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What Clinical Costs Are Covered by Medicare?

October 6, 2016

Medicare may cover the cost of most clinical services and supplies necessary to treat a beneficiary’s disease, condition or injury. Your benefits and costs will depend on which parts of Medicare you’re enrolled in, whether you get your coverage through Original Medicare or a Medicare Advantage plan, and whether you have prescription drug or Medicare supplemental coverage.

Clinical costs covered by Medicare Part A

Medicare Part A (hospital insurance) covers medical treatment and services you receive as an inpatient.  In general, this includes:

  • Hospital care, including acute and long-term care hospitals
  • Medications administered during your inpatient stay
  • Skilled nursing facility (SNF) care (generally short-term and not custodial care)
  • Hospice care
  • Home health services (generally short-term)

Medicare Part A doesn’t cover clinical costs that aren’t medically necessary to treat your condition. Examples of costs that aren’t covered include a private hospital room, round-the-clock nursing, meal delivery, and non-skilled, personal care (such as help with getting dressed or bathed).

Clinical costs covered by Medicare Part B

Medicare Part B (medical insurance) covers many of your clinical costs as an outpatient. This includes:

  • Doctors’ services
  • Screenings and diagnostic tests
  • Preventive services, such as flu shots and screenings
  • Outpatient surgeries
  • Ambulance services
  • Mental health services
  • Durable medical equipment (DME)
  • Participation in Medicare- qualifying clinical research studies

Some services, such as flu shots, are provided under Medicare Part B at no cost to you.

Clinical costs covered by Medicare Advantage

If you receive your Part A and Part B  coverage through a Medicare Advantage plan, your clinical costs will depend on the benefits of the Medicare-approved private insurance company that offers the plan. All Medicare Advantage plans are required to provide at least the same amount of coverage as Original Medicare (except hospice care, which remains covered by Part A), so you will receive the same Part A and Part B benefits regardless of the insurer. However, many Medicare Advantage plans offer additional benefits not included in Original Medicare.

Under a Medicare Advantage plan, you may pay a separate plan premium, along with the Medicare Part B premium. Cost-sharing expenses like copayments, coinsurance, and deductibles will vary by plan. Examine the plan to find out more about specific benefits and what clinical costs you may have to pay.

Clinical costs covered by Medicare Part D

Medicare Part D is prescription drug coverage available from Medicare-approved private insurance companies through either a stand-alone Medicare  Part D Prescription Drug Pan (PDP) or a Medicare Advantage plan that includes drug coverage, a Medicare Advantage Prescription Drug plan (MA-PD).

The most significant factor affecting your Part D clinical costs will be whether your plan covers all of the medications you take and where those prescription drugs fall into the plan’s pricing structure. Most stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans place drugs into separate tiers, with each tier having different cost-sharing amounts. Higher-tier medications usually have higher copayment or coinsurance costs. Plans differ in the prescription drugs they include in their formulary, or list of covered medications, and how they assign covered medications’ out-of-pocket cost to members, so it’s always wise to research the plans available where you live in order to identify the one that best meets your prescription drug needs and your budget.

Clinical costs covered by Medicare Supplement plans

If you decide to stay with Original Medicare (Part A and Part B), another option you may have is to sign up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

Keep in mind that Medigap benefits can’t be used to pay for Medicare Advantage costs.

Coverage of your clinical costs under a Medicare Supplement plan will depend on which plan you enroll in. A Medicare Supplement plan can reduce your clinical costs by paying for Original Medicare cost-sharing expenses, which may include such expenses as:

  • Part A coinsurance and inpatient hospital expenses for up to one year after Medicare benefits have been exhausted
  • Part A hospice care coinsurance/copayment
  • Part A skilled nursing facility coinsurance
  • Part A deductible
  • Three pints of blood, if your hospital has to buy blood for you as an inpatient
  • Part B deductible
  • Part B coinsurance/copayment
  • Part B excess charges (what your provider charges above the Medicare-approved amount)
  • Overseas emergency health coverage

Please note: Not every Medicare Supplement plan covers every out-of-cost expense listed above. In 47 states there are 10 standardized Medicare Supplement plans, with different plans covering different portions of Medicare Part A and Part B out-of-pocket costs. Medigap plans are standardized differently in Massachusetts, Wisconsin, and Minnesota.

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