Where Does Medicare Fall Short?

[harllee]

I think Shingles is covered by all Part D plans. It depends on the plan selected as to how much one pays. However, the Shingrix vaccine requires 2 shots. For DW, It was around $160 copay each. Virtually identical to the price if gotten via GoodRX discount. No real Medicare help there except it can be used toward the copay.

Yes the Shingrix vaccine is expensive but well worth it to avoid Shingles. I had a terrible case of Shingles 20 years ago and I have never fully recovered.

 

[imnontrad]

I have heard that one way that Medicare A, B &D fall short is that there is no cap on co-pays. SO if there is a MAJOR health issue, if could drive the person into bankruptcy just with the co-pays, let alone non-medical related expenses.

 

[Global Wizzo]

If you travel out of country, you have Zero coverage. Plan for the additional policies needed.

Copays and deductibles make up of the estimates. Stay healthy and your costs are low. Major accident or hospitalization can change things quickly.

 

[CRLLS]

I have heard that one way that Medicare A, B &D fall short is that there is no cap on co-pays. SO if there is a MAJOR health issue, if could drive the person into bankruptcy just with the co-pays, let alone non-medical related expenses.

Which is why choosing a supplement such as Plan G or F (now closed) is so important. With Part A and Part B along with Plan G supplement, talking about a cap on copays is not really applicable.

 

[CRLLS]

If you travel out of country, you have Zero coverage. Plan for the additional policies needed.

Copays and deductibles make up of the estimates. Stay healthy and your costs are low. Major accident or hospitalization can change things quickly.

I would not say zero coverage. it is true without a medigap supplement though. I belieive that most people on Original Medicare also purchase a supplement.

Medigap coverage outside the U.S.
If you have Medigap Plan C, D, E, F, G, H, I, J, M or N, your plan:

Covers foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn't otherwise cover the care.

Pays 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year.

Foreign travel emergency coverage with Medigap policies has a lifetime limit of $50,000.

 

[imnontrad]

If you travel out of country, you have Zero coverage. Plan for the additional policies needed.

This true - partly. Medicare MAY reimburse for emergency medical care if too far way to come back to the US/territories for care.

You can get travel insurance BUT travel insurance may not cover any travel more than 90 days in length. I got a 1 year policy from Allianz that covered me for my trips.

Someone who has Tricare/Tricare for Life knows that when overseas, Medicare does not work and Tricare becomes their primary policy for care outside of the US/territories.

 

[stedmakr]

I'm asking as a question not stating a position. It is my understanding that Long Term Care Facilities provide "custodial care" which is different from what Medicare pays for which are medically necessary services. Medicare will pay for medically necessary services for beneficiaries who are in or out of a long term care facility.

Is this a misunderstanding or is the misunderstanding that many people believe that Medicare should pay for custodial care (why)?

 

[athena53]

I'm asking as a question not stating a position. It is my understanding that Long Term Care Facilities provide "custodial care" which is different from what Medicare pays for which are medically necessary services. Medicare will pay for medically necessary services for beneficiaries who are in or out of a long term care facility.

Is this a misunderstanding or is the misunderstanding that many people believe that Medicare should pay for custodial care (why)?

Your understanding is correct. Two possibilities as to why people think Medicare covers LTC. First, they get it confused with MedicAID, which does, but there are some pretty strict rules that require you to spend down to almost nothing- it's meant for the indigent. Second- wishful thinking?

The same facilities that provide LT custodial care do take Medicare rehab patients but that's for a limit of 100 days (can sometimes be extended) after a stroke or some other medical event where you need to be monitored- BF was in rehab after knee replacements since he lived alone. Rehab care applies only if you were admitted to and discharged form a hospital.

My Dad was in self-paid LTC after a bad stroke with minimal improvement from rehab and yes, Medicare continued to pay for the medical care he got there.

 

[imnontrad]

My mother was in long term care for the last 18 months of her life. Every time she got ill (respiratory, infection, etc.), Medicare kicked in and paid for her care and for 30 days after she had recovered.
My uncle was in long term care for ~3 years, It started with a stroke and as long as he kept progressing, or had another stroke, Medicare covered the cost. it was only when he stopped progressing that Medicare would not longer cover his stay.

