Understanding Medicare Coverage

Medicare is a health insurance program maintained by the federal government for people age 65 or older and people with certain, qualifying disabilities. In order to be eligible for Medicare an individual must meet the requirements for disability or retirement payments under the Social Security or Railroad Retirement programs or be entitled to Social Security Disability Insurance — an individual may also purchase coverage through premium payments.

Securing and maintaining Medicare coverage can be an important component of long term planning. If you have questions or want to consult with us about how Medicare fits into your plans, we invite you to call today for a free initial telephone consultation. Mobile Legal Services works with individuals and families throughout Southeast Michigan. Our elder law attorneys meet clients in their homes, nursing homes, or other convenient locations — for no additional cost — in the Downriver Detroit area and all of Monroe County, Washtenaw County, Southern Macomb County, Oakland County, and Wayne County.

Medicare Parts A & B

Original Medicare has two parts:

  • Part A, which covers inpatient hospital services, a limited period of care in a skilled nursing facility, some part-time home health care, and 100% of qualified hospice care
  • Part B, which helps pay for doctor services, outpatient hospital services, and a variety of other medical services and supplies

Parts A and B have distinct eligibility requirements and appeals procedures — and they are administered differently.

Medicare Part C

If a Medicare recipient so chooses, they can elect to have their Medicare coverage through Medicare Part C, commonly known as Medicare Advantage, instead of Parts A and B. Medicare Advantage plans are privately run by Medicare and, by law, must at least be "equivalent" to original Part A and Part B coverage. However, because they are run privately, there can be significant variation among the various Medicare Advantage plans. Any given plan may cover less of one thing and more of another.

Additionally, with a Medicare Advantage plan, the insured cannot have a Medigap insurance policy. Medigap plans are private, supplemental insurance plans that cover additional health care costs that Medicare does not, such as co-payments, deductibles, and health care if you travel outside the United States.

Medicare Part D

Medicare Part D is the portion of Medicare that covers prescription drugs. Part D plans are also administered by private companies, and are purchased privately by the insured.

Each provider will have somewhat varying rules, but generally the insured individual will pay a monthly premium for prescription coverage and may also have an annual deductible around a few hundred dollars, if there is any deductible at all. Once the deductible is paid, the plan will then pay some, or all, of the drug costs. However, once the individual reaches $2,510 in total drug costs in one year, the plan D coverage stops paying for prescriptions.

The coverage does not start back up again until the insured reaches $4,050, leaving the individual to pay $1,540 out of pocket for prescriptions. Once the annual costs exceed $4,050, the individual pays just % of costs above $4,050 with Medicare picking up the other 9%. Certain Medigap plans can be used to cover the period of ineligibility for prescription drug coverage.

What Medicare Does Not Cover

While Medicare can be a very beneficial program, it does not cover everything, and things that aren’t covered need to be paid by the individual or through a supplemental insurance program.

Also, even if Medicare covers a service or item, the recipient generally still has to pay the deductible and copayment.

Here is a non-exhaustive list of some of the items and services that Medicare doesn't cover:

  • Long-term or nursing home care
  • Routine dental care and dentures
  • Eye examinations related to prescribing glasses
  • Elective surgery
  • Hearing aids and exams for fitting them
  • Most foot care

You can learn more at about what's not covered by Part A & Part B.

Contact Mobile Legal Services if you need further assistance understanding your Medicare options and how they fit into your long term plans.