Medicare Part A and Part B Coverage
Medicare Parts A and B do not cover all of your medical expenses. Fortunately, there are several options available to help you pay your portion of the expenses.
Part A Hospital Coverage.
Part A covers a portion of medical expenses incurred in the following areas:
- Hospital care.
- Skilled nursing facility care for a limited period of time
- Hospice care.
Hospital care. Medicare will pay for everything but the deductible for your first 60 days in a hospital during any benefit period. Medicare also pays for all but the co-insurance for days 61-90 in any benefit period.
Skilled nursing facility care. In order for Medicare to cover any part of a beneficiary’s stay in a nursing facility, the beneficiary must:
- Require skilled nursing care, which is more than custodial care and very narrowly defined.
- A three day hospitalization prior to being admitted to the skilled nursing facility for the same condition for which you were hospitalized.
If the Medicare beneficiary meets the above qualifications, Medicare pays the entire cost for covered care during the first 20 days of a benefit period. For days 21-100, Medicare pays all but the coinsurance . After 100 days, the beneficiary is responsible for paying for any further care at the nursing facility.
Psychiatric hospital. Medicare will pay for up to 190 days in a psychiatric facility during your lifetime.
Part B Medical Coverage
.Part B covers a portion of expenses incurred for doctors services, diagnostic tests, home health care, outpatient hospital treatment, durable medical equipment, blood and ambulatory surgical services, ambulance services.
To utilize Part B benefits, you must first pay a deductible in each calendar year. After payment of your deductible, Medicare will cover all or a portion of covered expenses.
Doctors services. After you meet your
calendar year deductible, Medicare pays 80% and you pay 20% of the
Medicare approved fee for doctor’s services.
Home health care. Medicare covers all costs for qualifying home health care. However the rules to qualify for coverage of home cares services are fairly strict. To qualify you must:
- Be considered home-bound,
- Be under a doctor’s care,
- Require skilled nursing care, physical therapy, occupational therapy or speech language pathology.
Medicare approved charges. Medicare has approved amounts that doctors can charge for various services.
Medicare assignment. If a doctor accepts the Medicare approved charge as full payment for a service, this practice is known as accepting assignment. Always ask any doctor you visit if they accept assignment. If they do not accept assignment, you may want to try and find another doctor who does. If your doctor does not accept assignment, you must pay a portion of the increased amount he charges. For example, assume a Medicare approved charge for a service is $200. If the doctor accepts assignment and you have met your $100 calendar year deductible, Medicare would pay $160 and you would pay $40. If your doctor does not accept assignment, she could charge, for example, $230 for the same service. Medicare would pay only $160 and you would pay $70.
Right To Appeal. If Medicare refuses to pay all or a portion of expenses you think should be covered, you have the right to appeal the decision. When you receive a statement denying payment on your claim, it will include instructions about how to file an appeal. You can also contact Colorado Attorney General’s Office Insurance Counseling and Assistance Program at for assistance with your appeal.
What Is Not Covered. Medicare Parts A and B do not cover all of your medical expenses. Fortunately, there are several options available to help you pay your portion of the expenses. Depending on your individual medical, financial and personal circumstances you can:
- Pay for non-covered expenses out of your pocket.
- Enroll in a Medicare HMO.
- Purchase a "Medigap policy to supplement your Medicare coverage
- Continue your coverage under an employer provided health insurance plan.
- Apply for state provided assistance (Medicaid).
