Medicare is a national social insurance program administered by the Centers for Medicare and Medicaid Services (CMS) for the government of the United States, together with the Social Security Administration and the Departments of Labor and Treasury. On the average, it can cover up to half of a number of healthcare services extended to a beneficiary while the remainder of the cost must be paid by the recipient himself either through a supplemental or separate medical insurance or as an out-of-pocket expense. US residents who meet the program’s eligibility criteria are entitled to receive medical care and health insurance coverage as part of their Medicare benefits in 2018.
Benefits and services provided by the program are categorized into different parts namely Parts A, B, C, and D. Part A basically covers charges for inpatient hospital care, skilled nursing facility care, hospice care, and home health care. On the other hand, Part B includes for particular services of a doctor, outpatient care, preventive and wellness services.
Upon hospital admission, it is essential for a Medicare beneficiary to know whether he or she is being admitted as an in-patient or an out-patient because this will be the basis of whether Part A or Part B Medicare benefits will be applied to cover the charges that will be incurred.
Part C is a different set of health care plan usually acquired through private insurance providers. This plan also referred to as Medicare Advantage Plan, offers coverage for most health care services which are not covered or paid for under Parts A and B benefits of the original Medicare.
Part D, on the other hand, offers prescription drug coverage, in addition to Parts A and B benefits, and may also be availed from private insurance companies. Some companies which give Medical Advantage Plan integrates Part D benefits in their plan offerings.
Medicare Benefits in 2018 Being Offered
In-patient hospital care
Medicare covers charges for inpatient hospital care under Part A. Coverage includes payment for semi-private rooms, meals, general nursing care, and other hospital services or supplies. It will also cover for medicines which the patient will consume as part of his or her in-patient treatment. However, this does not include private-duty nursing and other room amenities which are separately charged from room accommodation such as appliances like television, refrigerator, or telephone and personal care items.
Medicare will also cover ambulance services when a patient needs to be transported to a hospital, a critical access hospital, or to a skilled nursing facility, if it is medically-necessary and transportation using another vehicle may be dangerous given the patient’s condition.
Skilled nursing facility care
If it is medically necessary for a patient to receive specialized care, or a nursing and therapy care which can only be safely and efficiently administered by, or under the supervision of a professional, the Medicare program will also provide for such. Medicare will cover up to 100 days of skilled care services in a benefit period.
A patient who is certified as ‘home-bound’ by his or her doctor as someone who cannot leave his home without the help of a cane, a wheelchair, a walker, crutches, specialized transportation, or without any help from another person because of his illness or injury, or someone who is not recommended to leave the house because of his condition, is entitled to home health services under Medicare.
This service includes intermittent skilled nursing care, physical care, speech-language pathology care, and continued occupational therapy that is necessary for a patient to have as part of his recovery or treatment, without the need for him to leave his house.
Medicare benefits also cover hospice care for a patient who is terminally ill and has a life expectancy of six months or less. The patient must have accepted palliative care for comfort, instead of care, to cure the illness and have signed a statement that he is choosing hospice care over other Medicare-covered benefits to treat his disease and other related medical conditions.
Medicare-covered hospice care includes the following; services of a doctor, nursing care, medical equipment and supplies, prescription drugs, physical and occupational therapy, social work services, dietary counseling, and others.
Outpatient Hospital Services
Part B of the Medicare program covers medically-necessary outpatient services which include emergency or observation services that require a patient to stay overnight in the hospital; laboratory tests, mental health care; X-ray and other radiology services; medical supplies, certain drugs, and biologicals.
As part of its healthcare offerings, Medicare provides preventive care and services to prevent or detect illness at an early stage and apply treatment during this time, when it will work best. Some of this preventive services are flu shots; pneumococcal shots; glaucoma test for those who are at high risks for glaucoma; alcohol misuse screening; and depression screening, among others.
It also provides for health education and wellness programs such as medical nutrition therapy for those who have diabetes or kidney disease aside from diabetes self-management training, and kidney disease education services.
A newly-enrolled Medicare beneficiary may also avail of the one-time ‘Welcome to Medicare’ preventive visit which will review his medical and social history and will provide education, counseling, and preventive services such as screening for specific diseases, shots, and referrals for other types of care, if there is a need for it. The beneficiary must avail of this preventive visit within the first 12 months of his coverage under the Part B of the Medicare program.
After that, an annual “Wellness’ visit may be availed by the beneficiary, if he had Part B coverage for more than 12 months. In this Wellness visit, a personalized disease and disability prevention plans will be developed or updated based on the beneficiary’s current state of health and risk factors.
Generally, US citizens who are 65 years old or older are qualified to avail of Medicare benefits. They are entitled to Parts A and B on the first day of the month that they turn 65.
Younger people may also avail of Medicare benefits under certain conditions. They may have a disability and have been receiving benefits from Social Security or the Railroad Retirement Board for such or if they are continuously undergoing dialysis for end-stage renal disease or in need of a kidney transplant.
In their case, they must have been receiving disability benefits for at least 24 months before they become eligible for Medicare benefits for 2018.