You Need To Be Aware of What Your Medicare Does & Does NOT Cover

According to Gallup’s latest 2019 annual healthcare poll, 79 percent of people report their personal healthcare coverage to be “excellent” or “good,” which is a statistic that has fluctuated over the years. For those 21 percent of people who voted their healthcare coverage quality to be “poor,” their understanding of Medicare could have played a large part in their experience. Here is some Medicare information that might help better your Medicare experience. 

There are several playing parts to Medicare, and it all can be a bit confusing when not provided a clear explanation.

Medicare Part A covers: 

  • Inpatient care in a hospital 
  • Skilled nursing facility care
  • Inpatient care in a skilled nursing facility (not custodial or long-term care)
  • Hospice care
  • Home health care

Medicare Part B covers two types of services:

  1. Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and meet accepted standards of medical practice.
  2. Preventive services: Healthcare to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a healthcare provider who accepts the assignment.  

What exactly does Part B cover? 

  • Clinical research  
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
  • Inpatient
  • Outpatient
  • Partial hospitalization
  • Limited outpatient prescription drugs

But, what does Medicare NOT cover?

Long-term Care

As mentioned above, Medicare does cover a skilled nursing facility, but that is not the same thing as long-term care. Medicare only covers up to 100 days in a skilled nursing facility and that can come with a $176 daily copayment for days 21 through 100. In order to be covered, the hospital stay must follow a qualifying inpatient stay, and you must need a higher level of care than just assistance with daily living. 

Healthcare statistics tell us that 70 percent of people turning 65 this year will need long-term care at some point in their remaining years. 

Alternate Coverage: You can purchase a separate private long-term care insurance plan to help cover the costs of supportive care. The earlier you invest in this option, the lower your premiums will be. Also, you can invest in an health savings account, a tax-advantaged saving plan, to set aside money for long-term care. In these accounts, the money is free to be spent however you need, and the remaining balance passed on to your heirs. 

Routine Vision

Medicare does not cover eye exams, glasses, or contact lenses. If you are diagnosed with cataracts, Medicare will pay for surgery and one pair of corrective lenses, but further routine vision care is not covered. 

Regular eye exams are even more important as you reach your senior years. The American Optometric Association recommends annual eye examinations for everyone over age 60.

Alternate Coverage: Medicare Advantage plans generally cover routine vision care as a benefit or as a supplemental coverage with an additional monthly premium. Based on where you live, vision discount plans at low to zero cost are also available. 

Foreign Travel 

With retirement comes the freedom to travel more. When traveling abroad or across seas, you will not have Medicare, even for emergency care. Exceptions to this rule are when traveling to Alaska through Canada or if you are near a border and a foreign hospital is closer than one based in the U.S.

For many frequent flyers, this can be very alarming. One serious emergency could leave you with hundreds of thousands of crazy medical bills. 

Alternate Coverage: Medigap plans often include some sort of coverage for overseas travel medical emergencies. Although, there is a $50,000 coverage cap over the course of your lifetime. Also, many foreign hospitals request upfront cash payments, which leaves you to request reimbursement once you return to the United States. 

Many Medicare Advantage plans include some care aid outside of the states, but again, foreign health providers aren’t required to accept this form of payment. 

In most cases, it is a good idea to travel with a travel health policy if you plan on going overseas. These plans are generally affordable and cover most medical care, such as evacuations and transports, and often even cover other travel emergencies like lost luggage and canceled flights. 

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Routine Dental Care

Unfortunately, Medicare Part A and B do not cover routine dental care visits. Medicare only covers “medically necessary” dental services such as if you have oral cancer and need surgery as a part of your treatment. Routine dental care is only covered if deemed necessary for clearance for a heart surgery. 

According to the CDC (Centers for Disease Control and Prevention), 96 percent of adults 65 years or older have had one cavity. Two out of three older adults suffer from gum disease. Nearly one in five adults 65 years or older have lost all of their teeth. Dentures are also not covered by Medicare.

Alternate Coverage: There are a plethora of companion dental plans on the market for seniors today. These range from discount plans for common dental care needs to full coverage dental plans. 

Medicare Advantage plans also exist with dental care benefits. These plans typically cover routine exams and cleanings at 100 percent, with or without a copay. Many also offer set payment plans to go towards other procedures such as fillings, crowns, bridges, dentures, and extractions.   

Hearing Care

Very few insurance plans cover hearing aids, let alone routine hearing care. This means that 100 percent of the cost of hearing exams, hearing aid fitting, and the hearing aids themselves is out of pocket. 

According to the National Institute of Deafness and Other Communication Disorders (NIDCD),  one-third of seniors between ages 65 and 74 have hearing loss, and half of those age 75 and over are hard of hearing. Few insurance plans cover hearing aids; the average person spends about $2,700 out-of-pocket for a pair.

Alternate Coverage: Medicare Advantage plans have benefits for hearing care and discounts for hearing aid devices. This might be in the plan or an additional monthly premium. 

Prescription Drugs

Lastly, Medicare does not cover drugs that you pick up yourself at a retail pharmacy. 

Though costs for generic medications have dropped by nearly 40 percent over the past five years, costs for brand-name and specialty drugs increased by almost 60 percent. Over 90 percent of seniors take at least one prescription and 54 percent report on taking four or more daily medications. 

Even if you supplement your Medicare with Medigap (or Medicare Supplement Plan), you’re on your own for prescription medications. Medigap doesn’t cover your out-of-pocket costs for prescription drugs unless they’re covered under Part A or Part B.

Alternate Coverage: Part D Prescription plans are your best option, but if you do not enroll with Part D when you enroll with Medicare, there will be a late enrollment penalty fee.

Note: Other things that are not covered by Medicare are cosmetic surgery, routine foot care, and acupuncture. 

Medicare coverage is based on three main factors:

  1. Federal and state laws
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
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