Gerontological Nurse Certification Review

To locate the area agency on aging in each state, use the links tab located at http://www.n4a.org. In addition to this Web resource, the administration on aging offers a toll-free Eldercare Locator telephone number—(800) 677-1116—to help older adults, families, and health care providers obtain necessary community services throughout the United States. Operators at Eldercare Locator assist callers to find information and assistance to address health care and other issues to ensure high functioning and quality of life.

In addition to AAAs, senior service offices in hospitals are good sources of information about hospital and community-based resources.

Medicare and Medigap

Part B pays for visits to physicians, nurse practitioners, and for other health care expenditures, such as X-rays, physical and occupational outpatient therapy, and laboratory tests. There is a monthly premium that older adults must pay for this type of Medicare plan. The current monthly premium is about $78. The amount is usually deducted from the recipient’s monthly social security checks. Part B Medicare also requires recipients to pay the first $110 of charges before it will begin reimbursement. This is known as a deductible. The deductible for Part B Medicare is likely to increase annually. Coverage of Medicare for health care needs of older adults is detailed in Table 12.1.

Service or Supply	What is covered, and when?
Acupuncture	Medicare doesn’t cover acupuncture.
Ambulance Services	Medicare covers limited ambulance services. If you need to go to a hospital or skilled nursing facility (SNF), ambulance services are covered only if transportation in any other vehicle would endanger your health. Medicare helps pay for necessary ambulance transportation to the closest appropriate facility that can provide the care you need. If you choose to go to another facility farther away, Medicare payment is based on how much it would cost to go to the closest appropriate facility. All ambulance suppliers must accept assignment. Medicare generally doesn’t pay for ambulance transportation to a doctor’s office. Air ambulance is paid only in the most severe situations. If you could have gone by land ambulance without serious danger to your life or health, Medicare pays only the land ambulance rate, and you are responsible for the difference.
Ambulatory Surgical Centers	Medicare covers services given in an Ambulatory Surgical Center for a covered surgical procedure.
Anesthesia	Medicare covers anesthesia services along with medical and surgical benefits. Medicare Part A covers anesthesia you get while in an inpatient hospital. Medicare Part B covers anesthesia you get as an outpatient.
Artificial Limbs and Eyes	Medicare helps pay for artificial limbs and eyes. For more information, see Prosthetic Devices.
Blood	Medicare doesn’t cover the first three pints of blood you get under Part A and Part B combined in a calendar year. Part A covers blood you get as an inpatient, and Part B covers blood you get as an outpatient and in a freestanding Ambulatory Surgical Center.
Bone Mass Measurement	Medicare covers bone mass measurements ordered by a doctor or qualified practitioner who is treating you if you meet one or more of the following conditions:
	Women You are being treated for low estrogen levels and are at clinical risk for osteoporosis, based on your medical history and other findings. Men and Women Your X-rays show possible osteoporosis, osteopenia, or vertebrae fractures. You are on prednisone or steroid-type drugs or are planning to begin such treatment. You have been diagnosed with primary hyperparathyroidism. You are being monitored to see if your osteoporosis drug therapy is working. The test is covered once every two years for qualified individuals and more often if medically necessary.
Braces (arm, leg, back, and neck)	Medicare covers arm, leg, back, and neck braces. For more information, see Orthotics.
Breast Prostheses	Medicare covers breast prostheses (including a surgical brassiere) after a mastectomy. For more information, see Prosthetic Devices.
Canes/Crutches	Medicare covers canes and crutches. Medicare doesn’t cover canes for the blind. For more information, see Durable Medical Equipment.
Cardiac Rehabilitation Programs	Medicare covers comprehensive programs that include exercise, education, and counseling for patients whose doctor referred them and who have 1) had a heart attack in the last 12 months, 2) had coronary bypass surgery, 3) stable angina pectoris, 4) had heart valve repair/replacement, 5) had angioplasty or coronary stenting, and/or 6) had a heart or heart-lung transplant. These programs may be given by the outpatient department of a hospital or in doctor-directed clinics.
Cardiovascular Screening	Medicare covers screening tests for cholesterol, lipid, and triglyceride levels every five years. Ask your doctor to test your cholesterol, lipid, and triglyceride levels so he or she can help you prevent a heart attack or stroke.
Chemotherapy	Medicare covers chemotherapy for patients who are hospital inpatients, outpatients, or patients in a doctor’s office or freestanding clinics. In the inpatient hospital setting, Part A covers chemotherapy. In a hospital outpatient setting, freestanding facility, or doctor’s office, Part B covers chemotherapy.