 

[Sunset]

Your Medicare Coverage: Is my test, item, or service covered?

Medicare covers annual Flu shots and so far Covid shots have been covered. On Tetanus I think that comes under Part D so you would have to look at your Part D coverage. Same for Shingles vaccine. Shingrix is very expensive and most Part D plans cover very little.

I did look it up , and yes Flu shots are covered.

Watch out when you are really old though, as DD paid for his flu shots at the pharmacy, even though he had Medicare and plan F and a Plan D.

I now wonder if the pharmacy double dipped.

Of course it was a few years ago and then we had no clue it was NOT proper.

 

[youbet]

Your understanding is correct. Two possibilities as to why people think Medicare covers LTC. First, they get it confused with MedicAID, which does, but there are some pretty strict rules that require you to spend down to almost nothing- it's meant for the indigent. Second- wishful thinking?

The same facilities that provide LT custodial care do take Medicare rehab patients but that's for a limit of 100 days (can sometimes be extended) after a stroke or some other medical event where you need to be monitored- BF was in rehab after knee replacements since he lived alone. Rehab care applies only if you were admitted to and discharged form a hospital.

My Dad was in self-paid LTC after a bad stroke with minimal improvement from rehab and yes, Medicare continued to pay for the medical care he got there.

Agree with everything here but would also add:

1. Medicare +supplement + Part D continue to provide coverage while you are a resident in a LTC facility just as they did when you were living at home. Your doctor visits, PT, medications and similar things are covered by Medicare. But Medicare does not pay for the ongoing room and board, facility provided eldercare such as exercise class, crafts and that sort of thing, routine medical supervision such as pill dispensing or administering a shot.

2. Rehab - Medicare does pay for 100 days if you meet all requirements. This does include room and board, etc. But your stay must be medically necessary and you must be showing improvement.

There are multiple avenues for NH's to generate revenue. Paying your monthly bill for basic room and board and basic eldercare programs is the most important. But having you need physical therapy or other services for which they bill Medicare is also important. That continuing involvement with Medicare seems to cause much confusion with citizens.

 

[2retireearly]

This true - partly. Medicare MAY reimburse for emergency medical care if too far way to come back to the US/territories for care.

You can get travel insurance BUT travel insurance may not cover any travel more than 90 days in length. I got a 1 year policy from Allianz that covered me for my trips.

Someone who has Tricare/Tricare for Life knows that when overseas, Medicare does not work and Tricare becomes their primary policy for care outside of the US/territories.

My med supplement pays of out of country coverage. I would think, most would. I think part c, Medicare Advantage, doesn't though.

 

[Katsmeow]

Someone should tell my doctor. I get a full physical every year. Takes about an hour.

In fact, I've seen no difference in my doctor's procedures, tests or costs from before I had Medicare.

Then your doctor is coding it as something other than a routine physical. Maybe there is something in your medical condition that allows your doctor to do what the doctor is doing. Maybe.

Same for Shingles vaccine. Shingrix is very expensive and most Part D plans cover very little.

It is mostly the issue of your Part D deductible. DH and I both had our first Shingrix shot earlier this year. I had not met any of my deductible this year so I paid for the entire cost of it which was almost $200. Since then I paid for the entire cost of another medication ($140). When I go to have the second shot I will pay the balance of the deductible then my co-payment for it as a preferred Tier 3 drug (which I think is $35).

DH, on the other hand, just paid a $25 co-payment. His Part D plan is a group Part D plan (provided by his former employer as a retiree benefit). It is a great Part D plan with no deductible and great co-pays.

I have heard that one way that Medicare A, B &D fall short is that there is no cap on co-pays. SO if there is a MAJOR health issue, if could drive the person into bankruptcy just with the co-pays, let alone non-medical related expenses.

I think could be an issue for some people on Part D particularly if they need an expensive medication that is not covered by the Part D plan. This is not so much an issue for people who have a supplement on the medical end. When my mother was in and out of the hospital at the end of her life, the bills were a lot of money. But, she did not pay a penny because she had traditional Medicare and Part G. All she was liable for was her deductible. And she had major health issues. She was on lots of medication and there were some co-pays for her meds but they were all common, inexpensive medications.

