What is and is not covered by Medicare?

In this episode, John Ross and Lisa Shoalmire discuss the ins and the outs of Medicare… what it covers, what it doesn’t, and what happens when your treatment isn’t gonna be approved.

Episode Transcript
John
Welcome to Aging Insight. I'm your host, John Ross, and here with my partner Lisa Shoalmire. And we're here to talk about issues that relate to seniors, people with disabilities, basically try to address the types of issues that we see as elder law attorneys. Issues like avoiding nursing home care, issues like not becoming a burden on your friends and family, and issues like not going broke trying to pay for yourself as you get older. And we know that you can accomplish those goals, but we also know that you've got to have knowledge. You've gotta have a map that gets you from today to wherever you wanna be in the future. You gotta know where you're going, and that's the purpose of Aging Insight, that's why we're here. Lisa, welcome.
Lisa
Well, thanks. Another edition of Aging Insight and another opportunity to bring some really good information to folks out there. We kinda do it where all the questions you've ever thought about, but either didn't have the opportunity to ask, or forgot about it by the time you did.
John
That's right. Probably one of the biggest questions that we get on a regular basis relates to Medicare. I will say that this has got to be one of those issues out there that is just terribly confusing, trying to figure out what Medicare covers, what it doesn't cover, what happens when the doctor says that your treatment isn't gonna be approved, and all of the issues related to that sort of thing, and so that's what we're gonna be covering today is Medicare.
Lisa
Okay. Well, and just to give you a quick little background, Medicare is the medical insurance program that if you've ever worked you've paid something into that Medicare program, there's a little deduction, about a 1.4% deduction on your paycheck for Medicare. And when you turn 65, Medicare is a government medical insurance program for those folks in that age group. So the first thing to know about it is it's health insurance and it's for 65 and older. And John there is one exception to, you can be under 65 and receive Medicare if you have been determined to be disabled by the Social Security Administration for at least two years.
John
That's right. In fact one of the big issues related to Medicare with people with disabilities who are under 65 is the gap in coverage between the time where they are declared disabled. And you do have to be receiving those disability benefits for two years prior to getting that Medicare. For everybody else we get it when we turn 65, and it's a great benefit. Now, you may already have your own insurance, maybe you're still working. And so oftentimes if you become both eligible for Medicare and you have other insurance, typically what happens is that your other insurance will become your supplement. So for example, if you went to the hospital, Medicare would pick up, say, 80% of certain costs and then that work insurance that you have would pick up the other 20%. If you don't have work insurance, then you can purchase supplemental insurance out on the open market during the open enrollment period which starts in October and goes through December.
Lisa
Well and John, that brings one of the questions that we do frequently get which is whether or not, can you continue to work? Do you have to be receiving Social Security retirement in order to get on your Medicare benefit at the time you turn 65? And the answer is you can just get Medicare and continue to work so that you've got your health insurance coverage, but yet maybe you're not quite ready to retire or maybe financially you wanna hold off taking that Social Security, but you wanna go ahead and get your Medicare. And frankly these days, most employers, if you are still working at the age of 65, most employer-provided insurance programs require that you switch over to Medicare at age 65. It's no longer an option for the vast majority of employer-provided health insurance to remain on your employer's insurance as the primary payer at the time you turn 65. You have to switch over to Medicare.
John
Right. Now that doesn't necessarily mean that you're gonna lose your insurance, it just means that that insurance continues on, but as your supplement. It picks up that other cost. And of course there are other options out there when it comes to Medicare. There are lots of different plans and they all have letters out there, you've got Medicare A, which is your hospitalization. You've got Medicare B which is your doctor's visits. But then you have different other types. You have C plans, D plans, E plans, F plans, all of these different plans out there.
John
Now we're not gonna go into those today, but one thing I would certainly encourage people to do is that if you have questions about Medicare, supplemental insurances is get somebody... Find somebody out there who's experienced in dealing with these things. It can be very, very confusing. And one other little tip, when you are looking at these different supplemental insurances and trying to figure out what is good for you, don't just take the advice of the person who's selling it to you. It's not a bad idea to go, maybe call your doctor, call any friends that you might have in the medical community. Even swing by a hospital or a nursing home and ask them if they've had any experience with that Medicare supplement or that Medicare advantage plan or that Part F plan and see what they think about it.
Lisa
Well, yeah, it's almost... Without these different Medicare plans and the different letters, it's like alphabet soup, trying to figure out what you need. And when you go and look for a Medicare plan make sure you get a printout of your prescriptions. Make sure that you are up-to-date on what conditions that you have that may continue to necessitate treatment. High blood pressure, diabetes those type things. Because different plans address those chronic conditions in different ways, and you wanna be able to figure out what's gonna work best for you. So when we come back from the break in a moment, we're gonna talk about the different things that Medicare covers and things that Medicare doesn't cover. And we talk all the time that we want you to be armed with information as you glide into retirement to know that you can be self-sufficient and not be a burden to others and not go broke. And so Medicare and your health costs are a big part of this. So stick with us, and we'll come back and talk about what Medicare covers.
