With so many changes to Medicare each year, how is the average consumer supposed to keep up with everything? At South Coast Post Acute, we want to make sure that you have all of the information you need when researching your medical insurance options during your retirement years. Medicare may not cover all the services you may need as you retire and coverages can vary for long-term care. 

Many people may not know that there is no blanket Medicare services coverage. Overall, Medicare covers medical services in long-term, short-term, and hospital settings, but there are some restrictions as to the cost of staying at these facilities. 

Your Medicare coverage comes in 2 main ways – Original (Part A and Part B) or a Medicare Advantage Plan (Part C). To find out if Medicare covers your item, service, or supply visit Medicare.gov/coverage.

Deciding whether you need Original Medicare or a Medicare Advantage Plan (like an HMO or PPO) will be based on your needs. Let’s find out what each plan covers:

What Part A Covers

In general, Medicare Part A, or hospital insurance, covers in-patient care at a hospital, skilled nursing facility (SNF) care which can be non-custodial or long-term care, hospice care, or home health care.

Paying a monthly premium for Medicare Part A is not necessary if you have worked at least ten years while paying taxes. However, there are costs if you have worked fewer than 30 quarters per month. In 2019 the monthly cost would be $437 per month. 

What Part B Covers

Medicare Part B, or Medical Insurance, covers durable medical equipment, home health care, and some preventative services. Medically necessary services and preventative services are the two types of services covered by Part B. 

Although not a complete list, Part B is the right coverage if you need things like: 

  • Doctor office visits/Flu Shots
  • Clinical research
  • Ambulance services
  • Chemotherapy
  • Diabetes screenings, supplies, and therapy
  • Durable medical equipment (DME)
  • Mental health needs
  • Getting a second opinion before surgery
  • Limited outpatient prescriptions

Under Part B, in most cases, you will pay 20% of the Medicare-approved amount for each item or service where a deductible may apply.

What Part C Covers – The Medicare Advantage Plan

Medicare Part C includes both Part A and Part B provided by private insurance companies, which are approved by Medicare. Most Medicare Advantage Plans deliver the benefits of Medicare Original services while also including prescription drug coverage. The cost for your Part B premium must be paid with an Advantage Plan, as well as any premium the plan might charge. These plans operate in a limited geographical area so if you live in more than one state during the year or travel a lot, this plan may not be suited for you. One thing to note: Medicare supplemental insurance (Medigap) is not suited to work jointly with Medicare Advantage plans. This will require you to pay out-of-pocket for expenses like copays or deductibles.

Coverage for Medicare is based on 3 main factors:

  1. Federal and state laws
  2. National coverage decisions made by Medicare about whether something is covered
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area

Talk to your health care provider about what you need in your situation for services or supplies, ask if Medicare will cover them, and keep an open line of discussion. You may need something that’s usually covered, but there may be variables that lead your provider to think it is not covered for your situation. You will then read and sign a notice understanding that you may have to pay for items, services, or supplies out of pocket.

If you are in need of a post-acute care facility, reach out to South Coast Post Acute. Our people are our greatest resource. Our staff is committed to providing the highest quality care and outstanding customer service to become the most trusted and respected provider of healthcare services in Orange County. We can help you through some of the questions of what services your Medicare plan covers.

Real People. Remarkable Care.  South Coast Post Acute.