Editing Medicare (United States) (section)

==Benefits and parts==
{{multiple image
| align = right| direction = vertical| header = Medicare cards
| image1 = Medical Care Card USA Sample.JPG
| caption1 = A sample of the Medicare card format used through 2018. The ID number is the subscriber's [[Social Security number]], followed by a suffix indicating the holder's relationship to the subscriber (generally "A" for self).<ref name="numbers">{{cite web |title=Medicare Numbers Suffixes and Prefixes |url=https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?centerWidth=100%25&contentId=00101347&leftWidth=0%25&rightWidth=0%25&showFooter=false&showHeader=false&_adf.ctrl-state=mshv04j9_4&_afrLoop=681522025461411#! |website=Novitas-solutions.com |access-date=December 5, 2018}}</ref>{{paragraph}} There are separate lines for basic Part A and Part B's supplementary medical coverage, each with its own start date.
| image2 = New US Medicare Card Sample 2018.jpg
| caption2 = A sample of the new Medicare cards mailed out in 2018 and 2019 depending on state of residence on a Social Security database. The new ID number is randomly generated and not tied to any personally identifying information.<ref name="numbers"/>{{paragraph}} Beneficiaries on Medicare Part C health plans are issued with a separate card and ID number, in addition to their Original Medicare card.
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Medicare has four parts: Part A, B, C, & D. Coverage under the first two (Parts A and B), as opposed to Part C plans, is referred to as '''Original Medicare'''.<ref>{{Cite web |title=Your Medicare Coverage Choices |url=https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices |access-date=2024-05-17 |website=Medicare.gov |language=en}}</ref>

In April 2018, CMS began mailing out new Medicare cards with new ID numbers to all beneficiaries.<ref>{{cite web |title=New Medicare Card Mailing Strategy |url=https://www.cms.gov/Medicare/New-Medicare-Card/NMC-Mailing-Strategy.pdf |website=Cms.gov |publisher=[[Centers for Medicare and Medicaid Services]] |access-date=December 5, 2018}}</ref> Previous cards had ID numbers containing beneficiaries' [[Social Security number]]s; the new ID numbers are randomly generated and not tied to any other [[personally identifying information]].<ref>{{cite report |publisher=Center for Medicare and Medicaid Services |title=New Medicare Card Project Frequently Asked Questions (FAQs) |date=May 2, 2018 |url=https://www.cms.gov/Medicare/New-Medicare-Card/NMC-FAQs-5-18.pdf }}</ref><ref>{{cite web|url=http://www.aarp.org/health/medicare-insurance/info-2018/new-medicare-card-not-received.html|title=Still Haven't Received a New Medicare Card? Call the Hotline|last=Bunis|first=Dena|date=June 27, 2018|publisher=[[AARP]]|language=en|access-date=December 5, 2018}}</ref>

{{anchor|PartA|Part A}}

===Part A: Hospital/hospice insurance===
Part A covers [[Inpatient care|inpatient]] [[hospital]] stays. The maximum length of stay that Medicare Part A covers in a hospital admitted inpatient stay or series of stays is typically 90 days. The first 60 days would be paid by Medicare in full, except one copay (also and more commonly referred to as a "deductible") at the beginning of the 60 days of $1632 as of 2024.<ref name=":1">{{Cite web |title=2024 Medicare Parts A & B Premiums and Deductibles {{!}} CMS |url=https://www.cms.gov/newsroom/fact-sheets/2024-medicare-parts-b-premiums-and-deductibles |access-date=2024-08-15 |website=www.cms.gov}}</ref> Days 61–90 require a co-payment of $408 per day as of 2024.<ref name=":1" /> The beneficiary is also allocated "lifetime reserve days" that can be used after 90 days. These lifetime reserve days require a copayment of $816 per day as of 2024, and the beneficiary can use a total of only 60 of these days throughout their lifetime.<ref name="medicare-costs-2023-2024">{{cite web |title=Costs Medicare |url=https://www.medicare.gov/basics/costs/medicare-costs |website=www.medicare.gov |publisher=Medicare |access-date=16 December 2023}}</ref> A new pool of 90 hospital days, with new copays of $1632 in 2024 and $408 per day for days 61–90, starts only after the beneficiary has 60 days continuously with no payment from Medicare for hospital or Skilled Nursing Facility confinement.<ref>{{cite web|url=http://www.medicare.gov/glossary/b.html|title=Benefit period|publisher=Medicare|access-date=April 26, 2018|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310222928/https://www.medicare.gov/glossary/b.html|url-status=dead}}</ref>

