A Brief Explanation of Medicare

Medicare is our country’s health insurance program for people age 65 or older, certain people with disabilities who are under age 65 and people of any age who have permanent kidney failure.  It provides basic protection against the cost of health care, but it doesn’t cover all medical expenses or the cost of most long-term care.

Medicare has two parts and they are:

• Hospital insurance (also called Medicare "Part A"), which helps pay for care in a hospital or skilled nursing facility, home health care and hospice care; and
• Medical insurance (also called Medicare "Part B"), which helps pay for doctors, out-patient hospital care and other medical services.

Medicare hospital insurance can help pay for inpatient care in a hospital or skilled nursing facility following a hospital stay, home health care and hospice care.  Except for home health care, each is subject to a "benefit period," which measures your use of services covered by Medicare Part A.

A benefit period starts the day you enter a hospital.  It ends when you have been out of the hospital or other facility primarily providing skilled care for 60 days in a row.  If you remain in such a facility (other than a hospital), a  benefit period ends when you have not received any skilled care there for 60 days in a row.  There is no limit to the number of benefit periods for hospital and skilled nursing facility care.  But special limits do apply to hospice care.

Inpatient Hospital Care
If you need inpatient care, hospital insurance helps pay for up to 90 days in any Medicare-participating hospital during each benefit period.  Hospital insurance pays for all covered services for the first 60 days, except for a deductible amount that you must pay.  For days 61 through 90, hospital insurance pays for all "covered services" except for a daily co-insurance amount that you must pay.

If you are out of the hospital for at least 60 days in a row, and then go back in, a new benefit period begins—your 90 days of coverage starts all over again and you pay another deductible.

What if you need more than 90 days of inpatient care during any benefit period?  You can use some or all of your "reserve days."  Reserve days are an extra 60 hospital days you can use if your illness keeps you in the hospital for more than 90 days. You have only 60 reserve days in your lifetime and you decide when you want to use them.  For each reserve day you use, hospital insurance pays for all covered services except for a daily coinsurance amount.

Skilled Nursing Facility Care
If you need inpatient skilled nursing or rehabilitation services after a hospital stay and you meet certain other conditions, hospital insurance helps pay for up to 100 days in a Medicare-participating skilled nursing facility in each benefit period.

Hospital insurance pays for all covered services for the first 20 days.  For the next 80 days, it pays for all covered services, except for a daily coinsurance amount.

Note: It is important to know that Medicare does not pay for "custodial care" when that is the only kind of care you need.  Custodial care is the type of care many people receive in nursing homes.  It is care that could be given by someone who is not medically skilled (for example, help with dressing, walking or eating).

Home Health Care
If your health problems cause you to stay at home and meet certain other conditions, Medicare can pay the full-approved cost of home health visits from a Medicare-participating home agency.  There is no limit to the number of covered visits you can have.

If you need one or more of the services Medicare pays for, then hospital insurance also covers part-time or intermittent services of home health aides, occupational therapy, physical therapy, medical social services and medical supplies and equipment.  A 20 percent co-payment applies to covered durable medical equipment (e.g., wheelchairs and hospital beds).

Hospice Care
A hospice program provides pain relief and other support services for terminally ill people.  Medicare hospital insurance can help pay for hospice care for terminally ill beneficiaries if the care is provided by a Medicare-certified hospice and certain other conditions are met.

You can get hospice care as long as your doctor certifies that you are terminally ill and probably have less than six months to live.  Even if you live longer than six months, you can get hospice care as long as your doctor re-certifies that you are terminally ill.

Hospice care is given in periods of care.  As a hospice patient, you can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods.  At the start of each period of care, your doctor must certify that you are terminally ill in order for you to continue getting hospice care.  A period of care starts the day you begin to get hospice care.  It ends when your 90 or 60-day period is up.  If your doctor re-certifies that you are terminally ill, your care continues through another period of care.

Medical Insurance (Part B)
Medicare medical insurance helps pay for doctors’ services and many other medical services and supplies that are not covered by the hospital insurance part of Medicare.  Each year, you must pay an annual medical insurance deductible amount before Medicare begins paying.  After you have paid the deductible, Medicare will generally pay 80 percent of the approved charges for covered services during the rest of the year.  You are responsible for paying the remaining 20 percent of the cost.  This is called coinsurance. Medical Insurance (Part B) covers:

• Inpatient medical care;
• Outpatient hospital care;
• Inpatient and outpatient medical supplies;
• Ambulance services;
• X-rays;
• Laboratory tests;
• Durable medical equipment such as wheelchairs and home orthopedic beds;
• Services of certain especially qualified professionals that are not doctors;
• Physical and occupational therapy;
• Speech therapy;
• Partial hospitalization for psychiatric medical attention;
• Home attention if you don’t have Part A;
• Blood;
• Yearly mammograms;
• Pap smears;
• Pelvic and breast examinations;
• Diabetes glucose monitoring and education;
• Colorectal cancer screenings;
• Bone mass measurements;
• Flu and pneumococcal pneumonia shots.

You should contact the Social Security Administration Office nearest your home for complete information on Medicare benefits and exclusions or contact the telephone numbers and websites shown below.