Chiropractic Services	Medicare covers manipulation of the spine if medically necessary to correct a subluxation (when one or more of the bones of your spine moves out of position) when provided by chiropractors or other qualified providers.
Clinical Trials	Medicare covers routine costs, like doctor visits and tests, if you take part in a qualifying clinical trial. Clinical trials test new types of medical care, like how well a new cancer drug works. Clinical trials help doctors and researchers see if the new care works and if it is safe. Medicare doesn’t pay for the experimental item being investigated, in most cases.
Colorectal Cancer Screening	Medicare covers several colorectal cancer screening tests. Talk with your doctor about the screening test that is right for you. All people age 50 and older with Medicare are covered. However, there is no minimum age for having a colonoscopy. Colonoscopy: Medicare covers this test once every 24 months if you are at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, the test is covered once every 120 months, but not sooner than 48 months after a screening sigmoidoscopy. Fecal Occult Blood Test: Medicare covers this lab test once every 12 months. Flexible Sigmoidoscopy: Medicare covers this test once every 48 months for people 50 and older. Barium Enema: Once every 48 months (high risk every 24 months) when used instead of a flexible sigmoidoscopy or colonoscopy.
Commode Chairs	Medicare covers commode chairs that your doctor orders for use in your home if you are confined to your bedroom. For more information, see Durable Medical Equipment on page 46.
Cosmetic Surgery	Medicare generally doesn’t cover cosmetic surgery unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Medicare covers breast reconstruction if you had a mastectomy because of breast cancer.
Custodial Care (help with activities of daily living, like bathing, dressing, using the bathroom, and eating)	Medicare doesn’t cover custodial care when it’s the only kind of care you need. Care is considered custodial when it’s for the purpose of helping you with activities of daily living or personal needs that could be done safely and reasonably by people without professional skills or training. For example, custodial care includes help getting in and out of bed, bathing, dressing, eating, and taking medicine.
Dental Services	Medicare doesn’t cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions, or dentures. Medicare doesn’t pay for dental plates or other dental devices. Medicare Part A will pay for certain dental services that you get when you are in the hospital. Medicare Part A can pay for hospital stays if you need to have emergency or complicated dental procedures, evenwhen the dental care itself isn’t covered.
Diabetes Screening	Medicare covers tests to check for diabetes. These tests are available if you have any of the following risk factors: high blood pressure, dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a history of high blood sugar. Medicare also covers these tests if you have two or more of the following characteristics: age 65 or older, overweight, family history of diabetes (parents, brothers, sisters), a history of gestational diabetes (diabetes during pregnancy) or delivery of a baby weighing more than 9 pounds. Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.
Diabetes Supplies and Services	Medicare covers some diabetes supplies, including blood glucose test strips, blood glucose monitor, lancet devices and lancets, and glucose control solutions for checking the accuracy of test strips and monitors. There may be limits on how much or how often you get these supplies. For more information, see Durable Medical Equipment on page 149. Here are some ways you can make sure your Medicare diabetes medical supplies are covered: Only accept supplies you have ordered. Medicare won’t pay for supplies you didn’t order. Make sure you request your supply refills. Medicare won’t pay for supplies sent from the supplier to you automatically. All Medicare-enrolled pharmacies and suppliers must submit claims for glucose test strips. You can’t send in the claim yourself. Medicare doesn’t cover insulin (unless used with an insulin pump), insulin pens, syringes, needles, alcohol swabs, gauze, eye exams for glasses, and routine or yearly physical exams. If you use an external insulin pump, insulin and the pump could be covered as durable medical equipment. There may be some limits on covered supplies or how often you get them. Insulin and certain medical supplies used to inject insulin are covered under Medicare prescription drug coverage. Therapeutic Shoes or Inserts: Medicare covers therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease. The doctor who treats your diabetes must certify your need for therapeutic shoes or inserts. The shoes and inserts must be prescribed by a podiatrist or other qualified doctor and provided by a podiatrist, orthotist, prosthetist, or pedorthist. Medicare helps pay for one pair of therapeutic shoes and inserts per calendar year. Shoe modifications may be substituted for inserts. The fitting of the shoes or inserts is covered