Original Medicare Plan
Medicare is the health insurance program administered by the federal Centers for Medicare & Medicaid Services (CMS) for people 65 years of age or older, people of any age with permanent kidney failure, and some disabled individuals under age 65. Although Medicare may pay a large part of your health care expenses, it does not pay for them all. Some services and medical supplies are not fully covered. A book titled Medicare and You is available each year free from any social security office. The handbook provides a detailed explanation of Medicare.
Medicare is divided into two types of coverage, Part A and Part B.
Part A is commonly known as hospitalization insurance. For most people, Part A is premium-free, meaning that you do not have a monthly payment for the coverage. It pays your hospital bills and certain skilled nursing facility expenses. It also provides very limited coverage for skilled nursing care after hospitalization, rehabilitative services, home health care, and hospice care for the terminally ill. It does not pay for personal (custodial) care, such as help with eating, dressing, or moving around. Under Medicare Part A, a period of hospitalization is called a benefit period. A benefit period begins the day you are admitted into a hospital. It ends when you have been out of the hospital or a nursing facility for 60 consecutive days. If you are re-admitted within that 60 days, you are still in the same benefit period and would not pay another deductible. If you are admitted to a hospital after that benefit period ends, an entirely new benefit period begins and a new deductible must be paid.
If you do not automatically get premium-free Medicare Part A, you may be able to buy it. For more information, visit www.ssa.gov or call Social Security at 1-800-772-1213.
Part B is commonly known as medical insurance. It helps pay your doctors' bills and certain other charges, such as surgical care, diagnostic tests and procedures, some hospital outpatient services, laboratory services, physical and occupational therapy, and durable medical equipment. It does not cover prescription drugs, dental care, physicals, or other services not related to treatment of illness or injury.
Part B premium is based on annual income. In 2016, the standard Part B premium amount will be $121.80. Most people who enrolled in Part B prior to 2016 and get Social Security benefits will continue to pay a Part B premium of $104.90 each month. Single Medicare beneficiaries with annual incomes over $85,000 and married couples with incomes over $170,000 will pay a higher percentage of the cost of Medicare Part B coverage, reducing Medicare's share. You can find additional information regarding annual income and Part B premium at Medicare's Web site https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html#collapse-4809.
Specific Limitations Under Medicare
Medicare was not designed to pay all your health care expenses. It does not cover long-term care expenses. Medicare provides limited coverage for skilled nursing care and for home health care.
Skilled Nursing Care Limitations
Medicare pays limited benefits in a skilled nursing facility approved by Medicare if you need skilled nursing care as defined by Medicare. Medicare does not pay for personal care such as eating, bathing, dressing, or getting in or out of bed. Most nursing home care is not covered by Medicare! For more information, you can view or print the Guide to Long-Term Care on-line or contact the Office of the Commissioner of Insurance at (608) 266-0103 (in Madison) or 1-800-236-8517 (statewide) and ask for a printed copy to be mailed to you.
Home Health Limitations
Medicare pays limited benefits for home health care services that are considered "medically necessary" by Medicare. Medicare does not pay for personal care such as eating, bathing, dressing, or getting in or out of bed. Most home health care services are not covered by Medicare!.