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David Sayen: What Medicare Does — and Doesn’t — Cover

By David Sayen |

Medicare helps pay for a wide variety of medical services and goods in hospitals, doctor’s offices and other health-care settings. But it doesn’t cover everything, and it’s useful to know what is and isn’t included.

David Sayen

Services are covered either under Medicare Part A or Part B. If you have both Part A and Part B, you can get many Medicare-covered services whether you have Original Medicare or a Medicare health plan.

Part A is hospital insurance and it helps pay for:

» Inpatient care in hospitals

» Inpatient care in a skilled nursing facility (not custodial or long-term care)

» Hospice care services

» Home health care services

» Inpatient care in a religious nonmedical health-care institution

You can find out if you have Parts A and B by looking at your Medicare card. If you have Original Medicare, you’ll use this card to get your Medicare-covered services. If you join a Medicare health plan, in most cases you must use the card from the plan to get your Medicare-covered services.

Part B (medical insurance) helps cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment such as wheelchairs and walkers, and other medical services.

Part B also covers many preventive-care services.

Under Original Medicare, if the yearly Part B deductible ($147 in 2014) applies, you must pay all costs (up to the Medicare-approved amount) until you meet the Part B deductible before Medicare begins to pay its share.

After your deductible is met, you typically pay 20 percent of the Medicare-approved amount of the service, if the doctor or other health-care provider accepts assignment. (“Accepting assignment” means that a doctor or other provider agrees to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.)

You’ll pay more if you see doctors or providers who don’t accept assignment. And there’s no yearly limit on what you pay out-of-pocket.

If you’re in a Medicare Advantage plan (like an HMO or PPO) or have other insurance, your costs may be different. Contact your plan or benefits administrator directly to find out about the costs.

Under Part B, Medicare pays for many preventive services (such as screenings for cancer and heart disease) that can detect health problems early when they’re easier to treat. You pay nothing for most covered preventive services if you get the services from a doctor or other qualified provider who accepts assignment.

However, for some preventive services, you may have to pay a deductible, coinsurance, or both.

Medicare doesn’t cover everything, of course. If you need certain services that aren’t covered under Part A or Part B, you’ll have to pay for them yourself unless:

» You have other insurance (or Medicaid) to cover the costs.

» You’re in a Medicare health plan that covers these services.

Some of the services and goods that Medicare doesn’t cover are:

» Long-term care (also called custodial care)

» Routine dental or eye care

» Dentures

» Cosmetic surgery

» Acupuncture

» Hearing aids and exams for fitting them

— David Sayen is Medicare’s regional administrator for California, Arizona, Hawaii, Nevada and the Pacific Trust Territories. You can always get answers to your Medicare questions by calling 800.MEDICARE (633.4227).

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