in the Medicare payment for the shoes. Medicare covers these diabetes services: Diabetes Self-Management Training: Diabetes outpatient self-management training is a covered program to teach you to manage your diabetes. It includes education about self-monitoring of blood glucose, diet, exercise, and insulin. If you’ve been diagnosed with diabetes, Medicare may cover up to 10 hours of initial diabetes self-management training. You may also qualify for up to two hours of follow-up training each year if it is provided in a group of 2 to 20 people, it lasts for at least 30 minutes, it takes place in a calendar year following the year you got your initial training, and your doctor or a qualified non-physician practitioner ordered it as part of your plan of care. Some exceptions apply if no group session is available or if your doctors or qualified non-physician practitioner says you have special needs that prevent you from participating in group training. Yearly Eye Exam: Medicare covers yearly eye exams for diabetic retinopathy. Foot Exam: A foot exam is covered every 6 months for people with diabetic peripheral neuropathy and loss of protective sensations, as long as you haven’t seen a foot care professional for another reason between visits. Glaucoma Screening: Medicare covers glaucoma screening every 12 months for people with diabetes or a family history of glaucoma, African Americans age 50 and older, or Hispanics age 65 and older. Medical Nutrition Therapy Services: Medical nutrition therapy services are also covered for people with diabetes or kidney disease when referred by a doctor. These services can be given by a registered dietitian or Medicare-approved nutrition professional and include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Diagnostic Tests, X-rays, and Lab Services	Medicare covers diagnostic tests like CT scans, MRIs, EKGs, and X-rays. Medicare also covers clinical diagnostic tests and lab services provided by certified laboratories enrolled in Medicare. Diagnostic tests and lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare doesn’t cover most routine screening tests, like checking your hearing. Some preventive tests and screenings are covered by Medicare to help prevent, find, or manage a medical problem. For more information, see Preventive Services.
Dialysis (Kidney)	Medicare covers some kidney dialysis services and supplies, including the following: Inpatient dialysis treatments (if you are admitted to a hospital for special care). Outpatient maintenance dialysis treatments (when you get treatments in any Medicare-approved dialysis facility). Certain home dialysis support services (may include visits by trained dialysis workers to check on your home dialysis, to help in dialysis emergencies when needed, and check your dialysis equipment and hemodialysis water supply). Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, and topical anesthetics. Erythropoiesis–stimulating agents (such as Epogen^®, Epoetin alfa), or Darbepoetin alfa (Aranesp^®) are drugs used to treat anemia if you have end-stage renal disease. For more information, see Prescription Drugs. Self-dialysis training (includes training for you and the person helping you with your home dialysis treatments). Home dialysis equipment and supplies (like alcohol, wipes, sterile drapes, rubber gloves, and scissors).
Doctor’s Office Visits	Medicare covers medically necessary services you get from your doctor in his or her office, in a hospital, in a skilled nursing facility, in your home, or any other location. Routine annual physicals aren’t covered, except the one-time “Welcome to Medicare” physical exam. Some preventive tests and screenings are covered by Medicare. See Preventive Services, and Pap Test/Pelvic Exam.
Drugs	See Prescription Drugs (Outpatient).
Durable Medical Equipment (DME)	Medicare covers Durable Medical Equipment (DME) that your doctor prescribes for use in your home. Only your own doctor can prescribe medical equipment for you. Durable Medical Equipment is (long lasting) durable, used for a medical reason, not usually useful to someone who isn’t sick or injured, and used in your home. The Durable Medical Equipment that Medicare covers includes, but isn’t limited to the following: Air-fluidized beds Blood glucose monitors Canes (canes for the blind aren’t covered) Commode chairs Crutches Dialysis machines Home oxygen equipment and supplies Hospital beds Infusion pumps (and some medicines used in infusion pumps if considered reasonable and necessary) Nebulizers (and some medicines used in nebulizers if considered reasonable and necessary) Patient lifts (to lift patient from bed or wheelchair by hydraulic operation) Suction pumps Traction equipment Walkers Wheelchairs Make sure your supplier is enrolled in Medicare and has a Medicare supplier number. Suppliers have to meet strict standards to qualify for a Medicare supplier number. Medicare won’t pay your claim if your supplier doesn’t have one, even if your supplier is a large chain or department store that sells more than just durable medical equipment.