Lisa
Welcome back to Aging Insight. I'm Lisa Shoalmire, and I am here with John Ross. And we are elder law attorneys here in the Ark-La-Tex. And we are here to give you information on things you need to know as you age in our community. And today's hot topic is Medicare. Very important to our senior community. And we wanted to cover some of the things that Medicare covers and some things that Medicare does not cover. And I think this can be a very shocking area for some of our seniors when they realize certain care they thought would be covered by Medicare is not.
John
Yeah, certainly... Probably one of the most common mistakes that I see people make in my practice is people who have had the assumption that because they have Medicare, because they have supplemental insurance. And maybe they pay for that, maybe they get it from their retirement, maybe they're a retired military, and they get TRICARE. But they've operated under this assumption that their healthcare costs are gonna be covered throughout the remainder of their years. And the fact is Medicare and supplemental insurance covers a lot, no doubt about it. If you have a major heart attack and you need bypass surgery and all of these things, oftentimes, that costs very little. Maybe not even anything at all depending on the type of plans that you have. But there are still lots of other things that are not covered by Medicare.
John
In fact, according to a recent Forbes article, they had done a study, and they said that somebody who's turning age 65 right now will probably need in excess of $250,000 just to pay for their medical expenses that are not covered by Medicare and that supplemental insurance. So that's a lotta money for things that aren't covered so what are they talking about? What are these other medical expenses that are not covered?
Lisa
Well I guess probably one of the biggest out of pocket costs for Medicare is rehabilitation and long term care services. These services are the type of services where maybe you need to be at a skilled nursing facility. Maybe for a short term because you've had a medical crisis and you are getting stronger and recovering from that medical crisis with the intent that you're gonna go home. Or maybe your health has deteriorated to a point where staying at a long term care facility or a nursing home is what's required to address your health needs. The bottom line is, there is a very limited Medicare benefit for rehabilitation and long term care services and it runs out very quickly. John, you wanna give some details about what is covered with Medicare on those two long term care?
John
Right. Essentially if you have Medicare A and B, if you go to a hospital and you spend at least three midnights in that hospital, so you've been there for three nights, and then you leave from the hospital and go directly to a skilled nursing facility, a nursing home, Medicare will pay 100% of the first 20 days. After that Medicare will pay for 80% of the next 80 days. The problem is Medicare... The amount that Medicare pays is very, very high. Medicare pays around $700 a month towards that cost and so if Medicare is only paying 80%, that leaves you paying the other 20% which can easily be about $140 to $150 a day.
John
Now if you have supplemental insurance, the supplemental insurance will pick up that other 20%. So for nursing home care Medicare is gonna pay for the first 20 days and between Medicare and your supplement up to another 80 days on top of that. But at an absolute maximum, absolute maximum, Medicare and your supplemental insurance will pay for 100 days. After that, Medicare is gonna shut off and you're gonna be looking at private pay or some other form of payment to cover that. But now really who wants to go to the nursing home? I would rather probably stay home for example. Well Lisa is Medicare gonna send somebody out to my house, help me stay at home?
Lisa
No, not in any significant way, if you have had a health crisis or major surgery, often times you may be discharged home and home health care may come out to your home to do wound care, you may have some therapy at home for a short time, but it's a very episode related amount of care. So after a few weeks that care is no longer paid for by Medicare. Furthermore if your health has just simply deteriorated to where you just can't do the things that you need to do around the house and you need some assistance, there is absolutely no Medicare benefit that is going to assist you with things such as managing your medication or helping you getting in and out of the shower and bathing. There's no benefit for basically someone who can come deliver personal care. Medicare just does not pay for that type of benefit.
John
That's right. Probably the biggest ones that we see in our practice are related to Medicare not paying for nursing home care beyond that first 20 to 100 days and Medicare not paying for in-home care. Most people would rather stay at home, but if because of your current health condition you can't cook a meal, Medicare's not sending somebody over to the house to cook a meal for you. You're going to have to pay somebody out of pocket to do that and the costs can be pretty high. So if you wanna stay at home, you need to figure out how you're gonna pay for that assistance when the time comes because it's not gonna get covered by Medicare.
John
Now there are a few other things that Medicare doesn't cover. It doesn't cover cosmetic surgery, it doesn't cover... Generally Medicare A and B doesn't cover things like vision, dental, foot care. So there are a few other things that Medicare doesn't cover. Now some plans, for example there are some Medicare Advantage Plans as an added benefit they might have a dental coverage or they might have a vision coverage. So some of them are out there, but for Medicare A and Medicare B those do not cover vision, they don't cover dental and some of these other things.
Lisa
Oh and another one that Medicare does not cover is hearing loss and hearing aids, and that could be a significant expense. Got some great fancy hearing aids these days that you can barely see and they do a great job but...
John
Yeah, but if you've seen the price of those things.
Lisa
They're pretty pricey.
John
It's pretty pricey.
Lisa
It comes outta your pocket.
John
That's right.
Lisa
So those are... And also there are some if you want a private room while you're staying at rehab, Medicare does not cover the difference between a private or a semi private room. So that figure that you threw out earlier John about $250,000 of out of pocket expenses you can start to see where you're gonna be spending some money.
