Your Medicare Coverage Options

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An Overview of Medicare Coverage

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If you are a U.S. citizen and age 65 or more, you will likely qualify for Medicare coverage. If you are younger but have a qualifying disability, you will also be eligible.

You may qualify for Medicare if you have never worked. If you have never worked, you may still qualify for premium-free Medicare Part A. This is based on your spouse’s work history or if you have certain medical conditions or disabilities. It is also possible to get Medicare if you pay a monthly Part A premium.

Now that we’ve explained basic eligibility, let’s explore the coverage details of Medicare, including its various parts and how they work together to form the benefits under Medicare.


Understanding Coverage Limits and Exclusions

What does Medicare cover? A lot, but not everything. Depending on what plans you select, this will vary.

Original Medicare (Parts A & B) helps cover many medical and hospital services. Some things that are not covered:

  • Long-term care.
  • Most dental care.
  • Eye exams for prescription glasses.
  • Dentures.
  • Massage therapy.
  • Hearing
  • Cosmetic surgery.
  • Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care).
  • Covered items or services that you get from an opt-out doctor or other provider (except in the case of an emergency or urgent need).

Most prescription drugs administered by your provider or at a dialysis facility are covered by Part B. Part B also helps cover some outpatient prescription drugs that must be administered in clinic, mainly certain oral cancer drugs.

Medicare Part D is specifically drug prescription coverage. Each Part D plan varies in coverage and costs.

Some inpatient mental health services are covered under Part A and under Part B. It helps cover outpatient mental health services, including evaluation and visits with a mental health provider. The coverage and cost-sharing are usually the same as other inpatient hospital stays. 

Many preventative services are covered by Medicare Part B. You can get yearly  visits and many other preventative services like colorectal screenings and mammograms.


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How to Choose the Right Medicare Coverage For You

Medicare comprises four separate parts that can be combined to provide the best health coverage for you.

  • Medicare Part A Helps cover hospital inpatient costs, skilled nursing care, qualified home care, and hospice care.
  • Medicare Part B Helps cover doctors’ visits, outpatient care, preventative care, diagnostics, tests, and exams.
  • Medicare Advantage (or Part C) replaces Parts A and B and often helps pay for additional services covered by Medicare such as some dental procedures.
  • Medicare Part D is a prescription drug program that helps pay for your doctor-prescribed medicine. You can also have Part D included with your Medicare Advantage plan.

After getting to know the basics of Medicare’s various parts and plans, you’ll want to next consider your healthcare needs — both present needs and future needs. Do you visit the doctor often? Do you have a chronic condition? How many prescription drugs do you take? Do you require frequent hospitalization? Answering these questions can help you determine whether Original Medicare (Part A and B) or Medicare Advantage (Part C) would be more beneficial for you.

If you have preferred doctors or hospitals, you’ll want to make sure they’re in the network of the Medicare Advantage plan you’re considering. Another thing to keep in mind is your prescription drug needs — this can add up to a high out-of-pocket cost for some people unless they enroll in a Part D or Medicare Advantage plan that offers coverage.

Also consider the costs, not just the monthly premium, to make sure what you’re choosing will provide you the best healthcare that suits your needs and fits your budget.

Given the complexity of Medicare, consulting a professional might be beneficial, especially during enrollment periods that offer just a brief opportunity to make changes and consider alternate options for Medicare coverage.

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Making the Most of Your Medicare Coverage

Medicare is a valuable resource for millions of Americans, but understanding how to maximize its benefits is crucial. Here’s a guide on how you can make the most of your Medicare coverage.

Medicare consists of several different parts, each offering unique types of coverage.

  • Medicare Part A Helps cover hospital stays, skilled nursing facility care, home health care, and hospice care.
  • Medicare Part B Helps cover doctor’s services, outpatient care, preventive services, and medical equipment.
  • Medicare Part C, also known as Medicare Advantage, combines Part A and Part B and often includes Part D. These plans are offered by private insurance companies approved by Medicare and may offer additional benefits.
  • Medicare Part D provides prescription drug coverage.

It’s essential to understand what each part helps cover to utilize your plan fully.

Medicare helps cover a broad range of preventive services to help you maintain your health and to keep certain illnesses from getting worse. These services include flu shots, screenings for cancer, diabetes, and heart disease and more. Taking full advantage of these services can help prevent health issues before they start.

Each year, you’re eligible for a wellness visit to review your health with your doctor. This visit is an opportunity to create or update your personalized prevention plan and potentially detect health problems early when treatment works best. This benefit is covered under Medicare Part B, and you pay nothing if your doctor accepts the assignment.

If you have a Medicare Advantage plan (Part C), you may have access to additional benefits not covered by Original Medicare. These benefits could include vision, hearing, dental or fitness. Familiarize yourself with these extra benefits and take advantage if you need these services.

Medicare Part D can help cover the costs of your prescription medications. Be sure to review your list of medications before enrolling as certain plans cover different drugs. Also, check if your plan offers mail-order pharmacy benefits — it could potentially save you trips to the pharmacy and money.

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Review all your medical bills and the Medicare Summary Notice (MSN) you get in the mail quarterly to ensure that Medicare is correctly paying your healthcare providers and that you’re not paying more than you should. If you spot any discrepancies or don’t understand the charges, don’t hesitate to contact Medicare or your plan provider.

If you have Original Medicare, you might want to consider purchasing a Medigap policy. Medigap is supplemental insurance sold by private companies to help cover out-of-pocket expenses for Medicare-approved services not covered by Original Medicare, like deductibles, copayments, and coinsurance.

Finally, don’t be afraid to ask questions. Medicare can be complex, and understanding all its facets is key to utilizing it fully. Health Plus Life can enroll you in a Medicare Advantage plan from a trusted carrier with one monthly premium (besides your Part B premium)

Remember, the goal is to get the healthcare you need at the best possible cost. The more you know about your Medicare coverage, the better prepared you’ll be to make decisions that benefit your health and your wallet.