Medicare Covered Services Schedule

Medicare Covered Services Schedule

Medicare-covered services are in the main, not paid 100% by Medicare, although there are a number of exceptions. The following schedule of categories of benefits illustrates the gaps, and you are referred to Publication No. CMS-10050, “Medicare & You 2004”, for the full details of all

Each “benefit period” begins with the first day at the hospital or skilled nursing facility, and ends after the patient has been out of that facility for 60 consecutive days (including date of discharge).

**The exceptions are some hospital outpatient services and certain other outpatient services, for which the patient pays a fixed co-payment amount, which may vary, according to the service. Refer to Publication No. CMS-0218, “Your Guide to the Outpatient Prospective System” for details of the new payment procedure.

Year 2004

 

                                Medicare Benefits

 

Part A

 

Uncovered Gaps

 

Hospital

 

 

 

First 60 days in benefit period*:                     

 

$876

Next 30 days 61-90 (continuous confinement):

 

$219 each day

 

Days 91-150 charged against lifetime

aggregate reserve of 60 days:                                                       

       $438 each day

 

After Day 90, if lifetime reserve days have been used:

 

                   100%

 

 

Skilled Nursing Facility

 

 

 

First 20 days in full:

 

Nothing

 

Next 80 days (continuous confinement)

 

   $109.50 each day

 

 

 

 

Part B – Medical

 

 

 

Medicare pays 80% of approved charges

after a deductible of:

 

First $100 per
calendar year

 

Therefore, patient’s risk is:

 

 

**20% of approved amount


 

The above chart clearly indicates the potential financial liability for the Medicare Beneficiary who does not have Medigap, HMO, Medicaid or an Employer Health Supplement Plan. But the point I make goes far beyond finances. This individual may be intimidated by possible additional expenditures from going to a specialist, or seeking a second or third opinion. I dislike seeing any person caught in this trap, and will address the possibilities for avoiding this lack of supplementary coverage in the Medigap, HMO and Medicaid Pages.

An expense to be avoided is the penalty for late enrollment in Medicare Part B — 10% surcharge on the premium (currently $66.60, but paid by Medicaid for qualified low-income persons) for each year late. Over the years I have continuously seen such cases. You may initiate the application for Medicare Part A and Part B during a seven-month period beginning three months before the 65th birthday. I advise clients to file for Medicare benefits three months before age 65. If you do not enroll in Medicare Part B in the seven-month period, you will have to wait until the general enrollment period, January 1 through March 31, and the Part B coverage will become effective July 1. However, if you have group health insurance based on you own, or spouse’s current employment, you may delay Part B enrollment without having to pay higher premiums.

During the period of non-coverage for Part B services you will be billed “Actual Charge” by the health care provider and this may be more than the Medicare approved amount. People taking early Social Security will be automatically enrolled in Part A and Part B, and receive their Medicare cards about three months before their 65th birthday. They will have the opportunity to reject Part B. Don’t! Those who continue working after 65 and have employee health coverage need to decide, after close examination of the coverage, whether they wish to enroll in Part B Medicare; and they should refer to CMS Publication 02179 “Medicare and Other Health Benefits: Your Guide to Who Pays First” and the local Social Security office for full eligibility and enrollment rules. The disabled, kidney dialysis or kidney transplant patient, retired government employees without Social Security and spouses of Social Security-eligibles need to look to Social Security for guidance on relevant rules and regulations as well as to appropriate CMS reference material.

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