Emergency Room Services	Medicare covers emergency room services. Emergency services aren’t covered in foreign countries, except in some instances in Canada and Mexico. For more information, see Travel. A medical emergency is when you believe that your health is in serious danger. You may have an injury or illness that requires immediate medical attention to prevent a severe disability or death. When you go to an emergency room, you will pay a copayment for each hospital service, and you will also pay coinsurance for each doctor who treats you. Note: If you are admitted to the hospital within three days of the emergency room visit for the same condition, the emergency room visit is included in the inpatient hospital care charges, not charged separately.
Equipment	See Durable Medical Equipment.
Eye Exams	Medicare doesn’t cover routine eye exams. Medicare covers some preventive eye tests and screenings: See yearly eye exams under Diabetes Supplies and Services on page 25. See Glaucoma Screening. See Macular Degeneration.
Eyeglasses/Contact Lenses	Generally, Medicare doesn’t cover eyeglasses or contact lenses. However, following cataract surgery with an implanted intraocular lens, Medicare helps pay for corrective lenses (spectacles or contact lenses) provided by a licensed and Medicare-approved opthalmologist. Services provided by a licensed and Medicare-approved opthalmologist may be covered, if they are authorized to provide this service in your state. Important: Only standard frames are covered. Lenses are covered even if you had the surgery before you had Medicare. Payment may be made for lenses for both eyes even though cataract surgery involved only one eye.
Eye Refractions	Medicare doesn’t cover eye refractions.
Flu Shots	Medicare covers one flu shot per flu season. You can get a flu shot in the winter and the fall flu season of the same calendar year. All people with Medicare are covered.
Foot Care	Medicare generally doesn’t cover routine foot care. Medicare Part B covers the services of a podiatrist (foot doctor) for medically necessary treatment of injuries or diseases of the foot (such as hammer toe, bunion deformities, and heel spurs). See Therapeutic Shoes and Foot Exam under Diabetes Supplies and Services starting.
Glaucoma Screening	Medicare covers glaucoma screening once every 12 months for people at high risk for glaucoma. This includes people with diabetes, a family history of glaucoma, African Americans age 50 and older, or Hispanic Americans age 65 and older. The screening must be done or supervised by an eye doctor who is legally allowed to do this service in your state.
Health Education/Wellness Programs	Medicare generally doesn’t cover health education and wellness programs. However, Medicare does cover medical nutrition therapy for some people and diabetes education for people with diabetes.
Hearing Exams/Hearing Aids	Medicare doesn’t cover routine hearing exams, hearing aids, or exams for fitting hearing aids. In some cases, Medicare covers diagnostic hearing exams.
Hepatitis B Shots	Medicare covers this preventive service (three shots) for people at high or medium (intermediate) to high risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant), or a condition that lowers your resistance to infection. Other factors may also increase your risk for Hepatitis B. Check with your doctor to see if you are at high to medium risk for Hepatitis B.
Home Health Care	Medicare covers some home health care if the following conditions are met: 1. Your doctor decides you need medical care in your home and makes a plan for your care at home, and 2. You need reasonable and necessary part-time or intermittent skilled nursing care and home health aide services, and physical therapy, occupational therapy, and speech-language pathology ordered by your doctor and provided by a Medicare-certified home health agency. This includes medical social services, other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home. 3. You are homebound. This means you are normally unable to leave home and that leaving home is a major effort. When you leave home, it must be infrequent, for a short time. You may attend religious services. You may leave the house to get medical treatment, including therapeutic or psychosocial care. You can also get care in an adult day care program that is licensed or certified by your state or accredited to furnish adult day care services in your state, and 4. The home health agency caring for you must be approved by Medicare. Medicare covers durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). Note for Women with Osteoporosis: Medicare helps pay for an injectable drug for osteoporosis in women who have Medicare Part B, meet the criteria for the Medicare home health benefit, and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. You must also be certified by a doctor as unable to learn or unable to give yourself the drug by injection, and that family and/or caregivers are unable or unwilling to give the drug by injection. Medicare covers the visit by a home health nurse to give the drug.
