Created by FindLaw's team of legal writers and editors | Last reviewed June 18, 2019
You've probably heard of Medicare, which is the federal government's safety net health care program for older Americans. But what are the eligibility requirements for Medicare and what, exactly, does it cover? Answers to these and other frequently asked questions regarding Medicare are listed below.
What is Medicare and Who Qualifies?
Medicare is a health insurance program administered by the U.S. government. It provides coverage to people 65 years of age or older, people under 65 with certain disabilities, and people with end-stage renal disease. The plan is divided into different parts according to what's covered:
- Part A covers overnight hospital stays, including room, food, tests, and doctor's fees.
- Part B helps pay for some services and products not covered by Part A. These are typically outpatient costs.
- Part C plans give those eligible for Medicare the option of receiving their benefits via private health insurance plans.
- Part D covers certain prescription medicines.
Am I Eligible for Medicare Part A?
If you're 65 or older, you're eligible for Part A. Depending on you and your spouse's work records, this coverage is free for you. If you're not eligible for Medicare Part A, you can still enroll in it and receive the same coverage by paying a monthly premium, which is calculated according to the number of work credits you've accumulated.
If you don't enroll immediately when you turn 65, your premium increases by 10 percent each year after you turn 65. Note that if you want Part A's paid hospital insurance, you must also enroll in Medicare Part B and pay the premium for it.
What Does Medicare Part A Cover?
Medicare Part A covers the following:
- Overnight hospital stays, including room, tests, meals, general nursing, doctor's fees, and miscellaneous hospital services and supplies.
- Critical access hospital stays and mental health care.
- Reasonably necessary medical in-home services such as skilled nursing care, physical and occupational therapy, speech therapy, and medical social services.
- Home-use equipment such as wheelchairs, hospital beds, walkers, oxygen, and other certain medical supplies.
- Hospice, if you're terminally ill and have six months or less to live.
- Brief nursing home visits if you were previously required to stay at least three midnights in the hospital, your nursing home stay is due to something diagnosed during that previous stay, you have another issue requiring skilled nurses care, or your nursing home care is skilled care and not merely custodial, non-skilled, or long-term care.
Be advised that 100 days is the maximum length of nursing home stay that Medicare Part A will cover. Your first 20 days are paid in full, while the other 80 require a co-payment. Your maximum-days-covered clock for inpatient treatments (hospital and nursing home) is reset after 60 days of not using facility-based service coverage.
Am I Eligible for Medicare Part B?
You're eligible for Medicare Part B benefits if you're 65 or older and you're a U.S. citizen. You don't have to be eligible for Medicare Part A to be eligible for Medicare Part B.
What Does Medicare Part B Cover?
Not only is Medicare Part B easier to qualify for than Part A, but it also covers many things that Part A does not, including (but not limited to):
- Doctors care at a hospital, doctors office, or at home
- Laboratory tests (100%)
- Periodic exams such as mammograms, bone density tests, and pelvic exams for women
- Outpatient treatment, such as ER and clinic visits, X-rays, tests, and shots
- Medicines given while in the hospital or at your doctors office
- Medical equipment and supplies
- Some outpatient therapy
- Some counseling services
- Some preventive services
- Some Alzheimers-related care
- In-home (full coverage), part-time skilled nursing care, physical therapy, and speech therapy
How Much of My Bill will Medicare Part B Pay?
When added all together, Medicare really only ends up paying for about half of your total medical expenses. This is due to a few different factors:
- You'll likely have routine exams, medicines, glasses, hearing aids, dentistry, etc., that Medicare doesn't cover.
- Medicare decides on its own what the appropriate amounts, or approved charges are for each of your services.
- These approved charges are usually far less than what doctors are actually charging. Your health care providers can charge whatever they typically charge anyone else, and you are responsible for the difference.
- Although there are several services which are fully covered by Medicare Part B, it only pays about 80 percent of the approved charges of other services.
What is Medicare Advantage (Part C) Coverage and What Coes it Cover?
Medicare Part C is a private health insurance plan. Anyone who's eligible for Parts A and B are also eligible for Medicare Advantage. Beneficiaries pay monthly premiums and receive a more attractive plan than Plan A and Plan B, mainly because of the vast coverage of prescription drugs. Beneficiaries also pay a monthly premium to receive Medicare Part B coverage. The following is a list of benefits that various Plan C plans offer:
- Medically necessary services from any hospital or doctor in the country
- Prescription drugs
- Dental care
- Vision care
- Gym and health care memberships
Who's Eligible for Medicare Part D Coverage?
You're eligible for Medicare Part D coverage if you're:
- Eligible for Medicare Part A (even if you're not enrolled); or
- Enrolled in Medicare Part B.
Medicare Part D helps beneficiaries pay for prescription drugs. You don't have to enroll, unless you also receive Medicaid, in which case, the government enrolls you in Medicare Part D automatically.
How Much Does Medicare Part D cost?
Medicare Part D requires you to pay premiums, deductibles, and copayments, and also has a coverage gap during which you pay full price for all of your prescription costs. This gap begins once Medicare has paid a certain dollar amount of your prescriptions. Once you've paid an out-of-pocket required amount, the coverage gap ends and you're only responsible for the co-payments for the rest of that calendar year.
Part D plans pick and choose what types of drugs and brands they want to cover and can choose to deny coverage altogether. You should review the different Part D plans carefully to choose the one that is best fitted for your needs.
Can I Get Any of Medicare Part D's Costs Waived?
Maybe. If your income is below a certain amount, you may qualify for supplemental assistance from Social Security. In certain situations, your copayments may be significantly reduced or even waived. You may qualify for this copayment assistance if you:
- Are eligible for Medicaid;
- Have an income level that does not reach above 149 percent of the federal poverty level; or
- Live in a long-term nursing home, are enrolled in Medicaid, and are enrolled in Medicare Part D.
You also may qualify for assistance through pharmacies and drug companies if you:
- Take certain types of medications, like generic brands or
- Use a pharmacy that waives copayments for those under a certain income (ask your pharmacy if it participates in this program).
Where Can I Get Legal Help With My Medicare Concerns?
Ideally, you should be able to apply for Medicare coverage without any problems as long as you qualify for coverage. But if your situation is particuarly complicated or there's a dispute of some kind, you may need legal expertise. Contact a health care attorney near you if you need additional help.
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