No Medicare! Does Not Pay For Everything!

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No Medicare! Does Not Pay For Everything!
One of the most frequently asked questions by Medicare beneficiaries involves "Is this service or item covered by Medicare?" The Medicare program and associated Medicare health plans are extremely complex and most mature adults have difficulty understanding and remembering all of the rules, regulations and coverage.

Medicare does not cover everything. Health care services or supplies need to be medically necessary according to accepted standards of medicine to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms; therefore, if they are deemed "medically unnecessary" by health care officials, they will not be covered. If you need certain services, treatments or supplies not covered by Medicare, you will have to pay for them privately or use supplemental health insurance (such as Medicaid, employer-based health care coverage, Medigap or Medicare supplemental insurance policy, or Medicare Advantage Plan) to cover the costs.

Even if Medicare covers a service or item, you generally have to pay deductibles (an amount you pay before Medicare or your insurance begins to pay), coinsurance (your share of the cost of services after you pay any deductible as a percentage), and copayments (your share of the cost of a medical service or supply, like a doctor's visit, drug cost, etc.).

Medicare does not cover skilled nursing or rehabilitation care for a Medicare patient:

• Who was an inpatient in a hospital for less than three days, even if the admission was medically necessary.

• Does not require daily skilled care or physical therapy.

• After the 100th day in a benefit period (a benefit period ends when a person has not received any skilled care in a skilled nursing facility for at least 60 days in a row, so if you go into a skilled nursing facility after one benefit period has ended, a new benefit period begins).

In most cases, Medicare does not pay for custodial care in the home, inpatient hospital setting or in a nursing home. Custodial care is nonskilled personal assistance with the activities of daily living, such as eating, bathing, dressing, toileting, personal hygiene and mobility.

Medicare and most health insurance plans do not pay for long-term care for Medicare patients at home, in the community, in assisted living centers or in nursing homes. A person can pay for long-term care privately with coverage from a long-term care insurance policy, or through Medicaid if the patient is qualified.

The following are not covered by Medicare, although coverage may be available through some Medigap or Medicare Advantage Plans:

• Routine dental care or dentures.

• Routine eye care. Medicare does cover one pair of eyeglasses with standard frames or one set of contact lenses following cataract surgery that involves implantation of an intraocular lens, subject to deductibles and co-insurance.

• Routine foot care.

• Hearing aids and exams for fitting them.

• Acupuncture services.

• Experimental procedures.

• Cosmetic surgery (unless it is required to improve function).

• Nonemergency transportation.

• Health care while a person is traveling outside of the United States or its territories.

Medicare recipients may receive prescription drug coverage through adding a Medicare Prescription Drug Plan (Part D) or getting a Medicare Advantage Plan (Part C) that offers Medicare prescription drug coverage. Prescription drugs listed on your plan's formulary are covered by Medicare after the yearly deductible is met (if applicable) and any coinsurance payment from you has been applied. If you reach the coverage gap (known as the "donut hole") of your Medicare drug plan, you will have to pay for a percentage of the cost of the medications until you reach the end of the coverage gap. You will be provided with written notice if your Medicare Prescription Drug plan makes a determination the requested drug is not covered. You have a right to file a request for an expedited appeal of this determination.

2 thoughts on “No Medicare! Does Not Pay For Everything!

  1. I can say one thing, don’t even attempt to get mental health services after
    65. It’s like they are saying, “GO AND DIE, ALREADY!” They don’t want a
    bunch of old crazies coming to their offices. BTW, all people who need
    mental health services are NOT crazy. Some suffer from things like
    depression and anxiety.

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