Medicare Information

Medicare

Part—6 What Medicare Covers

The two parts of Medicare are designed to help pay for different kinds of health care costs. Some kinds of health care aren’t covered by Medicare at all.

Hospital Insurance (Part A)

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 coinsurance 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 that 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 health 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 copayment 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 recertifies 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 recertifies that you are terminally ill, your care continues through another period of care.

Part—7 What Medicare Does Not Cover

Medicare provides basic health care coverage, but it doesn’t pay all of your medical expenses. Here are examples of what Medicare does not pay for:

custodial care;

This is care that could be given safely and reasonably by a person who is not medically skilled and that is given mainly to help the patient with daily living. Examples include help with walking, bathing and dressing. Even if you are in a participating hospital or skilled nursing facility, or you are getting care from a participating home health agency, Medicare does not cover the cost of care if it is mainly custodial.

	most nursing home care;
	dental care and dentures;
	routine checkups and the tests directly related to these checkups (some screening, Pap smears and mammograms are covered);
	most immunization shots (some flu and pneumonia shots are covered);
	most prescription drugs;
	routine foot care;
	tests for, and the cost of, eyeglasses or hearing aids;
	personal comfort items, such as a phone or TV in your hospital room; and
	services outside the United States.

You can get more detailed information about what is covered under Medicare Part A and Part B from the publication, Your Medicare Benefits. To get a copy, call the Medicare toll-free number or go to www.medicare.gov on the Internet and click on “Publications.”