Expert Health Articles

Medicare FAQs

Niki SidleNiki Sidle MSW, LISW-S

Bereavement Coordinator, Bridge Home Health & Hospice

Although it has been around for decades, changes to Medicare have made it difficult to keep up with the details. Is a nursing home stay covered? Are my prescriptions paid for? How do I know what I need? These are all questions that individuals face and struggle with, so hopefully a few of your questions will be answered here.

What is Medicare?

  • Medicare is the federal health insurance program for those aged 65, younger individuals with specific disabilities and people with end-stage renal disease. Individuals who qualify for Social Security are granted Part A at no cost.

Parts of Medicare

  • Part A – This is known as “Hospital Insurance” as it is used to pay for inpatient hospital stays, hospice care, some home health care and skilled nursing facility care. There is no charge for Part A insurance to the individual, but there is a standard insurance deductible that individuals are responsible for when obtaining hospital care.
  • Part B – This is more of what people refer to as “traditional” insurance which covers doctor appointments, medical supplies, and preventative services and screenings.
  • Part C – Part C of Medicare is actually comprised of Medicare Advantage Plans. These insurance plans are offered by private companies (like an HMO or PPO) which contract with Medicare to provide Parts A and B, and quite often Part D, benefits to subscribers within one plan/payment.
  • Part D – This is the section that covers prescriptions (to an extent) through Medicare. Many Medicare Advantage Plans provide prescription coverage in addition to the health benefits, which is why many individuals find them advantageous.

Medigap

  • This is what people often refer to as a “supplemental plan” to traditional Medicare as it pays for some (or most) of the out-of-pocket expenses such as the Part A deductible for hospitalization or physician appointment co-pays. Medigap can be obtained from private companies, similar to a Medicare Advantage Plan, versus through the federal government.

“What will pay for my nursing home stay?” is one of the common questions that medical social workers discuss with individuals.

Most people have heard of the “three-day-stay” that is required for Medicare to cover a nursing stay, but it is not simple as it sounds. Medicare Part A will cover the cost 100% for an individual who has had a qualifying hospitalization (three nights) and requires skilled nursing care for up to 20 days. Days 20 through 100 are covered after a percentage is paid out-of-pocket ($161 per day in 2016), and anything beyond day 100 is the sole responsibility of the individual. One of the benefits of a Medicare Advantage Plan is that select plans include skilled nursing facility coverage without the three-night requirement, but not all plans include this.

Social workers always recommend for individuals to read their policy documents, ask questions, and do research before making decisions. Visit www.medicare.gov to find health and drug plans, read about Medicare changes and learn the associated costs. Or in Ohio, you can call Ohio Senior Health Insurance Information Program (OSHIIP) for personal assistance at 1-800-686-1578.