Personal Medicare

One of the most frustrating aspects of Medicare is figuring out what’s covered and what isn’t. Today, we’re going to address the issue of dental care and other oral health coverage. Is it available or not?

Seniors, it isn’t good news!

When trying to understand your Original Medicare benefits, that’s Part A (hospital) and Part B (medical), it’s important to understand that it’s for your major medical only. That means it covers anything about your overall health condition. And, as far as the government is concerned, that does not include your teeth or any other aspect of oral health.

There is an exception to the hard-and-fast, no dental coverage rule. Medicare will pay when your primary care physician or specialist determine that oral surgery, or another dental procedure, is “medically necessary”. This only happens in the treatment of another health condition, such as oral cancer. Curiously, Medicare may pay to have all of your teeth pulled, but they won’t pay for your dentures or implants.

How-to Get Coverage?

We all have a different situation, so, thank goodness, there are different solutions. For some luck people, Medicare Advantage is a solution. But, it’s a real crap shoot, because so many things need to match up (primary care doctor, specialists, prescription coverage, etc). Good luck finding the right plan that also offers dental.

The next option is an individual dental plan. Here’s where you’d think the government could have done some good, because dental plans are available through the federal healthcare exchange, but only if you’re enrolled in a health plan on the exchange. Where was Obama on that one? Okay, gripe over.

If you want traditional dental insurance, you’ll have to go to a private health exchange or an individual plan o get it. Plans start at about $25 per month, but be careful. These cheap-o dental plans are just that, and they come with a long list of caveats, like a 6+ month waiting period, annual limits or a lifetime limit. If you want a plan that does not have these limitations, then you’re looking at more money, on up to $60 to $70 per month. And, you still have deductibles and co-pays, driving the cost up even more.

The third option is to pay out of pocket and find the discounts. Hey, we’re seniors, right? We know how to get discounts! And, as far as I can see, there’s none better than the discount dental cards available from a wide variety of players, including CVS, Aetna, Cigna and man more.

If you’re not familiar with these cards, it’s a really simple concept. For a flat fee each year you get 40% to 60% off standard dental rates. I guess the dentists and specialists can afford to give these discounts because it reduces their advertising costs, or something like that. Whatever it is, it’s a great deal for us. Click here for a list of all savings plans.

References:

• Medicare.gov
• CMS.gov

Medicare Advantage, also known as Part C, is an alternative to Original Medicare (Part A and Part B) and is offered by private insurance companies. Each and every Medicare Advantage plan must provide the full coverage offered by Parts A (Hospital Insurance) and B (Medical Insurance) together. Most MA plans also cover prescription drug care (Part D). Some also offer extra benefits like dental, vision and hearing.

How does it work? Medicare pays the private companies a fixed amount for your monthly care. These companies in turn must follow all of Medicare’s rules. However, each Medicare Advantage Plan can charge different out-of-pocket costs and can have different rules on how you access your services. Make sure you take the time to find and compare plans in your area.

There are a number of different types of Medicare Advantage plans

• Health Maintenance Organization (HMO) Plans
• Preferred Provider Organization (PPO) Plans
• Private Fee-for-Service (PFFS) Plans
• Special Needs Plans (SNP)

To read about these and more types of Medicare plans, click here.

Enrolling in Medicare Advantage can be a bit confusing. You must first enroll in both Medicare Part A and Medicare Part B if you want to enroll in a Medicare Advantage plan. Don’t worry, you can switch back and forth from Original Medicare to a Medicare Advantage plan as long as you are enrolled in both Parts A and B. You can make this switch every year during the Annual Enrollment Period (AEP).

PLEASE NOTE: If you enroll in Part A, Part B or both you will receive your benefits through Original Medicare. You must choose and enroll in a specific Medicare Advantage plan should you wish to receive their specific benefits.

Still want more info on Medicare Advantage? Read here for a quick overview of facts you need to know.

You can use this Medicare Advantage plan catalog to browse plans by state or compare plans based on your exact prescription drugs and location.

Are you turning 65 soon? If so, there are a few things that you really need to know about the healthcare system, like what it provides and what it doesn’t.

