7 Important Facts on Medicare Coverage

One of the most frequently asked questions among Medicare beneficiaries is, “Does Medicare cover ______?” Generally, answers to this question are as cut and dry as you might hope. Medicare coverage can vary by person. Specific circumstances can affect the response, such as whether you meet the coverage criteria or if there is a limit to the coverage.

While on Medicare, you’ll find there are seven important facts on Medicare coverage you should remember. Knowing these coverage details will prepare you for potential future costs.

1. Medicare’s number one rule

When trying to figure out whether Medicare will cover something or now, the first thing you should ask yourself is, “Is this service/item medically necessary to treat, diagnose, or prevent a medical condition?” That is Medicare’s number one rule. The service/item must be medically necessary to treat, diagnose, or prevent a medical condition for Medicare to cover it.

Medicare determines medical necessity based on how your doctor codes the service. There are thousands of Medicare codes that can be used to describe a service and its purpose. If your doctor provides the correct codes to prove the service’s medical necessity, Medicare will likely cover it.

2. Medicare Part B offers free preventive services

Medicare Part B covers your outpatient medical services, such as doctor visits, lab work, and preventive care. Preventive care services covered under Part B include things like cancer screenings, vaccines, and wellness checks. Many of these preventive care services are covered at 100% if you meet the criteria.

For example, Part B will cover a mammogram screening once a year at 100% if you are at least 40 years old.

However, some of the services are only partially covered and have more criteria to meet. For example, Part B covers a glaucoma test once a year at 80% if you are at high risk for developing glaucoma. To be at high risk for glaucoma means you:

  • Have diabetes
  • Have a family history of glaucoma
  • Are at least 50 years old and are African American
  • Are at least 65 years old and are Hispanic

Depending on the service, you may qualify for more frequent screenings if you meet specific criteria.

3. Medicare Part B covers some vaccines, while Part D covers others

As mentioned above, Medicare Part B covers certain vaccines at 100% as a preventive service. These include the flu, pneumonia, and hepatitis B vaccines. However, some vaccines are subject to Part D coverage, such as the shingles vaccine.

All Part D plans are required to cover the shingles vaccine. However, unless you have met your Part D deductible, you may pay the full price for your vaccine. If you wait to receive your vaccine after you’ve met your deductible, you’ll pay a smaller copay instead.

4. Medicare has cost-sharing with no cap

Medicare Part A and Part B only cover a portion of your approved medical services. For example, Part B covers your doctor visits at 80%, while you cover the other 20%. There is no cap to how much you can spend each year on Part A and Part B cost-sharing expenses.

Therefore, you should consider enrolling in either a Medigap plan or Medicare Advantage plan to limit your out-of-pocket spending. For example, if you have a Medigap Plan G, you will pay no more than the Part B deductible for Medicare-approved services each year. If you have a Medicare Advantage plan, you will pay no more than your plan’s out-of-pocket maximum each year for approved services.

5. Medicare doesn’t cover routine dental, vision, and hearing services

Medicare doesn’t consider routine dental, vision, and hearing services to be medically necessary. Therefore, most routine dental, vision, and hearing services are never covered. However, there are some instances where Medicare might cover a routine service. For example, Part B might cover a dental exam if you are about to undergo organ transplant surgery.

Medicare will also cover procedures if it is needed to treat an actual medical condition. For example, Medicare covers cataract service since cataracts are an actual medical condition of the eye. If you would like coverage for routine dental, vision, and hearing services, you can enroll in a standalone plan or a Medicare Advantage plan that includes these benefits.

6. Medicare doesn’t cover long-term care

Medicare doesn’t cover long-term care. Long-term care involves various services that are expected to be needed for an extended period, such as lifelong. Medicare only covers short-term care for conditions that are expected to improve within a reasonable amount of time. Therefore, Medicare doesn’t cover rent for a nursing home, a live-in nurse, or other long-term care arrangements.

7. Medicare Part D coverage varies by payment stage

Medicare Part D plans are all structured the same way and must abide by the same rules. Therefore, they all have four payment stages – the deductible, initial coverage, coverage gap, and catastrophic coverage. As you move throughout these stages, your coverage for your drugs will change. For example, during the deductible stage, you may pay the full price for your drug, whereas you may pay a $20 copay during the initial coverage stage.

As you can see, Medicare coverage is never cut and dry. Discuss your Medicare coverage questions with your doctor before committing to getting a service done. If there is a coding error or a limit to how often you can get the service, you may be responsible for 100% of the bill.

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