There are 2 ways to find out if Medicare covers what you need
- Talk to your doctor or other health care provider about why you need certain services or supplies and ask if Medicare will cover them. You may need something that’s usually covered but your provider thinks that Medicare won’t cover it in your situation. If so, you’ll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
- Find out if Medicare covers your item, service, or supply.
Medicare coverage is based on 3 main factors
- Federal and state laws.
- National coverage decisions made by Medicare about whether something is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
In general, Part A covers:
- Hospital care
- Skilled nursing facility care
- Nursing home care (as long as custodial care isn’t the only care you need)
- Home health services
Part B covers 2 types of services
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.
Part B covers things like:
- Clinical research
- Ambulance services
- Durable medical equipment
- Mental health
- Partial hospitalization
- Getting a second opinion before surgery
- Limited outpatient prescription drugs
How to get drug coverage
Choose from 2 ways to get prescription drug coverage. You can choose a Medicare Part D plan. Or, you can choose a Medicare Advantage Plan (like an HMO or PPO) that offers drug coverage.
What drug plans cover
Each Medicare drug plan has its own list of covered drugs. Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost.
A drug in a lower tier will generally cost you less than a drug in a higher tier. Your prescriber may think you need a drug that’s on a higher tier. If so, you or your prescriber can sometimes ask your plan for an exception to get a lower copayment.
A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:
- Provide written notice to you at least 60 days prior to the date the change becomes effective.
- At the time you request a refill, provide both of these:
- A written notice of the change
- A 60-day supply of the drug under the same plan rules as before the change
Your actual drug plan costs will vary depending on:
- The drugs you use
- The plan you choose
- Whether you go to a pharmacy in your plan’s network
- Whether the drugs you use are on your plan’s formulary
- Whether you get Extra Help paying your Medicare Part D costs
Joining a health or drug plan
Find out when you can sign up for or change your Medicare coverage. This includes your Medicare Advantage Plan (Part C) or Medicare Prescription Drug Coverage (Part D).
How Part D works with other insurance
Call G2 Insurance to learn about how Medicare Part D (prescription drug coverage) works with other coverage, like employer or union health coverage.