policies help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services, and some policies cover certain costs not covered by the Original Medicare Plan. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will both pay their shares of covered health care costs. Insurance companies can only sell you a “standardized” Medigap policy. These Medigap policies must all have specific benefits.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You or someone on your behalf (like a former employer or union) will have to pay the monthly Medicare Part B premium You will also have to pay a premium to the Medigap insurance company.

In most states, you may be able to choose from up to 12 different standardized Medigap policies (Medigap Plans A through L). Medigap policies must follow Federal and state laws. These laws protect you. A Medigap policy must be clearly identified as “Medicare Supplement Insurance.” Each Medigap Plan A through L has a different set of basic and extra benefits. In Massachusetts, Minnesota, and Wisconsin, plans are standardized in a different way.

It’s important to compare Medigap policies because the benefits in any Medigap Plan A through L are the same for any insurance company, but the costs can vary a lot, and may go up as you get older. Each insurance company decides which Medigap policies it wants to sell and the price for each plan (with state review and approval).

Although some Medigap policies sold in the past covered prescription drugs, no new Medigap policies covering prescription drugs are being sold. To cover prescription drug costs, you may want to buy Medicare prescription drug coverage (Part D) offered by private companies approved by Medicare. If you join a Medicare Prescription Drug Plan, and your Medigap policy covers drugs, you must tell your Medigap insurer to remove the prescription drug coverage from your Medigap policy.

 

Medicare Advantage Plans

Medicare Advantage Plans are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include prescription drug coverage. Medicare Advantage Plans include:

• Medicare Health Maintenance Organization (HMOs)
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service Plans
• Medicare Special Needs Plans

When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most of these plans, generally there are extra benefits and lower copayments than in the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services.

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer.

If you join a Medicare Advantage Plan, your Medigap policy won’t work. This means it won’t pay any deductibles, copayments, or other cost-sharing under your Medicare Health Plan. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you have a legal right to keep the Medigap policy.

 

What is Medicare Prescription Drug Coverage?
Medicare offers prescription drug coverage for everyone with Medicare. This is called “Part D.” This coverage may help lower prescription drug costs and help protect against higher costs in the future. It can give you greater access to drugs that you can use to prevent complications of diseases and stay well.

If you join a Medicare drug plan, you usually pay a monthly premium. Part D is optional. If you decide not to enroll in a Medicare drug plan when you are first eligible, you may pay a penalty if you choose to join later. These plans are run by insurance companies and other private companies approved by Medicare.

There are two ways to get Medicare prescription drug coverage:

Both types of plans are called Medicare drug plans in this section.

Medicare offers help to employers and unions to help pay for prescription drug coverage. If you have employer or union drug coverage. Joining a Part D plan could end the retiree health benefits you and your family get. Talk to your benefits administrator.