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Medicare

What Traditional Fee-for-Service Medicare Pays

Medicare has separate methods of payment for Part A and Part B: Part A provides coverage based on benefit periods; Part B covers you on a calendar year basis.

Part A: Each category of service (see following table) has its own schedule of payments based on a benefit period. For example, the benefit period for hospitalization begins the first day you are admitted and ends after 60 consecutive days. If you are admitted from the hospital directly to a skilled nursing facility where you remain, the benefit period does not end until you've not received skilled care for 60 consecutive days. Each time a new benefit period begins, you are responsible for paying the deductible (see table below).

Part B: You have a deductible every calendar year ($185 in 2019 ($183 in 2018). After that, Medicare pays between 80 and 100% of the approved amount (see following table). Many doctors and other service providers accept what is known as "on assignment," meaning Medicare's approved schedule of charges is considered payment in full. Otherwise, you may have to pay for charges above what is approved by Medicare, although Medicare does limit how much a doctor can exceed its approved limits.

 

Medicare Part A: Hospital Insurance*

Services

Benefit

Medicare Pays

You Pay (2019 figures)

Hospitalization
Semi-private room, meals, general nursing, other hospital services and supplies.

First 60 days

100% of approved amount after you pay your portion.

$1,364 deductible for each benefit period.
Zero co-insurance for first 60 days

 

61st to 90th day

100% of approved amount after you pay your portion.

$341 per day

 

91st to 150th day (1)

100% of approved amount after you pay your portion.

$682 per day

 

Beyond 150 days

Nothing

All costs

Skilled Nursing Facility Care (2)
Semi-private room, meals, skilled nursing and rehabilitative services, other services and supplies (3)

First 20 days

100% of approved amount

Nothing

 

Additional 80 days

100% of approved amount after you pay your portion.

up to $170.50 per day

 

Beyond 100 days

Nothing

All costs

Home Health Care
Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, durable medical equipment and medical supplies and other services

No limit as long as you meet Medicare criteria

100% of approved amount; 80% of approved amount for durable medical equipment

Nothing for home health care services; 20% of approved amount for durable medical equipment

Hospice Care
Services for the terminally ill including drugs for symptom control and pain relief, medical and support services, and other services

Unlimited as long as doctor certifies need

All but limited costs for outpatient prescription drugs and inpatient respite care

Limited costs: A co-payment of up to $5 for outpatient prescription drugs and 5% of the approved amount for inpatient respite care

Blood

Unlimited

All but first 3 pints per calendar year

For first 3 pints (unless you or someone else donates blood to replace what you used)

 

*Source: U.S. Department of Health and Human Services.

  1. This 60-day reserve benefit can be used only once in a lifetime.
  2. To qualify, you must be admitted to a Medicare-approved facility generally within 30 days after being discharged from a hospital where your stay lasted at least 3 days.
  3. Neither Medicare nor private Medigap insurance will pay for most nursing home care.

 

 

Medicare Part B: Medical Insurance*

* Source: U.S. Department of Health and Human Services** A person pays for charges higher than the amount approved by Medicare unless the doctor or supplier agrees to accept Medicare's approved amount as the total charge for services rendered.*** In 2018, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits. 

Services

Benefit

Medicare Pays

You Pay (2019 figures)

Medical Expenses
Physician's services, outpatient medical and surgical services, physical and speech therapy, diagnostic services

All medically necessary doctor's services in and out of the hospital

80% of approved amount (after $185 deductible, paid once per calendar year. 

$185 deductible, paid once per calendar year, plus 20% of approved amount, and limited charges above approved amount.**

***

Clinical Laboratory Services
Blood tests, urinalysis, biopsies, etc.

All medically necessary services

Generally 100% of approved amount

Nothing for approved services

Home Health Care
Part-time or intermittent skilled nursing care, home health aide services, medical equipment and supplies and other services

No limit as long as you meet eligibility criteria

100% of approved amount; 80% of approved amount for durable medical equipment

Nothing for services; 20% of approved amount for durable medical equipment

Outpatient Hospital Treatment
Services for the diagnosis or treatment of illness or injury

Unlimited if medically necessary

Based on hospital cost

A coinsurance or co-payment amount which may vary according to the service. No copayment for a single service can be greater than the Part A hospital deductible.

Blood

Unlimited if medically necessary

80% of approved amount (after $185 deductible and starting with 4th pint)

First 3 pints plus 20% of approved amount for additional pints (after $185 deductible) or you pay nothing if you or someone else donates blood to replace what you used. Additionally there may also be a co-payment involved.

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