Industry Experts Explain What Medicare Actually Covers
Industry Experts Weigh in on Medical Services that Beneficiaries thought Medicare Paid for that Don’t
New Medicare beneficiaries tend to assume they’re fully covered by Original Medicare benefits. Unaware of the gaps in coverage, they end up finding out the hard way when they receive a medical bill in the mail. Industry Experts Explain What Medicare Actually Covers
Medicare Parts A & B only covers 80% of your medical costs. It has no out of pocket maximum and no prescription drug coverage. If you, or someone you know, only has Original Medicare, then this article pertains to you. Below, you’ll learn from industry experts as they explain what Medicare covers.
Medicare Does Not Cover it all
“We hear from many people who assume that long term care is covered by Medicare. Most are caught by surprise by that fact that Medicare does not cover long term care, only short-term rehab. This usually comes up when a loved one is no longer able to return home after a hospital stay and the shocking reality of paying privately for a care option is upon them. Another area we hear about Medicare not covering is scooters and walk-in tubs. These items are rarely covered by Medicare and once again, people are surprised by this harsh reality.” Amie Clark – Co-Founder of TheSeniorlist.com
- Medicare does not cover Long-term care or support for your personal care needs. Most long-term care is not medical care, it is help with activities of daily living or personal tasks of everyday life. Medicare does suggest visiting LongTermCare.gov for information and resources to help you plan your long-term care needs. Medicare does cover care in a long-term care hospital, skilled nursing care in a skilled nursing facility, eligible home health services, hospice and respite care. Medicare will help cover durable medical equipment (DME) like scooters, walkers and wheelchairs if you have a medical need and qualify.
“People often assume that long term care, such as that provided by a nursing home, or a home health aide, is covered by Medicare. Unfortunately, that is not the case. Medicare will only pay for some short-term services after a hospitalization. Long term care can become a massive financial burden for much of the elderly population in the United States.” – Rebecca Gilbert, MD, PhD, APDA Vice President, Chief Scientific Officer.
- Long term care not being covered can be a burden on beneficiaries and their families. I would recommend getting long-term care insurance before it is needed or too late. Many people are uninsured or underinsured, talking to an Insurance Agent to get questions answered and find the right plan for you is the best thing you can do.
“Patients and physicians are frequently confused about personal care services covered under Medicare benefits. They do not understand the difference between skilled and non-skilled home care services. For example, Medicare benefits cover a home health CNA when there is a skilled need and the patient meets home health criteria, including homebound status. Receiving this home health CNA service is temporary and can only be offered while nursing and/or therapy services are being provided, and at a low frequency (e.g. 1-2 visits per week). Non-skilled personal care services are not covered by insurance at this time and are paid privately or through special waivers. There is no time limit or guidelines as to who can receive personal care services since they are paid privately. Furthermore, DME supplies, such as transfer benches, adaptive feeding equipment and braces, are thought to be covered by Medicare, but are not. This is needed for safety in the home and should be covered to reduce further decline.” Sarah Deal – Interim Healthcare Inc
- Having affordable DME supplies is vital for the elderly and disabled. While there are some DME supplies covered by Medicare, there are strict standards and both the doctor and the DME supplier need to accept Medicare assignment.
“There are several medical services that are not covered by Medicare that can cause a problem for seniors and their families. Many people have the preconceived misconception that Medicare pays for everything. On the contrary, there are Medicare deductibles, coinsurance and copays that has spawned a whole industry of supplemental plans to fill in the Medicare “gaps”. One of the areas that is not covered by Medicare is long-term care. We see this as a surprise to people on Medicare and their families because it is an area of care that so many seniors rely on later in life. However, Medicare itself does not cover nursing homes or custodial care. Now, there are insurance plans that you can purchase to cover that type of care, but these would, ideally, need to be purchased well before those benefits are needed. Another medical service that is not covered by “original” Medicare is prescription drugs. Prescription drug coverage for Medicare beneficiaries is provided through Medicare Part D. This is always a separate plan, sold through a private company, and it must be signed up for separately (you are not automatically enrolled in prescription drug coverage in most situations). Also, if you delay enrollment into prescription drug Part D coverage, you may face higher premiums due to Medicare’s Part D late enrollment penalty. Other medical care that is non-covered by Medicare are services for routine hearing, vision and dental care. There are some related aspects of these services that are covered, such as cataract surgery for example. But overall, routine care is not covered for hearing, vision or dental – this includes hearing aids, eyeglasses, and fillings, extractions, crowns, etc. You can purchase insurance to cover these things, but Medicare itself does not cover them.” Garrett Ball – Medicare Specialist at Senior.com
- Medicare is not the most comprehensive coverage available. It does not cover many services. It is important for the Medicare beneficiary to purchase additional coverage. Some plans will include routine hearing, vision, and dental care. Part D Prescriptions Drug plans will need to be purchased through a private insurance company and you can be penalized if you are not enrolled in one when your part B goes into effect. Medicare is not the only insurance you want when something goes wrong with your health, you need to purchase additional coverage.
What you Can do to Prevent being Underinsured
Medicare does not cover everything; especially not long-term (custodial) care, routine dental, vision, hearing or prescription drugs. Working with an Insurance Agent or Counselor will help you get the coverage you need so you will be properly insured. Choose a plan that allows you to have the most consistent and reliable coverage year after year.
Looking for affordable DME products? Senior.com is a leader in the industry with affordable pricing and great customer service.
dustry Experts Explain What Medicare Actually Covers
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About the Author
Jagger Esch is the President & CEO of Elite Insurance Partners and MedicareFAQ, a senior healthcare learning resource center. As a young entrepreneur and seasoned insurance expert, he has a passion for helping people. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. Jagger lives in the Florida sunshine state and loves boating with his family on the weekends.View All Articles