Skip to:

Medicare FAQs « FAQs

We are teachers and advocates, and as a part of that process we frequently answer questions from our clients — so we started collecting our Frequently Asked Questions. We are collecting and sharing them with you by topic and hope these are helpful to you.

Please feel free to email Patti at pdudek@pekdadvocacy.com if you have a follow up question or comment. We'd also like you to let us know what you think of this new feature of our website.

KEEP IN MIND THESE ARE GENERAL QUESTIONS AND CANNOT BE CONSIDERED LEGAL ADVICE OR THE BEGINNING OF THE ATTORNEY-CLIENT RELATIONSHIP.

We have redacted names to protect the innocent! Sometimes they are posed in a give and take format because they were developed through an email exchange.

(Note: questions are not edited for spelling, grammar or content.)

FAQs about Medicare from official Government websites

  • Centers for Medicare & Medicaid Services
    The federal agency that administers the Medicare program and monitors the programs offered by each state.
  • Medicare.gov
    Get answers from the official U.S. government Medicare website that also allows you to sign up for notifications when information you care about is updated.

General Medicare Questions

Question: What is Medicare?

Answer: Medicare is a federal government program that provides health insurance for people age 65 and older, people under 65 with certain disabilities, and people with permanent kidney failure requiring dialysis or a kidney transplant.  The Medicare program is made up of several “parts” that offer various benefits, including hospital insurance (Part A), medical insurance for doctors’ services (Part B), and prescription drug coverage (Part D).

Question: Who is Eligible for Medicare Benefits?

Answer: If you get benefits from Social Security or the Railroad Retirement Board, you are automatically eligible for Medicare starting the first day of the month you turn 65.

If you are under 65 you are eligible to receive Part A benefits under the following circumstances:

  • You have been receiving Social Security Disability Insurance for more than two years
  • You have permanent kidney failure

Question: What does Medicare Part A Cover?

Answer: Medicare Part A, also known as the Hospital Insurance program, helps cover the costs of care in the following facilities:

  • Inpatient care in hospitals
  • Inpatient care in a skilled nursing facility
  • Inpatient rehabilitation facility
  • Hospice care services
  • Some home health care services
  •  Inpatient mental health and psychiatric care

Question: What does Medicare Part B Cover?

Answer: Medicare Part B is also known as the Medical Insurance program.  In general Part B covers two types of services:

  •  Medical services – healthcare that you may need to diagnose and treat a medical condition.  Medicare will only pay for services that they define as being medically necessary
  •  Preventative services – healthcare to prevent illness or help detect an illness in an early stage so it can be managed before getting worse

Under Part B, Medicare helps pay for durable medical equipment such as oxygen equipment, wheelchairs, walkers, and other medically necessary equipment that your doctor prescribes to use in your home.

Question: What is the Medicare Part D Coverage Gap?

Answer: Most Medicate drug plans have a coverage gap, also known as the “doughnut hole.”  This means that after you and your drug plan have spent a certain amount of money for covered medications, you have to pay out-of-pocket costs for your drugs (up to a limit).  Your yearly deductible, your co-insurance or copayments, and what you pay in coverage gap all count toward this limit.

Question: What is a Medicare Advantage Plan?

Answer: Medicare Part C, also known as the Medicare Advantage program, allows you to choose a health plan offered by a private insurance company that is approved by Medicare.  Medicare Advantage plans include:

  •  Managed Care Organizations
  • Private Fee-for Service Plans

Medicare Advantage plans receive payments from Medicare to provide you with the benefits covered by Medicare, including Part A and Part B.  Most Medicare Advantage plans include Part D drug coverage and many offer extra coverage, such as vision and hearing care, dental services, and wellness programs

Question: What happens to Medicare under health reform?

Answers: The Affordable Care Act makes several changes to Medicare that most likely will improve your benefits and your access to primary care services.  Some significant changes include:

  • Coverage Gap Savings: If you reach that coverage gap in 2010 you will receive a one-time rebate check of $250 from Medicare.  In 2011, you will be able to get a 50% discount on brand-name drugs and a 7% discount on generic drugs in the coverage gap.  There will be additional savings in the coverage gap each year until it’s completely closed by 2020.
  • Preventive Care: Beginning in 2011, Medicare will pay for an annual checkup, including a physical examination and a total elimination of cost sharing for appropriate preventive services and screenings.

Medicare Benefits in Skilled Nursing Facilities

Question: When does the "clock" get reset for Medicare benefits in a nursing home?  Example: dad enters nursing home (after 3 nights in hospital) for 20 days and then goes home.  Reenters nursing home 60 days later (after another 3 nights in hospital).  Does the clock get reset back to 100 day max?

Answer: From Medicare Advocacy website:

  • "Medicare Part A provides payment for post-hospital care in skilled nursing facilities (SNFs) for up to 100 days during each spell of illness.  A "spell of illness" begins on the first day a patient receives Medicare-covered inpatient hospital or skilled nursing facility care and ends when the patient has spent 60 consecutive days outside the institution, or remains in the institution but does not receive Medicare-coverable care for 60 consecutive days."
  • Therefore, the 3 days in the hospital prior to SNF admission result in the second SNF admission's still being considerated part of the first spell of illness.

Medicare Benefits and Hospice Care

  • Question: My mother is currently receiving Hospice care and just received notice that her Hospice Medicare coverage will end 8/4/2011. The Hospice’s MD made the decision that my mother is no longer eligible for Hospice Medicare coverage. My family likes the enhanced level of care that Hospice provides. I would appreciate receiving insights about effective methods to reverse the determination that a person is ineligible to receive Hospice benefits.
  • Answer: (compiled from forum answer after review of document):
  • This is not notice that her Medicare coverage will end.  It is a notice that the provider THINKS that Medicare will not cover its bills, and they will therefore stop submitting their bills to Medicare. The beneficiary is entitled to demand that the provider submit the bills to Medicare and, if Medicare does in fact not cover, to appeal that decision through the Medicare appeals process. Medicare must continue coverage during the appeal process.   If the beneficiary is unsuccessful in the appeal, any payments made by Medicare must be reimbursed to Medicare by the beneficiary.  If your mother has her own MD (not the hospice staff MD), perhaps you can get a second opinion. However, if hospice coverage is not appropriate (i.e., the doctor will not certify that it is likely that she has six months or less to live), you will need to look at other ways to get the enhanced services through the home care benefit or through private pay. In general, I defer any Medicare issue to the Center for Medicare Advocacy and have found them very helpful in answering questions and making suggestions.