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Does Medicare cover all my medical expenses?
Just the essentials...
There are various types of Medicare, and each one has its own purpose to the consumer
There is such thing as a “donut hole” in coverage for those with drug prescriptions, so having supplemental coverage is essential for many
Government-issued Medicare will not offer full coverage, so you may want to consider supplemental coverage or private Medicare Advantage insurance (Part C)
Persons new to Medicare may ask the question, “Will Medicare provide coverage for all of my medical expenses?’
The short answer is “no”; however, it will cover a significant portion of a person’s medical expenses.
Thus, the challenge for the patient is to understand what Medicare, Medigap, prescription plans, and other plans will cover.
Medicare is a federal insurance program that guarantees health coverage for people 65 and older, those with extreme disabilities and infants who have significant medical problems at birth. However, the entire cost of the health coverage is not covered.
Medicare for most people will only cover 80 percent of the medical costs. Medicare will usually discount a physician or hospital charges and then paid 80 percent of the adjusted cost.
The patient will be required to pay the remaining 20 percent either out-of-pocket or through the use of a supplemental policy.
There are many things that Medicare does not cover and accordingly will not be covered by a Medicare Supplemental Policy. These items include:
Long Term Health Care or Custodial Care, such as a nursing home.
Most dental care such as routine examinations, dentures, cavities, etc.
Eye Examinations related to prescribing glasses. The cost for eyeglasses or contact lenses will not be covered.
Hearing aids and the exams needed for fitting them.
Routine foot care.
Other Items and Procedures Not Covered by Medicare
It is virtually impossible to keep track of everything Medicare may or may not cover. However, there are certain criteria that must be met.
For example, the physician has to agree to accept Medicare payments. Doctors are not required to accept the government programs.
According to the Kaiser Family Foundation, close to 90 percent of the U.S. Doctors accept Medicare patients. However, approximately 80 percent are accepting new patients and the remainder does not accept new Medicare patients.
Virtually all family doctors accept Medicare. However, only 55 percent of psychiatrists in the nation accept Medicare patients, according to a story in the New York Times referencing a study published in the Journal for the American Medical Association (JAMA).
Medicare and Hospital Payments
No one likes to spend an extended amount of time in a hospital, but sometimes it is necessary. As a result, there are some limitations regarding of hospital coverage. Medicare does not cover hospital care indefinitely, there are limitations, but there are also other options.
The following prepared by Medicare Interactive shows how Medicare and a Medicare Supplemental Policy will cover the days spent in a hospital. The following assumes that the medical deductible for each benefit period is paid. The coverage then follows these steps:
Medicare will cover the hospital stay in full for days 1 to 60 that a person is in a hospital.
For days 61-90, the patient pays a daily co-insurance. If the patient has a supplemental policy, then the co-payments should be paid by that policy.
Medicare will then pay for an additional 60 days after the first 90 days have been used.
After the final 60 days have been used, no additional coverage will be provided during the current benefit period.
The benefit period starts when you enter a hospital or skilled nursing facility. It will end when the patient has been out of the hospital or skilled nursing facility and is not receiving Medicare-covered skilled services for at least 60 days in a row.
If the patient has any Medicare supplemental insurance policy (Plans A-L) that policy will pay all hospital coinsurance and will provide an additional 365 lifetime reserve days. Plans B-J will pay the hospital deductible but does not offer the reserved days.
As noted, Medicare will pay 80 percent of approved costs, leaving the remaining 20 percent to be paid by the patient or supplemental insurance.
Medicare approved supplemental policies usually have the same restrictions as original Medicare. Therefore, if something is not covered by Medicare, the supplemental policy is not going to cover it.
Prescription Drug Coverage
Medigap or supplemental Medicare policies do not provide for doctor prescribed prescription drugs. A separate policy is needed for that.
Medicare provides a list of approved prescription plans. An individual’s choice will depend on the fees, whether your local pharmacy accepts that plan and determining if the prescriptions you take are covered by the plan you select.
It is necessary to use the tools on the medicare.gov to determine if all your medications are covered and what will be the cost.
Many of the plans offers mail-order service, but the patient is usually required to purchase a 90-day supply of each medication that is used.
Durable Medical Equipment
It is easy to think of health care as something that can be treated in a doctor’s office or hospital and may only require a short recovery stage at home.
As people get older additional health care procedures are needed. Medicare will provide a significant number of what is termed durable medical equipment that is prescribed by a physician.
These are items that are used in the home for a medical reason. Some of the more popular common devices are:
• Blood sugar monitors. • Blood sugar tests strips. • Canes, except for white canes used by the blind. • Hospital beds. • Crutches. • Manual wheelchairs. • Oxygen Equipment. • Suction pumps. • Walkers.
There are many other devices that would fall under durable equipment and would be provided to the patient by Medicare. This partial list shows some of the most used pieces of durable equipment.
Medicare Advantage Plans
Using a Medicare Advantage Plan can be beneficial in many cases. The plan will cover everything that original Medicare will cover for parts A&B. The Advantage plan may also provide a prescription drug plan and other benefits such as prescription glasses. The extra benefits will vary among plans.
The Advantage Plans operate either as an HMO, Health Maintenance Organization, or PPO, Preferred Provider Organization.
In an HMO plan, you have name a primary care physician who can refer you to needed specialists. In the PPO plan, you do not have to designate a primary care physician and do not have to get a referral before seeing a specialist.
There are limitations in the various plans and the rules vary from plan to plan. However, you do have the right to change plans at certain enrollment periods during the year or revert back to Original Medicare.
No form of Medicare will cover 100 percent of all your medical expenses. Some will have a deductible and others will have co-pays for prescriptions and various services.
Thus, it is necessary to check the plans carefully and determine what is best for your needs. Also remember, that you can change plans at certain times during the year.
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