Medicare For Dummies. Patricia Barry

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СКАЧАТЬ alt="Remember"/> I’m not skimping on giving more-detailed information that you need to know in order to deal with certain aspects of Medicare. Some coverage issues are very straightforward — basically, you just show your Medicare card (or Medicare Advantage plan card or Part D drug plan card, as appropriate) to get a covered service for the required co-pay or, in some cases, for free. But other issues are more complex and may pose pitfalls that can trip you up if you’re not expecting them. I zoom in on those issues in Chapter 14, where I share the inside scoop on some of the finer points of Medicare coverage that are good to know about in advance so you don’t have to find out the hard way.

Understanding What Part A and Part B Cover

      Part A and Part B form the core of Medicare. They provide the coverage that you have if you enroll in the traditional or original Medicare program that has been around since 1966, although many more services have been added since then. Parts A and B are also the basis of your coverage if you’re in a Medicare Advantage health plan, because all those plans must by law cover the same services as the traditional program, although the plans can provide extra benefits if they want to. (I go into detail about the differences between traditional Medicare and Medicare Advantage plans in Chapter 9.)

      These two parts of Medicare cover entirely different services, as I explain in Chapter 1. But sometimes Parts A and B work in tandem. For example, if you need to go into the hospital, in most cases, Part A covers the cost of your room, meals, and nursing care after you’ve met the deductible. But Part B covers the cost of your medical treatment — services provided by surgeons, other doctors, and anesthetists. This division of coverage also applies to staying in a skilled nursing facility for continuing care after leaving the hospital, using home health services, and receiving hospice care.

      In the following sections, I describe broad categories of services that Parts A and B pay for.

      Necessary medical care

In essence, Medicare covers services that are reasonable or necessary to save life and maintain or improve health. That includes really big-ticket items — such as transplants of the heart and other organs, delicate surgery to repair severe injuries, cancer treatments, and many others — that cost Medicare tens of thousands, and in some cases hundreds of thousands, of dollars. The program also, of course, covers more-routine and less-expensive services, from allergy shots to X-rays.

      No doubt about it: Medicare can split hairs. It may cover a service in some circumstances but not others. One glaring example of this discrepancy is that Medicare covers power-operated vehicles, such as scooters and manual wheelchairs (as opposed to the conventional type) only if you need one to get around inside your home but not if you need one just to be mobile outdoors. In 2018, Medicare began requiring prior authorization for the coverage of certain types of power wheelchairs (33 in all) before Medicare will cover the cost. Medicare may also cover a treatment in some parts of the country but not everywhere. (I go into the difference between national coverage determinations, which cover people in need of them throughout the country, and other coverage determinations that are made regionally, in Chapter 14.) But on the whole, Medicare pays for a vast range of medical services that people need.

      

I’ve heard from people who’ve used a lot of services, or a few really expensive ones, and are scared to death that their Medicare coverage is going to “run out.” This isn’t something to worry about. In general, no limit caps the amount of coverage you can get from Medicare for necessary services — except for a few specific situations that I explore later in this chapter.

      Preventive care

      Being able to treat a medical problem is good, but dodging it altogether is better! These days, that seems an obvious truth. Yet Medicare has only fairly recently expanded coverage for services that help prevent or stave off some of the diseases that make people very ill and — not coincidentally — cost Medicare mountains of money. Even better: Many of these preventive tests, screenings, and counseling sessions now come free (no co-pays or deductibles) thanks to the 2010 Affordable Care Act. As of 2020, some 44 million people with Medicare took advantage of these services, at no cost to themselves, according to government reports.

      

But to get these services for free, you need to see a doctor who accepts assignment — meaning that she has agreed to accept the Medicare-approved amount as full payment for any service provided to a Medicare patient. (I go into detail about what Medicare doctors can charge in Chapter 13.) Otherwise, you have to pony up a co-pay or, in some circumstances, even the full cost.

Now take a look at Table 2-1, which shows the range of preventive tests, screenings, and counseling sessions that Medicare covers under Part B and whether they cost you anything. It’s a pretty impressive list!

TABLE 2-1 Preventive Care Services Medicare Covers

Service	Frequency Covered	Cost to You
“Welcome to Medicare” checkup	Once only, during first 12 months in Part B.	Free, but any other tests the doctor refers you for may require a co-pay.
Wellness checkup	Once every 12 months, after you’ve had Part B for one year.	Free as long as you ask for a wellness visit and not a “physical.”
Abdominal aortic aneurysm screening	One-time ultrasound for people at risk.	Free.
Alcohol misuse screening and counseling	One screening and up to four counseling sessions a year.	Free.
Bone mass measurements	Once a year if you’re at risk for broken bones; more if medically necessary.	Free.
Breast cancer screening (mammograms)	Once a year for women age 40 or older.	Free.
Cardiovascular disease (behavioral therapy)	Once a year.	Free.
Cardiovascular disease screening	Once every five years.	Free for the tests, but a co-pay is usually required for the doctor visit.
Cervical/vaginal cancer screening	Once every 24 months, or every 12 months if you’re at high risk.	Free.
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