The benefits you get depend on whether you have Part A Hospital Insurance, Part B Medical Insurance, or both, and the type of Medicare plan you choose.

People enrolled in both Part A and Part B may choose one of these plans:

the standard fee-for-service plan called the Original Medicare Plan
the Original Plan with supplemental coverage such as Medigap and/or Medicare Prescription Drug Plan (Part D)
a private Medicare Advantage plan such as a Medicare HMO (Part C)

The specific benefits you get vary somewhat from plan to plan. However, all Medicare plans must offer the following services when they are medically necessary:

Medicare Part A:

Inpatient hospital care
Skilled nursing facility care (not long-term care)
Home health care
Hospice care (for people with less than six months to live)
Blood (at a hospital or skilled nursing facility during a covered stay)

Medicare Part B:

Physical exam (one time only, "Welcome to Medicare" exam; must take place within six months of receiving Medicare Part B)
Doctors' services (not routine checkups)
Outpatient hospital care
Emergency care
Approved medical supplies and equipment (for example, kidney dialysis services and supplies, diabetic supplies, durable medical equipment such as oxygen or a wheelchair)
Prosthetic/orthotic items
Lab tests, X-rays, and certain other diagnostic tests
Ambulance services (when other transportation would endanger your health)
Ambulatory Surgery Center
Transplant services
Qualifying clinical trials
Home health services
Physical and occupational therapy, speech therapy
Chiropractic services (limited)
Eye exams (for people with diabetes only)
Approved practitioner services
Certain screening tests and other preventive care (cardiovascular, bone mass measurement, colorectal cancer, prostate cancer, diabetes, glaucoma, mammograms, pap test and pelvic exam)
Immunizations for flu, pneumonia, Hepatitis B
Outpatient mental health services (limited)
Other approved services may also be included.

The Original Medicare Plan offers the services listed above. Medicare Advantage plans (Part C) include additional services such as limited prescription drug coverage, eye exams, and routine checkups. Some Medigap supplemental insurance plans also include additional services.

Medicare Part D Prescription Drug Plans cover some of the costs of prescription drugs.

When you choose a Medicare plan, you will get a list of the services offered by that particular plan and also a list of services not covered. You can also read Medicare & You: 2010 published by the Department of Health & Human Services.

What health care services are not covered by Medicare?

These are some common health care services that are not included in the Original Medicare Plan (Part A and Part B):

Routine checkups/physical exams with the exception of the initial "Welcome to Medicare" exam
Most prescription drugs (see information on adding Part D)
Most immunizations other than those listed above
Custodial care, including most nursing home care
Most chiropractic services
Acupuncture
Cosmetic surgery
Care outside of the United States (except hospital care in Canada)
Eye care or eyeglasses, except after cataract surgery
Foot care (routine)
Dental care and dentures
Hearing aids or hearing aid exams

If you need these services, you must pay for them yourself or get other health care coverage. Medicare Advantage plans usually include some of these services.

Do I have to pay anything for Medicare?

Medicare is not free. Most people pay monthly premiums for their Medicare coverage and also pay deductibles and coinsurance for Medicare-covered services. The amount you pay depends on the Medicare plan that you choose and the services you need. Medicare costs can be quite high.

Your monthly premium is an amount that you pay each month for your insurance.

Part A Hospital Insurance: Most people do not pay a monthly premium for this coverage because they paid Medicare taxes while they were working. However, if you or your spouse did not earn 40 credits (10 years) of Medicare-covered employment, you must pay a monthly premium. In 2010, the monthly premium is $461 for people who do not have premium-free Medicare Part A.

Part B Medical Insurance: The following table lists monthly Medicare premiums in 2010 (using your 2008 tax return).

Yearly Income Yearly Income You Pay

File individual tax return File joint tax return

$85,000 or less $170,000 or less $110.50

$85,001-$107,000 $170,001-$214,000 $154.70

$107,001-$160,000 $214,001-$320,000 $221.00

$160,001-$214,000 $320,001-$428,000 $287.30

Above $214,000 Above $428,000 $353.60

Note: In some cases these amounts may be higher if you did not choose Part B when you first became eligible. The cost of Part B may go up 10% for each full 12-month period that you could have had Part B but didn't sign up for it, except in special cases. You may have to pay this penalty as long as you have Part B.

Medicare Advantage (Medicare + Choice) plans, Medigap, and Part D Prescription Drug Coverage: These plans, which offer additional benefits, usually charge a monthly premium in addition to the standard Medicare monthly premium. Depending on the type of plan you choose, these premiums can range from a low of about $50 to several hundred dollars per month in addition to the Part B premium.

Your deductible is the amount you must pay for health services before Medicare starts to pay.

Part A Hospital Insurance: If you have Part A alone or the Original Medicare Plan, you must pay a deductible of $1,100 in 2010 for each benefit period. If you have supplemental Medigap insurance or a Medicare Advantage plan, your deductible will be the same or less. After you have paid your deductible, Medicare pays all additional covered costs for hospital stays of 1 to 60 days.

Part B Medical Insurance: If you have Part B alone or the Original Medicare Plan, you must pay a deductible of $155 per year. If you have supplemental Medigap insurance or a Medicare Advantage plan, your deductible will be the same or less.
Your coinsurance is the percentage of your medical costs that you must pay, after you have paid your deductible.