Hospice Care	Medicare covers hospice care if you are eligible for Medicare Part A, your doctor and the hospice medical director certify that you are terminally ill and probably have less than six months to live, you accept palliative (care to comfort) instead of care to cure your illness, you sign a statement choosing hospice care instead of routine Medicare-covered benefits for your terminal illness, and you get care from a Medicare-approved hospice program. Medicare allows a nurse practitioner to serve as an attending doctor for a patient who elects the hospice benefit. Nurse practitioners are prohibited from certifying a terminal diagnosis. Respite Care: Medicare also covers respite care if you are getting covered hospice care. Respite care is inpatient care given to a hospice patient so that the usual caregiver can rest. You can stay in a Medicare-approved facility, such as a hospice facility, hospital or nursing home, up to five days each time you get respite care. Medicare will still pay for covered services for any health problems that aren’t related to your terminal illness.
Hospital Bed	See Durable Medical Equipment.
Hospital Care (Inpatient) for Outpatient Services.	Medicare covers inpatient hospital care when all of the following are true: A doctor says you need inpatient hospital care to treat your illness or injury. You need the kind of care that can be given only in a hospital. The hospital is enrolled in Medicare. The Utilization Review Committee of the hospital approves your stay while you are in the hospital. A Quality Improvement Organization approves your stay after the bill is submitted. Medicare-covered hospital services include the following: a semiprivate room, meals, general nursing, and other hospital services and supplies. This includes care you get in critical access hospitals and inpatient mental health care. This doesn’t include private-duty nursing, a television, or telephone in your room. It also doesn’t include a private room, unless medically necessary.
Implantable Cardiac Defibrillator	Medicare covers defibrillators for many people diagnosed with congestive heart failure.
Kidney (Dialysis)	See Dialysis.
Lab Services	Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA)–certified laboratory enrolled in Medicare. For more information, see Diagnostic Tests.
Macular Degeneration	Medicare covers certain treatments for some patients with age-related macular degeneration (AMD) like ocular photodynamic therapy with verteporfin (Visudyne^®).
Mammogram (Screening)	Medicare covers a screening mammogram once every 12 months (11 full months must have gone by from the last screening) for all women with Medicare age 40 and older. You can also get one baseline mammogram between ages 35 and 39.
Mental Health Care	Medicare covers mental health care given by a doctor or a qualified mental health professional. Before you get treatment, ask your doctor, psychologist, social worker, or other health professional if they accept Medicare payment. Inpatient Mental Health Care: Medicare covers inpatient mental health care services. These services can be given in psychiatric units of a general hospital or in a specialty psychiatric hospital that cares for people with mental health problems. Medicare helps pay for inpatient mental health services in the same way that it pays for all other inpatient hospital care. Note: If you are in a specialty psychiatric hospital, Medicare only helps for a total of 190 days of inpatient care during your lifetime. Outpatient Mental Health Care: Medicare covers mental health services on an outpatient basis by either a doctor, clinical psychologist, clinical social worker, clinical nurse specialist, or physician assistant in an office setting, clinic, or hospital outpatient department. Partial Hospitalization: Partial hospitalization may be available for you. It is a structured program of active psychiatric treatment that is more intense than the care you get in your doctor or therapist’s office. For Medicare to cover a partial hospitalization program, a doctor must say that you would otherwise need inpatient treatment. Medicare covers the services of specially qualified non-physician practitioners such as clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants, as allowed by state and local law for medically necessary services.
Nursing Home Care	Most nursing home care is custodial care. Generally, Medicare doesn’t cover custodial care. Medicare Part A only covers skilled nursing care given in a certified skilled nursing facility (SNF) or in your home (if you are homebound) if medically necessary, but not custodial care (such as helping with bathing or dressing).
Nutrition Therapy Services (Medical)	Medicare covers medical nutrition therapy services, when ordered by a doctor, for people with kidney disease (but who aren’t on dialysis) or who have a kidney transplant, or people with diabetes. These services can be given by a registered dietitian or Medicare-approved nutrition professional and include nutritional assessment, one-on-one counseling, and therapy through an interactive telecommunications system. See Diabetes Supplies and Services.
Occupational Therapy	See Physical Therapy/Occupational Therapy/Speech-Language Pathology.
Orthotics	Medicare covers artificial limbs and eyes, and arm, leg, back and neck braces. Medicare doesn’t pay for orthopedic shoes unless they are a necessary part of the leg brace. Medicare doesn’t pay for dental plates or other dental devices. See Diabetes Supplies and Services (Therapeutic Shoes).
