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COLUMN: What does Medicare cover?

William C. Lane, Ph.D., Special to the Daily Sentinel
Posted 1/30/23

Two major additions to Medicare coverage went into effect in January.

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COLUMN: What does Medicare cover?


Two major additions to Medicare coverage went into effect in January.

The first of these is a cap of $35, without any deductible, on the monthly cost for insulin covered by Medicare Part D drug plans. Drug plans have until March to implement this change in the cost of the drug. If you pay more than the $35 cap for insulin during January or February, your plan must reimburse you for any amount you paid above the cap. This refund must occur within 30 days. Contact your plan directly to obtain a refund.

A second major addition is the coverage of the shingles vaccine. The Centers for Disease Control (CDC) now recommends that this two-dose vaccine, which is more than 90% effective, be given to all adults aged 50 and older. Beginning this year, the shingles vaccination will be covered under your Part D drug plan without any co-pay.

This will save Medicare beneficiaries up to $200. As with the insulin cap, this change in coverage was part of the Inflation Reduction Act passed by Congress in August of last year. Other vaccinations - Medicare calls them shots - that continue to be covered under Part D plans, without a co-pay, include flu, Hepatitis B, Pneumococcal and all COVID-19 primary and booster doses.

Original Medicare. The information presented in this monthly column is always based on Original Medicare, coverage under Parts A and B as well as a Part D drug plan. This is because if you have a Part C or Medicare Advantage plan, all of the information will always apply to you. Additional coverages will vary by Advantage plan but all Part C plans must cover everything covered by Original Medicare.

Medicare Part A. Medicare Part A is the hospital insurance portion of Medicare. In additional to inpatient hospital care, Part A also covers:

Skilled nursing facility care. The coverage for nursing home care must follow a hospital stay of three or more days. Medicare pays the first 20 days in full, the next 80 days with deductibles and co-payments and nothing after day 100.

Nursing home care. This is for what is called non-custodial care. This a medical benefit for rehabilitation and is designed for short-term stays.

Hospice care/home health care. This coverage is limited to such things as physical therapy and nursing visits. It is designed for beneficiaries who no longer need to be in the hospital but still need some therapies and monitoring to return to full independent living at home.

Medicare Part B. Medicare Part B helps to cover what Medicare terms “medically necessary” doctor’s services, outpatient care, home health services, durable medical equipment, mental health services and a number of preventive services. The key word here is “help.” After you meet your yearly deductible, Medicare generally pays all but 20% of the Medicare-approved amount for the service if your provider accepts what is known as Medicare assignment.

If your physician or other provider does not accept assignment then you may be obligated to pay an amount above this 20% charge. In either case, this is why you need some type of Medigap policy to cover any out-of-pocket charges not covered by Medicare.

Many important Medicare preventive services are now covered in full without any deductible, co-payment or co-insurance charges proving your provider accepts Medicare assignment. The list of fully covered preventive services has expended greatly over the past 10 years.

Some of the most common fully covered preventive services include cervical and vaginal cancer screenings, colonoscopies, COVID-19 testing and antibody treatments, diabetes screenings, mammograms, PSA tests and the yearly “Wellness” visit with your primary care physician.

Medicare Part D. All Medicare beneficiaries must have a Part D drug coverage plan. Next month’s column will focus on these drug plans.

What does Medicare not cover. The lack of coverage for certain important services continues to be a topic of legislative discussions in Congress. A partial list includes most dental care, eye exams for prescription glasses, dentures, long-term care and hearing aids and exams for fitting them. For a complete list of non-covered services see page 55 of the annual Medicare and You 2023 publication.

Also, Medicare does not provide any coverage when the service is provided by a provider who has chosen to opt-out (not participate) in Medicare. While some estimate that only 1-2% of all physicians do not participate in Medicare, the Kaiser Family Foundation found that 93% of primary care physicians accept Medicare assignment but only 70% are now accepting new patients. Medicare assignment will also be discussed in a future column.

More information

The Oneida County HIICAP office is continuing to provide counseling services and in-person scheduling by phone as they have throughout the pandemic. If you would like to do a HIICAP counseling session over the phone or schedule an appointment at one of the two in-person locations call 315-798-5456 and select No. 2 from the choice list. In most cases you will be asked to leave your contact information on a voice mail and a staff member will return your call within 72 hours. Counselors are available at the following locations:

Copper City Community Connection, 305 E. Locust St. in Rome, will offer a counseling session from 9 a.m. to 3 p.m. on Thursday only. The HIICAP program will also be scheduling at Copper City.

North Utica Senior Citizens Center, 50 Riverside Drive in Utica. Hours have been expanded at this site. Appointments will now be accepted on Monday, Wednesday and Friday from 9 a.m. to 3 p.m. Sessions are expected to run 45 minutes. Call the HIICAP office at 315-798-5456, selecting option 2 to schedule an appointment.

Contacting HIICAP programs in other counties. To reach the Madison County HIICAP program call 315-697-5700 and ask to speak to a HIICAP counselor. For Herkimer County, call Catholic Charities of Herkimer County at 315-894-9917. For Lewis County call 315-376-5013 and select No. 2 from the choice list.

William Lane is the owner of William Lane Associates, a gerontological consulting firm located in Homer. He writes a monthly column on HIICAP related issues for the OFA. Lane does not sell insurance, work for any insurance company or recommend any insurance products.


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