John
That's right, but now there's one other question out there, what if, let's say that my doctor says that I need some form of surgery, maybe I need heart surgery, but then Medicare says they're not going to pay for it. Well that's different. Now here's a service that's covered by Medicare, but Medicare is saying they're not gonna pay for it; they're denying me. Well, we're gonna take a little break and when we come back, we're gonna talk about what happens with Medicare denials and what your rights are.
John
Welcome back to Aging Insight, everybody. I'm John Ross, here with Lisa Shoalmire, and today on Aging Insight, we're talking about Medicare and the issues related to Medicare. What does it cover, what does it not cover? Well, one issue that we have seen quite a bit is where Medicare might actually cover something, so for example Medicare would cover heart surgery, if you needed heart surgery. But sometimes you go to the doctor and the doctor recommends that you need that heart surgery, but when they submit all of that information to Medicare, Medicare decides, "You know what, we don't think you need it".
Lisa
Yeah, Medicare may decide that it's not medically necessary for you.
John
That's right. And so Medicare denials can come in a couple of different forms. For example, you might be looking at a treatment that you need in the future. So, the doctor has said, "I need surgery", and we submit that to Medicare and Medicare says, "No, we don't think you need surgery so we're not gonna cover it." The other kind are where you've already incurred the expense. So for example, you had a heart attack, you go to the hospital, they do a number of procedures, but when all of that is submitted to Medicare, Medicare then refuses to pay for some of them. And then the last type comes related to prescription drugs. Your doctor might decide that you need a particular drug, but when you bill Medicare for that, or when the pharmacy bills Medicare for that, Medicare refuses to pay. So Medicare denials can come in several different formats, the question is, what do you need to do when you get one of those?
Lisa
Well and John, usually you'd find out that Medicare is not paying for services and prescriptions that you've already received, when you receive a piece of paper called the Medicare Summary Notice. This looks like an explanation of benefits, it is Medicare's explanation of what services have been billed to Medicare on your behalf, and then what of those charges Medicare has paid on your behalf. And if there are charges on your Medicare Summary Notice that have been denied, and Medicare has paid zero, then that means they are not going to pay for that and they're making the determination that it either wasn't necessary or it's not covered. Well the first thing you need to do is flip over that Medicare Summary Notice and there are your appeal rights listed in writing on the back of that notice. You can then put in your name, you circle the service or prescription or whatever it was on the front of the form that you believe that Medicare is wrongfully denying. You circle that, and then you write an explanation as to why you believe it's necessary.
Lisa
Now, this may involve you needing to get your doctor's office involved in providing a letter from their office stating why it's necessary. But you have a limited timeline to do this. You only have 120 days from that time that service was given to you, to appeal a denial. So you gotta open your mail and you gotta check these things over, and I know that can be overwhelming, but you need to fill this appellate right out and send it back in. Keep copies of everything, but mail it back into Medicare. And this is where Medicare will do a redetermination, and they will look at it again to see if maybe they made a mistake.
John
And one thing about this. There's kinda the old adage of "Don't take no for an answer." And the same thing goes when we're talking about Medicare. Just because Medicare has denied a claim, refused a certain procedure, that's not the end of the story. Take advantage of these appeal rights. Now, I will say that Medicare is getting tighter and tighter on some of these, and so they are denying more and more of the appeals, but there's still a significant percentage of people who are denied, who appeal, and then it's approved. And you know what? It doesn't cost you anything. If you are successful, great! Then Medicare's gonna pick up that claim. If you're not successful, you're not in any worse shape than you were when you started. So you've got nothing to lose and everything to gain by appealing a denied claim if that ever happens to you. Just be sure, as Lisa said, and take very good care of your paperwork. Keep that benefit statement and pay attention to those timelines. They are very serious about those timelines. If it says 120 days, they mean 120 days, and there is no grace period. So be very careful with that sorta stuff.
Lisa
And John, I liked that you said don't take no for an answer, because oftentimes people are still denied on that first appeal. But you know what? You get a second appeal. [chuckle] And then it is a reconsideration instead of... Redetermination, then reconsideration. But that second appeal is done by an independent person who doesn't know anything about your file or your physician, and so it's a fresh set of eyes. So don't take "no" and keep pursuing that appeal. The further along you go, the greater chance of your success.
John
Yeah. So there's no doubt Medicare is, it's a bit complicated. But it is a good benefit. It is gonna pay for a lot of your stuff, but it's not gonna pay for everything. So what you need to know is what is your Medicare gonna cover, what is it not gonna cover, and how are you gonna pay for those things that it doesn't cover? And remember, if you get denied, file an appeal. And if you have any questions, get the advice of somebody who knows what they're talking about. Now, as always, if you have more questions, you can always catch us every Saturday on 107.1, that's Aging Insight Radio, and we're there to answer questions for people that call in. You can also catch us on the internet at Facebook.com/aginginsight. So if you've got questions out there, feel free. Reach out and find us out there on the internet, call us on the radio, we'll be happy to talk to you.
Lisa
Well, John, and we're gonna be back next week with another episode of Aging Insight, with information that impacts our families. So we'll see you next week.
John
Bye-bye.

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