Medicare Coverage

It is important to understand the coverage that Original Medicare offers. By understanding this, Medicare beneficiaries can make more informed decisions about other types of insurance that they choose to enroll in.

Original Medicare Coverage

Original Medicare consists of Part A and Part B. Together, these offer coverage for inpatient and outpatient services such as hospital stays, doctor visits, medical equipment, lab tests, preventive services, and more.

Medicare Part A Benefits

Part A benefits include:

A semi-private room
Operating room
Post-op recovery room
Care in special units
Hospital meals
Lab tests
X-rays
Medications and equipment
Rehabilitation services while and inpatient
Blood transfusions
Hospice
Skilled nursing care

Medicare Part B Benefits

Part B offers coverage for many outpatient medical services. It offers benefits for preventive services like cancer screenings, vaccines, lab work, and many more preventive services. It will also help pay for mental health services and durable medical equipment.

While Part A is your “room and board” for hospital stays, Part B will also pay for services performed while under inpatient hospital care. It will cover diagnostic images, surgeries, dialysis, chemotherapy, and medications delivered by injection.

What is not included in Medicare coverage?

Original Medicare does not offer long-term care, acupuncture, or routine dental, vision, and hearing services. It does not pay for hearing aids or any cosmetic procedures.

Medicare Age Requirements

Individuals who have been receiving disability benefits for 24 months or who have been diagnosed with ALS or ESRD can qualify for Medicare at any age. Otherwise, individuals must be at least 65 years old to enroll in medicare.

Medicare Advantage Coverage

Medicare Advantage (Part C) plans are Medicare-approved plans provided by private companies that offer an alternative to Original Medicare for your health and drug coverage. These plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare’s coverage rules. Also, each Medicare Advantage Plan can charge different out-of-pocket cost, and can also have different rules for how you get services.

Part D Coverage

Medicare Part D, also known as the prescription drug benefit, is the part of Medicare that covers most outpatient prescription drugs. Part D, like Medicare Advantage, is offered through private companies either as a:

stand-alone plan, for those enrolled in Original Medicare, or
as a set of benefits included with your Medicare Advantage Plan

Medicare Part D has a list of prescription medications it covers. This list is also known as the formulary which contains all the prescription drugs Part D offers coverage for. If a drug you need is not on the Part D formulary, you may have to request an exception, pay out of pocket for drug expenses, or file an appeal which you can use to ask your plan provider to reconsider the decision about the drug in question.

Effective Dates for

Medicare

Medicare coverage will begin at age 65 or on the 25 month of disability benefits. However, not all individuals are automatically enrolled in Medicare, so effective dates will be based on when the individual submits their application.

The Initial Enrollment Period is the best time to apply for those who are turning 65. It begins three months prior to their 65th birthday and ends three months after.

Individuals may qualify for a Special Enrollment Period in some cases and there is also a General Enrollment Period for those who miss their initial enrollment and do not qualify for a special enrollment. The General Enrollment Period runs from January 1 through March 31. Enrolling during this time makes the effective date July 1.

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