Medicare has gaps in coverage despite congressional efforts to expand it

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If Democratic lawmakers get what they want, Medicare will begin covering hearing services for the first time in the history of the program.

The coverage, which would come into effect in 2023, is included in the Democrats’ $ 1.85 trillion spending bill, dubbed the Build Back Better Act, and in part aimed at strengthening the social safety net. The legislative package still needs to be approved by both the House and the Senate before it can be enacted by President Joe Biden.

However, hearing is not the only gap in coverage. Along with many new registrants who find out that Medicare isn’t free – far from it – they may also be surprised that it doesn’t cover a variety of healthcare expenses that can hit retirees quite hard.

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About 63.3 million people are enrolled in Medicare. Most of them are 65 or over (55.1 million) and the rest are generally younger and permanently disabled.

Some low-income people are eligible for programs that reduce their health insurance costs. There is additional help with prescription drug coverage, and some state-run savings programs can help with co-payments, coinsurance, deductibles, and premiums.

For those who do not qualify, paying out of pocket for uncovered services or purchasing additional insurance are their options.

Here is what you need to know.

First, the ABCs (and D) of Medicare

Basic or original health insurance consists of parts A and B. You must enroll when you turn 65, unless you have qualifying health insurance elsewhere (i.e. say through an employer).

Part A covers hospital stays, skilled nursing care, palliative care and some home health services. As long as you have at least 10 years of professional experience contributing to the system, you pay no premium for Part A. However, it comes with a deductible ($ 1,484 this year and approximately $ 1,556 in 2022) by benefit period and with a ceiling on benefits.

“A surprise is that the Part A deductible is not a deductible per calendar year but a deductible per benefit period, which means you may have to pay it more than once if there are 60 days or more between hospital stays, ”Danielle said. Roberts, co-founder of insurance company Boomer Benefits.

Part B coverage begins when you see a doctor or receive other outpatient services, such as a flu shot. It also covers medical equipment, such as crutches or blood glucose monitors.

This year, the standard monthly premium for Part B is $ 148.50 and is expected to reach $ 158.50 in 2022. (However, higher income beneficiaries pay more.) It also comes with a deductible of 203. $ this year (estimated at $ 217 in 2022). Once this is reached, you typically pay 20% of covered services.

Basic health insurance does not cover prescription drugs. You can get this coverage through Part D, either as a stand-alone plan with its own premium, or through a Medicare Advantage (Part C) plan, which may also have a higher premium than what you pay for Part B.

If you opt for an Advantage plan, your Part A and B coverage would also be provided through the private insurance company offering the plan.

Also note that there is no limit on personal expenses for basic health insurance. There is also none for Part D prescription drug coverage, although the Democrats’ spending bill would limit it to $ 2,000 per year.

Teeth, eyes and ears

While the Democrats’ spending plan would add hearing care to Medicare, routine dental and vision care would remain uncovered despite earlier versions of the bill including it.

This means that basic health insurance does not cover dentures, which can range from around $ 1,000 to $ 5,000 for a full set. And while a routine cleaning and x-ray can cost you around $ 200 and a filling costs around $ 150 or $ 200, a single dental implant can cost over $ 4,000.

However, if a dental issue involves an emergency or a complicated procedure, it could be covered.

The same goes for routine vision checks. If you need glasses, it’s usually not covered. However, if you have an eye condition like glaucoma or cataracts, basic health insurance will cover your care.

If you do decide to opt for an Advantage plan, chances are good that dental, hearing and vision care will be included, although coverage may not be comprehensive.

You can also purchase a separate policy that gives you more coverage.

Stand-alone vision plans can cost around $ 10 to $ 30 per month depending on the extent of coverage, and dental plans can cost between $ 30 and $ 50 per month.

For jet-setters

If your plans later in life include moving from country to country, be aware that basic health insurance generally does not cover the care you receive outside of the United States.

If you choose an Advantage plan, emergencies are often covered worldwide. However, routine care received abroad may not be.

In this situation, you can consult travel insurance policies specifically intended for people aged 65 and over. Depending on the specifics of the coverage and your age, these policies can cost around $ 175 or more per month.

Meanwhile, if you choose to stick with basic health insurance instead of signing up for an Advantage plan, you have the option of purchasing a so-called Medigap policy that includes coverage while traveling. (You cannot buy Medigap if you have an Advantage plan.)

In general, Medigap plans cover the cost of certain deductibles or coinsurance associated with basic health insurance. Some of them also offer coverage when traveling abroad, with a cap of $ 50,000.

You can also purchase a stand-alone plan in addition to Medigap if you anticipate that this cap will be too low.

Long term care

While not all older people need long-term care – which usually means help with activities of daily living like bathing and dressing – those who do will not benefit much. health insurance coverage.

Recipients “are very surprised at the lack of long-term care coverage,” said Roberts. “While Medicare could cover your medical needs inside a nursing home or facility, it would not cover the cost of room and board and on-call care.”

There are insurance policies that cover long term care, although they can be expensive. And the older you are, the more they cost.

For example, rates for a couple, both aged 55, would be around $ 2,080 for an annual policy providing coverage of $ 165,000 to each insured, according to the American Association for Long-Term Care Insurance. If they are 65, this amount is approximately $ 3,750.

Qualified Nursing Coverage Eligibility

If you end up in the hospital, make sure you know if you have been admitted or if you are there for observation. It can make a big difference in whether Medicare pays if your follow-up involves skilled nursing care. This could include, for example, physical therapy after a fall.

“It’s a big deal,” said Elizabeth Gavino, founder of Lewin & Gavino and independent broker and general agent of Medicare plans.

“The qualification spends three days as an inpatient to qualify for skilled nursing care,” Gavino said. “Time spent in the hospital under observation is not counted.”

This qualified nursing care is covered by Medicare Part A if you qualify. During the first 20 days, Medicare pays the full cost of covered services, according to the Centers for Medicare & Medicaid Services. For days 21 to 100, you pay coinsurance. Beyond 100 days, you pay the full cost of treatment.


Basic health insurance also does not cover acupuncture, cosmetic surgery, or routine foot care.

Plus, many beneficiaries are surprised to find that a standard annual medical exam isn’t covered by Medicare – at least the type they were probably used to under previous insurance, Roberts said.

“Medicare has a ‘welcome to Medicare’ visit and an annual wellness visit which is similar to a physical visit, but not as comprehensive,” said Roberts.

About John Tuttle

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