Before reaching Medicare eligibility, many people believe that the federal health program will provide coverage for all their medical needs. However, this is not exactly the case.
Beneficiaries can purchase supplemental Medicare coverage in the form of Advantage or Medigap policies. These plans exist because Original Medicare (Parts A and B) only cover some costs. Part A is your hospital (inpatient) insurance, while Part B is the medical (outpatient) insurance you use for doctor appointments.
What Does Medicare Cover?
The Medicare coverage you get through the government is Original Medicare – Parts A and B. However, only 80% of your costs receive coverage.
For Medicare to cover a service, your practitioner must deem it medically necessary. With Original Medicare, you can see any practitioner in the nation who accepts Medicare assignment. Fortunately, this includes the vast majority of doctors and hospitals in the United States.
The inpatient health insurance you receive through Part A covers your stays at hospitals and skilled nursing facilities. It also covers nursing home care, hospice care, and home health care.
Part B covers the preventive and medically necessary care you receive in an outpatient setting. This includes ambulance services and a limited selection of prescription drugs taken in an outpatient setting. Additionally, all mental health services (including outpatient) are under Part B.
If you have an upcoming procedure or test, or if you’ll need to purchase a health-related item soon, Medicare.gov provides a list of what it covers regardless of where you live. They also have a search function that you can utilize to learn what you’ll need to pay for more specific items and care. In each situation, make sure you discuss Medicare coverage with your doctors first.
What Does Medicare Not Cover?
As we age, we may have a greater need for dental, vision, and hearing care. Unfortunately, Original Medicare has never included this coverage. Yet, some lawmakers are fighting for all Medicare beneficiaries to have access to payment for dental, vision, and hearing services through their Original Medicare.
In the meantime, one can enroll in a Medicare Advantage plan that includes a dental, vision, and hearing component. Alternatively, you can purchase a standalone policy to pair with Original Medicare (whether or not you also have Medigap coverage).
Further, Original Medicare doesn’t cover long-term or custodial care, meaning assistance that elderly individuals require daily at home. It also doesn’t cover cosmetic surgery or holistic care.
Aside from the prescription medications you take in an outpatient setting, Original Medicare doesn’t cover prescription drugs. Thus, for the medication that you pick up from the pharmacy and take at home, you have two coverage options while you’re on Medicare.
Medicare Advantage plans include a prescription drug component. Beneficiaries who stick with Original Medicare instead of picking up an Advantage plan can enroll in a standalone Part D prescription drug plan.
Without creditable drug coverage, you can incur penalties. So, if you aren’t on your employer’s health plan anymore after reaching eligibility, or if it isn’t sufficient, your enrollment in a prescription drug plan will be considered delayed.