What Does Medicare Cover?
Original Medicare has four parts:
Part A (Hospital Insurance) helps pay for:
- inpatient hospital care
- critical access hospitals
- skilled nursing facility care
- some home health care
- hospice care
Part B (Medical Insurance) helps pay for:
- doctors' services
- ambulance services
- outpatient hospital care
- x-rays and laboratory tests
- durable medical equipment and supplies
- home health care (if you don't have Part A)
- certain preventive care
- limited ambulance transportation
- other outpatient services
- some other medical services Part A doesn't cover, such as physical and occupational therapy
Part C (Medicare Advantage):
If you join a Medicare Advantage Plan you generally get all your Medicare benefits, which may include prescription drugs, through one of the following types of plans:
- Medicare HMOs – You must get your care from primary care doctors, specialists, or hospitals on the HMO's list of network providers, except in an emergency.
- Medicare PPO Plans – In most plans your share of plan costs is less when you use in-network primary care doctors, specialists and hospitals. Using out-of-network providers costs you more.
- Medicare Special Needs Plans – These plans generally limit enrollment to people in certain long-term care facilities (like nursing homes); people eligible for both Medicare and Medicaid; or those with certain chronic or disabling conditions.
- Medicare Private Fee-for-Service Plans – In these plans, you may go to any Medicare-approved primary care doctor, specialist, or hospital that will accept the terms of the private plan's payment.
- Medicare Medical Savings Account (MSA) Plans - These plans include a high deductible plan that will not begin to pay benefits until the high annual deductible is met. They also include a medical savings account into which Medicare will deposit money for you to use to pay your health care costs. Medical Savings Account Plans do not cover prescription drugs.
Part D (Medicare Prescription Drug Coverage)
Under this program, private companies provide Medicare Prescription Drug Coverage and you pay a monthly premium. Federal retirees already have excellent access to health benefits coverage for drugs through participation in the FEHB Program. However, if you choose to enroll in Part D, Medicare benefits for drugs will be primary (will pay first) in most cases for FEHB enrollees. (Medicare C plans that include prescription drugs will also be primary to FEHB benefits.)
It will almost always be to your advantage to keep your current FEHB coverage without any changes. The exception is for those with limited incomes and resources who may qualify for Medicare's extra help with prescription drug costs. Contact your benefits administrator or your FEHB Program insurer for information about your FEHB coverage before making any changes.
It is important to note that FEHB Program prescription drug coverage is an integral part of your total health benefits package. You cannot suspend or cancel FEHB Program prescription drug coverage without losing your FEHB plan coverage in its entirety (in other words, losing coverage) for hospital and medical services which would mean you might have significantly higher costs for those services.
Because all FEHB Program plans have as good or better coverage than Medicare, they are considered to offer creditable coverage. So, if you decide not to join a Medicare drug plan now, but change your mind later and you are still enrolled in FEHB, you can do so without paying a late enrollment penalty. As long as you have FEHB Program coverage you may enroll in a Medicare prescription drug plan from November 15 to December 31st of each year at the regular monthly premium rate. However, if you lose your FEHB Program coverage and want to join a Medicare prescription drug program, you must join within 63 days of losing your FEHB coverage or your monthly premium will include a late enrollment penalty. The late enrollment penalty will change each year but will be included in your premium each year for as long as you maintain the coverage.
Medicare does not cover:
- your monthly Part B premium or Part C or Part D premiums
- deductibles, coinsurance or copayments when you get health care services
- outpatient prescription drugs (with only a few exceptions) unless you enroll in a Part C plan which provides drug coverage or a Part D plan
- routine or yearly physical exams
- custodial care (help with bathing, dressing, toileting, and eating) at home or in a nursing home
- dental care and dentures (with only a few exceptions)
- routine foot care
- hearing aids
- routine eye care
- health care you get while traveling outside of the United States (except under limited circumstances)
- cosmetic surgery
- some vaccinations
- orthopedic shoes
Complete Medicare benefits information can be found in the Centers for Medicare and Medicaid Services publication, Medicare & You handbook which can be found on the Medicare website (www.medicare.gov).
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