The people at risk are those who need a very expensive Part D medication (not a Part B medication) particularly if they need a medication that their Part D plan does not include on its formulary.

 

[MissMolly]

My med supplement pays of out of country coverage. I would think, most would. I think part c, Medicare Advantage, doesn't though.

My Medicare Advantage PPO covers emergency medical care when out of the country.

 

[athena53]

My Medicare Advantage PPO covers emergency medical care when out of the country.

And who gets to define “emergency”? My concern would be getting taken to the hospital for chest pains and finding out it was a pulled muscle. Oops. Not an emergency.

 

[Scuba]

Thank you, Rianne, for starting this thread. The information in this thread is very helpful to those of us who will be signing up for Medicare in the next few years. DH will be eligible in 20 months. :dance

 

[Midpack]

While Medicare does not pay for physicals, they do pay for a "wellness check" which could lead to further tests. More importantly...

...the OP does have a Plan G supplement, and IME that does pay for bloodwork and other tests that would be part of a legit physical. Mine includes most every useful test - CBC, CMP, lipid panel, Hemoglobin, PSA and Vitamin D. I have never paid a dime for the physical I have every January, thanks to Plan G. So a physical is covered by the supplement (and some Advantage plans).

No, no, no. Plan G does not cover anything that Medicare doesn't already. Yes, doctors can often code things so that those things are covered by Medicare. Go look at your Medicare Summary Notice. If your supplement paid for testing I guarantee you that it paid after Medicare already paid its part (well, after the deductible).

Many of the things you are talking about will be covered under Medicare as screening every X amount of time. Others can be coded to be covered. But the fact you have Plan G is irrelevant to what is covered.

Evidently it’s not as straightforward as you think. I am in good health with no special issues whatsoever, and Medicare and my Plan G supplement have paid all of my costs for a physical for all three years I’ve been on Medicare - I opened my Medicare and Plan G claims to verify. I know you’re right Medicare is only supposed to cover a simple wellness check, but the actual Medicare claim (IOW, Medicare knows exactly what services they are paying for) has 13 line items including:

• Wellness Visit
• Established patient outpatient visit
• Alcohol Misuse Screening
• Depression Screening
• Tobacco Use
• Falls Risk Assessment
• Bloodwork (Hemoglobin, Vit D, PSA, CBC, CMP, Lipids)

In round numbers my PCP billed $807, Medicare reduced it to $378 and paid all of it, so my Plan G didn’t have to pay anything (I stand corrected on that, supplements don’t pay for claims Medicare disallows). And my PCP didn’t charge me anything after settling with Medicare.

I may have found out by accident in that I told my PCP I want a reasonably complete physical whether Medicare pays or not, so I didn’t want her to leave it at just a wellness check interview and she didn’t. However, Medicare has paid for all of it for all three years. I certainly don’t want to mislead anyone, but it’s not as simple as you alleged in #33.

So you can't get an annual physical with Medicare. They can't just do full lab panels.

I see one other poster here has had similar experiences.

And I can assure others here my PCP, a young lady I only met in 2020 with a bright future ahead of her, would not fudge coding to get $378 from Medicare on my behalf as a few posts have suggested - no way. I wouldn’t want her to cheat anyone out of a penny. Furthermore I’ve told her directly I am happy to pay for whatever Medicare or my Plan G do not - I don’t want to let just what’s covered dictate my health care, seems short sighted IMO.

 

[harllee]

Regarding the annual wellness exam under Medicare. I was going to a regular family physician and went in for the Medicare Annual Wellness exam--it was a waste of time. I did not get to see my doctor, just a nurse who took my blood pressure and asked a few questions, an absolute waste of time. The next year I asked for a full physical with blood work, etc. Medicare and my G supplement paid nothing and I had to pay $800. Then I changed to a geriatric doctor. I got the most complete physical I had ever had with blood work, etc. Medicare paid 100%. It is all in the coding by the doctor.

 

[MissMolly]

And who gets to define “emergency”? My concern would be getting taken to the hospital for chest pains and finding out it was a pulled muscle. Oops. Not an emergency.

Works the same way with a Medigap plan. Oops.

 

[pb4uski]

It seems it's all in the coding. I recall having this issue with our corporate health insurance policy years ago. It was considered gold standard insurance. But the Dr or whoever does the coding coded incorrectly or intentionally. I fought it and it was coded differently and covered.

