What is Part A Hospital & Part B MD Visits

How does it work, what is covered?

Medicare & You Booklet   Ambulance  Chiropractic 
Cancer     

Medicare Part A
(#Hospital Insurance)

Medicare Part A Hospital coverage helps pay for care in hospitals as an inpatient,... skilled nursing facilities, hospice care, and some home health care (see publication # 10969) but not Long Term Care.  

Most people get Part A automatically when they turn age 65 at no charge, since they or a spouse paid Medicare taxes while they were working.  You need to sign up close to your 65th birthday, even if you will not be retired by that time. (If you are getting Social Security benefits when you turn 65, your Medicare Hospital Benefits - Part A - start automatically.) 

Here's a chart it's just a illustration and is NOT official  that shows what Medicare pays, the gaps in Medicare and what you may get when you add a Medi Gap Plan or Medicare Advantage to cover those gaps.

Medi Gap what medicare pays

See 2022 Updates 

Medi Gap – Supplement Plans 

Part B (Medical #Insurance)

Part B - Outpatient helps Pay For Doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care see publication 10969, but not Long Term Care. Part B helps pay for these covered services and supplies when they are medically necessary.

The chart below is a very brief summary.  Check the actual Evidence of Coverage for the plan you want to enroll in, Medicare & You or actual Medicare documents.

Part B out of hospital

See 2022 Updates

Our Webpages with more detail:

Durable medical equipment (DME)

 

Medicare covers items like oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare for use in the home. Some items must be rented.  You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you have a Medi Gap plan, that should pay the 20%!   Medicare Advantage, check the summary of benefits or EOC Evidence of Coverage.

Make sure your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims they submit. It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment (that is, they’re limited to charging you only coinsurance and the Part B deductible for the Medicare-approved amount). If suppliers aren’t participating and don’t accept assignment, there’s no limit on the amount they can charge you.

To find suppliers who accept assignment, visit Medicare.gov/supplier directory or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. You can also call 1-800-MEDICARE if you’re having problems with your DME supplier, or you need to file a complaint. Copied from Medicare & You – see link in side panel

What about Stair Lifts?

 

Guide Dog or Other Service Animal

You can include in medical expenses [but apparently not as durable medical expense] the costs of buying, training, and maintaining a guide dog or other service animal to assist a visually impaired or hearing disabled person, or a person with other physical disabilities. In general, this includes any costs, such as food, grooming, and veterinary care, incurred in maintaining the health and vitality of the service animal so that it may perform its duties.  irs.gov/

Maybe you can get a grant?

us service animals.org/grants-resources/

disability-benefits-help.org/service-animals  

 

Resources & Links

Biden repeals Trump rule  that expedited coverage for “breakthrough technology”  Modern Health Care 9.13.2021 prior article * Federal Register 42 CFR Part 405 [CMS-3372-P2] RIN 0938-AT88

Wheelchair users can face hefty costs not covered by insurance, under age 65…  LA Times 11.15.2021

 

Medicare Coverage – #Ambulance # 11021

Medicare ambulance coverage

#Chiropractic coverage in Medicare

VIDEO explanation of this page

Here’s how Medicare A & B and the a Typical MAPD Plan. and Medi Gap would pay the 20% that Medicare allows, but leaves as a co payment.

Medicare Part B pays 80% for spinal manipulation  if medically necessary.   Thus, Medi Gap and Medicare Advantage only pay, if Medicare does.

Medicare doesn’t cover other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture. If you think your chiropractor is billing Medicare for chiropractic services that aren’t covered, you can report suspected Medicare fraud   Medicare.gov *

Medical Necessity get’s quite complicated.
Here’s more detailed definitions:

Here’s a Medicare Fact Sheet, something a little easier to read for the lay person.

medicare faact sheet chiropractic

For chiropractic services, medically necessary means the patient must have “a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct, therapeutic relationship to the patient’s condition and provide a reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine, as demonstrated by x-ray or physical exam.”

Treatment by means of manual manipulation of the spine to correct a subluxation  (incomplete or partial dislocation of a joint or organ.[1] Wikipedia )  (that is, by use of the hands).

Patient must require treatment by means of manual manipulation.
Manipulation services rendered must have direct therapeutic relationship to the patient’s condition.
There must be a reasonable expectation of recovery or improvement of function resulting from the planned treatment.    CMS.gov *

Medicare Exclusions from Coverage

Note that the specimen Medicare Advantage policy we used to analyze coverage has exclusions on page 115  for chiropractic, they only cover what Medicare covers, nothing extra!

For those of you who think that “Medicare for All” will be the solution to every health problem and that Medicare pays everything, take a look at this NINE page bulletin on the the Medicare records required from your chiropractor.

Medicare requirements to pay for chiropractic

Excerpts of Sample Medicare Advantage Plan

See above for Medicare definitions & requirements

medicare manual manipulation

Here’s an example where a Medicare Advantage plan is covering more than required

up to 24 visits non medicare covered

Sample Medi Gap EOC  Plan G

Medi Gap will provide coverage for the coinsurance amount or, in the case of hospital outpatient Services, the copayment amount of Medicare Eligible Expenses under Part B …, subject to the Medicare Part B Deductible provided the Subscriber is receiving concurrent benefits from Medicare for the same Services. Blue Shield EOC * 

Do #Health Care Reform compliant plans cover chiropractic?

