Medicare is a federally-sponsored health insurance program for people age 65 and older, certain people younger than 65 with a disability, and people with End-Stage Renal Disease (ESRD). Medicare provides coverage for hospital care (Part A) and medical services (Part B). The different parts of Medicare help cover many health services. Medicare Parts A and B are referred to as Original Medicare.
Medicare Part A covers inpatient hospital care, skilled nursing facility (SNF) care (in certain conditions on a short term basis, does not cover long-term care), hospice care, and some home health care (does not cover custodial only care). Part A benefits are subject to a deductible (per benefit period) and also a coinsurance for extended inpatient hospital and SNF stays.
Benefit Period - A benefit period (spell of illness) begins the day a beneficiary is admitted as an inpatient in a hospital or SNF, regardless of whether services qualify for payment by Medicare Part A. The benefit period ends when they haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If they go into a hospital or a SNF after one benefit period has ended, a new benefit period begins.
Lifetime Reserve Days - additional days that Medicare will pay for when a beneficiary is in a hospital for more than 90 days. A total of 60 reserve days can be used during a lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Medicare Part B covers medically necessary doctor and other health care provider’s services, outpatient services (including physical and speech therapy), laboratory tests, certain medical equipment and supplies, some home health care (does not cover custodial only care), and certain ambulance services. Part B also covers certain preventive services to prevent illness or detect it at an early stage. Most Part B benefits are subject to an annual deductible and also a coinsurance of 20 percent.* The Annual Wellness Visit and most preventive services are not subject to the deductible and/or coinsurance.*
- *If provider accepts assignment**
**Assignment: An agreement by the doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill for any more than the Medicare deductible and coinsurance (as applicable).
- Excess Charge - If the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.
Note: Limiting charge - the highest amount of money a beneficiary can be charged for a covered service by doctors and other health care suppliers who don't accept assignment. The limiting charge is 15% over Medicare's approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.
Physicians’ Services
Physicians' services are those professional services performed by a physician for a patient including diagnosis, therapy, surgery and consultation. The term “physician” includes a Doctor of Medicine or Osteopathy legally authorized to practice by a State.
Medical Services Covered
Covered Medical services include a number of different medical services and supplies which may be necessary in the treatment and diagnosis of an illness or injury. They may be furnished as part of a doctor's treatment, or by a provider, an independent laboratory, the outpatient department of a hospital, by a medical clinic, or by an ambulatory surgical center. They include services and supplies (e.g., drugs and biologicals which cannot be self-administered) furnished as an incident to a physicians' professional service.
Durable Medical Equipment (DME) (requires prescription by doctor)
DME covered by Medicare includes (but is not limited to) blood sugar meters, CPAP devices, hospital beds, infusion pumps, oxygen equipment, walkers, and wheelchairs. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment, a beneficiary may need to rent the equipment, buy the equipment, or may be able to choose whether to rent or buy the equipment.
Medicare will only cover DME if doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. It’s also important for beneficiaries to ask suppliers if they participate in Medicare before they get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment. If suppliers don't accept assignment, there’s no limit on the amount they can charge a beneficiary.
Other parts of Medicare include:
Medicare Part C (Medicare Advantage)
A private health plan in which beneficiaries can enroll and receive all Medicare-covered Part A and Part B benefits and often Part D benefits as well.
(See the separate link on this webpage for more information regarding Medicare Part C)
Medicare Part D (Prescription Drug Coverage)
Helps cover the cost of outpatient prescription drugs (including many recommended shots or vaccines) through private plans that contract with Medicare.
(See the separate link on this webpage for more information regarding Medicare Part D)
See the separate link on this webpage for more information regarding Medicare Eligibility and Enrollment.
Resources
Medicare costs at a glance.
This official government booklet has important information about the items and services covered.
“Medicare and You”The official U.S. government Medicare handbook.
Learn more about Medicare coverage for durable medical equipment coverage in your home.
