Medicare Part A and Part B are two separate types of health insurance coverage. Medicare Part A is “free” for most, Part B is optional and requires you to pay a premium. If you want a Medicare supplement plan, or Medicare Advantage, you must be enrolled in Medicare Part A and Part B.
Medicare Part A
Your Medicare Part A benefit is for INPATIENT hospital stays. Outpatient procedures, even when performed in a hospital setting are generally not considered to be Part A eligible expenses.
Many acute care facilities have Emergency Rooms, dialysis clinics, infusion therapy (chemo) clinics, radiology (X-ray, CT, MRI) and rehab care.
These expenses usually are not covered by Medicare Part A .
If you are admitted for observation. this is classified as outpatient care and is also not covered by Medicare Part A.
Part A as a rule should cover:
- Hospital INPATIENT care
- Skilled nursing care
- SOME nursing home care (cannot be just custodial care)
- SOME hospice care
- SOME in-home services
Follow this link to research what is covered by Medicare.
Part A expenses have an up front per benefit period deductible.
Medicare Part B
Your Medicare Part B benefit as a general rule covers outpatient treatment. This includes things like
- Doctor office visits
- Emergency room
- Infusion therapy
- Durable medical equipment
- Mental health (inpatient and outpatient)
- SOME outpatient prescription drugs
Medicare Part B requires you to pay an annual deductible plus 20% of the Medicare approved amount above the deductible. In some cases you will also be responsible for Medicare excess charges.
Most people underestimate their liability under Part B. They generally
only think of Part B as doctor visits and 20% of a doctor visit can’t be that much.
They would be wrong.
Most large claims, those that exceed $30,000 or so, are often 50% inpatient (Medicare Part A) expenses and 50% outpatient (Part B). Your 20% share of ambulance, ER, radiation and infusion therapy can be quite expensive.
Dan’s expensive quarter mile trip
I recently had breakfast with a long time friend who has generally enjoyed good health but has had a few bumps in the road like most of us.
Last year during a routine exam his doctor noticed a change in his usual medical history and told Dan to have some cardiac tests run at Northside Hospital. The test showed 90% blockage in his heart arteries. The doctor said he needed immediate bypass surgery.
St. Joseph’s Hospital is literally across the street from Northside. His doctors considered his situation so grave they ordered an ambulance to take him from the Northside ER to the St. Joseph ER, about 1,000 feet away.
Dan’s outpatient testing at Northside was covered by Part B. His admission to the St. Joseph ER was also covered under Medicare Part B. Admission as an inpatient to St. Joseph was a Medicare Part A expense.
Medicare at first denied his ambulance claim, then later approved it.
The cost of the 1,000 foot ride was $1700.
Without a good Medicare supplement plan Dan would have paid $340 for a ride across the street.
This is over and above the two ER visits in the same day as well as the outpatient heart scan.
That half day adventure would have cost Dan several thousand dollars without a Medigap plan.
Medicare Part A and Part B