What Medicare Parts A and B Leave Out: A Medicare Customer Question
Both programs expose clients to many coverage holes.
With the increase of Medicare premiums, consumers should know what services are covered and not covered by Medicare plans to determine which one is best for them.
Medicare Part A is hospital insurance that helps cover inpatient hospital and skilled nursing facility stays, surgery, hospice care, and some home health care.
Medicare Part B is medical insurance that covers doctor visit bills, outpatient care bills, some preventative services, and some essential equipment.
Thus, it is important to explore gaps in coverage to decide if Medicare Advantage (Part C), Medicare Part D (prescription drug plan), or Medicare supplement insurance should be incorporated into a beneficiary’s health plan.
The Question
What type of care isn’t covered by Medicare?
The Answer
Medicare Part A and Medicare Part B, also known as Original Medicare, does not cover the following services:
- Prescription drugs.
- Long-term care.
- Deductibles and copays.
- Hearing aids.
- Routine vision care, including eyeglasses/contact lenses.
- Routine dental care, including dentures.
Original Medicare does not cover most prescription drugs; however, one can sign up for Part D or Medicare Advantage during the annual open enrollment season, which runs from Oct. 15 through Dec. 7, to fill this gap.
Exceptions to the Exceptions
Medicare Part B covers outpatient drugs in certain circumstances.
Drugs covered under Medicare Part B are typically administered at a doctor’s office or in a hospital outpatient setting.
Examples include drugs used with an item of durable medical equipment and injectable osteoporosis drugs.
Long-Term Care Risk
Long-term care often accounts for the highest out-of-pocket costs.
Extended nursing home stays, assisted living facility stays, and custodial care are not included in Original Medicare coverage.
Medicare Part A covers highly specialized skilled nursing facility care for up to 100 days over the course of a beneficiary’s benefit period.
Medicare fully covers if one has received inpatient hospital care for at least three days and if one is admitted into a facility generally within 30 days of leaving the hospital.
For long-term care, it is important to keep in mind that Medicare Advantage also does not cover many of these bills either.
Private long-term care insurance is the best option in this case.
The Hole Story
Original Medicare covers hospital stays, doctors’ services, and outpatient care; however, beneficiaries are responsible for deductibles and copayments.
The Part A deductible is $1,556, and for extended hospital stays, beneficiaries are required to pay $389 per day from days 61 through 90 and $778 for stays longer than 90 days.
Beneficiaries should be mindful of “lifetime reserve days.” Medicare pays for 60 days beyond the 90-day limit.
Once this limit is reached, beneficiaries are required to pay the full hospital visit.
Beneficiaries seeking doctors’ services, lab tests, and X-rays under Part B have to pay 20% of costs after a $233 deductible.
This is where a Medigap or Medicare Advantage plan can supplement costs if one does not have other coverage.
Eyes, Ears and Teeth
Hearing aids, routine vision care, and routine dental care are not covered by Original Medicare.
This includes the exam required to choose and fit hearing aid devices, unless a doctor conducts an exam in an emergency or to determine if a patient needs urgent medical treatment, such as in instances to diagnose dizziness or vertigo.
The same emergency principle applies to vision care since eyeglasses and contact lenses are not covered.
Medicare Part B may cover tests and treatments for certain serious eye conditions, such as macular degeneration, glaucoma, and cataracts.
Dental cleanings, fillings, dentures, and most tooth extractions are not covered and will require a separate dental insurance policy.
..
..
..
(Image: Adobe Stock)