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  • Writer's pictureValerie Hopson-Bell

Navigating Through the Maze of Medicare

Oftentimes I am asked, “Why did they make Medicare so difficult to understand?” My set answer is, “I don’t know, they (the government) have never asked my opinion in developing these policies.” I have concentrated my time on trying to understand the dichotomies of Medicare, instead of the idiosyncrasy of the government.

The Various Parts of Medicare

Medicare has 4 parts: Part A (hospitalization), Part B (medical), Part C (Medicare Advantage) and Part D (prescription drugs). Most people 65 or older and those certified disabled through the Social Security Administration for 24 months are entitled to Medicare Part A. Part A has been paid for through one’s working years and paying into Medicare taxes, provided you accumulated at least 40 quarters of Medicare covered employment. Forty quarters is equivalent to approximately 10 years of covered employment. Part B has a monthly premium which can be a different amount for recipients.

Those new to Medicare in 2017 were brought in at the current Medicare monthly premium rate of $134.00. Beneficiaries whose modified adjusted gross income is over $85,000.00 as an individual or $170,000.00 as a couple pay quite a bit more on a monthly basis. Depending on their adjusted gross income, they could pay as much as $428.60 per month. Part C is purely a choice and the monthly premium varies. Part D covers prescriptions. There is a penalty if you choose not to participate without being covered under a creditable plan and later decide to. Part D plans have premiums that vary from $17.51 to $151.50 per month.

Medicare Coverage Explained

Now that we have the basics of Medicare out of the way, let’s talk about what it covers. Of course, your stay in the hospital, your doctor visits and lab work are all covered by Medicare. Medicare covers your rehabilitation in a skilled care facility, oftentimes referred to as SNFs. Medicare pays in full up to 20 days. It will pay much of your stay up to a maximum of 100 days, if you continue to show progress in your therapies. Your supplemental or Medigap policy can help pay some of the health care costs that Original Medicare doesn’t cover, like the daily co-pays and coinsurance.

Therapies covered in skilled care facilities are physical, occupational and speech and they include coverage of social and psychological services, nursing care, drugs you cannot give yourself and durable medical equipment (DME).

Medicare covers outpatient therapies, but at a different rate. It can include services mentioned above as skilled care, but you must go to a Medicare-certified provider multiple times per week.

If you’re “homebound,” Medicare will pay for home health agencies. Covered on a limited basis are cardiac rehabilitation, covered at two–one hour sessions for 36 weeks; and pulmonary therapy, which is limited to a maximum of 36 sessions, with no more than two sessions per day.

Medicare provides coverage of some ambulance transports, particularly in emergencies, but certain criteria must be met.

Many items are covered under durable medical equipment, including wheelchairs, scooters, walkers, hospital beds and home oxygen equipment, prosthetics and orthotics. Medicare coverage includes testing, fitting, or training in the use of these devices.

For People With Diabetes

People with diabetes are allowed one pair of shoes with orthotic innersoles per calendar year at no charge. They can also get diabetic supplies, i.e., glucose monitors, lancets and testing strips. Foot care to monitor for nerve damage is covered every six months. Medicare pays for annual glaucoma screenings. Medicare offers outpatient nutrition counseling covered by Part B to people with diabetes or have kidney disease, but are not on dialysis.

Medicare covers hospice care to help manage your pain and symptoms. Hospice care is an all-inclusive type of benefit depending on your condition. For some people hospice is prescribed at end of life or when the fragile senior shows no will to live. Hospice, under the Medicare benefit covers nursing and personal care, skilled care, durable medical equipment, respite for the caregiver and medications for pain relief and symptom control. Medicare also offers spiritual and emotional support for hospice patients.

The mental health parity law has forced Medicare to bring the individual out of pocket expenses for mental health services more in line with those of physical health care. They also cover in-hospital and partial hospital stays, as well alcohol and substance abuse treatments.

The last coverage item to discuss is preventive services. With the Affordable Care Act, most of these services are now covered at 100%. These include screenings for colon cancer, prostate cancer, mammograms, pap smears/pelvic exams, cardiovascular risk reduction, alcohol misuse, depression, sexually transmitted infection and obesity. Smoking cessation counseling is covered at 100% for persons who do not have a smoking related illness and 80% for those who do. Three vaccines are fully covered; flu, pneumonia and hepatitis B. A medical history and physical is covered at 100% for those who are within the first 12 months of Medicare and for all others, an Annual Wellness Visit.

Medicare is a topic that political pundits like to toss around to jolt the other party into a state of fear, yet it provides seniors and the disabled comprehensive coverage.


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