What Medicare Covers: A Caregiver’s Guide
Estimated read time: ~9 minutes
Summary: If you’re a caregiver for someone over the age of 65, you will likely have many questions about Medicare. Whatever your role, you will need to be aware of the ways that health care and health insurance — including Medicare — can help meet their needs.
We will guide you through what you need to know about Medicare coverage so you can provide the best care for those under your care.
Step 1: Know what the various Medicare parts cover
Even if the person under your care isn’t yet enrolled in Medicare, learning about the four parts of Medicare can help you prepare. It will help you understand what comprehensive Medicare coverage is and the associated Medicare costs when the time comes for them to enroll.
Original Medicare covers:
Medicare Part A (Hospital insurance)
- Hospital care: Covers inpatient hospital stays, including semi-private rooms, meals, general nursing and other hospital services and supplies.
- Skilled Nursing Facility (SNF) care: Provides coverage for a semi-private room, meals, skilled nursing care, rehabilitation services and other medically necessary services and supplies in a Medicare-certified skilled nursing facility.
- Hospice care: Offers care for individuals with terminal illnesses, including pain relief, symptom management and support services for both the patient and their family.
- Home health services: Includes part-time or intermittent skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (DME) and other services.
- Limited coverage for blood: Covers the first three pints of blood per calendar year for blood transfusions, after which the beneficiary may need to pay for additional blood.
Medicare Part B (Medical insurance)
- Outpatient care: Covers most medically necessary services and supplies that are needed to diagnose or treat a medical condition, including doctor visits, lab tests, X-rays, outpatient surgeries and preventive services such as screenings and vaccinations.
- Medical equipment and supplies: Provides coverage for durable medical equipment (DME) such as wheelchairs, walkers, oxygen equipment and diabetic supplies deemed medically necessary.
- Ambulance services: Helps cover transportation to a hospital or skilled nursing facility when other transportation could endanger the patient’s health.
- Clinical research studies: Offers coverage for certain approved clinical research studies that meet Medicare’s criteria.
- Mental health services: Includes both inpatient and outpatient mental health services, such as individual and group therapy, psychiatric evaluation and partial hospitalization programs.
- Second opinions: Supports beneficiaries in obtaining a second opinion from a different healthcare provider before certain surgeries or medical procedures.
Original Medicare (Part A and Part B) pays for generally about 80% of health care expenses. Other parts of Medicare may help cover the remaining costs.
Other parts of Medicare
Medicare Part C (Medicare Advantage)
This is an alternative to Original Medicare (Medicare Parts A and B) and typically includes all the benefits of Part A and Part B.
This plan also often comes with additional benefits such as prescription drug coverage, vision, dental and wellness programs. Private insurance companies approved by Medicare typically offer Medicare Advantage plans.
Medicare Part D (Prescription drug coverage)
Prescription Drug Plans (PDP) provide coverage for outpatient prescription drugs. Like Medicare Advantage, private insurance companies typically offer separate Part D plans.
This coverage can be purchased as a standalone plan or is included as part of a Medicare Advantage plan.
Medicare Supplement Insurance
This plan is designed to pair with Original Medicare by helping to cover things that Medicare doesn’t, like copayments, coinsurance and deductibles.
If you need help deciding which Medicare solutions may be right the person under your care, visit Mutual of Omaha’s online Medicare Advice Center. It will guide you through a brief questionnaire to create a personalized recommendation.
Step 2: Review what Medicare does not cover
While Medicare provides coverage for many healthcare services, there are certain areas where it does not extend its benefits. You need to be aware of these and adequately plan for the healthcare needs of the person(s) under your care.
Here are some aspects of your healthcare that Original Medicare typically does not cover:
- Long-term care
- Dental care
- Vision care
- Hearing aids
- Cosmetic procedures
- Alternative therapies
- Prescription drugs
- Medical services outside the United States
Step 3: Understand Medicare guidelines
Medicare guidelines serve as the framework for determining coverage and eligibility for various healthcare services.
Caregivers need to have a solid understanding of Medicare guidelines to get the best out of their Medicare coverage.
