By Nancy B. O’Connor
More than 47 million seniors age 65 and older, and people with certain disabilities and medical conditions, get their health care coverage through Medicare. While Medicare covers many health care services, it does not cover everything. In fact, people are often surprised at the items and services that Medicare does not cover.
So what does, and doesn’t, Medicare cover? For those with original, fee-for-service Medicare, the following lists offer the highlights.
Services Medicare Part A (“Hospital Insurance”) does cover:
• Inpatient hospital care.
• Inpatient care in a skilled nursing facility for a limited number of days, following a qualifying three-day minimum inpatient hospital stay for a related illness or injury.
• Home health services as ordered by a doctor (or other health care provider), including nursing care; physical, speech or occupational therapy; medical social services; home health aide services and medical supplies for use at home.
• Hospice care if you have a terminal illness with a life expectancy of six months or less, as certified by a doctor, at home or facility where you reside. Limited coverage for stays in a hospice facility, hospital or skilled nursing facility for pain or symptom management.
Services Medicare Part A does not cover include:
• Custodial care or long-term care in a skilled nursing facility or nursing home. Custodial care includes non-skilled personal care, like help with bathing, dressing, eating, getting in and out of a bed or chair, or toileting.
• Private duty nursing.
Confusion often exists about Medicare coverage and nursing homes. Medicare does not pay for room and board costs or non-skilled personal (custodial) care in a nursing home, or long term care or assisted living facility. It does cover Medicare-approved medical care and services, ordered and rendered by a Medicare-enrolled health care provider, such as a doctor or physical therapist, to the beneficiary who is a resident.
Services Medicare Part B (“Medical Insurance”) does cover:
• Doctors’ visits, services and tests; outpatient care and services; some home health services not covered under Part A; certain durable medical equipment (DME), prosthetics, orthotics and supplies.
• Medicare-covered services provided by non-physician health care providers, such as nurse practitioners, physician assistants, social workers, psychologists, physical therapists and others.
• Many preventive services and tests.
• Outpatient mental health care.
• Kidney dialysis services and supplies.
• Ambulance transport for medically-necessary services (limited).
• Chiropractic services (limited).
• Eyeglasses (limited to after-cataract surgery that implants an intraocular lens).
• Some prescription drugs (i.e. injections in doctor’s office, certain oral cancer drugs).
• Transplants and immunosuppressive drugs.
Things that are not covered by Medicare, under either Parts A or B, include routine dental care, dentures, hearing aids and exams for fitting hearing aids, cosmetic surgery and acupuncture.
For those who get coverage through a Medicare Advantage Plan (Medicare Part C), the story is somewhat different. Medicare Advantage Plans are offered by Medicare-approved private insurers, and must cover all the services covered under original Medicare, except hospice care, which continues to be covered by original fee-for-service Medicare even when a person is enrolled in a Medicare Advantage Plan.
These plans, which may charge a premium, deductible and co-insurance, may include extra benefits and services not covered under original fee-for-service Medicare, such as dental and vision care, glasses, hearing aids and health and/or wellness programs. Most plans also include prescription drug coverage, available to those in original Medicare under Part D.
Information about what Medicare does and doesn’t cover is available in the “Medicare & You” handbook, updated and mailed annually to every beneficiary in October, and also available at medicare.gov. This Medicare website is also a great source of information, as is 1-800-MEDICARE (633-4227) – TTY users call 1-877-486-2048 – where trained customer service representatives can help. In addition, VICAP, the Virginia State Health Insurance Program, can provide personalized help in your community; call 1-800-552-3402 to get the help you need.
Nancy B. O’Connor is the Medicare Regional Administrator for the states of Delaware, Maryland, Pennsylvania, Virginia, West Virginia and the District of Columbia. You can get always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).