 

No,  Chiropractic is Excluded on page 106 of the Specimen policy, Page 14 brochure   It’s not an essential benefit, in CA

Here’s the  CA Kaiser Benchmark Plan which is the “model” for ACA compliant plans

Other States may cover chiropractic, but CA doesn’t.  Here’s a report from dynamic chiropractic.com 

However,

Blue Shield INDIVIDUAL 

Chiropractor benefits available for Silver 1950 PPO and Silver 2600 HDHP PPO plans as of Jan 1, 2021

We are the first off-exchange health plan to offer embedded chiropractic services to members through the American Specialty Health (ASH) network with Silver 1950 PPO and Silver 2600 HDHP PPO plans.

Benefits include:

$15 copayments for Silver 1950 PPO
35% coinsurance for Silver 2600 HDHP PPO
Both plans have an annual limit of 15 visits

 

At one time you could Buy your OWN Chiropractic Plan!  

But Landmark Health Plan has discontinued selling for individuals.  Employer Groups can still enroll.

Provider Directory

#Hearing & balance exams & hearing aids

How often is it covered?

Medicare Part B (Medical Insurance) covers diagnostic hearing and balance exams if your doctor or other health care provider orders these tests to see if you need medical treatment.

Medicare doesn’t cover hearing exams, hearing aids, or exams for fitting hearing aids.

Who’s eligible?

All people with Part B are covered.

Your costs in Original Medicare

Medicare Advantage Plans might cover

header

Oscar Clinicial Guideline 

hearing care solutions.com/ 

 

Medi Gap – Supplement Plans

Health Savings Accounts HSA?

Cochlear Implants?

#Cochlear Implants

cochlear implant is a small electronic device that can help “make” sound if you have severe or total hearing loss. The implant does the job of the damaged or absent nerve cells that in a normal ear make it possible to hear (auditory nerves). Cochlear implants can be programmed according to your specific needs and degree of hearing loss. Web MD

Will an implant be covered on your Medical Insurance?

Aetna’s Bulletin on Cochlear Implants, includes billing codes.

NO MORE!   Pre-Existing Condition Clause

Is the implant Medically Necessary

Guaranteed Issue ACA/Obamacare for Individuals &  Employer Groups – AB 1672

 

Consumer Resources

cochlear.com

Cochlear Americas.com/

Insurance FAQ’s

hearing loss.org/

“Inventor?” William F House

#Physical therapy/occupational therapy/speech-language pathology services

 

Medicare Part B (Medical Insurance) helps pay for medically necessary, see clinical guidelines!, outpatient physical  medicare.gov/physical-therapy     Medicare Coverage Physical Therapy  #10988

and Occupational therapy

and.  Speech-language pathology services

  • Your medical record must include information to explain why the services are medically necessary

A Medicare contractor like Livanta  may review your medical records to be sure your therapy services were medically necessary. This happens when your bills go over say $2k  cms.gov/theraphy caps

Your therapist or therapy provider must give you a written notice before providing services that aren’t medically necessary. This includes therapy services that are generally covered but aren’t medically reasonable and necessary for you at the time. This notice is called an “Advance Beneficiary Notice of Noncoverage” (ABN). The ABN lets you choose whether or not you want the therapy services. If you choose to get the medically unnecessary services, you agree to pay for them.

Who’s eligible?

All people with Part B are covered as long as the services are medically reasonable and necessary.

Your costs in Original Medicare

You pay 20% of the Medicare-approved amount, and the Part B deductible applies.   If you have a Medi Gap or Medicare Advantage plan, those will pay all or part of the 20%.

 

Medicare Coverage Physical Therapy  #10988

medicare coverage physical theraphy

 

 

 

14 comments on “Coverage in Part A Hospital & B Doctor Visits? Part D Rx

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  1. If I stay overnight in a hospital, doesn’t that make me an inpatient, so that I can then qualify for Skilled Nursing care, etc?

    • Am I an inpatient or outpatient?

      Staying overnight in a hospital doesn’t always mean you’re an inpatient. Your doctor must order your hospital admission and the hospital must formally admit you for you to be inpatient. Without the formal inpatient admission, you’re still an outpatient, even if you stay overnight in a regular hospital bed, and/or you’re getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays. You or a family member should always ask the hospital and/or your doctor if you’re an inpatient or an outpatient each day during your stay, since it affects what you pay and can affect whether you’ll qualify for Part A coverage in a skilled nursing facility.

      A “Medicare Outpatient Observation Notice” (MOON) is a document that lets you know you’re an outpatient in a hospital or critical access hospital. You must receive this notice if you’re getting observation services as an outpatient for more than 24 hours. The MOON will tell you why you’re an outpatient receiving observation services, rather than an inpatient. It will also let you know how this may affect what you pay while in the hospital, and for care you get after leaving the hospital. Citation Medicare & You 10050 or Medicare Benefits 10116 See links above

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