Here are some key points to consider:
Eligibility criteria
Medicare is primarily available to individuals aged 65 and older, as well as certain younger individuals with disabilities or end-stage renal disease. Be sure to verify the eligibility status of the person under your care before enrolling in Medicare coverage.
Coverage determination
The Medicare coverage your loved one will get is determined by established guidelines set forth by the Centers for Medicare & Medicaid Services (CMS).
These guidelines outline the specific services and treatments that are covered under each part of Medicare, as well as any limitations or exclusions.
Enrollment periods
Understanding Medicare enrollment periods is crucial for ensuring timely access to coverage.
Initial Enrollment Periods, Special Enrollment Periods, and General Enrollment Periods each have distinct rules and deadlines that caregivers need to be aware of when enrolling or making changes to the coverage.
Coverage options
Medicare includes varying coverage options, including Original Medicare (Part A and Part B), Medicare Advantage (Part C) and Medicare prescription drug plan (Part D).
You can evaluate the available options to determine the best fit for your loved one’s healthcare needs and budget.
Appeals process
In cases where Medicare may deny coverage for a particular service or treatment, caregivers have the right to appeal the decision.
If you understand the appeals process and know how to process it effectively, it can help ensure that your loved ones receive the necessary care they deserve.
Medicare coverage for the people you love
As a caregiver, your understanding of Medicare coverage plays a vital role in ensuring the well-being of the individuals under your care.
By familiarizing yourself with the different parts of Medicare and being aware of what is covered and what is not, you equip yourself with the necessary tools to support those in your care.
At Mutual of Omaha, we are with you every step of the way. Use our Medicare Advice Center to help discover the right Medicare solution for your loved one.
Frequently asked questions about Medicare coverage
Q1: Is Medicare a 100% coverage solution?
No, Medicare does not cover 100% of all medical expenses. Original Medicare covers about 80% of health care services. So caregivers may need to explore additional insurance options like a Medicare Supplement insurance policy or a Medicare Advantage plan to pay the 20% that Medicare doesn’t pay. Enrollment requirements may vary, so consider working with an insurance agent to understand where you qualify.
Q2: What types of medical costs does Medicare not cover?
Original Medicare does not cover long-term care, routine dental and vision care, certain prescription drugs, elective cosmetic surgeries, overseas medical care and certain alternative therapies.
Q3: What does Medicare Part A cover?
Medicare Part A helps cover hospital care, skilled nursing facility care, hospice, home health services and some limited outpatient prescription drugs.
Q4: What does Medicare Part B cover?
Medicare Part B helps cover outpatient services, preventive care, mental health services, ambulance services and durable medical equipment.
Q5: Is Medicare Advantage a suitable option for additional coverage?
Yes, Medicare Advantage plans can be an alternative to Original Medicare, providing coverage for Part A and Part B services along with additional benefits like vision, dental and prescription drug coverage.
Q6: Does Medicare cover acupuncture and alternative therapies?
Generally, Medicare does not cover alternative therapies like acupuncture. Caregivers may need to explore alternative coverage options for these services.
Q7: Can I choose any doctor under Medicare?
While Original Medicare (Parts A and B) allows flexibility in choosing healthcare providers, Medicare Advantage and Medicare Supplement insurance plans may have a network of preferred providers. It’s essential to check the plan details for provider options.
Q8: How can caregivers ensure comprehensive coverage for their loved ones under the Medicare program?
Caregivers should understand the specific type of Medicare plan the person under their care has, be aware of what it covers and doesn’t cover, and explore additional coverage options for areas Original Medicare does not cover.
Q9: Can I change a Medicare plan during the year?
In most cases, you can only change a Medicare plan during the Annual Enrollment Period, which occurs from October 15 to December 7 each year. However, there are some special circumstances that may allow you to change the plan outside of this period. If your loved one elects to change their plan, be sure to review enrollment and underwriting requirements, as certain health conditions could impact enrollment.
Q10: How do I know if a specific service or treatment is covered by Medicare?
To find out if a specific service or treatment is covered by Medicare, you can contact Medicare directly or speak with your healthcare provider. They can help you understand what services are covered and any associated costs. You can also download the “What’s Covered” app provided by the Centers for Medicare and Medicaid to find out the services covered.
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