Part A: For Medicare-covered hospitalization, you must pay a deductible and no coinsurance of $1,100 for days 1-60. For days 61-90 you pay $275 per day. For days 91-150, you may use "Lifetime Reserve Days" which are 60 days of extra coverage you can use in your lifetime at a rate of $550 per day. All costs for each day beyond 150 days you pay yourself, or you may pay all hospitalization costs yourself.

For many medical services, you must pay coinsurance under standard Medicare. Some services have no coinsurance charge. If you have supplemental Medigap insurance or a Medicare Advantage plan, your coinsurance will usually be less. Some plans have a copayment (a flat fee per service, for example, $20 per doctor's visit) rather than coinsurance.
- Blood: You pay all costs for the first three pints of blood you get as an inpatient, then 20% of the Medicare-approved amount for additional pints of blood.
- Home Health Care: You pay $0 for home health care services and 20% of the Medicare-approved amount for durable medical equipment.
- Hospice Care: You pay a copayment of up to $5 for outpatient prescription drugs and 5% of the Medicare-approved amount for inpatient respite care.
- Skilled Nursing Facility: You pay $0 for the first 20 days of each benefit period; $137.50 per day for days 21-100 of each benefit period; and all costs for each day after day 100 in the benefit period.

Other fees may also apply.

Part B: For many medical services, you must pay coinsurance under standard Medicare. Some services have no coinsurance charge. If you have supplemental Medigap insurance or a Medicare Advantage plan, your coinsurance will usually be less. Some plans have a copayment (a flat fee per service, for example, $20 per doctor's visit) rather than coinsurance.

Blood: You pay all costs for the first three pints of blood you get as an inpatient, then 20% of the Medicare-approved amount for additional pints of blood.
Clinical Laboratory Services: You pay $0 for Medicare-approved services.
Home Health Services: You pay $0 for Medicare-approved services and 20% of the Medicare-approved amount for durable medical equipment.
Medical & Other Services: You pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, most preventive services, and durable medical equipment.
Mental Health Services: You pay 50% for outpatient mental health care.
Outpatient hospital services have coinsurance and copayment amounts that vary by service.

Other fees may also apply.

If I have low income, can I get help paying my Medicare costs?

If you have limited income and assets, you can get help paying your Medicare costs.

You may be eligible for Medicaid. Medicaid will pay your Medicare premiums, deductibles, and coinsurance. In addition, Medicaid offers many benefits not included in Medicare, including prescription drugs, preventive care, and dental services. In New Mexico, contact the Department of Health and Human Services for more information on Medicaid: 1-888-997-2583; Espanol: 1-800-432-6217.

You may be eligible for a Medicare Savings Program such as the Qualified Medicare Beneficiary Program (QMB) or the Specified Low-Income Medicare Beneficiary Program (SLIMB). Medicare Savings Programs will pay your Medicare Part B premiums, and depending on your income, may also pay your Part A premiums (if any), hospital and medical deductibles, and coinsurance. They do not offer any additional benefits. These programs are called Medicare Buy-In programs.

To qualify, you must:

Have Medicare Part A;
Be an individual with resources of $4,000 or less or a married couple with resources of $6,000 or less (resources include such things as stocks, bonds, and money in checking or savings accounts, but not things like your house or car);
Be an individual with a monthly income of less than $1,169 or a married couple with a monthly income of less than $1,561.

Extra Help with Medicare Prescription Drug Plan Costs: If you have limited income and assests, you may qualify for Extra Help from the Social Security Administration to help pay your Part D costs. Depending on your income, Extra Help will pay all or part of your Prescription Drug Plan monthly premiums and annual deductible, and will limit the amount of your copayments. For more information go to: Extra Help with Medicare Prescription Drug Plan Costs.

If you would like to talk to someone about Medicare Savings Programs or other assistance programs, call the Medicare Hotline at 1-800-633-4227.

Does Medicare pay for prescription drugs?

Medicare offers prescription drug coverage for everyone with Medicare. This is called "Part D" and is optional. You usually pay a monthly premium to enroll in the Medicare prescription drug program. There are two ways to get Medicare prescription drug coverage:

Join a Medicare Prescription Drug Plan to add drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
Join a Medicare Plan (like an HMO or PPO) that includes prescription drug coverage as part of the plan.

Each Medicare prescription drug plan offers different benefits and may or may not charge a premium, coinsurance, or a deductible. You can find and compare Medicare prescription drug plans on the Medicare website Prescription Drug Plan Finder, or you can call the Medicare hotline at 1-800-MEDICARE (1-800-633-4227). You can also find more information at the New Mexico Resources website at Medicare Prescription Drug Plans.

If I need emergency health care when I am out of state, will Medicare pay for it?

If you have an emergency out of state, Medicare will cover your emergency medical expenses. You are covered anywhere within the U.S. If you are enrolled in a Medicare Advantage plan such as an HMO, and you normally have to see doctors within your plan's network, you will still be covered out of state for emergencies and urgently needed care. You should notify your plan as soon as possible after you get treatment.

Can I get Medicare coverage for an emergency outside of the U.S.?

Medicare (the Original Medicare Plan) does not pay for coverage outside of the U.S. except in rare instances (for example, if a Canadian or Mexican hospital is closer to your home than the nearest U.S. hospital that can provide the care you need). If you travel often outside of the U.S., you should enroll in a Medicare Advantage program that offers emergency care coverage out of the country. Some Medigap policies also offer this coverage. You may also buy a travel insurance policy to cover you when you travel.

Top of Page | Home Page | Printer-friendly Version

Search | Site Map | How to Use this Web Site | Contact Us | Guestbook