Fundamentals of Medicare
How Medicare Works & What It Covers
Part A - Hospital
Part A is the room and board part of hospitalization for Medicare, and as long as you either worked 10 years contributing to Medicare or had a spouse contributing, this benefit is available at no extra cost to you.
Currently, the 2021 deductible is $1,484. Once the deductible is met, the hospital benefit applies for a 60 day benefit period. If you were to reenter the hospital within that benefit period, the same deductible applies. If you enter the hospital after the 60 days, a new deductible is due. The amount of the deductible can change annually.
Part A - Rehab & Skilled Nursing
Room & board
The other benefit of Part A is the room and board at a skilled nursing facility,more commonly referred to as Rehab. As long as you are admitted to the hospital for three days, Medicare pays 100% of the first 20 days of rehabilitation in a facility.
There is a co-pay amount, currently in 2020 of $184 a day, for days 21 through 100 in the same facility. After 100 days, you are responsible for 100% of your care unless you have Long Term Care Insurance. Medicare does not cover nursing home facility care after that 100 days.
Have you been admitted?
When Obamacare was introduced, a section was written which delegated liability to hospitals for patients who returned to the emergency room within 30 days of discharge from the emergency room. The hospital would be liable for their stay. In conjunction with Medicare denying claims of hospital stays as being unnecessary, hospital boards throughout the country met and the "Under Observation" status was invented.
While under observation status, your liability increases outside of your hospitalization coverage. You may be charged for services that your policy does not cover. The practice has grown to hospitals devoting a whole floor to this loop hole in hospital coverage driving the individuals cost and liabilities.
A client of mine went to the emergency room with horrific back pain and was put in a room. She had back surgery and was never admitted to the hospital. As she had original medicare with supplemental coverage, she was responsible for her rehab room and board which would have been covered if she was admitted. Her husband was charged $17,000.
Part B is the Medical portion of Medicare. There is a monthly premium which must be paid to participate, currently $148.50 a month. Social Security prefers to deduct the fee from your benefit check but, if you aren't getting a check you must pay quarterly. There are specific times which you are eligible to enroll and there may be a penalty assessed if a candidate does not elect the benefit when initially eligible.
The premium for Part B can cost more for beneficiaries over a certain income threshold and must be paid for all Medicare recipients regardless of the plan coverage. If your income is below a certain level you may be eligible for help in paying the premium.
Once the premium is paid, there is an annual deductible, currently $203 in 2021 which must be paid. Once the deductible is met, Medicare pays 80% of the medical cost leaving 20% due.
Generally, Medicare does not cover routine eye care. There are a couple of exceptions: if you are suffering cataracts, original Medicare will cover the surgery and a pair of corrected glasses post surgery; if you are diabetic, eye degeneration is a medical side effect and therefore covered; and if you suffer from Macular Degeneration, another medical condition, you are covered under Medicare.
Routine dental care is not covered by Medicare and it is recommended you purchase separate coverage for your teeth and gums. Since 2010 there are more options available to seniors than previously offered.
Typically there are no waiting periods but there may be graduated coverage for major services.