Ostomy Supplies	Medicare covers ostomy supplies for people who have had a colostomy, ileostomy, or urinary ostomy. Medicare covers the amount of supplies your doctor says you need, based on your condition.
Outpatient Hospital Services	Medicare covers medically necessary services you get as an outpatient from a Medicare-participating hospital for diagnosis or treatment of an illness or injury. Covered outpatient hospital services include services in an emergency room or outpatient clinic, including same-day surgery, laboratory tests billed by the hospital, mental health care in a partial hospitalization program, if a doctor certifies that inpatient treatment would be required without it, X-rays and other radiology services billed by the hospitals, medical supplies such as splints and casts, screenings and preventive services, and certain drugs and biologicals that you can’t give yourself.
Oxygen Therapy	Medicare covers the rental of oxygen equipment. Or, if you own your own equipment, Medicare will help pay for oxygen contents and supplies for the delivery of oxygen when all of these conditions are met: Your doctor says you have a severe lung disease or you’re not getting enough oxygen and your condition might improve with oxygen therapy. Your arterial blood gas level falls within a certain range. Other alternative measures have failed. Under the above conditions Medicare helps pay for systems for furnishing oxygen, containers that store oxygen, tubing and related supplies for the delivery of oxygen, and oxygen contents. If oxygen is provided only for use during sleep, portable oxygen wouldn’t be covered. Portable oxygen isn’t covered when provided only as a backup to a stationary oxygen system.
Pap Test/Pelvic Exam	Medicare covers Pap tests and pelvic exams (and a clinical breast exam) for all women once every 24 months. Medicare covers this test and exam once every 12 months if you are at high risk for cervical or vaginal cancer or if you are of childbearing age and have had an abnormal Pap test in the past 36 months. If you have your Pap test, pelvic exam, and clinical breast exam on the same visit as a routine physical exam, you pay for the physical exam. Routine physical exams aren’t covered by Medicare, except for the one-time “Welcome to Medicare” physical exam.
Physical Exams (routine) (“One-time Welcome to Medicare” physical exam)	Routine physical exams aren’t generally covered by Medicare. Medicare covers a one-time review of your health, as well as education and counseling about the preventive services you need, including certain screenings and shots. Referrals for other care, if you need them, will also be covered. Important: You must have the physical exam within the first six months you have Medicare Part B (deductibles and coinsurance apply).
Physical Therapy/Occupational Therapy/Speech-Language Pathology	Medicare helps pay for medically necessary outpatient physical and occupational therapy and speech-language pathology services when your doctor or therapist sets up the plan of treatment, and your doctor periodically reviews the plan to see how long you will need therapy. You can get outpatient services from a Medicare-approved outpatient provider such as a participating hospital or skilled nursing facility, or from a participating home health agency, rehabilitation agency, or a comprehensive outpatient rehabilitation facility. Also, you can get services from a Medicare-approved physical or occupational therapist, in private practice, in his or her office, or in your home. (Medicare doesn’t pay for services given by a speech-language pathologist in private practice.) In 2007, there may be limits on physical therapy, occupational therapy, and speech-language pathology services. If so, there may be exceptions to these limits.
Pneumococcal Shot	Medicare covers the pneumococcal shot to help prevent pneumococcal infections. Most people only need this preventive shot once in their lifetime. Talk with your doctor to see if you need this shot.
Prescription Drugs (Outpatient) Very Limited Coverage	Part B covers a limited number of outpatient prescription drugs. Your pharmacy or doctor must accept assignment on Medicare-covered prescription drugs. Part B covers drugs that aren’t usually self-administered when you are given them in a hospital outpatient department. You can get comprehensive drug coverage by joining a Medicare drug plan (also called “Part D”). For more information. The following outpatient prescription drugs are covered: Some Antigens: Medicare will help pay for antigens if they are prepared by a doctor and given by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Medicare helps pay for an injectable drug for osteoporosis for certain women with Medicare. See note for women with osteoporosis, under Home Health Care. Erythropoisis–stimulating agents (such as Epogen,^® Epoetin alfa, or Darbepoetin alfa Aranesp^®): Medicare will help pay for erythropoietin by injection if you have end-stage renal disease (permanent kidney failure) and need this drug to treat anemia. Blood Clotting Factors: If you have hemophilia, Medicare will help pay for clotting factors you give yourself by injection. Injectable Drugs: Medicare covers most injectable drugs given by a licensed medical