Some "hospital services" are provided as inpatient services, which would be reimbursed under Part A; or as outpatient services, which would be reimbursed, not under Part A, but under Part B instead. The "Two-Midnight Rule" decides which is which. In August 2013, the [[Centers for Medicare and Medicaid Services]] announced a final rule concerning eligibility for hospital inpatient services effective October 1, 2013. Under the new rule, if a physician admits a Medicare beneficiary as an inpatient with an expectation that the patient will require hospital care that "crosses two midnights", Medicare Part A payment is "generally appropriate". However, if it is anticipated that the patient will require hospital care for less than two midnights, Medicare Part A payment is generally not appropriate; payment such as is approved will be paid under Part B.<ref>{{cite journal |last=Hord|first=Emily M.|publisher=McBrayer, McGinnis, Leslie & Kirkland|title=Clarifying the 'Two-Midnight Rule' and Part A Payments Re: Inpatient Care|journal=The National Law Review|volume=III|issue=253|date=September 10, 2013|url=http://www.natlawreview.com/article/clarifying-two-midnight-rule-and-part-payments-re-inpatient-care|access-date=June 29, 2022}}</ref> The time a patient spends in the hospital before an inpatient admission is formally ordered is considered outpatient time. But, hospitals and physicians can take into consideration the pre-inpatient admission time when determining if a patient's care will reasonably be expected to cross two midnights to be covered under Part A.<ref>{{cite journal|last=Hord|first=Emily M.|title=Clarifying the "Two-Midnight Rule" and Part A Payments, cont.|journal=The National Law Review|date=September 12, 2013|url=http://www.natlawreview.com/article/clarifying-two-midnight-rule-and-part-payments-cont}}</ref> In addition to deciding which trust fund is used to pay for these various outpatient versus inpatient charges, the number of days for which a person is formally considered an admitted patient affects eligibility for Part A skilled nursing services.

Medicare penalizes hospitals for [[Hospital Readmission|readmissions]]. After making initial payments for hospital stays, Medicare will take back from the hospital these payments, plus a penalty of 4 to 18 times the initial payment, if an above-average number of patients from the hospital are readmitted within 30 days. These readmission penalties apply after some of the most common treatments: [[pneumonia]], [[heart failure]], [[heart attack]], [[COPD]], [[knee replacement]], and [[hip replacement]].<ref>{{cite web|url=http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html |title=Readmissions Reduction Program, seen June 25, 2013 |website=Cms.gov |access-date=August 30, 2013}}</ref><ref>{{cite web|url=http://www.kaiserhealthnews.org/stories/2013/march/14/revised-readmissions-statistics-hospitals-medicare.aspx |title=Kaiser health News, Medicare Revises Readmissions Penalties – Again |website=Kaiserhealthnews.org |date=March 14, 2013 |access-date=August 30, 2013}}</ref> A study of 18 states conducted by the [[Agency for Healthcare Research and Quality]] (AHRQ) found that 1.8 million Medicare patients aged 65 and older were readmitted within 30 days of an initial hospital stay in 2011; the conditions with the highest readmission rates were congestive heart failure, [[sepsis]], pneumonia, and COPD and [[bronchiectasis]].<ref>{{cite journal | vauthors = Hines AL, Barrett ML, Jiang HJ, Steiner CA | title = Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011. | journal =HCUP Statistical Brief |issue=172 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = April 2014 | pmid = 24901179 | url = http://hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.jsp | access-date = May 21, 2014 | archive-date = March 4, 2016 | archive-url = https://web.archive.org/web/20160304052719/http://hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.jsp | url-status = dead }}</ref>

