Medicare For Dummies. Patricia Barry

which means receiving treatment at a hospital’s outpatient department or clinic or at a community mental health center during the day, but not spending the night there. Your costs for this type of service vary according to the treatment provided, but under Medicare rules it can’t be more than 40 percent of the Medicare-approved amount.

      

For more details, see the publication “Medicare & Your Mental Health Benefits” at www.medicare.gov/Pubs/pdf/11358-Medicare-Mental-Health-Getting-Started.pdf.

      Mental health benefits in Medicare Advantage plans

      Because mental health benefits may vary among Medicare Advantage plans, look at the evidence of coverage documents for your plan. But most plans stick to the same limit of 190 lifetime days for inpatient care in a psychiatric hospital.

      Limits on therapy services

      Medicare Part B covers physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). Previously, Medicare limited the amount of coverage you could get for therapy services in any given year as an outpatient or in a hospital outpatient department or emergency room, known as the therapy cap; however, in 2019, Medicare removed the cap, covering outpatient therapy at 80 percent of the Medicare-approved amount. When you receive services from a participating provider, you pay a 20 percent co-pay after you meet your Part B deductible, which in 2020 is $198.

These dollar limits are the total cost of the services received in a year — including what Medicare pays (80 percent of the Medicare-approved amount) and what you pay (20 percent). Medicare may continue to cover these services beyond the annual limits if you have a condition that requires ongoing therapy, such as extensive rehabilitation for stroke or heart disease. To get this exception, your therapist must justify the need when she bills Medicare. If the total cost reaches $3,000 in a year, Medicare automatically reviews your case.

      

For specific information, see the publication “Medicare Coverage of Therapy Services” at www.medicare.gov/Pubs/pdf/10988-Medicare-Limits-Therapy-Services.pdf.

Chapter 3

      Understanding What You Pay Toward Your Costs in Medicare

      IN THIS CHAPTER

      

Getting the scoop on Medicare premiums, deductibles, and co-payments

      

Shelling out higher premiums if your income is over a certain level

      

Understanding why you may pay higher premiums than other people in certain years

      

Continuing to pay Medicare taxes when you’re already receiving Medicare benefits

      What will Medicare cost you, and how much will it save you? That’s the killer question for people just coming into the program. In a way, the answer really depends on where you started out. Did you have low-cost insurance from an employer when you were working? Then Medicare may seem expensive in comparison. Were you paying through the nose for an individual policy that didn’t actually provide much coverage? Or perhaps you just couldn’t find insurance that you could afford? In those cases, Medicare probably seems like the promised land.

This point bears repeating: Medicare isn’t free. Some people do think that the Medicare payroll taxes they pay while working will net them totally free health care after they hit 65. Sorry, not so. In fact, on average, Medicare is said to cover only about half of beneficiaries’ total health-care costs if they have no extra insurance.

      In this chapter, I explain the way in which all the various costs of Medicare — premiums, deductibles, and co-payments — may hit your pocket in each of the parts of Medicare. I also go into detail about the higher-income premiums for Part B and Part D because you need to know whether they affect you and, if so, by how much. (However, you may be able to lower some of those costs, a topic I delve into in Chapter 4.) Finally, I explain why some people may pay different premiums than others in certain years and the instances when you need to pay Medicare taxes while receiving Medicare benefits.

Boning Up on Premiums, Deductibles, and Co-payments

      

What Medicare pays toward your medical care is coverage. What you contribute out of your own pocket can be several kinds of expenses: premiums, deductibles, and co-payments. If you’ve had U.S.-style health insurance before, you know exactly what these terms mean. If not, here’s a quick primer:

       Premium: A premium is an amount you pay each month to receive coverage. In other words, it’s your entrance ticket to the program.

       Deductible: A deductible is an amount you pay before coverage kicks in. You can think of it as a kind of down payment before getting the goods.

       Co-payment: This amount is what you pay as your share of the cost of each service you receive. Strictly speaking, co-pays are fixed dollar amounts (such as $20), whereas coinsurance is the correct term when your share is a percentage of the cost (such as 20 percent). But because coinsurance is too wonky for words, I use co-pays in these pages.

If you had insurance in the past, you probably paid a single premium for all your health care and a single deductible for the whole year (maybe a hefty one if you were in a high-deductible plan), with co-pays for each service. But Medicare, of course, is divided into four parts, each with its own costs and charges. The following sections explain each set of costs under Part A, Part B, Part D, and Medicare Advantage (Part C) plans. Finally, Figure 3-1 shows the costs for Parts A, B, and D at a glance. Note: The costs in the chart are for people enrolled in traditional Medicare plus stand-alone Part D drug plans. Medicare Advantage plan costs are different and vary among plans.

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      FIGURE 3-1: 2020 premiums, deductibles, and co-payments at a glance.

      Part A costs

      Part A covers nursing care, room, and meals in a hospital or skilled nursing facility (such as a rehab center or a nursing home); home health services; and hospice care. The following sections describe the possible out-of-pocket costs that you may pay for those services. Note: The costs in the following sections apply if you’re enrolled in the traditional Medicare program. They’ll likely be different if you’re in a Medicare Advantage health plan such as an HMO or a PPO — see the later section “Medicare Advantage costs.”

      Premiums