practitioner, if the drug is considered reasonable and necessary for treatment. Immunosuppressive Drugs: Medicare covers immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare (or paid by private insurance that paid as a primary payer to your Medicare Part A coverage) in a Medicare-certified facility. Oral Cancer Drugs: Medicare will help pay for some cancer drugs you take by mouth if the same drug is available in injectable form. Currently, Medicare covers the following cancer drugs you take by mouth: Capecitabine (brand name Xeloda^®) Cyclophosphamide (brand name Cytoxan^®) Methotrexate Temozolomide (brand name Temodar^®) Busulfan (brand name Myleran^®) Etoposide (brand name VePesid^®) Melphalan (brand name Alkeran^®) As new cancer drugs become available, Medicare may cover them. Oral Anti-Nausea Drugs: Medicare will help pay for oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen. The drugs must be administered within 48 hours and must be used as a full therapeutic replacement for the intravenous anti-nausea drugs that would otherwise be given. Medicare also covers some drugs used in infusion pumps and nebulizers if considered reasonable and necessary.
Preventive Services	Medicare covers the following preventive services: Bone Mass Measurement. Cardiovascular Screening Blood Tests. Colorectal Cancer Screening. Diabetes Screenings. Glaucoma Screening. Mammogram Screening. Nutrition Therapy Services. Pap Test/Pelvic Exam. Prostate Cancer Screening. Shots on page 52 including - flu shot, - pneumococcal shot, and - Hepatitis B shot. Smoking Cessation Counseling. One-time “Welcome to Medicare” physical exam.
Prostate Cancer Screening	Medicare covers prostate screening tests once every 12 months for all men age 50 and older with Medicare (coverage begins the day after your 50th birthday). Covered tests include the following: Digital Rectal Examination Prostate Specific Antigen (PSA) Test
Prosthetic Devices	Medicare covers prosthetic devices needed to replace an internal body part or function. These include Medicare-approved corrective lenses needed after a cataract operation (see Eyeglasses/Contact Lenses), ostomy bags and certain related supplies (see Ostomy Supplies), and breast prostheses (including a surgical brassiere) after a mastectomy (see Breast Prostheses).
Radiation Therapy	Medicare covers radiation therapy for patients who are hospital inpatients or outpatients or patients in freestanding clinics.
Religious Nonmedical Health Care Institution (RNHCI)	Medicare doesn’t cover the religious portion of RNHCI care. Medicare covers inpatient nonmedical care when the following conditions are met: The RNHCI has agreed and is currently certified to participate in Medicare, and the Utilization Review Committee agrees that you’d require hospital or skilled nursing facility care if it weren’t for your religious beliefs. You have a written agreement with Medicare indicating that your need for this form of care is based on your religious beliefs. The agreement must also indicate that if you decide to accept standard medical care you may have to wait longer to get RNHCI services in the future. You’re always able to access medically necessary Medicare Part A services. The care provided is reasonable and necessary.
Respite Care	Medicare covers respite care for hospice patients (see Hospice Care).
Second Surgical Opinions	Medicare covers a second opinion before surgery that isn’t an emergency. A second opinion is when another doctor gives his or her view about your health problem and how it should be treated. Medicare will also help pay for a third opinion if the first and second opinions are different.
Shots (Vaccinations)	Medicare covers the following shots: Flu Shot: Once per flu season. You can get a flu shot in the fall and the winter flu seasons of the same year. Hepatitis B Shot: Certain people with Medicare at medium to high risk for Hepatitis B. Pneumococcal Shot: One shot may be all you ever need. Ask your doctor.
Skilled Nursing Facility (SNF) Care	Medicare covers skilled care in a skilled nursing facility (SNF) under certain conditions for a limited time. Skilled care is health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. Examples of skilled care include changing sterile dressings and physical therapy. Care that can be given by non-professional staff isn’t considered skilled care. Medicare covers certain skilled care services that are needed daily on a short-term basis (up to 100 days). Medicare will cover skilled care if all these conditions are met: 1. You have Medicare Part A (Hospital Insurance) and have days left in your benefit period to use. 2. You have a qualifying hospital stay. This means an inpatient hospital stay of three consecutive days or more, including the day you’re admitted to the hospital, but not including the day you leave the hospital. You must enter the SNF within a short time (generally 30 days) of leaving the hospital and require skilled services related to your hospital stay (see item 5). After you leave the SNF, if you reenter the same or another SNF within 30 days, you don’t need another three-day qualifying hospital stay to get additional SNF benefits. This is also true if you stop getting skilled care while in the SNF and then start getting skilled care again within 30 days. 3. Your doctor has decided that you need daily skilled care. It must be given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you are in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just five or six days a week, as long as you need and get the therapy services each day they are offered. 