The highest penalties on hospitals are charged after knee or hip replacements, $265,000 per excess readmission.<ref>{{cite web|url=http://ehrintelligence.com/2013/08/15/knee-and-hip-replacement-readmissions-may-cost-265000/|title=Knee and hip replacement readmissions may cost $265,000 |publisher=EHR Intelligence |access-date=August 24, 2013|date=August 15, 2013 }}</ref> The goals are to encourage better post-hospital care and more referrals to hospice and end-of-life care in lieu of treatment,<ref>{{cite web|url=http://www.medpac.gov/documents/Mar12_EntireReport.pdf |title=Report to Congress, Medicare Payment Policy. March 2012, pp. 195–96 |publisher=MedPAC |access-date=August 24, 2013 |url-status=dead |archive-url=https://web.archive.org/web/20131019105819/http://www.medpac.gov/documents/Mar12_EntireReport.pdf |archive-date=October 19, 2013 }}</ref><ref>{{cite web|url=http://www.fha.org/showDocument.aspx?f=FHA5YearsOnlineversion.pdf|title=Five Years of Quality, p. 8|publisher=Florida Hospital Association|access-date=August 24, 2013|archive-date=February 27, 2021|archive-url=https://web.archive.org/web/20210227015108/http://www.fha.org/showDocument.aspx?f=FHA5YearsOnlineversion.pdf|url-status=dead}}</ref> while the effect is also to reduce coverage in hospitals that treat poor and frail patients.<ref>{{Cite journal | doi=10.1056/NEJMp1201598 | title=Thirty-Day Readmissions – Truth and Consequences | year=2012 | last1=Joynt | first1=Karen E. | last2=Jha | first2=Ashish K. | journal=New England Journal of Medicine | volume=366 | issue=15 | pages=1366–69 | pmid=22455752}}</ref><ref>{{cite journal|title=Thirty-day readmissions—truth and consequences|pmid=22455752|year=2012|last1=Joynt|first1=KE|last2=Jha|first2=AK|volume=366|issue=15|pages=1366–9|doi=10.1056/NEJMp1201598|journal=The New England Journal of Medicine}}</ref> The total penalties for above-average readmissions in 2013 are $280 million,<ref>{{cite web|url=https://www.federalregister.gov/articles/2012/08/31/2012-19079/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the#h-22 |title=Summary of Costs and Benefits |website=Federalregister.gov |date=August 31, 2012 |access-date=August 30, 2013}}</ref> for 7,000 excess readmissions, or $40,000 for each readmission above the US average rate.<ref>{{cite web |url=http://globe1234.com |archive-url=https://archive.today/20130624212152/http://globe1234.com/ |url-status=dead |archive-date=June 24, 2013 |title=Math Underlying the Penalties |website=Globe1234.com |date=July 18, 2013 |access-date=August 30, 2013 }}</ref>

Part A fully covers brief stays for rehabilitation or convalescence in a [[skilled nursing facility]] and up to 100 days per medical necessity with a co-pay if certain criteria are met:<ref name="medicare-costs-2023-2024"/><ref name="Kodjak">{{cite news |last1=Kodjak |first1=Alison |author-link1=Alison Kodjak |title=How Medicare's Conflicting Hospitalization Rules Cost Me Thousands Of Dollars |url=https://www.npr.org/sections/health-shots/2018/04/20/583338114/how-medicares-conflicting-hospitalization-rules-cost-me-thousands-of-dollars |access-date=2019-01-01 |publisher=NPR |date=2018-04-20}}</ref>

# A preceding hospital stay must be at least three days as an inpatient, three midnights, not counting the discharge date.
# The skilled nursing facility stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay.
# If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision (e.g., wound management) then the nursing home stay would be covered.
# The care being rendered by the nursing home must be skilled. Medicare part A does not pay for stays that ''only'' provide custodial, non-skilled, or [[long-term care]] activities, including [[activities of daily living]] (ADL) such as personal hygiene, cooking, cleaning, etc.
# The care must be medically necessary and progress against some set plan must be made on some schedule determined by a doctor.

The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment of $204 per day as of 2024.<ref name="medicare-costs-2023-2024" /> Many [[insurance]] group retiree, Medigap and Part C insurance plans have a provision for additional coverage of skilled nursing care in the indemnity insurance policies they sell or health plans they sponsor. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 90-day hospital clock and 100-day nursing home clock are reset and the person qualifies for new benefit periods.

