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What Does Medicare Cover?

Medicare covers services such as lab tests, surgeries, and doctor visits, as well as supplies like wheelchairs and walkers that are considered to be medically necessary in order to treat a disease or a condition.

If you are enrolled in a Medicare Advantage Plan or other Medicare plan than Original Medicare (Medicare Parts A and B), then you may have different rules. However, your plan must provide you with at least the same coverage that you would have in Original Medicare.

Medicare coverage is based upon three primary factors. These include federal and state laws, national coverage decisions made by Medicare regarding whether something is covered, and local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

The Parts of Medicare an What They Cover

In general, Medicare Part A covers hospital care, skilled nursing facility care (provided that custodial care is not the only type of care that you require), hospice care, and some home health care services.

Medicare Part B covers two types of services. These include medically services, which include services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Part B also covers preventive services – health care to prevent illness – such as the flu – or to detect it at an early state, when treatment can be the most likely to work best.

Part B of Medicare will cover services such as:

  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs

Medicare Part C is also known as Medicare Advantage. This form of Medicare provides an alternate method of receiving your Medicare Part A and B coverage. Because Medicare Advantage plans are sold via private insurance carriers, the benefits that are offered can differ from one plan to another.

Plan D of Medicare provides prescription drug coverage. Each Medicare prescription drug plan has its own list of covered drugs, referred to as a formulary. Many of these plans place drugs into different “tiers” within their formularies. The drugs that are in each tier will have a different cost. For example, drugs that are in a lower tier will typically cost less than those that are in a higher tier. Because Medicare Part D plans are sold by private insurers, the costs of these plans, as well as the coverage, can differ from plan to plan.

How to Determine If Medicare Covers What You Need

There are two primary ways of finding out whether Medicare will cover what you need. One way to do so is to talk with your doctor or other health care provider about why you need certain services and / or supplies, and ask if Medicare will cover them.

You can also check on Medicare’s website to see if your test, item, or service is covered by visiting: https://www.medicare.gov/coverage/your-medicare-coverage.html and then typing in the name of the test, item, or service in question.

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