Above: It’s important to know what’s not covered by Medicare. Photo by Pixabay
There’s a lot to learn about Medicare and what the program covers. One of the most important things to find out is what Medicare doesn’t cover. That’s the best way to know how to protect both your health and finances.
Watch for “observation”
Today, hospitals are required to provide information to patients stating any “observation status.” Although you may be in a hospital bed, or in a critical access hospital, you may still be considered as an “outpatient” for billing purposes.
That’s a surprise to many Medicare patients. And even more so to their children who thought their parents were protected.
If you go to a rehab facility or a nursing home (unless you were admitted as an in-hospital patient before the transfer), the high cost of rehab could mean family bankruptcy. According to an AARP study, of the 2.1 million people who were in hospitals under observation status in 2015, about 150,000 were discharged with instructions to go to a skilled nursing facility for rehab or other skilled care. Only 50,000 did so. Some paid the tab out-of-pocket, says AARP. Others did without the care they needed so they could save money.
Vaccines are not always free
Dr. Mark Perloe received a surprise bill for vaccines required by his volunteer activities at a children’s hospital recently. He needed specific shots for volunteering with his dog through Happy Tails Pet Therapy.
He says his last-minute surprise came to a $432 bill for shots before he could visit a children’s hospital with his mini-goldendoodle Andrew.
“My T-dap [Tetanus, diphtheria and pertussis]was covered,” said Perloe, “but the insurance company would not pay for the MMR [mumps, measles and rubella].”
Why not? Well Part B, Part C and Part D can be confusing when it comes to immunizations and vaccines. Medicare’s annual flu shots are covered by Part B — as are pneumonia and hepatitis B shots.
However, other shotsare only covered if they are directly related to the treatment of an injury or direct exposure, according to the American Academy of Family Physicians website.
Part B covers vaccines after you have been exposed to a dangerous virus or disease. For example, Part B will cover a tetanus shot if you step on a rusty nail or a rabies shot after a dog bite.
Payment for Part D-covered vaccines and their administration are made by each person’s participating prescription drug plan (Part D). If you have a Medicare Advantage (Part C) plan, it may vary from company to company — and year to year. Perloe was on Part C at the time.
Bridges that fall down
Do not look to Medicare to cover most dental care, dental procedures or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates or other dental devices — even bridges.
I lost a 20-year-old bridge about six years ago, which required a permanent tooth implant and three oral surgeries. After accruing a $6,000 bill, I learned that none of the expenses were covered.
Part A, however, will pay for certain dental services that you get when you’re in a hospital. (Perhaps you were admitted for an over-the-handlebars bicycle accident where you were admitted to a hospital with serious facial damage.)
What did you say?
If you notice your hearing isn’t quite what it used to be, remember that Medicare Part B (Medical Insurance) will only cover the following:
- A hearing and balance exam — IF your doctor or other healthcare provider orders it to see if further medical treatment is required.
- Hearing aids or hearing aids fittings are NOT covered – in other words, you pay 100 percent for exams and hearing aids. However, many providers offer free screenings.
- Some ear-related coverage following a serious head injury might be approved. Every situation is different. Hospital outpatients will also pay the hospital copay.
Medicare doesn’t cover routine eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses. But Medicare Part B covers some preventive and diagnostic eye exams, such as glaucoma tests and exams to rule out macular degeneration every year.
The good news is separate supplemental policies are available that might have affordable plans, which could cost little or no more than you might expect to pay out of pocket. Another consideration is Medicare Advantage (Part C) plans often provide some extra coverage (like vision, hearing, dental and/or health and wellness programs), according to Medicare.gov.
Do you need travel insurance?
You may have Medicare (and hopefully a supplement plan), but there’s still more to consider before your next international trip.
Medicare’s hospital insurance (Part A and Part B) will not cover your healthcare services or supplies outside of the U.S. (although there are a few rare exceptions) according to Medicare.gov.
Many supplemental insurance companies will wait to see what Medicare covers before paying their portion. When making travel plans, Medicare suggests the following:
- Check your Medigap policy to see if it includes coverage when traveling outside the U.S.
- Review other Medicare health plans (such as a Medicare Advantage coverage) and learn how they handle medical bills if you’re outside of the U.S.
- Purchase a travel insurance policy that includes health coverage if you have limited or no overseas coverage.
- Remember: if you’re looking for Medicare coverage, all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa are part of the U.S.
So, is Medicare good or bad?
All in all, Medicare is still pretty great, says Danielle Kunkle, in an online article for “Boomer Benefits.”
“While no program is perfect, we see people who are spending over a thousand dollars a month on [their] COBRA benefits,” states Kunkle. For them, Medicare is a welcome plan.
COBRA, (the Consolidated Omnibus Budget Reconciliation Act) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their employer’s group health plan if they’re not Medicare eligible. (The plans are for limited periods of time under certain circumstances and known to be expensive.)
For today’s seniors, Medicare delivers a guaranteed level of insurance to people who might not otherwise be able to afford it, says AARP. Before Medicare, about half the older population had no coverage at all, according to the organization.
Seniors may still pay thousands of dollars a year for healthcare, but access is vastly better than before Medicare.
Where to Learn More
The annually revised booklet “Medicare & You” makes coverage for Part A and B groups as clear as possible. Even if Medicare does cover a service or item, a deductible, coinsurance and copay may still be yours.
Medicare.gov offers a list of the main services not covered:
- Long-term care (also called custodial care)
- Most dental care
- Eye exams related to prescribing glasses
- Cosmetic surgery
- Hearing aids and exams for fitting them
- Routine foot care
Important Note: This is general information to help older adults begin learning about Medicare. For specific and personal information, contact Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.