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Guide to Medicare Benefits & Coverage - Parentgiving

Guide to Medicare Benefits

The Basics: What is Medicare?

Medicare was created in 1966 as a federal health insurance plan to cover the elderly population. Over the years it has grown into the second-largest social insurance plan, right behind Social Security. To put it into numbers, the total cost of Medicare in the fiscal year of 2020 was $776 billion. Spending surrounding Medicare has only increased, often accounting for 15% of all federal spending. If you are eligible for Medicare, make sure to get your cut of this huge government payout.

The benefits of Medicare are so expansive that many people plan their retirement for when they turn 65 and become eligible for the program. It should be noted that Medicare can also cover younger individuals if they have certain disabilities. However, Medicare is largely for the elderly with 54.5 million enrollees over the age of 65. In your later years, doctor visits tend to go up along with medical expenses. So, when you are retired and living on a fixed income, a federal benefit program like Medicare can be crucial to reduce the cost of health care.

Medicare Options

Medicare Coverage Plans

  • Medicare Part A

    Medicare Part A is designed to cover inpatient care in hospitals and skilled nursing facilities. Additionally, it can cover home health care, hospice care, and acute care. It is a hospital insurance policy that will cover your stay in a hospital or nursing facility.

    While this policy will cover your stay in these facilities, you should keep in mind that it does not cover custodial or long-term care. Some in-home health care and hospice services are covered depending on your eligibility. However, Medicare Part A should just be considered as an insurance policy that simply covers your stay. Meaning it does not cover the cost of treatments you receive while in the hospital. To look into the specifics of what Medicare Part A could cover from you, you will need to see what you are eligible for under federal law and if there are any additional benefits under state law.

    Most of those who are enrolled in Medicare Part A have already paid for this insurance plan with the payroll tax that was collected while working. They could have also paid for this coverage from a payroll tax paid by a spouse.

    Individuals become eligible for Medicare Part A if they are aged 65 years and older, or if they are diagnosed with 5th stage chronic kidney disease. If you are already receiving Social Security or Railroad Retirement Board benefits, you will automatically be enrolled in Medicare Part A without any premiums to pay.

  • Medicare Part B

    Medical insurance that covers things like doctor visits falls under Medicare Part B. Medicare Part B can be viewed as traditional medical insurance. With this increased coverage, you will have to pay a monthly premium. It will cover some doctor bills and outpatient costs but won’t cover the goods and services that come with it entirely. However, it will cover fully what Centers for Medicare Services (CMS) calls medically necessary services and preventative services.

    When Medicare Part B covers “medically necessary services” it covers all the supplies, tests, and other services that go into diagnosing and treating a medical condition. “Preventative services” are health care treatments that detect and treat medical conditions early on to prevent them from worsening.

    Medicare Part B can also cover ambulance services, clinical research, select outpatient prescription drugs, mental health services, and durable medical equipment.

    Your eligibility and options for Medicare Part B depends a lot on your eligibility for Medicare Part A. If you have Medicare Part A and do not have to pay a premium for it, you can also sign up for Part B if you apply during the designated enrollment periods. If you do pay a premium for Medicare Part A, then to access Part B you must be 65+ years old, a U.S. citizen, or a lawfully admitted alien residing in the U.S. for at least 5 years.

  • Medicare Part D

    This is a more expansive option of Medicare that is provided via private insurers. Those that enroll in Medicare Part D should expect to pay a monthly premium. In return, policyholders will have the prescription drugs they buy from their local pharmacy or online covered by this insurance plan.

    While the federal government does provide authority and oversight over Part D, coverage and payment will vary widely depending on the private insurer of your choice. Make sure to take your time in selecting your insurer as most states have over two dozen private coverage providers. Medicare Part D is available to anyone who is already a part of Original Medicare.

  • Medicare Part C: Medicare Advantage and Medigap

    Medicare Part C can come in two forms, Medicare Advantage and Medigap.

    Enrollment in Medicare Advantage is voluntary as it is a form of private insurance. Medicare Advantage plans are sold by private insurance companies that have contracts with the federal government. This plan provides the same coverage as Medicare A and B, but at a lower cost. This lower cost comes with additional rules. Such as limiting services to settings and differing coverage depending on the health of the member. While Medicare Advantage covers the same things as Plan A and B since it is provided by private insurers it can also provide additional benefits. While most Medicare Advantage plans cover prescription drugs, they can also bundle coverage for things like vision, hearing and dental. These areas of coverage go beyond the basic coverage found in Medicare A, B, and D. Be aware that you will have to deal with co-payments, deductibles and other out of pocket costs.

