Understanding Medicare Part A, B, and D Coverage
Basics of Medicare Part A, B, and D
Most providers struggle with understanding exact coverage while billing for Medicare beneficiaries for part A, B or D coverage. In this article, we shared basics of Medicare coverage and services covered under every plan. It will help providers and billers to collect accurate patient responsibility at the time of service only. Let’s begin with what Medicare part A, B, and D means:
- Part A i.e., Hospital Insurance covers inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care
- Part B i.e., Medical Insurance covers services from doctors and other health care providers, outpatient care, home health care, durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment), and many preventive services (like screenings, shots or vaccines, and yearly ‘Wellness’ visits)
- Part D i.e., Drug coverage covers the cost of prescription drugs (including many recommended shots or vaccines). Plans that offer Medicare drug coverage (Part D) are run by private insurance companies that follow rules set by Medicare.
Understanding of Medicare Coverage
When beneficiary enrolls in Medicare and during certain times of the year, they can choose how to get Medicare coverage. There are 2 main ways to get Medicare:
Original Medicare
Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). Beneficiaries can join a separate Medicare drug plan to get Medicare drug coverage (Part D). They can use any doctor or hospital that takes Medicare, anywhere in the U.S. To help pay out-of-pocket costs in Original Medicare (like 20% coinsurance), they can also shop for and buy supplemental coverage. They can also add supplemental coverage. This includes Medicare Supplement Insurance (Medigap). With original Medicare, in most cases, you don’t need a referral to see a specialist.
Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams. As mentioned earlier, separate Medicare drug plan might require to get Medicare drug coverage (Part D). In most cases, beneficiary don’t have to get a service or supply approved ahead of time for Original Medicare to cover it.
Medicare Advantage
Medicare Advantage which also known as Part C is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These ‘bundled’ plans include Part A, Part B, and usually Part D. These plans may have lower out-of-pocket costs than Original Medicare. Plans may offer some extra benefits that Original Medicare doesn’t cover like vision, hearing, and dental services. For Medicare advantage, in many cases, beneficiaries need to only use doctors and other providers who are in the plan’s network (for non-emergency care). Some plans offer non-emergency coverage out of network, but typically at a higher cost. Medicare Advantage may need to get a referral to see a specialist.
Medicare advantage plans covers all of the medically necessary services that original Medicare covers. As mentioned above, most plans offer some extra benefits that Original Medicare doesn’t cover like some routine exams and vision, hearing, and dental services. In some cases, prior approval is needed to get a service or supply for the plan to cover it. Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, there is no need to join a separate Medicare drug plan.
Legion Health Care Solutions is a leading medical billing company that can assist you in revenue cycle functions for your practice. If you are having any trouble billing for Medicare, Medicaid, other government payers or private payers, we can assist you. Our expert medical billers and coders follows updates billing and coding guidelines to receive timely insurance reimbursements. Please call us to know more about our billing and coding services at 727-475-1834 or email us at info@legionhealthcaresolutions.com
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