Medicare has protection gaps regardless of congressional effort to broaden it


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If Democratic lawmakers get their way, Medicare will cover hearing services for the first time in the program’s history.

The coverage, due to go into effect in 2023, is included in the $ 1.85 trillion spending bill proposed by the Democrats, known as the Build Back Better Act, which aims in part to strengthen the social safety net. The legislative package has yet to be approved in the House and Senate before President Joe Biden can put it into effect.

Hearing isn’t the only supply gap, however. Besides finding that Medicare isn’t free – on the contrary – they may also be surprised to find that it fails to cover a wide variety of healthcare expenses that can hit retirees pretty hard.

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Approximately 63.3 million people are enrolled in Medicare. Most of them are 65 years of age or older (55.1 million) and the rest are generally younger with permanent disabilities.

Some low-income people qualify for programs that reduce their Medicare-related costs. There is additional help with prescription drug insurance coverage, and some government savings programs can help with co-payments, co-insurance, deductibles, and premiums.

For those who don’t qualify, you can pay out of pocket for uncovered services or purchase additional insurance.

Here’s what you should know.

First the ABC (and D) of Medicare

Basic or Original Medicare consists of Part A and Part B. You are expected to enroll when you are 65 years old unless you have otherwise qualifying health insurance (e.g. health insurance).

Part A covers hospitalization, skilled nursing, hospice and some home health services. As long as you’ve been paying into the system for at least 10 years, you won’t pay any Part A premium, however, it does come with a deductible ($ 1,484 this year and an estimated $ 1,556 in 2022) per benefit period and has benefits cap.

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

Part B coverage occurs when you see a doctor or use other outpatient services such as a flu shot. It also includes medical devices such as crutches or blood glucose meters.

This year, the standard monthly premium for Part B is $ 148.50 and is expected to increase to $ 158.50 in 2022. (However, higher-income beneficiaries pay more.) Also includes a deductible of $ 203 this year (an estimated $ 217 in 2022). . After it is met, you will typically pay 20% of the benefits covered.

Basic Medicare 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 Plan (Part C), which may also have a premium in excess of what you pay for Part B.

If you choose an Advantage plan, your coverage for Parts A and B will also be provided through the private insurance company that offers the plan.

Also, note that there is no cap on home spending for basic Medicare. There are also none for Part D of prescription drug coverage, though the Democrats’ spending bill would cap it at $ 2,000 a year.

Teeth, eyes and ears

While the Democrats’ spending plan would expand Medicare to include hearing care, dental care and routine vision would remain exposed despite previous versions of the bill.

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

However, when dental disease requires an emergency or complicated procedure, it can be covered.

The same goes for routine eye tests. If you need glasses, they are usually not covered. However, if you have an eye condition like glaucoma or cataract, Medicare Basic has your treatment covered.

If you choose an Advantage plan, there is a good chance dental, hearing, and visual aids are included, although coverage may not be comprehensive.

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

Standalone vision plans can cost around $ 10 to $ 30 per month, depending on the level of coverage, and dental plans could be anywhere in the neighborhood of $ 30 to $ 50 per month.

For jet setters

If your plans for later life involve jumping from country to country, be aware that primary health care generally doesn’t cover the care you receive outside of the United States

When you choose an Advantage Plan, emergencies are often covered worldwide. However, routine care abroad cannot be.

In this situation, you can look at travel medical guidelines specifically geared towards the target audience 65 and over. Depending on the specifics of your coverage and your age, these policies can cost around $ 175 or more per month.

If you choose to just stay with Medicare instead of signing up for an Advantage plan, you have the option of taking out a so-called Medigap policy, which includes coverage while you are traveling. (You can’t buy Medigap if you have an Advantage Plan.)

In general, Medigap plans cover the cost of some deductibles or co-insurances related to basic Medicare. Some of them also offer international travel coverage with a cap of $ 50,000.

You can also purchase a standalone plan in addition to Medigap if you think this cap is too low.

Long term care

While not all older people need long-term care – which generally means help with everyday activities like bathing and getting dressed – those who do are not covered by much Medicare.

Beneficiaries “are very surprised at the lack of long-term care insurance,” said Roberts. “While Medicare can meet your medical needs in a nursing home or facility, it would not cover the cost of room, board, and 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, according to the American Association for Long-Term Care Insurance, the tariffs for a couple, both under the age of 55, would be about $ 2,080 for an annual policy that gives each policyholder $ 165,000 in coverage. If they are 65 years old, that amount will be around $ 3,750.

Qualification for qualified long-term care insurance

When you end up in the hospital, make sure you have been admitted or are there for observation. It can make a world of difference whether Medicare pays if your follow-up includes skilled care. This can include physiotherapy after a fall, for example.

“This is a big issue,” said Elizabeth Gavino, founder of Lewin & Gavino and independent broker and general agent for Medicare plans.

“The qualification is a three-day inpatient stay to qualify for qualified nursing,” said Gavino. “The time spent in the hospital under observation is not counted.”

Such skilled care is covered by Medicare Part A if you qualify for it. For the first 20 days, Medicare pays the full cost of the Covered Services as per Centers for Medicare & Medicaid Services. You pay co-insurance for days 21 to 100. From 100 days you pay the full care costs.

bits and pieces

Basic Medicare also doesn’t cover acupuncture, cosmetic surgery, or routine foot care.

Additionally, many beneficiaries are surprised to find that standard annual health coverage isn’t covered by Medicare – at least the kind they were likely used to from previous insurances, Roberts said.

“Medicare has a Medicare visit and an annual wellness visit that is similar to, but not nearly as extensive, a physical visit,” said Roberts.

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