    Medigap is also called Medicare Supplemental coverage. This plan is crafted to fill in the gaps of Medicare A and B. While the federal government provides oversight over Medigap plans, they are still provided and sold by insurance companies. One thing the federal government does is require all private insurers to standardize their plans in a particular state, making it easy to compare costs. It should also be known that Medigap cannot be used if you are already a member of Medicare Advantage.

How to Enroll in Medicare

For some, enrolling in Medicare will be extremely easy. If you are currently over the age of 65 and receiving Social Security benefits, you will be automatically enrolled in Medicare Part A and B.

If there are other plans you wish to enroll in or you are not currently receiving Social Security benefits, there are other steps you can take. Just remember not to wait too long to sign up! To be safe, sign up within three months of your 65th birthday month to make sure you do not face additional costs.

One way to sign up is to apply online at the Social Security website. The process is quick and easy, the Social Security Administration claims that it only takes 10 minutes to fill out the information required. Another benefit of applying online is that it allows you to check back on the website to see if your status has been approved or pending. If using the internet is not the easiest for you or a loved one, you can also call toll free at 1-800-772-1213 from 7 AM to 7 PM Monday through Friday. Lastly, you can always go to your local Social Security office, but you must call ahead and make an appointment.

Does Medicare Cover my Senior Necessities?

For many of the items you need in your later years, Medicare is here to help. While your insurer may not cover the cost completely, every bit of help counts when you are living on a fixed income. Often, Medicare Part B will cover 80% of the cost of senior necessities if they qualify as durable medical equipment. However, each piece of medical equipment is different, and you must meet different conditions for each to qualify for coverage. This section of the article will help you understand what necessities are covered and what conditions you must meet to save money.

  • Adult Diapers

    All Medicare plans do not commonly cover adult diapers. But if you are using Medicare Advantage you may be able to choose a private insurer that covers over-the-counter supplies. Over-the-counter supplies would include adult diapers. If this is a necessity for you, check with private insurers to see if they provide it before enrolling with one through Medicare Advantage. If you are already enrolled in a Medicare Advantage plan, check with your coverage plan to see if over-the-counter supplies are included.

    If you are looking for quality adult diapers, you can examine our selection of over 75 different products at parentgiving.com. To make sure it is the right adult diaper for your needs, you can check the reviews members of our community have posted on specific products. One great brand we offer is Dry Direct Ultimate Underwear, with over 500 reviews and a 4.7/5-star rating.

  • Hospital Beds

    If you need a hospital bed, you’ll be glad to hear that the majority of the cost can be covered by Medicare Part B and Medicare Advantage plans.

    Before Medicare can cover the costs, there are some conditions that must be met. For one, you must have a well-documented medical condition that requires a home hospital bed. Your condition must also be attended to at least once every 6 months by a doctor. Further, you must have proof of a doctor’s order that you need a hospital bed for home use along with a description on how that aids your medical condition. Lastly, your doctor and the equipment provider you choose for your hospital bed must participate in Medicare.

    If you meet the above conditions, Medicare Part B will pay for 80 percent of the cost of a home hospital bed. This is because Medicare Part B covers all durable medical equipment, and hospital beds fall under this category.

    If you are enrolled in a Medicare Advantage or Medigap plan, it is possible that an even higher percentage of the hospital bed can be covered. It’s also possible for you to rent a hospital bed instead of purchasing it. The cost for this will still be covered by Medicare Part B and Medicare Advantage.

    Purchasing a hospital bed is an important decision that should be made with a high level of care. If you or your loved one is struggling with a medical condition that requires a hospital bed, you must ensure that is best fit for your needs and the most comfortable. It is the compassionate thing to do and the most medically sound. There is no point in getting a hospital bed for your home if it is uncomfortable for the user as this can exacerbate aches and inflammation and worsen certain conditions.

    If you want to be confident in your hospital bed selection, you can always search through parentgiving.com. We provide 20 different hospital bed brands and accessories. Such as the Delta Ultra-Light Full Electric Bed. This hospital bed functions phenomenally and can even fit into smaller rooms. If that doesn’t sound just right for you, we encourage you to browse our collection further.

  • Lift Chair

    Lift chairs are great assets for elderly individuals that struggle with stiff joints, muscle pain, or struggle with mobility issues like getting up from seated positions. They operate similarly to a typical recliner. However, they come with a motorized lift device. With this device, you can raise and lower your recliner chair with just the push of a button. It can also adjust the angle of the seat to help individuals get into a standing position by doing most of the work for them.

