Medicare Part A and Part B: Coverage and Eligibility

For professionals preparing for the complete FL 2-15 exam guide, understanding the nuances of Medicare is essential. Medicare is a federal health insurance program originally designed to provide financial security for those who have reached a specific age or meet certain disability criteria. It is divided into several parts, but the foundation consists of Part A and Part B, collectively known as Original Medicare.

Medicare is administered by the Centers for Medicare & Medicaid Services (CMS), though enrollment is handled through the Social Security Administration. As you study for your license, focus on how these two parts differ in terms of funding, benefits, and costs, as these distinctions are frequently tested in practice FL 2-15 questions.

Medicare Part A is often referred to as Hospital Insurance. It primarily covers expenses incurred while an individual is confined to a facility. Most individuals do not pay a monthly premium for Part A if they have worked and paid Medicare taxes for a sufficient number of quarters throughout their lifetime.

The primary services covered under Part A include:

• Inpatient Hospital Care: This covers semi-private rooms, meals, general nursing, and drugs as part of the inpatient treatment.
• Skilled Nursing Facility (SNF) Care: Coverage applies if the patient requires skilled nursing care following a hospital stay of at least three days.
• Hospice Care: This is provided for terminally ill individuals and focuses on comfort rather than curative treatment.
• Home Health Care: Limited to medically necessary part-time or intermittent skilled nursing care and physical therapy.

It is important to note that Part A does not cover private-duty nursing, private rooms (unless medically necessary), or television/telephone charges in the hospital room.

Medicare Part B is Medical Insurance. Unlike Part A, Part B is a voluntary program that requires the payment of a monthly premium. If an individual chooses not to enroll when they are first eligible, they may face a late enrollment penalty unless they have creditable coverage through an employer.

Part B covers a wide range of medically necessary and preventive services, including:

• Doctor Services: Visits to primary care physicians and specialists.
• Outpatient Hospital Services: Emergency room visits or same-day surgeries.
• Durable Medical Equipment (DME): Items such as wheelchairs, walkers, and oxygen equipment.
• Preventive Services: Screenings for various conditions and annual wellness visits.
• Clinical Research and Lab Tests: Blood work, X-rays, and diagnostic tests.

Part B is funded by a combination of general government revenues and the premiums paid by beneficiaries. It typically operates on a deductible and coinsurance basis, where the beneficiary pays a set percentage of the Medicare-approved amount after the annual deductible is met.