[[Hospice]] benefits are also provided under Part A of Medicare for terminally ill persons with less than six months to live, as determined by the patient's physician. The terminally ill person must sign a statement that hospice care has been chosen over other Medicare-covered benefits, (e.g. [[assisted living]] or hospital care).<ref>[http://www.medicare.com/assisted-living/hospice-care.html Medicare Guide to Covered Products, Services and Information] {{webarchive|url=https://web.archive.org/web/20140209113031/http://medicare.com/assisted-living/hospice-care.html |date=February 9, 2014 }}. Medicare.com. Retrieved on July 17, 2013.</ref> Treatment provided includes pharmaceutical products for symptom control and pain relief as well as other services not otherwise covered by Medicare such as [[grief counseling]]. Hospice is covered 100% with no co-pay or deductible by Medicare Part A except that patients are responsible for a copay for outpatient drugs and respite care, if needed.<ref name="medicare">{{cite web|url=http://www.medicare.gov/publications/pubs/pdf/hosplg.pdf |title=Medicare Hospice Benefits |publisher=Medicare, the Official U.S. Government Site for People with Medicare |date=March 2000 |access-date=February 1, 2009 |url-status=dead |archive-url=https://web.archive.org/web/20090306191044/http://www.medicare.gov/publications/pubs/pdf/hosplg.pdf |archive-date=March 6, 2009 }}</ref>

{{anchor|PartB|Part B}}

===Part B: Medical insurance===
The Monthly Premium for Part B for 2025 is $185.00 per month (for 2024 it was $174.70 per month).<ref name="medicare-costs-2023-2024"/>

Part B coverage begins once a patient meets his or her deductible ($257 for 2025), then typically Medicare covers 80% of the RUC-set rate for approved services, while the remaining 20% is the responsibility of the patient,<ref name="medicare-costs-2023-2024"/><ref>{{cite journal|first=Julie|last=Allen|title=Dewonkify – Medicare Part B|journal=The National Law Review|volume=III|issue=309|date=November 5, 2013|url=http://www.natlawreview.com/article/dewonkify-medicare-part-b|publisher=Faegre Drinker Biddle & Reath|access-date=June 29, 2022}}</ref> either directly or indirectly by private group retiree or [[Medigap]] insurance. Part B coverage covers 100% for preventive services such as yearly mammogram screenings, osteoporosis screening, and many other preventive screenings.

Part B also helps with [[durable medical equipment]] (DME), including but not limited to [[cane (medical device)|canes]], [[walker (mobility)|walkers]], [[lift chair]]s, [[wheelchair]]s, and [[mobility scooter]]s for those with [[mobility impairment]]s. [[Prosthesis|Prosthetic devices]] such as [[artificial limb]]s and [[breast prosthesis]] following [[mastectomy]], as well as one pair of [[eyeglasses]] following [[cataract surgery]], and [[oxygen therapy|oxygen]] for home use are also covered.<ref>[https://web.archive.org/web/20050830095452/http://www.uihealthcare.com/topics/aging/agin3390.html Medicare: Part A & B], [[University of Iowa Hospitals and Clinics]], 2005.</ref>

[[Medical necessity|Medically necessary]] emergency ambulance transport is covered by Part B if transport by any other method is dangerous to health.<ref name="t237">{{cite web | title=Ambulance services | website=Medicare | url=https://www.medicare.gov/coverage/ambulance-services | access-date=2025-01-14}}</ref> Non-emergency ambulance transport, or transport when not suffering from a medical emergency, may be covered if a physician orders that ambulance transport is medically necessary. Transport by an [[Air ambulance|air ambulance]], either [[Fixed-wing aircraft|fixed-wing]] or [[Helicopter|helicopter]], may also be covered if specialized services are required that are unable to be provided by ground services.<ref name="l832">{{cite web | last=Lankford | first=Kimberly | title=Does Medicare Cover the Cost of Ambulance Services? | website=AARP | date=2022-11-23 | url=https://www.aarp.org/health/medicare-qa-tool/does-medicare-cover-ambulances.html | access-date=2025-01-14}}</ref>

Anyone on Social Security (SS) in 2019 is "held harmless" from the 2019 amount if the increase in their SS monthly benefit does not cover the increase in their Part B premium from 2019 to 2020. This hold harmless provision is significant in years when SS does not increase but that is not the case for 2020. There are additional income-weighted surtaxes for those with incomes more than $85,000 per annum.

