Items not initially covered by Medicare - waiting periods

[spncity]

Calling on the Medicare experts!

Saw a mention of a physical or screening (annual screening) that is not paid for by Medicare until after a certain amount of time...?

What doctor visits or screenings are not covered at all or not covered until after a certain waiting period (and how long)? Are there things that are not covered annually? Think Plan G Medigap (aware of deductible).

Are other typical annual screenings covered? Mammogram, etc.

I never thought I'd be wishing for Medicare age until experiencing "affordable" health care (speaking financially, not politically).

Not there yet, but dreaming

 

[MichaelB]

Not an expert. My understanding is all recommended screenings are covered, as is an annual wellness check. Two things I know are not covered. One is an annual physical. The second is hospital stays that are “under observation”.,

 

[REWahoo]

Directly from the source:

https://www.medicare.gov/coverage/preventive-screening-services

 

[athena53]

Be VERY careful and consult the Medicare guide on-line. I became eligible for Medicare on 1/1/18 and thought I was home free. Ha. First of all, SO much depends on whether or not your doc's office codes things correctly. I got $800 of bloodwork kicked back as "not medically necessary" (a1C because I have high fasting glucose, lipids panel because total cholesterol is high, etc.) and escaped it only because they sent me a letter saying I hadn't signed some form at the lab agreeing to pay what Medicare didn't. Last month I appealed a coding that lumped the doc's exam of my breasts and a pap smear into one procedure; Medicare denied the whole bill ($110) because it was too early for another pap smear.

Then yesterday I got another love note from Medicare. The $1,500 bone density scan I just got is "not medically necessary". I'm 66, have never had one, and have low BMI which puts me at risk for osteoporosis (and they did find some osteopenia).

Sigh. The guy I'm dating works for the SHIP hotline and he's coming over today. Before we get into some serious sex, I have to ask him about this.

Having said that- my late DH had chronic health problems and Medicare plus our supplement were fantastic- very little out of pocket other than some prescription copays. Just be very careful on the preventative stuff. I'd love to get a skin cancer screening but that's not covered either, unless there's some reason for concern (and it's coded properly).

 

[REWahoo]

Are there things that are not covered annually? Think Plan G Medigap (aware of deductible).

A side note: Remember that Plan G (and all supplemental/Medigap policies) only pay when Medicare pays. If it isn't covered by Medicare your supplement will pay zero.

 

[MichaelB]

A side note: Remember that Plan G (and all supplemental/Medigap policies) only pay when Medicare pays. If it isn't covered by Medicare your supplement will pay zero.

+1, but two exceptions. Plan G pays emergency medical expenses when traveling abroad, and it covers the 15% additional cost some (a few) providers charge.

 

[Alan]

I just had my AAA screening which is offered to all men over 65 here in England. Interesting to see that Medicare covers it with the following exception.

Medicare Part B (Medical Insurance) covers an abdominal aortic screening ultrasound once if you’re at risk. You’re considered at risk if you have a family history of abdominal aortic aneurysms, or you’re a man age 65-75 and have smoked at least 100 cigarettes in your lifetime.

I think it is worth having done, so even if you are a man over 65 and have never smoked it would be worth saying that you had smoked at least 100 when you were young. Who knows what secondary cigarette smoke any of us oldies have inhaled before it was banned from work and public places.

 

[REWahoo]

+1, but two exceptions. Plan G pays emergency medical expenses when traveling abroad, and it covers the 15% additional cost some (a few) providers charge.

You got me on the overseas coverage. However, that 15% additional cost under Plan G is covered only if Medicare paid the provider Medicare's approved amount, which does fall under the "Medigap pays only if Medicare pays" rule.

 

[athena53]

I have Medigap from UHC through AARP and it pays outside of the US but has a lifetime limit of $50K. I have no pre-existing conditions but I typically go for a lot of hiking, swimming, kayaking, etc. (one hike I went on in Baja California was the "boulder bash") so I always get travel insurance with good medical coverage.

 

[candrew]

I think it is worth having done, so even if you are a man over 65 and have never smoked it would be worth saying that you had smoked at least 100 when you were young.

Pretty sure that most of us in that cohort have smoked at least 100 of something.

 

[candrew]

The guy I'm dating works for the SHIP hotline and he's coming over today. Before we get into some serious sex, I have to ask him about this.

Pouring over medical bill is not my idea of foreplay, but as Sly Stone reminded us all, "different strokes for different folks".

 

[HFWR]

Pouring over medical bill is not my idea of foreplay, but as Sly Stone reminded us all, "different strokes for different folks".