With that in mind, we’ve prepared these ten quick and simple general facts to make sure you know when considering your Medicare options:

1. Original Medicare includes Parts A and B which are offered through the Federal government.
2. Part D prescription drug coverage, is a standalone add-on plan to Original Medicare. You can browse Part D Plans by state in our online catalog here.
3. Original Medicare doesn’t cover all of your hospital and medical expenses, there are significant coverage gaps that you should know about.
4. Medigap insurance plans, sometimes called Medicare Supplemental Plans, can help fill in the gaps that come with Medicare Parts A and B.
5. Medicare Advantage Plans, also known as Part C, are offered by private insurance companies and provide your Part A, Part B and often Part D coverage.
6. Cost and coverage for Parts A and B are the same all over the US, but Medigap, Medicare Advantage and Part D Plans vary by state and sometimes even by county.
7. Those who are currently employed or those who have retiree insurance from a former employer, might not need to enroll in a privately insured Medicare plan. Check with your HR department on how your current plan fits with Medicare. You still might want to enroll in Original Medicare.
8. Don’t put off enrolling in Medicare, because if you wait you could end up paying more for your coverage and have fewer choices. There are penalties for late enrollment.
9. Medicare allows for freedom and flexibility in plan selection. It’s important to make sure your plan meets your needs. You have the ability to change plans at least once a year.
10. Medicare is your right, you earned it! Ask for help and take full advantage of your benefits.

What Medicare Does Not Cover

The most significant point to come to grips with is what Medicare covers and what it doesn’t. In general, Medicare covers services deemed medically necessary. There is one caveat to this, and that’s your outpatient prescription medications. Even though your prescription might be medically necessary to handle a chronic health condition, Medicare does not cover this expense, you do by purchasing a Medicare Part D prescription drug plan.

Here’s the short list of what Medicare doesn’t cover:

• Long-term care (also called custodial care)
• Most dental care and oral health procedures
• Eye examinations related to prescribing glasses
• Dentures
• Cosmetic surgery
• Acupuncture
• Hearing aids and exams for fitting them
• Routine foot care

In addition to what Medicare does not cover, they only pay for about 80 percent of what is covered. You’re on the hook for the rest. We’ll be blogging more on this topic in the coming weeks.

Related:

• Senior Health Issues Related to Poor Oral Health
• How to Approach Medicare for the First Time
• Late Enrollment Penalties in Medicare

Ever wonder why you may be getting bills for your physical therapy even though you’re covered by Medicare?  You may not know, and you’re certainly not alone, that Medicare puts limits on what they pay for your physical therapy.  Specifically, we’re talking about outpatient physical therapy versus inpatient therapy which would involve admittance into a skilled nursing facility.

Medicare Limits Your Physical Therapy (Sort of)

Yes, Medicare does limit or cap what they will pay in a calendar year for your outpatient physical therapy; however, you can have an exception granted that will increase the coverage.  This increase is not unlimited of course and also has a cap as well.  Here are the limits for 2017:

• Occupational Therapy (OT) – $1,980
• Physical Therapy (PT) or Speech Language Pathology (SLP) – $1,980

These therapy caps or therapy cap limits are your initial limits to what Medicare will pay without needing to qualify for an exception.  You’ll also see that the limits are broken up into both physical therapy and occupational therapy, so if you’re needing both you will receive more care before hitting that limit.

What If Additional Physical Therapy Is Needed?

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), you are able to seek additional coverage through Medicare for physical therapy that is deemed medically necessary and reasonable.  This is continued in 2017 to allow you to get physical therapy care that is needed.  The limits for this exception in 2016 and 2017 are:

• Occupational Therapy (OT) – $3,700
• Physical Therapy (PT) or Speech Language Pathology (SLP) – $3,700

This almost doubles the amount of coverage that Medicare limits you to when receiving outpatient physical therapy.  Of course, they don’t just automatically give this extra coverage to you.  The provider has to deem it to be medically necessary and reasonable.  A Medicare contractor has the ability to go back and review you claims to make sure that they are medically reasonable and necessary.  Also, if the care that you are given is not going to meet the medically necessary and reasonable requirement, the provider must notify you so you can make the decision knowing that it won’t be paid for by Medicare.  They do this by written notice, also known as a Advance Beneficiary Notice of NonCoverage (ABN).  This protects you from receiving care that is not going to be paid for by Medicare.

Of course, with Medicare Part B coverage only, they are not paying all of the costs associated with the physical therapy anyway.  You still will have to pay the annual deductible and coinsurance which is 20% under Medicare Part B.  Other factors that can affect how much you pay will be how much the provider charges, where the services are received, whether or not the provider accepts assignment, and of course any other insurance that you may have.

This “extra” coverage provided through MACRA, is not guaranteed beyond this year 2017.  We currently don’t know if it will be available to you next year or beyond so now may be the time to consider having that procedure or at least looking at the best time to have the procedure that will require outpatient physical or occupational therapy.