What Traditional Fee-for-Service Medicare Pays

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Medicare

Medicare has separate methods of payment for Part A and Part B: Part A provides coverage based on benefit periods; Part B covers you on a calendar year basis.

Part A: Each category of service (see following table) has its own schedule of payments based on a benefit period. For example, the benefit period for hospitalization begins the first day you are admitted and ends after 60 consecutive days. If you are admitted from the hospital directly to a skilled nursing facility where you remain, the benefit period does not end until you've not received skilled care for 60 consecutive days. Each time a new benefit period begins, you are responsible for paying the deductible (see table below).

Part B: You have a deductible every calendar year ($198 in 2020 ($185 in 2019). After that, Medicare pays between 80 and 100% of the approved amount (see following table). Many doctors and other service providers accept what is known as "on assignment," meaning Medicare's approved schedule of charges is considered payment in full. Otherwise, you may have to pay for charges above what is approved by Medicare, although Medicare does limit how much a doctor can exceed its approved limits.

Medicare Part A: Hospital Insurance*

Services	Benefit	Medicare Pays	You Pay (2020 figures)
Hospitalization Semi-private room, meals, general nursing, other hospital services and supplies.	First 60 days	100% of approved amount after you pay your portion.	$1,408 deductible for each benefit period. Zero co-insurance for first 60 days
	61st to 90th day	100% of approved amount after you pay your portion.	$352 per day
	91st to 150th day ⁽¹⁾	100% of approved amount after you pay your portion.	$704 per day
	Beyond 150 days	Nothing	All costs
Skilled Nursing Facility Care ⁽²⁾Semi-private room, meals, skilled nursing and rehabilitative services, other services and supplies ⁽³⁾	First 20 days	100% of approved amount	Nothing
	Additional 80 days	100% of approved amount after you pay your portion.	up to $176 per day
	Beyond 100 days	Nothing	All costs
Home Health Care Part-time skilled nursing care, physical therapy, occupational therapy, speech-language therapy, home health aide services, durable medical equipment and medical supplies and other services	No limit as long as you meet Medicare criteria	100% of approved amount; 80% of approved amount for durable medical equipment	Nothing for home health care services; 20% of approved amount for durable medical equipment
Hospice Care Services for the terminally ill including drugs for symptom control and pain relief, medical and support services, and other services	Unlimited as long as doctor certifies need	All but limited costs for outpatient prescription drugs and inpatient respite care	Limited costs: A co-payment of up to $5 for outpatient prescription drugs and 5% of the approved amount for inpatient respite care
Blood	Unlimited	All but first 3 pints per calendar year	For first 3 pints (unless you or someone else donates blood to replace what you used)

*Source: U.S. Department of Health and Human Services.

This 60-day reserve benefit can be used only once in a lifetime.
To qualify, you must be admitted to a Medicare-approved facility generally within 30 days after being discharged from a hospital where your stay lasted at least 3 days.
Neither Medicare nor private Medigap insurance will pay for most nursing home care.

Medicare Part B: Medical Insurance*

Services	Benefit	Medicare Pays	You Pay (2020 figures)
Medical Expenses Physician's services, outpatient medical and surgical services, physical and speech therapy, diagnostic services	All medically necessary doctor's services in and out of the hospital	80% of approved amount (after $198 deductible, paid once per calendar year.	$198 deductible, paid once per calendar year, plus 20% of approved amount, and limited charges above approved amount. *
Clinical Laboratory Services Blood tests, urinalysis, biopsies, etc.	All medically necessary services	Generally 100% of approved amount	Nothing for approved services
Home Health Care Part-time or intermittent skilled nursing care, home health aide services, medical equipment and supplies and other services	No limit as long as you meet eligibility criteria	100% of approved amount; 80% of approved amount for durable medical equipment	Nothing for services; 20% of approved amount for durable medical equipment
Outpatient Hospital Treatment Services for the diagnosis or treatment of illness or injury	Unlimited if medically necessary	Based on hospital cost	A coinsurance or co-payment amount which may vary according to the service. No copayment for a single service can be greater than the Part A hospital deductible.
Blood	Unlimited if medically necessary	80% of approved amount (after $198 deductible and starting with 4th pint)	First 3 pints plus 20% of approved amount for additional pints (after $198 deductible) or you pay nothing if you or someone else donates blood to replace what you used. Additionally there may also be a co-payment involved.

* Source: U.S. Department of Health and Human Services** A person pays for charges higher than the amount approved by Medicare unless the doctor or supplier agrees to accept Medicare's approved amount as the total charge for services rendered.*** In 2020, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits.

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