{{anchor|PartC|Part C}}

===Part C: Medicare Advantage plans===
{{main|Medicare Advantage}}
{{More citations needed|section|date=September 2019}}

Public Part C Medicare Advantage and other Part C health plans are required to offer coverage that meets or exceeds the standards set by Original Medicare but they do not have to cover every benefit in the same way (the plan must be actuarially equivalent to Original Medicare benefits). After approval by the Centers for Medicare and Medicaid Services, if a Part C plan chooses to cover less than Original Medicare for some benefits, such as Skilled Nursing Facility care, the savings may be passed along to consumers by offering even lower co-payments for doctor visits (or any other plus or minus aggregation approved by CMS).<ref>{{cite web |title=What is Medicare Part C? |url=https://www.hhs.gov/answers/medicare-and-medicaid/what-is-medicare-part-c/index.html |website=hhs.gov|date=June 7, 2015 }}</ref>

Public Part C Medicare Advantage health plan members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by Original Medicare (Parts A & B), such as the [[Out-of-pocket expense|out-of-pocket]] (OOP) limit, self-administered prescription drugs, dental care, vision care, annual physicals, coverage outside the United States, and even gym or health club memberships as well as—and probably most importantly—reduce the 20% co-pays and high deductibles associated with Original Medicare.<ref>{{cite journal |last1=Pope |first1=Christopher |year=2016 |title=Supplemental Benefits Under Medicare Advantage |url=https://www.healthaffairs.org/do/10.1377/forefront.20160121.052787 |journal=Health Affairs |doi=10.1377/forefront.20160121.052787 |access-date=January 25, 2016}}</ref> But in some situations the benefits are more limited (but they can never be more limited than Original Medicare and must always include an OOP limit) and there is no premium. The OOP limit can be as low as $1500 and as high as but no higher than $9350 (as with all insurance, the lower the limit, the higher the premium).{{Citation needed|date=March 2025}} In some cases, the sponsor even rebates part or all of the Part B premium, though these types of Part C plans are becoming rare.{{Citation needed|date=March 2025}}

{{anchor|PartD|Part D}}

===Part D: Prescription drug plans===
{{Main|Medicare Part D|Medicare Part D coverage gap}}

[[Medicare Part D]] went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D, which covers mostly self-administered drugs.{{Citation needed|date=March 2025}} It was made possible by the passage of the [[Medicare Modernization Act]] of 2003. To receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or public Part C health plan with integrated prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by various sponsors including charities, integrated health delivery systems, unions and health insurance companies; almost all these sponsors in turn use pharmacy benefit managers in the same way as they are used by sponsors of health insurance for those not on Medicare. Unlike Original Medicare (Part A and B), Part D coverage is not standardized (though it is highly regulated by the Centers for Medicare and Medicaid Services). Plans choose which drugs they wish to cover (but must cover at least two drugs in 148 different categories and cover all or "substantially all" drugs in the following protected classes of drugs: anti-cancer; anti-psychotic; anti-convulsant, anti-depressants, immuno-suppressant, and HIV and AIDS drugs). The plans can also specify, with CMS approval, at what level (or tier) they wish to cover it, and are encouraged to use [[step therapy]]. Some drugs are excluded from coverage altogether and Part D plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.<ref>{{cite web |url=http://oig.hhs.gov/oas/reports/region6/60600022.pdf |title=Report on the Medicare Drug Discount Card Program Sponsor McKesson Health Solutions, A-06-06-00022 |access-date=February 19, 2011 |archive-url=https://web.archive.org/web/20110717232756/http://oig.hhs.gov/oas/reports/region6/60600022.pdf |archive-date=July 17, 2011 |url-status=dead }}</ref>