What Medicare Won’t Cover

Q. When my mom turns 65, she will enroll in Medicare, as most seniors do. My understanding about Medicare is that Part A is hospital insurance and

Medicare Part B helps pay for doctors’ services and other medical services and supplies that are not covered by Part A.

My mother seems to think that Medicare covers everything, including home health services AND nursing home care. I really want to set her straight so that she isn’t blindsided and will actually plan for long-term care. Can you help clarify for my mother what Medicare does and does not cover?

A. Medicare is our country’s health insurance program for people age 65 or older. You are correct in that the program helps with the cost of health care, but it doesn’t cover all medical expenses or ANY of the cost of long-term care.

What Medicare Covers

● Hospital insurance (Part A) helps pay for inpatient care in a hospital or temporary skilled nursing facility (following a qualifying hospital stay), some minimal home health care (following a qualifying hospital stay), and hospice care (assuming your doctor has given you less than 6 months to live).

● Medical insurance (Part B) helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.

● Medicare Advantage plans (Part C) are available in many areas. People with Medicare Part C choose to receive all of their health care services through a single HMO provider.

● Prescription drug coverage (Part D) helps pay for the costs of prescription drugs.

Wellness Visits: Within the first 12 months of signing on for Part B, your mother will get a “Welcome to Medicare” visit where her weight, height and blood pressure will be measured and her body mass index calculated; she will be given a simple vision test, and her medical and social history will be reviewed. She will also be counseled about preventive services available and provided with a written plan about screenings, shots, and other preventive services that may be appropriate. After that, she will get an annual “wellness” visit that covers much of the same material, and checks for any signs of cognitive impairment. She will also get personalized health advice and a list of any risk factors and treatment options. She will pay nothing for these wellness visits as long as her health care provider accepts Medicare assignment. If she receives any additional tests, she may have to pay co-insurance and the Part B deductible may apply. If her doctor recommends other tests or services that Medicare doesn’t cover, she may have to pay some, or all, of the costs.

To see a list of the preventative and screening services covered by Medicare, click here. You can get more details about what Medicare covers from Medicare & You (Publication No. CMS-10050).

What Medicare Does Not Cover

As you can see, Medicare doesn’t cover everything. If your mother needs certain services that Medicare doesn’t cover, she’ll have to pay for them herself unless she has other insurance or is in a Medicare health plan that covers these services. Even if Medicare covers a service or item, she generally would have to pay a deductible, coinsurance, and copayments.

The following is a list of what Medicare DOES NOT Cover:

● Deductibles, Co-Pays, and Patient’s Share of the Bill: There are co-pays, deductibles, and the portion of a bill that Medicare will not cover. Uncovered Part B expenses can add up quickly, which is why many consider another monthly outlay for Medicare Supplement Insurance, also known as a Medigap policy or a Medicare Supplement Insurance policies. (See Section 6 of the “Medicare and You” Handbook, which shows in chart format the basic information about the different benefits under each category.)

● Medical Devices and Services: If your mother ends up needing dental care or hearing aids, 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 she has other insurance, or is in a Medicare Advantage Plan that covers them, she will have to pay. Please read our article about Medicare and hearing aids for more details on this topic.

● Care Outside the U.S.: If your mother likes to travel outside of the country, Medicare coverage ceases unless her Medigap policy covers her for travel.

● Hospital care: Medicare Part A covers 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. If your mother is treated in the emergency room, has outpatient surgery, or is being kept overnight for “observation,” she has not been formally admitted. Please read our most recent article on observation status for more details on the distinction.

● Home Health Services Covered in Certain Circumstances: If your mother becomes homebound, and needs a walker or a wheelchair to get around, and your doctor has a “plan of care” that specifies the need for 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, she may qualify for home health care coverage for up to 28 hours per week. In reality, most people get no more than a few hours per week of this type of care.

● Doctors Who Do Not Accept Assignment: You should check to be sure that your mother’s doctor accepts assignment, which means that the physician or health care provider has agreed to accept the amount approved by Medicare as full payment. 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. If 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 partial reimbursement. Non-participating providers can also charge more than the amount Medicare approved for a service. (Form CMS-1490S is used to submit a claim).

● Nursing Home Care: It is important to understand that Medicare does not pay one penny for long-term care. Medicare only pays for medical care delivered by doctors and hospitals, and in certain cases short-term rehabilitation which might take place in a nursing home. Medicare covers, at most, 100 days of short-term rehabilitation, and does not cover help with activities of daily living, such as eating and bathing, that the aged can need for years. Please read our blog post, “Ask the Expert: Medicare’s 100-Day Rule vs. Long-Term Care” for more details.

Medicaid Planning for Long-Term Care

What if your mother or another loved one needs long-term nursing home in the future? Long-term care in our area costs $10,000 to $14,000 a month (and as you can see from this article, it is not covered by Medicare.) To protect your mother’s hard-earned assets from these catastrophic costs, the best time to create her own long-term care strategy is NOW.

If your mother has not done Long-Term Care Planning, Estate Planning, or Incapacity Planning, she should call us as soon as possible to make an appointment for a no-cost initial consultation:

Fairfax Elder Law: 703-691-1888
Fredericksburg Elder Law: 540-479-1435
Rockville Elder Law: 301-519-8041
DC Elder Law: 202-587-2797