What’s Covered? How to Use Medicare’s Website to Understand Original Medicare Coverage Better
Many people want to know how Original Medicare will cover a specific health condition, treatment, service, etc. Luckily for me, as an agent, and for you, as a Medicare beneficiary, the Medicare.gov website lets you easily search for this. For example, I am going to search how Original Medicare covers Kidney Dialysis. First, I go to medicare.gov. On the homepage, you will see a search field. This is where you can type the service you’d like more info on. Once I have typed Kidney dialysis, I hit “GO”, and within a few seconds, a list of services pops up, dialysis services and supplies being the first. I click on the link, and am led to a detailed summary of coverage. It discusses inpatient coverage versus outpatient, training for home dialysis, support services, equipment and supplies, and certain drugs for home dialysis that are covered under Original Medicare. In addition to a list of what is covered is a brief mentioning of what is not. Medicare does not pay for aides to assist with home treatment, any lost pay during self-dialysis training, a place to stay during your treatment, and blood or packed red blood cells for home self-dialysis unless part of a doctors’ service. The page then details how much Medicare will pay for the coverage offered, which in this case seems to be an 80/20 split for just about everything. This is where Medicare Supplements step in to help you with out-of-pocket costs. As you can see, with Original Medicare alongside a Supplement, your coverage will be quite comprehensive.
Medicare.gov also explains, in broader terms, what Parts A and B cover. There is a link to “What Part A Covers” as well as a link to “What Part B Covers.” I truly love Medicare’s website, I think it is so well done, and I urge you to explore it more!
Just as I discussed with Kidney Dialysis earlier, Medigap policies fill in the gaps of Original Medicare’s coverage for different services and treatments. For example, Medicare pays for the first 60 days of a Hospital Inpatient Stay (there is a deductible that has to be met before they pay anything), but from days 61-90 you pay coinsurance every day, which is $304/day. All Medigap Plans cover this hospital donut hole, and this is good news, because the coverage gets even worse the longer you stay in the hospital. Days 91-150 include a $608 daily coinsurance. A Medigap plan will cover this, and you won’t have to worry about these gaps in coverage with Medicare. In fact, Medicare Supplement hospital coverage will go up to an additional 365 days in coverage past what Original Medicare will help cover!
A quick note: there have been stories in the news lately concerning the labeling of hospital patients as outpatient instead of inpatient and making sure you know your classification. This is another important factor in whether Medicare will cover the costs; how they label you can determine whether Medicare will pay. Part A (which covers hospital stay) will pay if you are labeled an inpatient, and Part B (which does not cover hospital stay) will pay if you are an outpatient. I am going to write a blog about this soon; keep on the lookout for more detailed information!
The list below should help to give you a foundation in understanding what is covered and what is not covered by Original Medicare (and therefore Medicare Supplements):
1. Dental and Vision
2. Nothing cosmetic is covered.
3. If it is routine, preventative, and a yearly sort of deal-you will most like get help with it, although it is always good to check with Medicare.
4. If your doctor is a Medicare provider and accepts Medicare Assignment.
My fourth point in the ground rules list is important to understand. After making sure that your provider works with Medicare, your next question should be whether or not they accept Medicare Assignment. This is a term used to describe the price per service that Medicare is willing to pay. For example, if Medicare pays $1,200 for a certain surgery, if the doctor accepts Medicare Assignment, he is accepting this amount as payment for the surgery. Doctors who work with Medicare are allowed to charge an additional 15% above the Approved Amount (the $1,200), which means they are not accepting Medicare Assignment although they work with Medicare. Now you see why it is imperative that you ask both of these questions before receiving any service from a provider. Medicare Supplement Plans F and G covers this 15% “Excess Charge” for Part B services.
There are many nuances like the one above, but the ones in this article are the major players in the game. I hope this article gave you a better understanding of what is covered by Original Medicare and how Medicare Supplements work alongside Parts A and B.
I have also made a YouTube video that will give you a visual to this article, and also introduce you to my website, which has more information on how Medicare Supplements work with Parts A and B. The link for that video is below!