The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation's largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).
*If you are not a U.S. citizen or a lawfully admitted alien who has lived in the U.S. continuously for a five-year period, please contact Social Security at 1-800-772-1213 for your Medicare enrollment and eligibility.
Medicare has the following parts:
Medicare Part A (Hospital Insurance)
Part A helps cover:
- Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care 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 usually don't pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working. This is called "premium-free Part A."
If you aren't eligible for premium-free Part A, you may be able to buy Part A if you meet one of these conditions:
- You're 65 or older, you're entitled to (or enrolling in) Part B, and you meet the citizenship or residency requirements.
- You're under 65, disabled, and your premium-free Part A coverage ended because you returned to work.
In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. If you have limited income and resources, your state may help you pay for Part A and/or Part B.
Services Part A Covers
Blood: In most cases, the hospital gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.
Home Health Services: Limited to medically-necessary part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor must order your care, and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment (see page 30), and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort.
Hospice Care: For people with a terminal illness. Your doctor must certify that you‘re expected to live 6 months or less. Coverage includes drugs for pain relief and symptom management; medical, nursing, social services; and other covered services as well as services Medicare usually doesn’t cover, such as grief counseling. A Medicare-approved hospice usually gives hospice care in your home (or other facility like a nursing home).
Medicare covers some short-term inpatient stays for pain and symptom management that can’t be addressed in the home. These stays must be in a Medicare-approved facility, such as a hospice facility, hospital, or skilled nursing facility. Medicare also covers inpatient respite care which is care you get in a Medicare approved facility so that your usual caregiver can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness. You can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies that you are terminally ill.
Hospital Stays (Inpatient): Includes semi-private room, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. Examples include inpatient care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care. This doesn't include private-duty nursing, a television or telephone in your room (if there is a separate charge for these items), or personal care items like razors or slipper socks. It also doesn’t include a private room, unless medically necessary. If you have Part B, it covers the doctor and emergency room services you get while you are in a hospital.
Skilled Nursing Facility Care: Includes semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury). To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn’t cover long-term care or custodial care in this setting.
Medicare Part B (Medical Insurance)
What Is Part B (Medical Insurance)?
Part B helps cover medically-necessary services like doctors' services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Check your Medicare card to find out if you have Part B.
How Much Does Part B Cost?
You pay the Part B premium each month. Most people will pay the standard premium amount (link to current amount?. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay more.
Your modified adjusted gross income is your taxable income plus your tax exempt interest income. Social Security will notify you if you have to pay more than the standard premium. If you have to pay a higher amount for your Part B premium and you disagree (even if you get Railroad Retirement Board benefits), call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
If you don't sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.
How You Get Part B
- If you get benefits from Social Security or the Railroad Retirement Board (RRB), in most cases you'll automatically get Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, your Part B will start the first day of the prior month.
- If you're under 65 and disabled, you'll automatically get Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You’ll get your Medicare card in the mail about 3 months before your 65th birthday or your 25th month of disability.
- If you don't want Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will pay Part B premiums.
- If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease), you automatically get Part B the month your disability benefits begin.
Services Part B Covers
There are two kinds of Part B-covered services:
Medically-necessary services — Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
Preventive services — Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best (for examples see Medicare & You Handbook ).
What You Pay for Part B Services
Costs for Part B services depend on whether you have Original Medicare or are in a Medicare health plan. For some services, there are no costs, but you may have to pay for the doctor’s visit. If the Part B deductible applies, you must pay all costs until you meet the yearly Part B deductible before Medicare begins to pay its share. Then, after your deductible is met, you typically pay 20% of the Medicare-approved amount of the service. You can save money if you choose doctors or providers who accept assignment.
There are two additional parts to Medicare that are covered under the sections