Medicare
What is Medicare?
What is covered under Medicare?
Medicare coverage for nursing home care
Filling in the gaps of Medicare
Who do I call for more information?
Medicare was established in 1965 as "comprehensive" health coverage for elderly Americans. It is administered by the federal government through the Social Security Administration, and provides health insurance for people over the age of 65, and for people younger that 65 who are permanently disabled (including people with kidney failure). The program uses only federal funds.
Financial need is not a factor in determining eligibility. People who have paid into the Social Security or Railroad Retirement systems, their spouses, and their disabled children are eligible for Medicare.
Although initially enacted as comprehensive coverage, Medicare has many limitations and exclusions. The beneficiary must often pay a part of the cost for covered services. Services which are "medically necessary" are covered, which means that "well" care, preventative or routine care is frequently not covered.
What is covered under Medicare?
There are two parts to Medicare: Part A, hospital insurance; and
Part B, medical insurance.
Medicare Part A pays for:
Medically reasonable and necessary services ordinarily furnished by a hospital.
Extended-care services in a "skilled-nursing facility" for a maximum of 100 day per spell of illness. It does not pay for custodial care.
Home Health Services, for qualified individuals who are confined to their home. This includes: intermittent nursing care, physical, speech, or occupational therapy, direct personal assistance, medical supplies and appliances.
Hospice Services for a person who is terminally ill, with a medical prognosis of six or fewer months to live.
Medicare Part B pays for:
80% of reasonable charge for doctors and other health care professionals after the annual deductible is met (includes M.D.'s osteopaths, chiropractors, optometrists, dentists, and podiatrists).
Services and supplies incidental to a physician's professional services, including drugs and biologicals that cannot be self-administered, such as chemotherapy.
Ambulance services when any other transportation would endanger the patient's health.
Physical, speech and occupational therapy.
X-rays and other diagnostic tests.
Outpatient hospital and mental health services.
Durable medical equipment furnished to a patient for use in the home.
Transfusions of blood and blood components furnished on an outpatient basis.
Outpatient surgery.
Prosthetic devices.
Nurse-midwife services as a substitute for covered physician services to the extent that services are authorized under state law.
Screening mammography annually for all women age 40 and older.
Pap smear screening and pelvic exam every three years unless woman is at high risk for cervical cancer.
Home health services when the patient does not have Part A coverage.
Heart, lung, and liver transplants under limited circumstances in a Medicare-approved facility.
Certain colorectal screening tests and diabetes screening tests.
Bone mass measurement screenings for high risk person (effective July 1, 1998)
Medicare Coverage for Nursing Home Care
In order to receive care in a nursing home covered by Medicare, three basic requirements must be met:
- You must begin receiving skilled nursing home care within 30 days of a hospital stay of three days or longer;
- You must require skilled care for the same condition for which you were hospitalized; and
- You must receive your care in a nursing home that is certified to participate in the Medicare program.
Filling in the Gaps of Medicare Coverage
Although Medicare covers many health care costs, you will still have to pay the required coinsurance and deductibles. There are also many medical services that Medicare does not cover. Fortunately, there are several ways you can fill in the gaps.
You could purchase Medicare Supplemental insurance, also known as "Medigap Insurance". This is private insurance that is designed to help pay your Medicare cost-sharing amounts. The Michigan Insurance Bureau is a good source of basic information about Medigap Insurance. Contact them at:
Michigan Insurance Bureau
P. O. Box 30220,
Lansing, MI 48909
(517) 373-0240 (for general information)
(517) 335-1702 (for senior issues and concerns)
You could continue coverage under an employer-provided health insurance policy, if you are eligible for such protection.
You could enroll in a managed care plan, such as a health maintenance organization (HMO) that has a contract to serve Medicare beneficiaries.
Or, you could qualify for full Medicaid benefits.
If you need more information about what Medicare covers, contact your local Social Security office, or call their toll-free telephone number: 1-800-772-1213. The TDD number for people with special needs is 1-800-323-0778.