Learn About Medicare Benefits in Spanish

Understanding Medicare: Basic Program Structure and Coverage Types

Medicare is a federal health insurance program designed primarily for people age 65 and older, though some younger individuals with specific conditions may participate. The program began in 1965 as part of the Social Security Act and today covers more than 66 million Americans. Learning about Medicare's basic structure helps you understand what different parts of the program cover.

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Medicare consists of four main parts, each covering different types of medical services. Part A covers inpatient hospital care, including hospital stays, skilled nursing facility care, hospice care, and some home health services. Part B covers outpatient services such as doctor visits, diagnostic tests, preventive care, and medical equipment. Part D focuses specifically on prescription drug coverage through private insurance companies approved by Medicare. Part C, also called Medicare Advantage, is an alternative way to receive Parts A and B coverage through private insurance companies that contract with Medicare.

The structure of Medicare means that most beneficiaries who enroll in Original Medicare (Parts A and B) will need to make additional choices about prescription drug coverage through Part D. Those who choose Medicare Advantage (Part C) typically receive prescription drug coverage as part of their plan, though they may need to pay more for certain services or have restrictions on which doctors they can visit.

According to the Centers for Medicare & Medicaid Services (CMS), approximately 28 million beneficiaries are enrolled in Medicare Advantage plans, while about 26 million remain in Original Medicare. This split shows that both options serve significant portions of the Medicare population.

Practical Takeaway: Understanding that Medicare has different parts helps you recognize which services fall under which coverage type. When you see information about Medicare benefits, identifying whether it relates to Part A (hospital), Part B (doctor visits), Part C (alternative plans), or Part D (prescriptions) will help you determine if it applies to your situation.

Part A Coverage: Hospital and Skilled Care Services Explained in Spanish

Medicare Part A primarily covers inpatient hospital services. When you are admitted to a hospital as an inpatient (meaning you stay overnight for medical treatment), Part A helps pay for your room, meals, nursing care, and other hospital services. Part A does not cover outpatient care when you visit a hospital for treatment and return home the same day, though those services may be covered under Part B.

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Part A also covers skilled nursing facility care, but only under specific circumstances. You must have had a qualifying hospital stay of at least three consecutive days before entering the skilled nursing facility, and a doctor must determine that you need skilled nursing or rehabilitation services. Skilled nursing facilities provide services like physical therapy, wound care, and medication management for people recovering from illness or injury. Part A covers up to 100 days of skilled nursing care per benefit period, though you may owe a daily copayment starting on day 21.

Home health services are another Part A benefit when a doctor determines you are homebound and need medical care at home. Medicare Part A covers intermittent skilled nursing visits, physical therapy, occupational therapy, speech-language pathology services, and medical social services. Durable medical equipment such as hospital beds, wheelchairs, and oxygen equipment may also be covered. However, Part A does not cover ongoing personal care assistance for activities like bathing or dressing unless skilled nursing care is also being provided.

Hospice care is covered under Part A when a doctor certifies that a person has a terminal illness with a life expectancy of six months or less. Hospice services focus on comfort and pain management rather than curative treatment. These services may include nursing care, doctor services, medications, medical equipment, and counseling services.

It is important to note that Part A includes deductibles and coinsurance amounts that beneficiaries must pay. For 2024, the Part A hospital inpatient deductible is $1,632 per benefit period. A benefit period begins when you are admitted to the hospital and ends after you have been out of the hospital or skilled nursing facility for 60 consecutive days.

Practical Takeaway: Part A covers hospital stays and certain follow-up care, but understanding the specific requirements—like the three-day hospital stay before skilled nursing care—helps you know what to expect when you or a family member receives inpatient treatment.

Part B Services: Doctor Visits, Tests, and Preventive Care

Medicare Part B covers medical services and supplies you receive outside a hospital setting. This includes visits to doctors, specialists, and other healthcare providers. Whether you see a cardiologist, dermatologist, or primary care physician, Part B helps pay for these outpatient visits when the provider accepts Medicare.

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Diagnostic tests and imaging services fall under Part B coverage. When your doctor orders blood tests, X-rays, CT scans, ultrasounds, or other diagnostic procedures to evaluate your health condition, Part B typically helps pay for these services. Laboratory work to measure cholesterol levels, blood sugar, kidney function, and other health markers is included. These services must be ordered by a doctor and performed by an approved provider or facility.

Part B includes a broad range of preventive services at no cost to you beyond the Part B premium. These include annual wellness visits with your doctor to assess your overall health and create or update a preventive care plan. Screening tests such as mammograms for breast cancer, colonoscopies for colorectal cancer, and bone density scans for osteoporosis are covered without cost-sharing. Blood pressure checks, diabetes screening, and cholesterol tests are also preventive services. Vaccinations including the flu shot, pneumococcal vaccine, and shingles vaccine (Shingrix) are covered without cost-sharing when given by a Medicare-approved provider.

Mental health services including individual and group psychotherapy, psychiatric evaluations, and medication management visits with psychiatrists or other qualified mental health professionals are covered under Part B. Substance use disorder treatment services are also included.

Medical equipment and supplies covered under Part B include items like canes, walkers, wheelchairs, hospital beds, continuous positive airway pressure (CPAP) machines for sleep apnea, and diabetic supplies such as test strips and lancets. These items must be prescribed by a doctor and obtained from a Medicare-approved supplier.

Part B beneficiaries pay an annual deductible (currently $240 for 2024) and then typically pay 20% coinsurance for most services after the deductible is met. However, preventive services have no coinsurance charge once the deductible is met for some services, though certain preventive services are covered before you meet the deductible.

Practical Takeaway: Part B covers the regular doctor visits and health screenings that form the foundation of ongoing healthcare. Knowing which preventive services are covered without cost-sharing can help you take advantage of important health screenings.

Part D Prescription Drug Coverage: How it Works and Plan Comparison

Medicare Part D provides coverage for prescription medications through private insurance plans approved by Medicare. If you are enrolled in Original Medicare (Parts A and B), you must choose a standalone Part D prescription drug plan to have coverage for most medications. Those enrolled in Medicare Advantage (Part C) usually have prescription drug coverage included in their plan, though the drugs covered and the costs may differ from standalone Part D plans.

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Part D plans use a structure called the "coverage gap" or "donut hole" that determines how costs are shared between you and the insurance plan at different spending levels. In 2024, this structure works as follows: first, you pay a plan deductible (which can vary by plan, up to $585 maximum). After the deductible, you typically pay a copayment or coinsurance for each prescription. Once combined spending by you and the plan reaches $5,850, you enter the coverage gap where you pay a higher percentage of drug costs. When your out-of-pocket costs reach $8,550, you exit the coverage gap and enter catastrophic coverage, where the plan pays most of the remaining costs.

Each Part D plan maintains a formulary, which is a list of covered medications. Formularies vary significantly between plans—a drug covered by one plan may not be covered by another, or it may require different cost-sharing amounts. Plans typically organize drugs into tiers, with Tier 1 (generic drugs) usually having the lowest copayments, and higher tiers (brand-name drugs) requiring larger copayments or coinsurance.

Some medications require prior authorization, meaning your doctor must get approval from the insurance plan before the prescription can be filled. Other drugs may require step therapy, where