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What Is And Isn't Covered: Understanding Your Medicare Coverage

October 19, 2023

Navigating the complex landscape of healthcare coverage can be a daunting task, especially when you're approaching retirement age.

Navigating the complex landscape of healthcare coverage can be a daunting task, especially when you're approaching retirement age. Fortunately, Medicare is here to provide a safety net for millions of Americans aged 65 and older, as well as some younger individuals with disabilities. In this article, we'll delve into what Medicare covers and explore the two main ways to get your Medicare coverage: Original Medicare and Medicare Advantage Plans.

Original Medicare vs. Medicare Advantage Plan (Part C)
Before delving into the specifics of what Medicare covers, it's essential to understand the two primary options available for coverage: Original Medicare and Medicare Advantage Plans, often referred to as Part C.

Original Medicare consists of two main parts: Part A and Part B. Medicare Part A, also known as Hospital Insurance, covers a wide range of medical services, including Inpatient Hospital Care, Skilled Nursing Facility Care, Hospice Care, Lab Tests, Surgery and Home Health Care. Let's take a closer look at what Part A covers.
What Part A Covers

Medicare Part A serves as a crucial component of your healthcare coverage, offering protection in various healthcare scenarios. In general, Part A covers the following:

Inpatient Care in a Hospital: Part A helps cover the costs of staying in a Hospital, including Room Charges, Nursing Services, Meals and more.

Skilled Nursing Facility Care: This covers Skilled Nursing Care and Rehabilitation Services provided in a Skilled Nursing Facility following a hospital stay.

Nursing Home Care: While not Long-Term or Custodial Care, Part A can help cover limited stays in a Nursing Home if it's deemed Medically Necessary.

Hospice Care: Medicare provides Hospice Care Benefits for individuals facing Terminal Illness to ensure comfort and support during this difficult time.

Home Health Care: Part A covers medically necessary Home Health Services, such as Skilled Nursing Care, Physical Therapy and Occupational Therapy.

While Medicare Part A offers substantial coverage, it's essential to remember that it doesn't cover everything. To determine if Medicare will cover a specific service or item, consult with your healthcare provider or a licensed professional. In some cases, you might require a service that's typically covered, but your provider believes it won't be covered in your particular situation. If this happens, you'll be required to read and sign a notice indicating that you may need to pay for the item, service, or supply.

Let's explore what Medicare Part B covers.
Medicare Part B extends coverage to two main categories of services: Medically Necessary services and Preventive Services.

Medically Necessary Services or supplies encompass diagnostic and treatment services that are essential to managing your medical conditions and adhere to accepted medical practice standards.

On the other hand, Preventive Services are designed to promote good health by preventing illness or detecting it in its early stages when treatment is most effective. Most preventive services under Part B come at no cost to you if provided by a healthcare provider who accepts Medicare assignment.

Understanding the scope of coverage provided by Medicare Parts A and B is crucial. However, it's equally important to be aware of what is not covered.

What's Not Covered by Part A and Part B Medicare, while comprehensive, doesn't cover everything. Here are some items and services that are not covered by Medicare Part A and Part B:

Long-Term Care (Custodial Care): Medicare does not cover Custodial Care, which involves assistance with daily activities such as bathing, dressing and eating for an extended period.

Most Dental Care: Routine Dental Care, including Cleanings, Fillings and Dentures, is typically not covered by Medicare.

Eye Exams for Prescription Glasses: Routine Eye Exams for obtaining Prescription Glasses are generally not covered.

Cosmetic Surgery: Any elective Cosmetic Procedures that aren't medically necessary are not covered.

Massage Therapy: While Massage Therapy can have health benefits, it's usually not covered by Medicare.

Routine Physical Exams: Medicare does not cover Routine Physical Exams for preventive purposes.

Hearing Aids and Exams for Fitting Them: The cost of Hearing Aids and Related Exams is usually not covered.

Concierge Care (Direct Care): Services provided by Concierge Medicine practices, where patients pay a retainer for personalized care, are not covered.

Covered Items or Services from Opt-Out Providers: Medicare generally does not cover items or services obtained from providers who have opted out of Medicare, except in Emergencies or Urgent Situations.

It's important to note that while Original Medicare (Parts A and B) offers substantial coverage, many individuals choose to supplement their coverage with additional insurance, such as Medicare Part D (Prescription Drug Coverage) and Medicare Supplement Insurance (Medigap), to fill in the gaps and provide more comprehensive coverage.

Understanding what Medicare covers is essential for making informed healthcare decisions as you approach retirement age or become eligible for Medicare due to a disability. While Medicare Parts A and B offer valuable coverage, it's equally crucial to be aware of their limitations and consider additional coverage options to meet your specific healthcare needs. Consult with a Medicare expert or healthcare provider to create a coverage plan tailored to your individual requirements and preferences.

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