    If you need a lift chair and have Medicare Plan B, it can help deduct some of the costs. The lifting device qualifies as durable medical equipment under Medicare Plan B, so the policy will pay for that. But the rest of the chair cost, such as the fabric, cushions, and other accessories will not be covered by insurance.

    Medicare Part C, whether that is Medicare Advantage of Medigap, may cover more if not all of your lift chair. This will depend on the private insurer that is working through Medicare. So, if you need a lift chair, check with your insurance provider before you make a purchase.

    If you want your lift chair covered by Medicare, whether that is Part B or Part C, there are some requirements you must meet. First and foremost, you must obtain a prescription from your physician that states why a lift chair would be a medical necessity for you. After this, you can go through this form with your physician that must be submitted to your Medicare provider.

    If you know that a lift chair would help you greatly, but are unsure whether you qualify, here are the medical requirements. You must have severe arthritis in your hip or knee, or instead, have a severe neuromuscular disease. Also, your doctor must confirm that you cannot stand up from a regular chair on your own without help. Another requirement is that once you are in the standing position you can walk without help, excluding the use of a walker or cane. Lastly, you cannot qualify for a lift chair if you reside in hospice care or a skilled nursing facility. In those situations, the insurer assumes there are other people to assist you.

    Much like with hospital beds, lift chairs are considered durable medical equipment so Medicare Plan B will cover 80% of the motorized lifting device. With Medicare Plan C, a private insurance company may be able to provide you additional funds.

    To find the lift chair that will look great in your home and help increase the mobility of you or a loved one, examine our selection on parentgiving.com. Our Golden Technologies PR-510 Cloud Lift Chair might be just right for you. With a 5-star rating, one reviewer claimed, “this is the best recliner lift chair of all time”.

  • Mobility Scooters

    As you get older, doing daily tasks like going to the grocery store, visiting your neighbor, or just getting around the house get more difficult. Mobility issues should not limit what you can and can’t do in your later years of life. That’s why Medicare can cover most of the cost to get a mobility scooter.

    Coverage for a mobility scooter would fall under Medicare Part B, as this is considered durable medical equipment. Unlike other durable medical equipment where you have to fulfill various conditions in order to get coverage, just by being enrolled in Medicare B has you entitled to a motorized scooter.

    If your mobility scooter supplier accepts Medicare, you will only have to pay for 20% of the cost. For most durable medical equipment covered by Medicare Part B, the insurer pays for 80% of the product.

    If you are not enrolled in Medicare Part B, but are still in need of a mobility scooter, do not worry. There are affordable mobility scooters you can conveniently find online. Scooters can be found priced between $750-$2,000. Parentgiving.com provides a wide selection of scooters, with over 88 different products and brands. If you want a reliable scooter with great value, you could go with the Pride Mobility 3 Wheel Go-Go Elite Traveller. Priced reasonably at approximately $1,000, this scooter has been noted as easy to use for senior citizens by reviewers.

  • Wheelchairs

    If your walker or cane is no longer enough to get around due to mobility issues, it may be time to purchase a wheelchair. Wheelchairs can be a great asset to a senior citizen who is looking to experience life without having to be concerned about potentially falling, slipping, or stumbling. There are a variety of medical issues that can make walking just not a viable option for an individual’s later years, and you shouldn’t limit yourself.

    If you need a wheelchair, Medicare Part B will cover most of the cost. Like other durable medical equipment, you can expect Medicare to cover 80% of the upfront cost. However, there are conditions that you must meet to qualify for coverage.

    For one, you cannot only claim to be having mobility issues outside of your home. Requiring extra help to get around outside of the home is a totally legitimate reason to get a wheelchair. Yet, Medicare expects you to verify that you need a wheelchair due to mobility issues inside the home. So, you would need to confirm that you are having difficulty getting to the bathroom or kitchen safely, even when using the aid of things like walkers and canes. Medicare also mandates that your physician must write an order for a wheelchair which explains the medical condition that inhibits your mobility. Another requirement is that you are capable of safely operating a wheelchair. If operating a wheelchair is too difficult for you, you can alternatively explain to a Medicare representative that there is always someone at the home with you that can aid you in the use of the wheelchair. Lastly, for Medicare to cover the wheelchair, your physician and the medical equipment supplier you choose must be authorized Medicare providers.

