Is Medicare Enough? What’s Covered and What's Not Covered?
Original Medicare covers a lot of medical treatments and services, but it doesn't cover everything. Here are some supplemental insurance plans you can buy to get the full health coverage you need.
Because you get it through the federal government, it's easy to assume Medicare covers every health and medical treatment and service a person might need.
In reality, it only covers a portion of the average U.S. senior's medical bills.
That's not to suggest the government's trying to put one over on Americans. Medicare.gov does a good job of laying out what the national health insurance program does and doesn't cover. The same is true of the other methods it uses to inform the public about Medicare's many benefits.
The thing is, you have to do a lot of reading before it's clear that Medicare Part A and Part B, often called "Original Medicare," combine forces to cover most of the care you receive in a doctor's office or hospital.
That's not all they cover, of course. Medicare Parts A and B cover quite a bit more than the basics. Specifically, they also help you pay for:
- outpatient hospital care and mental health care
- various kinds of preventive care
- some of the care you receive in a skilled nursing facility
- hospice and certain home health services
- "medically necessary" lab tests, x-rays, or other forms of imaging (like CT scans, MRIs, and ultrasounds)
- durable medical equipment and supplies such as canes, wheelchairs, sleep apnea devices, and blood sugar monitors
What about the many health and medical services and treatments that aren't included in the list above? What about prescription drugs, for instance? Or dental care? Or eye exams, glasses, and contact lenses? Or hearing aids?
Also, what about all of those deductibles, copayments, and co-insurance you're responsible for every time you go to see a doctor or have some kind of procedure done? Or what about medical care you receive while traveling outside the U.S.? Or even long-term care?
Are you simply on your own for those and other healthcare bills once you enroll in Original Medicare? Or can other types of insurance help you pay them?
Actually, you have a number of options in each of these situations. Here are the most common:
- Medicare Advantage policies (also called Medicare Part C)
- Medicare prescription drug plans (aka Medicare Part D)
- Medicare Supplement Insurance (MedSup or Medigap)
Keep reading to learn about how these supplemental forms of coverage can help you better afford the healthcare costs listed above. You'll also learn about a few other insurance options that can similarly bolster what Original Medicare provides.
Deductibles, Copayments, and Co-insurance Coverage
If you want or need help paying your Medicare deductibles, copayments, or co-insurance costs, take a look at MedSup policies.
Don't go to medicare.gov to do so, though. Private companies sell MedSup or Medigap coverage. In fact, you can buy these supplemental policies from all the insurers in your state that are licensed to sell them.
A few things to keep in mind before you sign on the dotted line for one of these plans:
- You have to be enrolled in Medicare Part A and Part B before you can buy MedSup.
- MedSup covers only one person. So, if both you and your spouse want to benefit from its extra coverage, you each have to buy your own policy.
- The extent to which MedSup pays for your deductibles, copayments, or co-insurance costs differs from plan to plan. So take your time, shop around, and read the fine print before choosing one over another.
- After you enroll, you'll pay a monthly premium to the provider of your MedSup plan as well as whatever premium you pay to the government for your Part A and B benefits.
Also, don't forget that you can't have both MedSup and a Medicare Advantage plan. In fact, it's against the law for an insurer or other private company to sell you MedSup or Medigap coverage if you already have a Medicare Advantage plan. (The only time it isn't illegal is when you're switching from Medicare Advantage to Original Medicare.)
There's a lot more to Medicare Supplement Insurance than what's mentioned here. See our Medigap and MedSup FAQ for additional information. Or read: "When Does it Make Sense to Get a Medicare Supplement Plan?"
Prescription Drug Coverage
Although Original Medicare doesn't cover prescription medications, it's easy enough to find that coverage elsewhere if you need it. (Not everyone does, by the way. Some people still have access to drug coverage from their employers or unions when they first become eligible for Medicare. If you're one of them, you can keep that coverage and not pay a penalty should you go to buy a Part D plan later.)
Medicare Prescription Drug Plans are one option. Like the MedSup policies discussed earlier, these plans are sold by insurers and other private companies that have been approved by Medicare.
Another option is Medicare Advantage. Once again, insurance companies contract with Medicare to offer these plans to Americans. Medicare Advantage plans provide more than just prescription drug coverage, however. They also provide all Medicare Part A and Part B benefits. And some cover dental, hearing, and vision care, too.