4. You get these skilled services in a SNF that is certified by Medicare. 5. You need these skilled services for a medical condition that was treated during a qualifying three-day hospital stay, or started while you were getting care in the SNF for a medical condition that was treated during a qualifying three-day hospital stay. For example, if you are in the SNF because you had a stroke, and you develop an infection that requires I.V. antibiotics and you meet the conditions listed in items 1–4, Medicare will cover skilled care.
Smoking Cessation (Counseling to stop smoking)	Medicare covers minimal regular doctor’s office visits, and up to 8 face-to-face visits in a 12-month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco.
Speech-Language Pathology	See Physical Therapy/Occupational Therapy/Speech-Language Pathology.
Substance-Related Disorders	Medicare covers treatment for substance-related disorders in inpatient or outpatient settings. Certain limits apply.
Supplies (you use at home)	Medicare generally doesn’t cover common medical supplies like bandages and gauze. Supplies furnished as part of a doctor’s service are covered by Medicare, and payment is included in Medicare’s doctor payment. Doctors don’t bill for supplies. Medicare covers some diabetes and dialysis supplies. See Diabetes Supplies and Services on page 146 and Dialysis (Kidney). For items such as walkers, oxygen, and wheelchairs, see Durable Medical Equipment.
Surgical Dressings	Medicare covers surgical dressings when medically necessary for the treatment of a surgical or surgically treated wound.
Therapeutic Shoes	See Diabetes Supplies and Services (Therapeutic Shoes).
Transplants (Doctor Services)	Medicare covers doctor services for transplants, see Transplants (Facility Charges).
Transplants (Facility Charges)	Medicare covers transplants of the heart, lung, kidney, pancreas, intestine/multivisceral, bone marrow, cornea, and liver under certain conditions and, for some types of transplants, only at Medicare-approved facilities. Medicare only approves facilities for kidney, heart, liver, lung, intestine/multivisceral, and some pancreas transplants. Bone marrow and cornea transplants aren’t limited to approved facilities. Transplant coverage includes necessary tests, labs, and exams before surgery. It also includes immunosuppressive drugs (under certain conditions), follow-up care for you, and procurement of organs and tissues. Medicare pays for the costs for a living donor for a kidney transplant.
Transportation (Routine)	Medicare generally doesn’t cover transportation to get routine health care. For more information, see Ambulance Services.
Travel Outside of the United States (Health Care Coverage During Travel)	Medicare generally doesn’t cover health care while you are traveling outside the United States. Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are considered part of the United States. There are some exceptions. In some cases, Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the United States. In rare cases, Medicare can pay for inpatient hospital services that you get in a foreign country. Medicare can pay only under the following circumstances: 1. You are in the United States when a medical emergency occurs and the foreign hospital is closer than the nearest United States hospital that can treat the emergency. 2. You are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest United States hospital that can treat the emergency. 3. You live in the United States and the foreign hospital is closer to your home than the nearest United States hospital that can treat your medical condition, regardless of whether an emergency exists. Medicare also pays for doctor and ambulance services you get in a foreign country as part of a covered inpatient hospital stay.
Walker/Wheelchair	Medicare covers power-operated vehicles (scooters), walkers, and wheelchairs as durable medical equipment that your doctor prescribes for use in your home. For more information, see Durable Medical Equipment. Power Wheelchair: You must have a face-to-face examination and a written prescription from a doctor or other treating provider before Medicare helps pay for a power wheelchair.
X-rays	Medicare covers medically necessary diagnostic X-rays that are ordered by your treating doctor. For more information, see Diagnostic Tests.
Source: U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services (2007). Your Medicare benefits. Retrieved September 2, 2007 from http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf

Medicare Managed Care, Prospective Payment Systems, and Other Medicare Systems

Medicaid

Long-Term Care Insurance

Veteran’s Benefits

References

Sultz, H. A., & Young, K. M. (1999). Health care USA (2nd ed.). Gaithersburg, MD: Aspen.

Organizational and Health Policy Issues

12

Advocacy for Older Adults

Health Care Delivery Systems

Reimbursement