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Medicare has coverage gaps despite congressional effort to expand it


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Medicare will cover hearing services for the first-time in its history if Democratic lawmakers win.

Coverage would become effective in 2023 under the Democrats’ $1.85 billion spending bill. This is known as the Build back Better Act. Partly it aims at strengthening the social security net. Before President Joe Biden can sign it into law, the legislative package must be approved by both the House of Representatives and Senate.

Hearing isn’t the only gap in coverage. In addition to many new enrollees finding out that Medicare is not free — far from it — they also may be surprised that it doesn’t cover a variety of health-care expenses that can hit retirees pretty hard.

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Medicare covers approximately 63.3 millions people. The majority are over 65 (55.1 million), and those who are not are usually disabled are typically younger.

Programs that lower Medicare-related costs may be available to low income individuals. Extra help is available for prescription drug coverage. Additionally, some state-run savings programmes can assist with premiums, copays, deductibles, and coinsurance.

The only options for those not eligible are to pay out of their own pocket or purchase additional insurance.

These are the things you need to know.

Let’s start with the ABCs of Medicare (and D).

Original Medicare, also known as basic, consists of Parts A and B. Except if you already have qualified health insurance through another source (e.g. an employer), then you must sign up once you are 65 years old.

Part A includes coverage for skilled nursing, home care, hospital stay, and hospice. You don’t have to pay a premium for Part A as long you have a minimum of ten years worth of work experience. The deductible is $1,484 for this year, and $1,556 in 2022. There are also caps on benefits.

One surprise is the Part A Deductible isn’t a per-benefit period deductible. It is a per-year deductible. Danielle Roberts is cofounder of Boomer Benefits insurance company.

When you see a doctor, or get outpatient care such as a flu shot, Part B coverage begins. This also includes medical equipment such as crutches and blood-sugar meters.

The standard monthly Part B premium is $148.50 this year, rising to $158.50 by 2022. (However, higher-income beneficiaries pay more.) You also get a $203 deductible for this year, which is expected to reach $217 in 2022. After the deductible is met, typically 20% of your covered services will be paid.

Prescription drugs are not covered by basic Medicare. This coverage can be obtained through Part D. It is available as either a standalone plan or as part of a Medicare Advantage (Part C) which may also have a premium above what you pay for your Part B.

Advantage plans include coverage for Parts A andB. These benefits are also provided by private insurance companies.

You should also know that the out-of pocket expense for Medicare Basic is not subject to a limit. The same is true for Part D prescription drugs coverage. But, the Democrats’ spending bill would allow it to be limited to $2,000 per year.

Teeth, eyes, and ears

The Democrats’ spending plan would include hearing care in Medicare. However, routine vision and dental work would still be covered by the bill, despite previous versions. 

Basic Medicare doesn’t cover dentures. A complete set can cost anywhere from $1,000 up to $5,000. A routine cleaning, X-ray and filling could cost you around $200. However, an implant for a single tooth can run upwards of $4,000.

If a condition that involves a complicated or emergency procedure, however, coverage may be available.

The same applies to routine vision tests. You won’t be covered for glasses if you have a vision problem. Basic Medicare covers you if your eye condition is glaucoma, cataracts or other serious conditions.

You can choose to have an Advantage Plan. Although coverage may not always be complete, it’s likely that dental, hearing, vision and other services will be covered. 

An additional policy, which provides more comprehensive coverage, can also be bought.

Standalone vision plans cost between $10 and $30 per month depending on the extent of coverage. Dental plans may run from $30 to $50 per month.

The jet-setters

Be aware, if you plan to travel from one country to the next in your life later on, basic Medicare does not usually cover medical care that is received outside of the U.S.

You can have your emergency coverage worldwide if you opt for an Advantage Plan. But routine care overseas might not be.

You might consider travel-medical insurance policies that are specifically designed for the over-65 crowd. These policies cost approximately $175 per month, depending on your age and the details of the coverage.

If you prefer to keep your Medicare basic instead of signing up for an Advantage Plan you still have the choice of purchasing a so-called Medigap policyThis includes travel coverage. If you are part of an Advantage Plan, Medigap cannot be purchased.

Medigap policies generally cover coinsurance and deductibles associated with basic Medicare. Some plans also provide coverage for overseas travel with a maximum of $50,000

If the Medigap cap is too low, you may also be able to purchase an additional plan.

Long-term care

But not all older people will need long-term care — which generally means help with daily living activities like bathing and dressing — those who do won’t get much coverage from Medicare.

Roberts explained that long-term care is not covered for beneficiaries. Although Medicare covers your medical expenses in nursing homes or facilities, it does not pay for room and board or custodial care.

Insurance policies can cover long-term health care but they may be expensive. The more you age, the higher the cost.

The American Association for Long-Term Car Insurance estimates that rates for a married couple of 55 years would cost $2,080 for a policy offering $165,000 worth coverage. The amount for a couple who are 65 or older is approximately $3,750

Qualifications for skilled nursing coverage

You should know whether or not you were admitted to the hospital. If skilled nursing is involved, it can affect whether Medicare will cover your treatment. It could also include physical therapy after a falls.

“This is a big one,” said Elizabeth Gavino, founder of Lewin & Gavino and an independent broker and general agent for Medicare plans.

Gavino stated that three consecutive days spent as an inpatient is required to be qualified for skilled nursing care. The time spent at the hospital while under observation is not included.

Medicare Part A covers skilled nursing care if you’re eligible. For the first 20 days, Medicare pays the full cost of covered services, according to the Centers for Medicare & Medicaid Services. Coinsurance is required for days 21-100. The full cost of your care is payable for any days above 100.

There are always odds and ends

Acupuncture, routine foot care and cosmetic surgery are not covered by basic Medicare.

Additionally, many beneficiaries are surprised to discover that a standard annual physical is not covered by Medicare — at least the kind they were likely accustomed to under previous insurance, Roberts said.

Roberts stated that Medicare does offer a “welcome Medicare” visit as well as an annual wellness appointment. These visits are comparable to a regular physical but less comprehensive.