A Practitioner’s Guide to the Types of Medicare

While many practitioners have a general idea of what Medicare is, most still lack basic knowledge about what the different Parts of Medicare are and what each of them cover. Advising your elderly and disabled clients on how to pay for injury-related and post-settlement medical treatment is contingent upon knowing what type of coverage your client has and what types are available to sign up for. For instance, if your client was involved in a work-related accident, and needs an MRI of his low back, will Medicare Part A cover the cost? What about if your client has both Parts A and B, and is going to need post-settlement custodial care in a nursing home. Do these parts of Medicare cover the cost of a long term facility? This article seeks to provide a quick reference guide to help attorneys understand the types of Medicare available and what each part covers.

By way of background, Medicare is a federal program that provides health insurance for most people who have attained the age of 65 or older and have worked and paid Medicare taxes for at least 10 years. Some younger people may also be eligible if they qualify for Social Security Disability Insurance (SSDI) or have end-stage renal disease (permanent kidney failure requiring dialysis or a transplant).

Part A: covers inpatient hospital stays, including semi-private rooms, meals, general nursing, and other hospital services and supplies. It also covers care in a skilled nursing facility, including semi-private rooms, meals, rehabilitation services, and other skilled nursing care. Hospice care and some home health care services, such as nursing care and physical therapy, are also covered under Part A. There are no premiums associated with Part A but deductibles, and copayments do apply.

Part B: covers outpatient medical services, such as doctor’s visits, preventive care, diagnostic tests, and some medical equipment. It also covers some services that may not be covered by group health insurance, such as mental health care, ambulance services, and durable medical equipment.

Part C: also known as Medicare Advantage, is an alternative to Original Medicare (Parts A and B). Medicare Advantage plans are offered by private insurance companies and must provide the same benefits as Parts A and B, but they may also offer additional benefits, such as vision, hearing, and dental coverage. Medicare Advantage plans may have lower out-of-pocket costs than Original Medicare, but they may also have more limited networks of providers.

Part D: covers prescription drugs and is offered by private insurance companies. Beneficiaries can choose a stand-alone Part D plan or a Medicare Advantage plan that includes drug coverage. Part D plans have a list of covered drugs, known as a formulary, and may have tiers of coverage with different copayment or coinsurance amounts for each tier.

Knowing the type of Medicare that your client has can be essential to advising your client regarding medical bills in his personal injury or workers’ compensation claim. Let us know if you have any questions on whether your client’s injury-related medical bills are covered by Medicare.