Medicare 101

A couple of years ago, my father, well into his 70s, finally bought himself a high-performance automobile.
The kids and grandkids had all grown up, so there was no need for a larger car. And heck, he had waited a long time to drive something fun.
All was fine with the new car until my mother broke her hip, had surgery and needed extensive outpatient physical and occupational therapy.
Getting into and out of a sporty car isn’t easy for someone using a walker and cane. So I got a phone call asking what could be done. (Actually, I think he was angling for my new minivan, whose video screens would give him something to do during Mom’s therapy sessions.)
But I told him he didn’t need to take Mom to a clinic or hospital. As a Medicare beneficiary, she could receive most of the therapy in her own home.
Medicare covers a variety of health care services that you can get in the comfort and privacy of your home. These include intermittent skilled nursing care, physical therapy, speech-language pathology services and occupational therapy.
Such services used to be available only at a hospital or doctor’s office. But they’re just as effective, more convenient and usually less expensive when you get them in your home.
To be eligible for home health services, you must be under a doctor’s care and receive services under a plan of care established and reviewed regularly by a physician. He or she also needs to certify that you need one or more home health services.
In addition, you must be homebound and have a doctor’s certification to that effect. Being homebound means leaving your home isn’t recommended because of your condition, or your condition prevents you from leaving without using a cane, wheelchair or walker; arranging special transportation; or getting help from another person.
Also, you must get your services from a Medicare-approved home health agency.
If you meet these criteria, Medicare pays for covered home health services for as long as you’re eligible and your doctor certifies that you need them.
For durable medical equipment (like a walker or wheelchair), you pay 20 percent of the Medicare-approved amount.
Skilled nursing services are covered when they’re given on a part-time or intermittent basis. In order for Medicare to cover such care, it must be necessary and ordered by your doctor for your specific condition. Medicare does not cover full-time nursing care.
Skilled nursing services are given by either a registered nurse or a licensed practical nurse under an RN’s supervision. Nurses provide direct care and teach you and your caregivers about your care. Examples of skilled nursing care include giving IV drugs, shots or tube feedings, changing dressings and teaching about prescription drugs or diabetes care.
Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services it gives you aren’t covered by Medicare and how much you’ll have to pay for them.
This should be explained by both talking with you and in writing. The agency should give you a notice called the Home Health Advance Beneficiary Notice before giving you services and supplies that Medicare doesn’t cover.
What isn’t covered?
Some examples are:
• 24-hour-a-day care at home
• Meals delivered to your home
• Homemaker services like shopping,
cleaning and laundry (when this is
the only care you need and when these
services aren’t related to your plan of
• Personal care given by home health
aides like bathing, dressing and using
the bathroom (when this is the only
care you need)
If you get your Medicare benefits through a Medicare Advantage or other Medicare health plan (not Original Medicare), check your plan’s membership materials. Contact the plan for details about how the plan provides your Medicare-covered home health benefits.
If your doctor decides you need home health care, you can choose from among the Medicare-certified agencies in your area. (However, Medicare Advantage or other Medicare plans may require you to get services only from agencies they contract with.)
One good way to look for a home health agency is by using Medicare’s “Home Health Compare” web tool, at It lets you compare agencies by the types of services they offer and the quality of care they provide.
For more details on Medicare’s home health benefit, please read our booklet, “Medicare and Home Health Care.” It’s online at
How Medicare works with other insurance
If your family is anything like mine, everyone has a certain specialty or role in keeping the household running.
Since I wash dishes faster than anyone, I’m the family dishwashing expert. I’m also the point man for paying medical bills. My wife and I have separate health coverage, so I have to make sure our providers have the up-to-date information they need to accurately bill our respective insurance plans.
If you have Medicare as well as other insurance, always be sure to tell your doctor, hospital and pharmacy. This is important because it determines whether your medical bills are paid correctly and on time.
When there’s more than one insurance payer, certain rules determine which one pays first. These rules are called “coordination of benefits.”
The primary payer pays what it owes on your bills first – and then sends the balance to the secondary payer to pay. In some cases, there may also be a third payer.
Medicare is the primary payer for beneficiaries who aren’t covered by other types of health insurance. The primary payer pays up to the limits of its coverage. The secondary payer only pays if there are costs the primary insurer didn’t cover.
But keep in mind that the secondary payer (which may be Medicare) may not pay all the uncovered costs.
If you currently have employer insurance and it’s the secondary payer, you may need to enroll in Medicare Part B before your job-based coverage will pay. (Most people who sign up for Part B for the first time this year will pay a monthly premium of $134.)
Here’s who pays first in various situations when you have Medicare and some other type of insurance:
• If you have retiree insurance (coverage
from a former job), Medicare pays first.
• If you’re 65 or older, have group
coverage based on your or your
spouse’s current employment, and the
employer has 20 or more workers, your
group plan pays first. (If the company
has fewer than 20 employees, Medicare
pays first.)
• Your group plan also pays first when
you’re under 65 and disabled, have
group coverage based on your or a
family member’s current employment,
and the employer has 100 or more
employees. (Medicare pays first if the
company has fewer than 100
• If you have Medicare because of
end‑stage renal disease (permanent
kidney failure), your group plan pays
first for the first 30 months after you
become eligible for Medicare. Medicare
pays first after this 30‑month period.
Medicare may pay second if you’re in an accident or have a workers’ compensation case in which other insurance covers your injury or you’re suing another entity for medical expenses.
In such situations, you or your lawyer should tell Medicare as soon as possible. The following types of insurance usually pay first for services related to each type:
No-fault insurance (including automobile insurance)
Liability (including automobile and self-insurance)
Black Lung Benefits
Worker’s compensation
Medicaid and TRICARE (the health care program for U.S. armed service members, retirees, and their families) never pay first for services that are covered by Medicare. They only pay after Medicare, employer plans, and/or Medicare Supplement Insurance (Medigap) have paid.
For more information, read the booklet “Medicare and Other Health Benefits: Your Guide to Who Pays First.” You can find it online at Or call us toll-free at 1-800-MEDICARE (800‑633‑4227) and ask for a copy to be mailed to you. TTY users should call 877‑486‑2048.
If you have questions about who pays first, or if your coverage changes, call the Benefits Coordination & Recovery Center toll-free at 855-798-2627. TTY users should call 855-797-2627.
You can also contact your employer or union benefits administrator. You may need to give your Medicare number to your other insurers so your bills are paid correctly and on time.