Complete Topic List

     

Medicare Benefit Summary

Medicare Part A - Hospital Insurance

Hospital Services - Semi-private room and board, general nursing, and other hospital services and supplies.

Skilled Nursing Facility Care - You must have been in a hospital for at least three days, enter a Medicare-approved facility generally within 30 days after hospital discharge, and meet other program requirements. Medicare does not pay for most nursing home care.

Home Health Care -Medically necessary skilled care, home health aide services, medical supplies, etc.

As long as you meet Medicare requirements for home health care benefits, Medicare pays 100% of the approved amount. It pays 80% of the approved amount for durable medical equipment.

Hospice Care - Pain relief, symptom management and support services for the terminally ill. Medicare pays all but limited costs for outpatient drugs and inpatient respite care, for as long as the doctor certifies the need.

Blood - Medicare will pay 80% of all but the first three pints per calendar year, if medically necessary.

Medicare Part B - Medical Insurance

Medical Expenses - Physician’s services, impatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, and other services.

After the $187 deductible, Medicare pays 80% of the approved amount. Medicare pays 50% of the approved charges for most outpatient mental health services.

Clinical Lab Services - Medicare generally pays 100% of the approved amount for blood tests, urinalysis, etc.

Home Health Care - Medically necessary skilled care, home health aide services, medical supplies and other services. (Home health care is covered under Part B only if you do not have Part A.)

As long as you meet Medicare requirements for home health care benefits, Medicare pays 100% of the approved amount. It pays 80% of the approved amount for durable medical equipment.

Outpatient Treatment

  • Hospital - Reasonable and necessary services for the diagnosis or treatment of an illness or injury.
     
  • After the $187 deductible, Medicare pays 80% of the billed amount, as long as medically necessary.

Blood - After the $187 deductible, and starting with the fourth pint, Medicare will pay 80% of the approved amount, as long as medically necessary.

If any of the three pints of blood are paid for or replaced under one part of Medicare during the calendar year, they do not have to be paid for or replaced under the other part.

Medicare Part B - Preventive Services

Bone Mass Measurements - Medicare pays 80% of the approved amount for certain people who are at risk of losing bone mass.  Service covers once every 24 months.

Colorectal Cancer Screening - Medicare pays all costs for fecal occult blood test once a year, for all people age 50 and older.

Medicare pays 80% of the approved amount for Flexible Sigmoidoscopy once every four years, for all people age 50 and over.

Medicare pays 80% for Colonscopy once every two years, if you are at high risk of cancer of the colon. There is no age limit for this test.  If not at high risk, Medicare pays once every 10 years or within 4 years of a Flexible sigmoidoscopy.

Medicare pays 80% of the approved amount for a Barium Enema, for all people age 50 and older. The doctor can substitute this for a sigmoidoscopy or colonscopy.

Diabetes Monitoring - Includes coverage for glucose monitors, test strips, lancets, and self-management training.

Medicare pays 80% of the approved amount, for all people who have diabetes.

Mammogram Screening - Medicare pays 80% of the approved amount once every year, for all women age 40 and over.

Pap Smear, Pelvic Exam and Breast Exam - Medicare pays all lab charges and 80% of the approved amount for doctor services for a pap smear and pelvic exam every two years and every three years for a breast exam. Medicare will pay all lab charges and 80% of the approved amount for doctor services and other exams once every year, if you are at high risk for cervical or vaginal cancer, or if you are of child bearing age and have had an abnormal pap smear in the preceding three years.

Prostate Cancer Screening - Medicare pays 80% of the approved amount for a digital rectal exam once every year for all men age 50 and older.

Medicare pays all costs for a Prostate Specific Antigen (PSA) test once every year, for all men age 50 and older.

Vaccinations - Medicare pays all costs for everyone for a flu shot and a pneumonia shot.

Medicare pays 80% of the approved amount for everyone for a Hepatitis B shot, if at medium to high risk for hepatitis.

Other Covered Services - Limited ambulance and chiropractic services; braces; kidney dialysis; prosthetic devices; and artificial limbs and eyes. Coverage for routine glaucoma screening for persons at risk of glaucoma. Coverage for medical nutrition therapy services for patients with diabetes or kidney disease.

Services Not Covered - Routine eye, foot, and dental care; hearing aids; dentures; yearly exams; orthopedic shoes; most drugs and vaccinations; and custodial care.

To see if you qualify for Medicare, contact your local Social Security Office.

For more detailed information on your Medicare Benefits, pick up a copy of Medicare and You 2014, or go on to the Internet to Medicare.gov

Disclaimer: This information is not legal advice. If you have a legal problem, you should talk to a lawyer and ask for advice about your options.


August 2018

Section 42 CFR 400-429
Published in conjunction with Department of Aging Services -Title III.