    If you or your physician do not utilize Medicare Part B, or the wheelchair you want isn’t provided by a Medicare provider, you can check our listings at parentgiving.com. If you are still looking to exercise your legs but want to be able to utilize the comfort and safety of a wheelchair when you need it, you could look to purchase a Medline Excel Translator-Combo Rollator and Wheelchair. This highly rated wheelchair is great to give seniors options in how they get around. The Medline Excel Combo Rollator and Wheelchair can be used as a walker or wheelchair. If this does not sound like the right wheelchair for you, parentgiving.com provides 156 wheelchair models and wheelchair accessories. Shop with us today to make sure you get the right wheelchair for you or a loved one’s needs.

  • Walkers

    Walkers, like other mobility aids, qualify as durable medical equipment and therefore are covered by Medicare Part B. As with other products, you must meet various conditions and have a physician and medical equipment supplier that are authorized by Medicare.

    Like other mobility equipment, Medicare wants your care provider to verify that you have a medical condition that makes a walker necessary. So, the walker must be prescribed to you. Other than that, there are not any other major hoops to jump through to have your walker covered by Medicare. If you decide that you instead would need a rollator, the same rules apply.

    We at parentgiving.com supply approximately a hundred different walkers and walker related products. Make sure to browse our selection and read our product reviews to make sure that the walker you choose is correct for your specific needs.

Senior Care and Medicare Coverage

Since there are a variety of different senior care options, there are also a variety of different conditions and rules that Medicare has on the subject. Generally, enrollees in Medicare Part A and Part B will be covered for in-home care services as long as a doctor has confirmed that they are homebound. Nursing home care can also be covered by Medicare. Yet, Medicare coverage does not normally extend to assisted living communities. Choosing the correct senior care is important. Especially when you are on a tight budget to support a loved one or are financing it through a fixed income. The following section should help you understand the different options and the various levels of coverage you should expect to receive.

  • Nursing Homes

    Are nursing homes covered by Medicare? The answer is yes and no.

    Nursing homes are covered by Medicare if it is done in an approved facility and when it is medically necessary. Medically necessary means that the nursing home stay is intended to diagnose or treat an illness, disease, injury, or other medical condition.

    Nursing home care will not be covered if it is only for custodial care, meaning non-medical care. In simple terms, nursing home stays will not be covered by Medicare if this is the only type of care they require. As this is considered non-medical and only custodial.

  • In-Home Care

    Like nursing home care, in-home care also comes with different conditions in order to warrant Medicare coverage.

    Medicare only covers certain types of in-home care. For example, your in-home care must be part-time or intermittent. So, any skilled nursing care, home health aide services, or physical therapies will be covered by Medicare Part A and B. However, if you need full-time or long-term care at home, Medicare will not cover such services. Medicare also will not cover non-medical care such as meal deliveries. Certain non-medical care such as help with chores and activities of daily living can be covered if they are provided alongside care that is deemed medically necessary.

  • Residential Senior Care

    Assisted living communities and other forms of residential care are great for seniors. For many, it provides the sense of living independently while providing security and care when needed. Despite this, assisted living is not directly covered by any Medicare plans.

    If you are set on assisted living and still want some form of coverage, you could look into Programs of All-Inclusive Care for the Elderly (PACE). PACE is available to Medicare and Medicaid members in some U.S. locations. It should be noted that PACE still doesn’t directly cover residential senior care. Instead, it can cover some of the services provided to seniors in assisted living communities. These services do not include the major costs, such as the long-term boarding costs.

What Medicare Does Not Cover

Since it can be complicated to know what Medicare covers and under what conditions, it can be simplified by listing some of the things Medicare explicitly does not cover.

Original Medicare will not cover non-medical home care. This includes services like meal deliveries and homemaker services. Further, assistance with activities of daily living is also not covered. They are only covered if, as previously mentioned, they are provided alongside medically necessary services.

Medical services such as dental, ear, or eye care are also not covered unless you are using Medicare Advantage or Medigap. So, if you are a senior citizen who needs dentures, glasses prescribed, or new hearing aids, you may want to go beyond the traditional Medicare Plan A and B.

If you know you require these various services and require coverage for them, look into Medicare Plan C options. These will be private insurance companies that are authorized by the federal government. They can provide more expansive care options than both Medicare Plan A and B.

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- Written By

Thomas Anderson

Geriatric Care Manager
Thomas Anderson has over 15 years of experience providing care and support to elderly individuals. He specializes in helping seniors manage their medical needs and navigate the healthcare system. Thomas keenly understands how to help aging adults stay as independent as possible while ensuring they have access to the best available resources.