Not Sly, but a reasonable facsimile...

https://youtu.be/90QXhl95qP8

 

[MichaelB]

You got me on the overseas coverage. However, that 15% additional cost under Plan G is covered only if Medicare paid the provider Medicare's approved amount, which does fall under the "Medigap pays only if Medicare pays" rule.

I wasn’t challenging your post, just complimenting it.

REWahoo’s point is simple and easy, and correct. Medicare determines if something is covered, the MediGap supplemental plan just covers more of the cost.

 

[ivinsfan]

Be VERY careful and consult the Medicare guide on-line. I became eligible for Medicare on 1/1/18 and thought I was home free. Ha. First of all, SO much depends on whether or not your doc's office codes things correctly. I got $800 of bloodwork kicked back as "not medically necessary" (a1C because I have high fasting glucose, lipids panel because total cholesterol is high, etc.) and escaped it only because they sent me a letter saying I hadn't signed some form at the lab agreeing to pay what Medicare didn't. Last month I appealed a coding that lumped the doc's exam of my breasts and a pap smear into one procedure; Medicare denied the whole bill ($110) because it was too early for another pap smear.

Then yesterday I got another love note from Medicare. The $1,500 bone density scan I just got is "not medically necessary". I'm 66, have never had one, and have low BMI which puts me at risk for osteoporosis (and they did find some osteopenia).

Sigh. The guy I'm dating works for the SHIP hotline and he's coming over today. Before we get into some serious sex, I have to ask him about this.

Having said that- my late DH had chronic health problems and Medicare plus our supplement were fantastic- very little out of pocket other than some prescription copays. Just be very careful on the preventative stuff. I'd love to get a skin cancer screening but that's not covered either, unless there's some reason for concern (and it's coded properly).

Most of this in not a good thing, however so happy see you have a DBF, unless I missed something I haven't seen you mention this before

 

[athena53]

Most of this in not a good thing, however so happy see you have a DBF, unless I missed something I haven't seen you mention this before

Yes, I do! We're both pretty independent, neither in a rush to cohabitate or be together 24/7 so it works well.

One clarification on my earlier post: the denial was not for my bone scan (haven't heard on that yet) but for a breast MRI because I'm high risk due to family history. They happened to be in the same week and I had to check my calendar to see which procedure it was.

Weirdly, the contrasting imaging stuff they shot into my veins beforehand was covered. The subsequent procedure was not.

 

[Moemg]

s. Just be very careful on the preventative stuff. I'd love to get a skin cancer screening but that's not covered either, unless there's some reason for concern (and it's coded properly).

I've had skin screening and it was totally covered .They usually find something to zap and can code it correctly .

 

[kaneohe]

I've had skin screening and it was totally covered .They usually find something to zap and can code it correctly .

I don't know if I've had "screening" but I've usually gone in when there was something that bothered me....like something that didn't heal immediately .
Even if the doc said it was no problem and since I was there,would I want a
full body check, it has always been covered..................perhaps not free like some screenings, but to me essentially free since I have a supplement and except for the small deductible for Plan G, everything else is covered by either Medicare or the supplement.

 

[MBSC]

Two things I know are not covered. One is an annual physical. The second is hospital stays that are “under observation”.

Observation stays are covered as a Part B benefit. If the person is then transferred to a SNF, it's the SNF stay that is not covered since the 3-day inpatient hospital stay rule has not been met.

Observation services are short-term outpatient services received when you are in the hospital for monitoring purposes and/or to determine whether you should be admitted as an inpatient.

Part B pays for care received at the hospital by an outpatient under observation status.

Medicare will not cover skilled nursing facility (SNF) care if you have not had a three-day inpatient stay. This means that if you have been under observation status and your provider suggests you receive SNF care, you may have to pay out of pocket for all SNF costs.

Source: https://www.medicareinteractive.org...al-services/medicare-and-observation-services

 

[davebarnes]

All of you are confirming my decision to go with Medicare Advantage thru Kaiser.

Over 5+ years my total co-pays have been under $3000.
And, they include colon cancer (surgery+chemo), perianal abscess, vaccines, wellness visits, 10 million blood tests.

 

[ivinsfan]

All of you are confirming my decision to go with Medicare Advantage thru Kaiser.

Over 5+ years my total co-pays have been under$3000.
And, they include colon cancer (surgery+chemo), perianal abscess, vaccines, wellness visits, 10 million blood tests.

I'm glad it's working for you, yet it won't work for a lot of people...hope you are doing well.