The Advocates For Seniors

 Dallas/Fort Worth Texas local Medicare Brokerage

What is Medicare?

Medicare is the United States federal health insurance program for people who are 65 or older. It is also available for certain people younger than 65 with disabilities or people with End-Stage Renal Disease.

There are several “parts” to Medicare that contain different coverage.

Medicare

Medicare Part A

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Most of the time Part A does not cost a dime.

Medicare Part A covers:

  • Inpatient hospital care: This includes all care you receive after being admitted into a hospital by a physician. Medicare covers up to 90 days of each benefit period in a general hospital. In addition, you receive 60 lifetime reserve days. It also covers up to 190 lifetime days in a Medicare-certified psychiatric hospital.
  • Skilled nursing facility care: Medicare covers your room, board, and certain services provided in a skilled nursing facility. This includes medications, tube feedings, and wound care. It covers up to 100 days for each benefit period. To qualify, you must have spent at least three consecutive days in the hospital within 30 days of admission to a skilled nursing facility and must have needed skilled nursing or therapy services.
  • Home health care: Though it is normally covered by Part B, Part A coverage will kick in if you have spent at least three consecutive days as a hospital inpatient within 14 days of receiving home care. Up to 100 days of daily care are covered or an unlimited amount of intermittent care.
  • Hospice care: Hospice care is covered for as long as your provider certifies it is necessary.

Medicare Part B​

Medicare Part B is outpatient medical coverage. Part B helps pay for medically necessary services performed on an outpatient basis that is needed to diagnose and treat a medical condition. Surgeries, lab work, and preventative services are all covered under Part B.

Medicare Part B covers:


  • Provider services: Services deemed medically necessary are covered under Part B.
  • Durable medical equipment: Equipment that serves a medical purpose, is able to withstand repeated use, and is appropriate for home use, is covered.
  • Home health services: If you are homebound and need skilled nursing or therapy care, you’re covered under Part B.
  • Ambulance services: Emergency transportation by ambulance. Limited coverage for non-emergency transportation is available in which there is no safe alternative as long as it is medically necessary.
  • Preventative services: Outpatient physical, speech, and occupational therapy services are covered as long as they are administered by a Medicare-certified therapist.
  • X-rays and lab tests: All doctor-ordered x-rays and lab tests are covered.
  • Chiropractic care: Only when medically necessary to fix subluxation of the spine.
  • Certain prescription drugs: Certain drugs such as immunosuppressants, select anti-cancer, select antiemetic, select dialysis, and other typical drugs administered by a physician.

Medicare Part C

Medicare Part C is also called Medicare Advantage (MA). It’s an alternative benefit form to Original Medicare. Medicare Advantage may include prescription drug coverage, along with other extra benefits. It is offered through private insurance companies, so you don’t enroll in it at the Social Security office or website.

Medicare Part C, also known as Medicare Advantage, is a private health plan provided by insurance companies contracted with the federal government.

You will still be enrolled in Original Medicare (Part A and B), however, Medicare Advantage plans may offer certain benefits that Original Medicare doesn’t cover, such as:

  • Dental coverage
  • Vision coverage
  • Caregiver Counseling and Training
  • Housekeeping
  • Prescription Drug Coverage

Medicare Part D

Medicare Part D is also known as prescription drug coverage. Part D coverage is available as a Stand-Alone Option (PDP) or as part of a Medicare Advantage plan (Part C). Part D plans are offered by private insurance companies contracted and approved by Medicare.

Part D is prescription drug coverage. This covers most outpatient prescription drugs.


Part D is offered through private insurance companies as either a stand-alone plan or as a set of benefits included with a Medicare Advantage Plan.


Each Part D plan has a list of covered drugs called a formulary. If the drug you need is not on the formulary, you are allowed to request an exception, payout of pocket, or file an appeal.


These formularies differ from plan to plan so be sure to request a copy. However, each plan must cover all drugs in the following categories:


  • HIV/AIDS treatment
  • Antidepressants
  • Antipsychotic medications
  • Anticonvulsive treatments for seizure disorders
  • Immunosuppressants
  • Anticancer drugs (unless they are being covered under Part B)
  • Most vaccines are also covered under Part D unless they are already covered under Part B.

Need help deciding your coverage?

Mike Capricciuolo an Advocate for Seniors for 20 years now is ready to answer questions about your Medicare or health insurance and put together a comprehensive plan to fit your needs.


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