Key Takeaways:

• Medicare covers a wide range of essential health services but leaves some significant gaps, so understanding what’s not included is crucial.
• Asking questions and reviewing your options annually can ensure you get the best possible coverage for your needs.

What Does Medicare Really Cover?

If you’re looking into Medicare or even already enrolled, knowing what’s actually covered can feel a bit like solving a puzzle. Let’s break it down so that by the time you’re done reading, you’ll feel more in control of your choices and better prepared to navigate the system.

The Foundation: Medicare Part A and Part B

Medicare is split into different parts, each with its unique benefits and coverage limits. Here’s a closer look at the fundamentals:

Part A (Hospital Insurance)
Part A covers your hospital stays, skilled nursing facility care, some home health services, and hospice care. For most people, there’s no monthly premium, but there is an annual deductible. Once you meet that deductible, Part A typically pays for most of your inpatient services.

However, it’s not an all-you-can-eat buffet. Part A covers semi-private rooms and basic nursing services, but things like private-duty nursing or personal comfort items are on you. Also, long-term custodial care isn’t covered, which is an essential point to consider if you or a loved one might need extended support down the road.

Part B (Medical Insurance)
Part B is your go-to for medical services outside of the hospital. Think doctor visits, outpatient care, and some preventive services. You’ll pay a monthly premium and a yearly deductible. Once that’s out of the way, Medicare typically covers 80% of the Medicare-approved amount for services, leaving you with the remaining 20%.

Preventive care under Part B includes important screenings and annual wellness visits. These services can help catch health issues before they become more severe (and costly). But even here, there are nuances. Some diagnostic tests or follow-up treatments may not be covered fully, catching many off guard when the bill arrives.

What Medicare Does Not Cover

Understanding what Medicare doesn’t cover is as vital as knowing what it does. Here are some key gaps to be aware of:

Routine Dental, Vision, and Hearing Care

One of the biggest misconceptions people have is that Medicare covers routine dental, vision, and hearing services. Unfortunately, that’s not the case. Routine checkups, eyeglasses, and hearing aids fall outside the scope of Original Medicare (Part A and Part B). If you need regular care in these areas, consider looking into supplemental coverage or budgeting for out-of-pocket expenses.

Long-Term Care

Many people are surprised to learn that long-term custodial care, such as assistance with daily activities like bathing and eating, is not covered by Medicare. While Part A will cover a short stay in a skilled nursing facility after a hospital stay, long-term or indefinite stays are not included.

Prescription Drugs

If you’re only signed up for Original Medicare, prescription drugs aren’t covered under Part A or Part B. To get drug coverage, you’d need to enroll in Part D or consider a Medicare Advantage plan that includes it. Even then, the coverage varies by plan and might not cover every drug you need.

Medicare Advantage: A Mix of Pros and Cons

The Benefits of Medicare Advantage

Medicare Advantage plans (Part C) bundle Part A and Part B and often come with additional perks like dental, vision, or wellness programs. They may seem appealing due to their all-in-one nature. Some plans may even include drug coverage (Part D), making them more comprehensive than Original Medicare.

The Not-So-Great Side

However, the trade-offs can be significant. You may face network restrictions, needing to choose providers within a specific list. Additionally, out-of-pocket costs can be higher if you see a specialist without a referral or go out of network.

Many plans come with their own set of rules, and it’s essential to ask questions about what’s covered, what’s not, and what conditions apply. Make sure you know the limits of the plan’s coverage, as well as the copays, deductibles, and any annual out-of-pocket maximums.

What You Should Be Asking About Your Medicare Plan

To get the most out of your Medicare plan and avoid nasty surprises, here are the questions you should be asking:

1. What Are My Deductibles and Out-of-Pocket Costs?
Even with comprehensive coverage, knowing your out-of-pocket expenses is essential. Different parts of Medicare have different cost structures, so be sure you understand these upfront.

2. Are My Doctors and Hospitals in Network?
If you’re using a Medicare Advantage plan, make sure your current healthcare providers are in-network. This can save you from higher costs or needing to switch doctors.

3. Does My Plan Cover the Medications I Need?
For those with Part D or a Medicare Advantage plan that includes drug coverage, ensure that your current prescriptions are on the formulary list. If not, you may want to explore other options during the Annual Enrollment Period.

4. What Preventive Services Are Included?
Medicare Part B covers many preventive services, but specifics can vary. Confirm which screenings and wellness services are covered so you can take full advantage of them.

5. Are There Any Coverage Gaps I Should Know About?
Understand what services aren’t covered and consider whether you need supplemental insurance (like a Medigap plan) to fill those gaps.

The Importance of Reviewing Your Plan Annually

Medicare isn’t a set-it-and-forget-it type of coverage. Each year, during the Annual Enrollment Period from October 15 to December 7, you should review your plan. Insurers change their benefits, premiums, and coverage details regularly. The drugs on your plan’s formulary might change, or your preferred doctor could leave the network.

Taking the time to review your plan can help you avoid surprises and ensure you’re getting the best value for your money. Ask yourself if your healthcare needs have changed in the past year. If so, it might be worth switching to a plan that aligns better with your current situation.

Plan Beyond What Medicare Offers

Even with comprehensive Medicare coverage, there are situations where additional planning is wise. Long-term care insurance, for instance, can offer peace of mind if you’re concerned about needing extended support as you age. Saving for out-of-pocket expenses, especially those related to dental, vision, and hearing care, can also be a smart move.

Additional Coverage Options to Consider

Medigap policies, also known as Medicare Supplement plans, can help cover things like copayments, coinsurance, and deductibles that Original Medicare doesn’t. If you’re leaning towards Original Medicare but want added protection, a Medigap plan could be beneficial. Keep in mind that these policies come with their own rules and costs.

How to Stay Proactive with Your Medicare Coverage

Understanding the scope of what Medicare offers is just the start. To make the most of your plan, stay proactive:

• Review Your Plan Annually: As we mentioned, your needs and your plan’s offerings can change each year.
• Use Preventive Services: Take advantage of covered screenings and wellness visits to maintain your health and catch potential issues early.
• Keep an Eye on Out-of-Pocket Costs: Understanding your cost responsibilities helps you budget better and plan for potential medical expenses.

Making the Most of Your Medicare Benefits

At the end of the day, understanding your Medicare coverage is essential to managing your health and finances. Knowing what’s included, what’s not, and what you need to ask can make all the difference. Stay informed, ask questions, and make use of the resources available to you.