What Can I Claim From Medicare?

Medicare is a national health insurance program designed mainly for people aged 65 years or older. When it was created as part of the Social Security Act of 1964, Medicare had only two parts, named A and B. In the years since, two more have been added, dubbed C, or Medicare Advantage, and D. Each has its own set of benefits, although some overlap. Exactly what services beneficiaries can claim from Medicare depends on which parts of the program they are enrolled in.

Part A

• Part A, along with Part B, makes up what is often referred to as Original Medicare. Users can choose not to enroll in either part if they desire, however. Part A is often premium-free if an individual or his spouse has paid at least 10 years of Medicare taxes. If not, seniors can still enroll if they meet a monthly premium. Benefits Part A users can claim include inpatient hospital services, home health and hospice. Part A will also cover noncustodial inpatient stays in a skilled nursing facility or rehabilitation hospital. All of these services must meet certain conditions, however. Stays in a skilled nursing facility must come after a qualifying three-night stay as a hospital inpatient. A person must be in the last six months of a terminal illness to claim the hospice benefit, or be considered home bound to claim the home health benefit.

Part B

• Part B Medicare mainly covers outpatient medical services and preventive services. Many preventive screenings are free, although a patient may pay the hospital or doctor for performing them. Other services, such as ambulance transportation and physical therapy, are only covered if they are determined to be medically necessary. Part B users also can claim a one-time "Welcome to Medicare" physical exam and a yearly wellness exam.

Medicare Advantage (Part C)

• Medicare Part C, Medicare Advantage, allows beneficiaries to buy their Original Medicare benefits from private insurance companies instead of the government. Medicare Advantage plans must offer all the same benefits as both Part A and Part B, with the exception of hospice care, which is always covered by the government. Beneficiaries can claim the inpatient and outpatient care, preventive services and physical exams with Medicare Advantage the same as with Original Medicare. Some Medicare Advantage plans offer extra benefits not part of Original Medicare, such as prescription drug coverage, vision, dental and hearing. If an individual's MA plan has these, he can claim them as well, according to the rules and restrictions of his particular policy.

Part D

• Part D Medicare has benefits only for prescription drugs. Part D also is sold by private companies rather than the government and is included in some Medicare Advantage policies. Customers can claim only the kinds of drugs offered through their plans. Some Part D plans have benefits only for generic drugs, while others cover both generic and name brands. Part D plans also may only cover some prescriptions, or must be filled at a particular pharmacy. Part D also features the "doughnut hole", wherein insurance benefits stops once the retail costs of all prescriptions reaches an initial coverage limit. Benefits do not resume until retail costs reach the catastrophic limit, although customers must continue to pay monthly premiums to keep their plans. Reforms aimed at closing the hole began in 2011, but until 2020, seniors with Part D cannot claim prescription drugs coverage while in the hole. They do, however, receive a 50 percent discount on name-brand drugs and a 7 percent discount on generics.