Gaps in Medicare
To be eligible for Medicare, you must meet one or more of the following requirements:
Age: You must be 65 years old or older.
Disability: You must have a disability and receive Social Security Disability Insurance (SSDI) benefits for at least two years.
End-Stage Renal Disease (ESRD): You must have ESRD, which is permanent kidney failure requiring dialysis or a kidney transplant.
Amyotrophic Lateral Sclerosis (ALS): You must have ALS, also known as Lou Gehrig's disease.
If you meet any of these eligibility requirements, you can enroll in Medicare. It's important to note that if you are already receiving Social Security benefits, you will be automatically enrolled in Medicare Part A and Part B when you turn 65. If you are not receiving Social Security benefits, you will need to enroll in Medicare during your initial enrollment period.
GAPS IN MEDICARE
While Medicare provides important health insurance coverage to millions of Americans, there are some gaps in the program that beneficiaries should be aware of. Some of the key gaps in Medicare include:
Limited coverage for long-term care: Medicare only covers limited stays in skilled nursing facilities or home health care if certain conditions are met, and it does not cover custodial care or long-term care in a nursing home.
No coverage for some types of care: Medicare does not cover certain types of care, including most dental care, vision care, hearing aids, and routine foot care.
Cost-sharing: While Medicare covers a significant portion of many medical services and treatments, there are still out-of-pocket costs that beneficiaries are responsible for, including deductibles, copayments, and coinsurance.
Coverage gaps in Part D: Part D prescription drug plans have coverage gaps, also known as the "donut hole," where beneficiaries are responsible for a larger portion of their prescription drug costs.
Limited coverage outside of the United States: Medicare does not generally cover medical care received outside of the United States, with some exceptions for emergency care in certain circumstances.
It's important for beneficiaries to be aware of these gaps in Medicare coverage and to plan accordingly, whether by purchasing supplemental insurance or taking other steps to ensure they have the coverage they need.
LIMITED COVERAGE BY MEDICARE
Medicare provides coverage for a wide range of healthcare services and treatments, but there are some treatments and services that have limited coverage by Medicare. Here are some examples:
Physical therapy: Medicare provides coverage for physical therapy, but there are limitations on the number of visits covered per year. After the initial evaluation, Medicare covers up to 20 therapy visits per year, and additional visits may be covered with a medical necessity.
Mental health services: While Medicare covers mental health services, there are limitations on the number of therapy sessions covered per year. Additionally, Medicare covers 80% of the cost of mental health services, leaving the beneficiary responsible for the remaining 20%.
Home health services: Medicare provides coverage for home health services, but there are limitations on the duration and frequency of care. To be eligible for coverage, the beneficiary must have a qualifying condition and meet certain other criteria.
Hospice care: Medicare provides coverage for hospice care, but there are limitations on the duration of care. Hospice care is covered for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods if the beneficiary continues to meet certain criteria.
Medical equipment and supplies: Medicare provides coverage for medical equipment and supplies, but there are limitations on the types and quantities of items covered. Additionally, Medicare covers 80% of the cost of most durable medical equipment, leaving the beneficiary responsible for the remaining 20%.
It's important to note that while these treatments and services have limited coverage by Medicare, there may be exceptions or specific circumstances under which they may be covered. It's always best to check with your healthcare provider and/or Medicare to determine your specific coverage and any potential costs you may be responsible for.
Medicare does not generally cover long-term care in a nursing home. However, there are certain conditions under which Medicare may provide coverage for a limited period of time in a skilled nursing facility. In order to be eligible for this coverage, the following conditions must be met:
Hospitalization: The individual must have been hospitalized for at least three consecutive days.
Skilled care: The individual must require skilled nursing or rehabilitation care, which must be provided on a daily basis and ordered by a doctor.
Time frame: The individual must enter a Medicare-certified skilled nursing facility within 30 days of being discharged from the hospital.
Coverage limits: Medicare will cover up to 100 days of care in a skilled nursing facility. However, the individual must meet certain criteria to continue to receive coverage beyond the first 20 days.
It's important to note that even if these conditions are met, Medicare will only cover skilled nursing care for a limited period of time. If an individual requires long-term care in a nursing home or other facility, they may need to look into other options for coverage, such as Medicaid or private insurance.