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Medicare is an insurance program for the elderly. Provided by the government, Medicare covers almost 64 million people according to the Centers for Medicaid and Medicare Services. Though those enrolled in Medicare still have to pay premiums, deductibles, and copays, the coverage is often more affordable than what a person might get using the federal or state insurance exchanges[1]. But while Medicare – and its partner programs, known as Medigap and Medicare Advantage Plans – can provide an excellent base of insurance coverage, there are things that the program does not cover for seniors.
Having certain aging in place solutions denied for coverage can be a surprise to those who enroll in Medicare. At the age of 65 – the earliest a person can enroll in the program – many of those who need coverage are already facing chronic conditions and a variety of prescription medications to take on a daily basis. That’s why it’s so important to understand what Medicare does cover, as well as what it doesn’t.
Extended Hospitalization
Many elderly individuals were hospitalized during the worst of the COVID pandemic in 2020 and 2021, so it’s safe to say that concerns about hospital coverage are pretty serious these days. According to Medicare Interactive, Medicare covers 90 days of hospitalization during each benefit period. That coverage kicks in after your deductible is met and you will have co-pays during that time.
However, once the 90 days is up, you then start using your “lifetime reserve days.” These days have higher co-pays than those first 90 days did. You have 60 lifetime reserve days, and once they are used up, Medicare will not cover any further hospitalization costs. This can be a big surprise to those who believed that Medicare would cover whatever they needed if they were hospitalized.
This is a very good reason to consider an emergency response solution for the elderly. Of the one in four seniors who falls down every year, 20% will suffer a very serious injury, such as a traumatic brain injury or a bone fracture. In fact, the CDC reports that 95% of hip fractures are caused by falls, and falls are the leading cause of traumatic brain injuries. And there’s no doubt that these injuries can lead to lengthy hospitalizations – but the sooner you get assistance, the better the outcome will be[2]. A medical alert device right at your fingertips is your peace of mind that if the worst does happen, you can get help right away.
Deductibles and Co-Payments
It’s important to note that Medicare does require not only premiums, but deductibles and co-pays as well. For instance, those who have original Medicare in 2022 paid a deductible of $1,556 for Part A and $233 for Part B before their coverage kicked in; after that, Medicare covered 80% of physician services, x-rays, and laboratory testing. Medicare supplemental insurance or a Medigap plan can cover the 20% a Medicare beneficiary will owe, so carefully consider your out-of-pocket costs to ensure that you are making the best financial move before you choose a supplemental plan[3].
Dental, Vision, and Hearing Costs
If you have original Medicare, you’re financially responsible for routine dental exams and cleanings, dental work, or even dentures. In most cases, Medicare doesn’t cover eye exams or the cost of glasses or contacts – but it will cover some vision expenses if you have had cataract surgery or if you have diabetes. And Medicare won’t help pay for hearing exams or hearing aids. However, some Medicare Advantage Plans will contribute payments toward some of these.
Unfortunately, this lack of coverage could mean that those on a tight, fixed income might not be able to afford the care they need to ensure vision, hearing, and dental health are up to par. And that can lead to other problems. For instance, problems with vision can lead to issues with driving or walking safely, as it becomes more difficult to clearly see your surroundings.
And when vision problems come into play, so do falls. According to HealthInAging, while about 30% of those over the age of 65 will suffer a fall, that risk doubles among those who have vision issues. And those who have hearing problems are also at risk of falls. The American Speech-Language-Hearing Association found that even those with mild hearing loss see a three-fold greater risk of falling down, and that risk increases by an astounding 140% with every 10 decibels more of hearing lost.
If you are suffering from vision or hearing problems, it’s a great idea to consider a medical alert pendant. Wearing an emergency button alarm can ensure that help is literally at your fingertips. It’s especially helpful to consider a medical alert system with fall detection, as fall sensors in the device can automatically send an alert for help without even having to press the button.
