Don’t Be Blindsided: What Medicare Won’t Cover

Published In Government Programs

September 13th, 2015

Your parents are enrolled in Medicare and they’re insured for hospital, outpatient visits and drugs, so their basic health needs are covered.

Well, yes and no. Don’t be blindsided. There are some glaring gaps in coverage–especially when it comes to an aging population–and you should be aware of those gaps and what you can do to avoid them.

Deductibles, Co-Pays and Patient’s Share of the Bill
Medical Devices and Services That Medicare Doesn’t Cover
Nursing Home Coverage is Limited
Home Health Services Covered in Certain Circumstances
Does Your Doctor Accept Assignment?
An Ounce, or Two, of Prevention – Wellness Visits Usually Covered

Deductibles, Co-Pays and Patient’s Share of the Bill

First are the co-pays, deductibles, and the portion of a bill that Medicare will not pay. Those uncovered Part B expenses can add up quickly, which is why you should consider another monthly outlay for Medicare Supplement Insurance, also known as a Medigap policy. The two terms are interchangeable. Some insurance companies call them Medicare Supplement Insurance policies, and some call them Medigap policies.

If your parents have been on Medicare for any period of time, they may already have purchased a Medigap policy–unless they have Part C, a Medicare Advantage Plan, in which case they can’t have Medigap insurance, by law. Medigap policies are standardized–in most states they go by an alphabet designation that determines what is covered: A through D, F, G, and K through N. (See Section 6 of the “Medicare and You” handbook, which shows in chart format the basic information about the different benefits under each alphabet category.)

Different insurance companies charge different premiums for the same coverage. A licensed insurance agent can help you compare plans offered by different insurance companies and guide your election since, all things being equal, the only difference in Medigap insurance for the most popular option, Plan F, for instance, is the cost of the monthly premium.

Medical Devices and Services That Medicare Doesn’t Cover

Once you’ve taken care of the potentially costly blindside problem for Part B, you need to be aware of some things Medicare does not cover. For instance, if your parents need dental care or hearing aids, Original Medicare does not cover these needs under Part B, nor does Part B cover eye exams for prescription glasses, dentures, cosmetic surgery or acupuncture. Unless you have other insurance, or are in a Medicare Advantage Plan that covers them, you will have to pay.

Too, if your parents like to travel outside of the country, Medicare coverage ceases unless their Medigap policy covers them for travel. Note that six of the alphabet Medigap plan choices cover up to 80 percent of foreign travel emergency care, something to consider when selecting your alphabet plan (Note that Plan F does provide the 80 percent coverage). Another option is to purchase separate travel policies.

Hospital care is another area where you might be blindsided. Part A does cover hospital care in a semi-private room, with meals, nursing and drugs included–but only if you have been admitted to the hospital. Be careful here. Staying overnight in a hospital doesn’t necessarily mean you have been admitted as a patient. Even if your parent is treated in the emergency room, has had outpatient surgery, or is being kept overnight for “observation,” your parent has not been formally admitted.

If your parents are in this situation, you need to find out if they are an in-patient or an outpatient. It affects what you pay and eventually may even affect whether your parent qualifies for Part A coverage in a skilled nursing facility.

Nursing Home Coverage is Limited

Which leads to another situation where you may be blindsided. Medicare pays for care in a skilled nursing facility, more commonly known as a nursing home, only under certain circumstances and for a limited period of time. In other words, Medicare does not pay for custodial long-term care.

Medicare does pay for care in a skilled nursing facility after your parent has had a “medically necessary” stay in a hospital for at least three days–that’s why it is important to be formally admitted to the hospital–if your parent’s doctor certifies that your parent needs daily skilled care–physical therapy or IV injections qualify. Then Medicare pays full costs for the first 20 days, a coinsurance per day for days 21-100, and your parents pay full cost every day after 100 days. (The Medicare.gov website lays this out in detail.)

Home Health Services Covered in Certain Circumstances

If your parents are homebound, need a walker or a wheelchair to get around, and your doctor has a “plan of care” that specifies they need skilled nursing care delivered by a home health aid to assist with such “activities of daily living” as bathing and dressing, or part-time speech, occupational or physical therapy, your parents qualify for home health care coverage for up to 28 hours per week.

Medicare now pays for these services for those with chronic conditions, such as multiple sclerosis or Parkinson’s disease, in order to prevent a condition from deteriorating. Before this change, Medicare only covered chronic conditions for those expected to make a full recovery.

Note, though, that Medicare will not pay for home health services if your parents do not need skilled nursing or skilled therapy, will only pay if they use a Medicare certified home health agency, and if their doctor renews the care plan every 60 days. (For Medicare beneficiaries, Medicare Home Health Compare lists certified home health agencies. With a Medicare Advantage Plan, the plan can advise which providers it uses).

So, you need to be alert to what Medicare covers and what it doesn’t cover, what you need to do to fill in the coverage gaps, and be alert to any changes so you can help your parents get the best coverage.

Does Your Doctor Accept Assignment?

Here’s another potential blindside. You should check to be sure that your parent’s doctor accepts assignment, which means that physician or health care provider has agreed to accept the amount approved by Medicare as full payment. (Check with Medicare Physician Compare or Medicare Supplier Directory to determine if a particular provider accepts assignment).

Providers who accept assignment submit the claim directly to Medicare and have agreed to charge you only the Medicare deductible and coinsurance amount, and will usually wait until Medicare pays (and that can be slow) before charging you for your share.

When your doctor doesn’t accept assignment, you may be asked to pay the entire charge at the time of service, and you may have to submit your own claim to Medicare to get paid back. Non-participating providers can also charge more than the amount Medicare approved for a service. (Form CMS-1490S is used to submit a claim).

An Ounce, or Two, of Prevention – Wellness Visits Usually Covered

Your parents and their physicians may be among those who believe an annual physical exam is essential. Not only does the annual physical reassure that you are healthy but, in theory, it also provides an opportunity to pick up problems early and avoid even more serious complications in the future.

At least as far as Medicare is concerned, the annual physical is past history and has been replaced by “wellness” visits. Within the first 12 months of signing on for Part B, you get a “Welcome to Medicare” visit where your weight, height and blood pressure are measured, your body mass index calculated, you are given a simple vision test, and your medical and social history are reviewed. You are also counseled about preventive services available and provided with a written plan about screenings, shots and other preventive services that may be appropriate.

After your “welcome,” you get an annual “Wellness” visit that covers much of the same material but also updates your list of health care providers and prescriptions, and checks for any signs of cognitive impairment. You also will get personalized health advice and a list of your risk factors and treatment options. Your parents pay nothing for these wellness visits as long as their health care provider accepts Medicare assignment, but if they receive any additional tests, they may have to pay coinsurance and the Part B deductible may apply. If their doctor recommends other tests or services that Medicare doesn’t cover, they may have to pay some, or all, of the costs.

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