Our former doctor's office could never get the coding for routine blood work done with our annual physical's right. Each year I would get a bill for blood work and have to call the doctor's office and have them resubmit it with the right coding so the insurance company paid for it. That is part of why they are our former doctor's office.

 

[mathjak107]

Works the same way with a Medigap plan. Oops.

No it doesn’t ….

Medigap plans have no say in what they pay or don’t pay for ..

If Medicare covers it then they have to cover it .

Only advantage plans run in to medical necessity out of networks.


When does Medicare cover health care services in a
foreign hospital?
There are 3 situations when Medicare may pay for certain types of health care services you get in a foreign hospital (a hospital outside the U.S.):
1. You’re in the U.S. when you have a medical emergency, and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.
2. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable delay” on a case-by-case basis.
3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it’s an emergency..

However


What if I have a Medicare Supplement Insurance (Medigap)
policy?
Your Medigap policy may offer additional coverage for health care services or supplies that you get outside the U.S..
Medigap plans C, D, E, F, G, H, I, J, M, and N provide foreign travel emergency health care coverage when you travel outside the U.S. Even though Plans E, H, I, and J are no longer for sale, you may keep it if you bought one of these plans before June 1, 2010.
Medigap plans C, D, E, F, G, H, I, J, M, and N pay 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year. These Medigap policies cover foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn’t otherwise cover the care. Foreign travel emergency coverage with Medigap policies has a lifetime limit of $50,000.

 

[MissMolly]

No it doesn’t ….

Medigap plans have no say in what they pay or don’t pay for ..

If Medicare covers it then they have to cover it .

Only advantage plans run in to medical necessity out of networks.


When does Medicare cover health care services in a
foreign hospital?
There are 3 situations when Medicare may pay for certain types of health care services you get in a foreign hospital (a hospital outside the U.S.):
1. You’re in the U.S. when you have a medical emergency, and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.
2. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable delay” on a case-by-case basis.
3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it’s an emergency..

However


What if I have a Medicare Supplement Insurance (Medigap)
policy?
Your Medigap policy may offer additional coverage for health care services or supplies that you get outside the U.S..
Medigap plans C, D, E, F, G, H, I, J, M, and N provide foreign travel emergency health care coverage when you travel outside the U.S. Even though Plans E, H, I, and J are no longer for sale, you may keep it if you bought one of these plans before June 1, 2010.
Medigap plans C, D, E, F, G, H, I, J, M, and N pay 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year. These Medigap policies cover foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn’t otherwise cover the care. Foreign travel emergency coverage with Medigap policies has a lifetime limit of $50,000.

Again, the key to this is "medically necessary". Medicare won't cover if not medically necessary. Medigap won't cover if not medically necessary. Medicare Advantage won't cover if not medically necessary. So, oops.

 

[mathjak107]

What constitutes a medical emergency vs medical necessity is quite different.
Seeing a doctor for a minor issue and prescription can be a medical necessity but it is not the same as an emergency which usually means life threatening not just ones uncomfortable or does not feel well .

International use is touchy in both cases and it is best to have separate coverage for international issues

 

[athena53]

Works the same way with a Medigap plan. Oops.

I always get a travel policy anyway for longer trips and those outside of the US. As someone noted earlier, they pay first so you don't have to max out your credit cards for treatment and seek reimbursement later. I'm also concerned about breaching that $50K limit although medical costs seem to be lower in most other countries. For travel to remote areas I even get a separate policy through MedJet Assist for evacuation to the nearest hospital in the US if that becomes necessary. I have few chronic health issues but I'm every active on trips.

 

[MissMolly]

What constitutes a medical emergency vs medical necessity is quite different.
Seeing a doctor for a minor issue and prescription can be a medical necessity but it is not the same as an emergency which usually means life threatening not just ones uncomfortable or does not feel well .

International use is touchy in both cases and it is best to have separate coverage for international issues

Seeing a foreign doctor for a minor issue and prescription is not going to be covered by Medicare. Read what you posted. They all contain the word "emergency". So it's no better than my Advantage plan. And I agree with the comments that travel policies are the best protection.