Some Foot Care Expenses
When it comes to living with diabetes, you probably know that many things can go wrong in the body. Diabetic neuropathy, or nerve problems that often affect the feet, as well as slower wound healing, mean that your feet need extra attention. If you are accustomed to going to a podiatrist, you might be disheartened to learn that in many cases, Medicare won’t cover that expense – unless your primary care physician can make a clear case of medical necessity. Medicare also declines to provide coverage for orthopedic shoes, nail care, the removal of corns or calluses, treatment of flat feet, or creams that are designed to maintain skin tone.
When you have problems with your feet, you can also have a greater risk of falls. A study in the journal Gerontology found that those who suffered foot pain were 62% more likely to suffer falls than those who had no pain. But even those who suffer the opposite – numbness – as a result of diabetic neuropathy are often at an increased risk of falls too[4]. A medical alert watch or pendant is a great solution to help ensure that if you do fall down, you can press a button to summon help in seconds.
Cosmetic Surgery Payments
When it comes to cosmetic surgery, Medicare is in line with what most private insurance companies cover – Medicare will not cover cosmetic surgery in general, but there are some exceptions. Those exceptions include things that affect your quality of life, such as cosmetic surgery to repair burns or facial injuries. If you need surgeries for clear medical reasons, but the surgery also happens to change your appearance in a positive way, that’s covered – it’s the “medical reason” that counts here. A good example of this is breast reconstruction after a mastectomy. This is considered medically necessary, so Medicare will pay for it.
It’s also interesting to note that some things you might normally consider to be purely cosmetic, such as Botox injections, can be used for other things that make them a medically necessary procedure, and therefore might be covered. For example, in the case of Botox, it freezes the muscles where injected, and that can be quite effective in stopping the painful spasms and twitches that occur with some muscle disorders. When in doubt, check your coverage.
Medical Care in Other Countries
If you deliberately choose to get elective medical care in another country, Medicare doesn’t travel with you – that procedure won’t be covered. Most of us will expect that, but what happens if you suffer an accident while vacationing in another country and need urgent medical care that can’t wait until you get back to the US? In most cases, Medicare won’t cover those costs either. However, Medigap plans might cover 80% of the costs, and some Medicare Advantage Plans will offer coverage for necessary medical care no matter where you are in the world. If you often travel internationally, it’s a good idea to look into the variety of plans available to find one that covers a good percentage of medical costs wherever you might travel.
Nursing Home Care
Long-term care insurance is a very good idea for those on Medicare, as the program doesn’t cover long-term nursing care, whether it’s at home, in a nursing home, or in a similar facility. However, Medicare does still cover other services. If you need medical supplies, that’s covered. If you need to go to the hospital from the nursing home for emergency treatment, that is covered at the usual hospitalization rate. When you see your physician, that is covered as well. But the cost of a nursing home stay itself is not covered by Medicare.
Keep in mind that Medicare defines nursing home care as “custodial care,” which is help with the activities of daily living. Medicare does cover skilled nursing care, however. If you need consistent medical attention, such as for the changing of dressings on wounds, this might be covered. Speak with your doctor about what your options are for coverage in the event of a serious medical condition, and consider long-term care insurance as a backup, just in case.
Costs for Spouses and Dependents
This one can come as a surprise to those who have worked for an employer who offered a comprehensive health plan. Employer coverage almost always offers dependent and spousal insurance as an option. When you go on Medicare, however, there is no spousal or dependent benefit. That means that the others in your household will have to get their own insurance.
If you are still working for an employer when you become eligible for Medicare, you’ve got a choice to make. Does your employer plan currently cover your spouse or others in your household? If it does, consider what it might cost for those individuals to get their own coverage. You might find that it’s cheaper to stay with the employer plan until you are ready to retire.
If you have other questions about what is covered and what is not, visit Medicare.gov for more information. Alert1 hopes this summary has been helpful for seniors!