Medicare and Caregivers

Illness and Hospitalization

Facing a chronic health condition or surgery will raise questions and increase concerns for the person you care for. Talk with this person about his or her condition and treatment, and about what the doctor said during visits. Going over the facts may relieve some concerns and give a more realistic picture of the situation. Having your support is important.

Second and Third Opinions

When a person's doctor recommends surgery or a major medical test, encourage the patient to get a second opinion -- even a third opinion. Getting a third opinion is beneficial when the first and second opinions are different. Seeing a second or third doctor can provide information that helps patients decide on the best course of action for their health.

Medicare covers second and third opinions for non-emergency surgery. Original Medicare also helps pay for certain medical tests that may be required to get additional doctors' opinions. Examples of non-emergency surgery are a gall bladder procedure, hysterectomy, hernia repair, or cataract operation. Some Medicare Advantage Plans may require the primary care doctor to give a written referral to another doctor for a second or third opinion.

Ask About “Assignment”

Always ask if a doctor or supplier accepts "assignment." Assignment is an agreement between Medicare doctors, health care providers, and suppliers to accept the Medicare- approved amount as payment in full. If a doctor or supplier does accept assignment, Medicare will pay 80 percent of the cost, and the patient pays the rest. Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.

Here’s what happens if your doctor, provider, or supplier accepts assignment.

  • Your out-of-pocket costs may be less.
  • They agree to charge you only the Medicare deductible and coinsurance amount, and usually wait for Medicare to pay its share before asking you to pay your share.
  • They have to submit your claim directly to Medicare and can’t charge you for submitting the claim.

In most cases, doctors, providers, and suppliers must accept assignment, like when they have a participation agreement with Medicare and give you Medicare-covered services.

When Does Medicare Cover Hospital Care?

If a person needs to be hospitalized, Medicare will cover inpatient hospital care when all of the following are true.

  • A doctor says the person with Medicare needs inpatient hospital care to treat an injury or illness.
  • The person with Medicare needs the kind of care that can be given only in a hospital.
  • The hospital has an agreement with Medicare.
  • The Utilization Review Committee of the hospital approves the stay while the person with Medicare is in the hospital.

If a person is hospitalized, Medicare helps pay for certain types of services:

  • Care - general nursing
  • Room - semiprivate room
  • Hospital services - meals, most services and supplies

If a person is hospitalized, Medicare does NOT pay for the following services:

  • Care - private-duty nursing
  • Room - private room (unless medically necessary)
  • Hospital services - television and telephone

For more information about Medicare Part A, visit www.medicare.gov and click on “What Medicare Covers.” Or, view or print a copy of "Your Medicare Benefits" and "Medicare & You." (Under "Forms, help, & resources,” select “Publications.”)

If You Have a Concern

If you have a concern regarding care received while on Medicare, contact your state Quality Improvement Organization, or QIO. QIOs are groups of doctors and health care experts who check on and improve the care given to people with Medicare. To get the address and phone number of the QIO for your state or territory, visit www.medicare.gov and click on “Forms, Help, & Resources” and select “phone numbers and websites.” Then select your state, and click on QIO. Or, call 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048.

Take Care of Yourself

Helping the person you care for cope with a serious health condition, especially over a long period of time, can be physically and emotionally draining. In fact, studies show that long-term caregiving is associated with an increased risk for illness in the caregiver. If you are a caregiver, there are a few things you can do. Find someone you can talk to about your feelings -- all of them are legitimate, even those that upset you. It is also important to set realistic goals. Balancing work, family, and time for yourself is difficult. Determine your priorities each day and turn to other people for help with some tasks. Carve out time for yourself, even if it is just an hour or two.

Check Out Community Resources

There should be resources in your community that can help.

  • Check the newspaper or local library to locate a caregiver support group in your area.
  • Sharing experiences with others can help you manage stress, locate resources, and reduce feelings of isolation.
  • Talk to a professional who is trained to provide counseling on caregiving issues.
  • Help may also be available through your employee assistance program at work.
  • For information about caring for someone with Alzheimer's disease, go to Alzheimer's Caregiving.

Consider Respite Care

If available, take advantage of respite care. Respite care is a service that provides temporary care for an older person. Respite care may mean help with a specific task or having health care providers care for the individual at home or in an extended care facility while you take time off. Respite services have been shown to help with caregiver stress and to allow caregivers to more effectively continue their caregiving tasks. Medicare doesn't usually pay for respite care, but other help may be available.