what medicare wont coverMoney, Money, Money 

How To Pay For What Medicare Doesn’t Cover

Our working years are spent paying taxes and saving money to pay for those blissful years of active retirement.

The Medicare program helps make our retirement years easier by covering essential healthcare services. While many American retirees count on the benefits provided by Medicare, the average retired couple may be surprised to find that it doesn’t cover everything.

In fact, the average 65-year-old couple may spend $280,000 out of pocket on their healthcare after retirement.

Medicare covers the basics, but it doesn’t include some of the most expensive parts of complete health care. Do you know what Medicare covers and more importantly what Medicare won’t cover?

Find everything you need to plan for your health below.

What Medicare Covers

The basic Medicare program consists of Part A and Part B.

Medicare Part A covers hospital stays and visits while Part B covers visits to your primary care physician and medical specialists. Medicare Part A covers the following list of expenses:

  • Hospital care
  • Nursing home care
  • Skilled nursing facility care
  • Home health services
  • Hospice care

Medicare Part B covers:

  • Medically necessary services
    • Services and supplies required to diagnose and treat a medical condition
  • Preventative services
    • Services that detect or prevent illnesses to provide early or preventative treatment
      • Ambulance services
      • Clinical research
      • Doctor visits
      • Mental health services
      • Second opinions
      • Specialist services
      • A select list of outpatient prescription drugs

Services covered by Part B vary by state and locality. Federal and state laws govern Medicare coverage and local companies manage claims in each state. These local companies assess what services are to be deemed to be medically necessary and where to extend coverage.

These coverage offer primary medical coverage, but it may be less than you expect, particularly if you had an excellent private medical plan during your working years.

What Medicare Won’t Cover

What doesn’t Medicare cover?

Original Medicare covers hospital services and doctor visits for medically necessary and preventative treatments. However, if you’ve enjoyed comprehensive health insurance during your working years, you’ll notice there are many things Original Medicare doesn’t cover like:

  • Dental care (including dentures)
  • Eye care related to glasses
  • Custodial/long-term care
  • Hearing exams
  • Podiatry

These elective services are part of comprehensive healthcare but aren’t considered medically necessary. Medicare does cover some services under the umbrella.

For example, Original Medicare may cover cataract surgery or retina-related eye health issues as long as they are medically necessary.

Does Medicare Cover Prescriptions?

Original Medicare doesn’t cover prescription drugs. Instead, the Medicare program offers prescription coverage in a secondary program called Medicare Part D Prescription Drug Plan (PDP).

Anyone enrolled in Medicare can sign up for Medicare Part D. In fact, it’s encouraged to do it immediately when you become eligible for Medicare, or you might receive a late enrollment penalty.

You may use Part D in conjunction with another form of drug coverage including coverage from your union, the VA, Indian Health Insurance, TRICARE, or a Medigap policy.

The list of drugs covered by Medicare varies by state and plan, so read the policy carefully before enrolling to find the one that works best for you.

Medicare Part D will never cover some types of drugs including drugs for erectile dysfunction, wrinkles, baldness, infertility, and obesity. Medicare also doesn’t pay for non-prescription or over-the-counter medications.

If you arrive at the pharmacy to find Medicare doesn’t cover your prescription, call the customer service number run by your Part D plan’s service provider. You’ll receive a “coverage determination” form, which is a standardized form outlining the rejection. Patients use this form to file an appeal and find a potential alternative.

Struggling with getting your prescription or unsure what to do when insurance denies medication? Contact your State Health Insurance Assistance Program for step-by-step help for dealing with Medicare bureaucracy.

How to Pay for the Rest

Medicare covers basic and necessary health needs, but it leaves out many of the more expensive health items like dentures and glasses and many prescription drugs. Additionally, Medicare comes with copays, deductibles, and other fees in addition to premiums to pay for Part B.

Medicare reduces the cost of healthcare for eligible enrollees, but healthcare isn’t free.

If you’re worried about the additional out-of-pocket costs associated with what Medicare won’t cover, then you have two options: Medicare Part C and supplemental insurance.

Medicare Part C

First, consider enrolling in Medicare Part C better known as Medicare Advantage. Private insurance companies manage this form of Medicare and simplify it to include all the Original Medicare benefits as well as Medicare Part D and often other health costs like hearing, vision, and dental coverage.

Medicare Advantage requires paying the Medicare Part B premium as well as an additional fee to the private insurance company managing the plan. However, it simplifies billing and offers a cap on expenses, so everything is covered once you hit the ceiling.

Supplemental Insurance

Medicare covers the cost of appointments and care, and providers aren’t allowed to come after patients for the balance when Medicare doesn’t include the whole cost of the appointment. What Medicare doesn’t cover is a small portion of the services. These are collected through copays and deductibles.

Enrollees who visit the doctor on a regular basis (more than once per week) may see their copays begin to add up, particularly if routine tests are required. A $50 copay every six months is manageable, but it’s devastating to those with limited, restricted incomes.

That’s where supplemental insurance steps in. Supplemental insurance is also known as Medigap. It covers copays and deductibles that Medicare doesn’t cover.

Supplemental insurance doesn’t cover programs not covered by Medicare: it only pays the fees associated with Medicare use. The program is best for those who see themselves spending more than $200 a month on Medicare fees because that is the average cost of a Medigap policy.

To learn more, visit medigap.com.

Read Between the Lines

Medicare is an excellent program to help retirees care for their health, but there are strings attached. It provides for the primary and necessary care, but expensive prescription drugs and other services like hearing, vision, and dental make comprehensive healthcare expensive.

If you read through Medicare benefits and only see what Medicare doesn’t cover, there are options. Medicare Advantage and other programs may help you get the kind of care you’ve come to expect while still availing of all the rights and benefits of Medicare.

Are you about to be eligible for Medicare? Visit our healthcare resources here.

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