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Basic Needs

Health Care Coverage
Medicare

Benefits/Coverage:

See What Medicare Covers on Medicare.gov

Under this plan, you may go to any doctor or specialist who accepts Medicare or to any hospital or other facility that offers Medicare-covered services. If you do not choose another plan, you will be enrolled in the Original Medicare Plan.

Your out-of-pocket costs can be quite high under the Original Medicare Plan. In addition to your Part B premiums, you have to pay a hospital deductible and coinsurance each benefit period, a medical deductible each year, and a 20% coinsurance fee for most Part B services that you get.

In 2022, beneficiaries are responsible for the following costs:

Cost Patient Pays
Part B monthly premium The standard Part B premium amount is $170.10 (or higher depending on your income).
Part B deductible $233 per year
Part B coinsurance After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy, and durable medical equipment (dme)
Part A hospitalization deductible $1,556 per benefit period
Hospitalization coinsurance

$0 coinsurance for Days 1-60 in each benefit period
$389 per day for days 61-90
$778 per "lifetime reserve day" after day 90 of each benefit period
(up to a maximum of 60 days over your lifetime)
All costs beyond 150 days
Skilled Nursing Facility coinsurance Days 1–20: $0 for each benefit period
Days 21–100: $194.50 per day of each benefit period.
Days 101 and beyond: all costs
Part A Premium Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $499 each month in 2022. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $499. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $274.

Reference and for more information:https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html and http://www.medicareinteractive.org/page2.php?topic=counselor&page=section&toc_id=77

 

Other additional costs: you have to pay total costs for certain preventive care, dental care, and other health care services that are not included in Medicare. If you do not enroll in a Part D Prescription Drug Plan, you must also pay prescription drug costs. Certain outpatient therapies (physical therapy, occupational therapy, speech/language) have been subject to therapy caps, however the therapy cap was removed as of January 1, 2018.

What's NOT Covered (under Original Medicare):

  • Alternative medicine, including experimental procedures and treatments, acupuncture, and chiropractic services, except when manipulation of the spine is medically necessary to fix a subluxation of the spine (when one or more of the bones of the spine move out of position)
  • Most care received outside of the United States
  • Cosmetic surgery, unless needed to improve the function of a malformed part of the body
  • Most dental care
  • Hearing aids, including examinations for prescribing or fitting hearing aids—though in some cases implants to treat severe hearing loss are covered
  • Personal care, including help with bathing, dressing, and eating, when it is the only care you need
  • Custodial care (homemaker services), including light housekeeping, laundry, and meal preparation, when it is the only care you need
  • Nursing home care (long-term care), including medical care, therapy, 24-hour care, and personal care, except during a Medicare-covered skilled nursing facility (SNF) stay
  • Non-medical services, including a private hospital room, hospital television and telephone, canceled or missed appointments, and copies of x-rays
  • Most non-emergency transportation, including ambulette services
  • Certain preventive services, including routine foot care
  • Most vision care, including eyeglasses (except following cataract surgery) and examinations for prescribing or fitting eyeglasses

You are responsible for the full cost of care if you receive a service that Medicare does not cover. If you have a Medicare Advantage Plan, your plan may cover some of these services.

 

Special Coverage Topics (see also Special Topics below):

Ambulance (non-emergent)

Eye Care- Medicare Advantage plans typically offer limited eye care coverage, but since they vary contact the plan for details. Original Medicare will generally not pay for routine eye care. However, Medicare can make an exception and pay for routine eye care in the following situations:

    • If you have diabetes, Medicare helps to pay for an eye exam once every 12 months to check for eye disease due to diabetes.
    • If you are at high risk for glaucoma, Medicare helps to pay for an eye exam by a state-authorized eye doctor once every 12 months. You are considered to be at high risk for glaucoma if you have diabetes, have a family history of glaucoma, are an African American over age 50, or are a Hispanic American age 65 or older.

Medicare may also pay for eye care services if you have a chronic eye condition, such as cataracts or glaucoma. Specifically, Medicare can cover cataract surgery, as well as eye exams to diagnose potential vision problems.

Medicare generally does not cover eyeglasses or contact lenses, unless you have had cataract surgery. Original Medicare may cover one pair of eyeglasses or one set of contact lenses if you need them after cataract surgery.

Intravenous Immune Globulin (IVIG) At-Home Infusions- New Law - MGH Community News, January 2013

Smoking cessation- Since 2005 Medicare has covered smoking cessation counseling, but only for those who have an illness caused by, or complicated by, tobacco use. In September 2010 CMS announced Medicare will now cover tobacco cessation counseling regardless of whether the patient has tobacco-related disease. For more information: Medicare to Cover Smoking Cessation - MGH Community News, September 2010.

Vaccines

  • Medicare Part B will cover vaccines for Influenza, Pneumonia and Hepatitis B (for those at medium to high risk). Part B will cover other immunizations only if one has been exposed to a disease or condition. For example, Part B will cover a tetanus shot if a member steps on a rusty nail or a rabies shots if a member is bitten by a dog.  Part D may cover other vaccines such as the vaccine for shingles (herpes zoster). Before getting a vaccination, members should check coverage rules with their Part D plan and see where it will be covered at the lowest cost. (Medicare Reminder - Vaccines MGH Community News, July/Aug 2011)
  • Medicare Part D covers the RSV vaccine if it’s recommended for you by the Advisory Committee on Immunization Practices (ACIP), a government agency that gives advice about who should get certain vaccines. At this time, the RSV vaccine is recommended for adults over the age of 60. There should be no cost to you to get this vaccine. This means your pharmacy shouldn’t charge you a copay or deductible to get the RSV vaccine. If you have Medicare Part D, it should be free to you. If you have Medicare Part D and your doctor or pharmacy tries to charge you for the RSV vaccine, you should call 1-800-MEDICARE (1-800-633-4227) for help. If you have non-Medicare drug coverage (like drug coverage from an employer or union), you should check to see its coverage rules for the RSV vaccine. Because this is a newer vaccine, it may not be listed on an insurance plan’s list of covered drugs yet, so you should check with your plan before making an appointment. (medicareinteractive.org/resources/dear-marci/does-medicare-cover-the-rsv-vaccine)

Hospice demonstration project- coverage of hospice while still pursuing treatment. More information: "Medicare will experiment with expansion of hospice coverage"- MGH Community News, September, 2010.