MedSup policies don't cover prescriptions. Or at least those sold after Jan. 1, 2006, don't cover them. Although policies sold before that date could include drug coverage, policies sold since then cannot.
To learn more about these plans, check out our "Ultimate Guide to Medicare Advantage Plans." Read this article, too--"Medicare Part D: Prescription drug benefits to people over the age of 65."
Dental, Hearing, and Vision Coverage
As mentioned earlier, Original Medicare doesn't cover most kinds of dental, hearing, or vision care.
Medicare Part A does pay for certain dental services you receive while you're in the hospital. And Part B covers some preventive and diagnostic eye exams, but that's about it.
They won't help pay for cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. They also won't help pay for routine eye exams, eyeglasses, contact lenses, or hearing aids.
For that, you need a Medicare Advantage plan. Or you can buy stand-alone vision, hearing, or dental plans from a number of insurance companies.
If all you need is dental coverage, check out healthcare.gov or your state's health insurance exchange. You should be able to find some stand-alone plans there, too.
Don't bother looking for MedSup policies that cover these forms of care. They rarely include vision, hearing, or dental coverage. (Just like they rarely include prescription drug coverage.)
Curious to see what your options are beyond supplemental insurance? Read this article: "Dental, Vision, and Hearing Care with Medicare." It's full of advice about groups and programs that can help you pay for this kind of care.
Long-Term Care Coverage
Considering how expensive long-term care tends to be, it shouldn't be much of a surprise to hear Original Medicare doesn't cover it. Medicare Advantage and MedSup or Medigap policies also don't cover it.
Where does that leave you if you want or need this coverage? Basically, it leaves you having to buy something called long-term care coverage.
This type of insurance can help you pay for all, or just some, of the care you receive in:
- an adult day care center
- an assisted living community
- a skilled nursing facility
It also can help you pay for home health care or homemaker services.
Long-term care benefits usually are paid by the day, week, or month. An example: your policy might pay up to $215 per day for a stay in a skilled nursing facility. Or it might pay $1,500 per week or $5,000 per month. For home health care, it might pay just a portion of the above—like $100 or so a day.
These benefits don’t pay out forever, though—or at least most of them don't. The majority of long-term care insurance policies place limits on how much they cover (a maximum dollar amount), or how long (a specific number of years) they provide coverage.
They also don't cover everything related to long-term care. Some long-term care policies don't cover certain conditions or situations. They may not cover you if you had a stroke within the last few years, for instance, or if you have a history of strokes.
A long-term care insurance policy also may not cover you if you're living with AIDS or AIDS-Related Complex (ARC). Or it may not cover you if you have Alzheimer’s disease or some other form of dementia. It's also not unusual for one of these policies to not cover people living with a progressive neurological condition like Parkinson’s disease or multiple sclerosis.
This is just the tip of the iceberg as far as this type of insurance is concerned. For more information, read up on long-term care insurance basics.
Coverage for Medical Care You Receive Outside the U.S.
Don't expect Medicare to reimburse you if you see a physician, visit a hospital, or need a drug refill while traveling overseas. Although Part A and Part B pay for some international doctor visits, hospital stays, and ambulance calls, they only do so in a limited number of circumstances.
What other types of insurance can you, as a Medicare enrollee, turn to for help with these bills? Medicare Advantage is one possibility.
As you already know, Medicare Advantage plans usually cover prescription drugs. Many cover dental, hearing, and vision care, too. Well, they also often pay for at least a portion of medical care performed outside the U.S.
That's not true of all Medicare Advantage plans, however. Some offer this kind of coverage, and some don't. If you think you might need it down the road, do your research before buying anything. Shop around. Thoroughly weigh your options.
Also, read through the "Summary of Benefits and Coverage" of any plan that piques your interest. If it doesn't make things clear, contact your insurer and ask if the plan covers you while you're outside the U.S. Don't be shy about asking for specifics. When does it cover overseas medical care? When doesn't it?
Some MedSup policies cover overseas medical bills, too. Usually, though, they limit that sort of coverage to "medically necessary emergency care." And they tie reimbursement to a handful of requirements. (One is to meet your deductible for the year. Another is to receive the emergency care during the first 60 days of your trip.)
Want to know more about this topic? See this article: "Do Medicare, Medicare Advantage, or Medigap plans pay for medical treatments in foreign countries?"
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