Medicare is a federal health insurance program primarily for older adults aged 65 and over. It also covers certain younger people with disabilities or specific conditions, particularly Lou Gehrig’s disease or amyotrophic lateral sclerosis (ALS) and end-stage renal disease (ESRD).
While most people are familiar with the basic coverage options under Medicare Parts A and B, many aspects of Medicare remain lesser-known. Knowing and understanding these is important to help beneficiaries make informed decisions about their healthcare.
Here are the top five facts about Medicare that fewer people know about:
Medicare Coverage Outside the United States
Medicare’s coverage typically extends to services received within the United States. However, unknown to many, there are certain circumstances where Medicare may cover healthcare services for travel abroad. In specific emergencies, Medicare may pay for services in Canada if traveling directly between Alaska and another state and the nearest hospital is in Canada.
Additionally, some Medicare Supplement Insurance (Medigap) plans provide coverage for travel outside the U.S., covering 80% of the billed charges for particular medically necessary emergency care abroad that begins during the first 60 days of a trip, subject to a $250 annual deductible.
This coverage is crucial for beneficiaries who travel frequently or live near border areas, providing a safety net during emergencies. However, the conditions under which Medicare covers these services are specific, emphasizing the importance of understanding healthcare coverage before traveling internationally.
No Dental Coverage
A common question among Medicare beneficiaries is: does Medicare pay for braces or dentures? The straightforward answer is no. Original Medicare (Parts A and B) doesn’t cover braces and dentures or most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, or dental plates. This lack of coverage extends to most routine dental care, including dentures, which can be a significant out-of-pocket expense for seniors.
The good news is that some Medicare Advantage Plans (Part C) may offer additional dental coverage, including dentures. Beneficiaries need to review the specifics of their Medicare Advantage Plan to understand what dental services are covered and to what extent. This knowledge can help seniors plan for and manage dental care costs, including dentures.
Late Enrollment Penalties
A fact often overlooked by new beneficiaries is the penalty associated with late enrollment in Medicare Part B and Part D. If beneficiaries don’t sign up for Part B when they’re first eligible, they could be subject to a late enrollment penalty, which adds a 10% increase to their premium for every 12 months they were eligible but didn’t enroll.
Similarly, for prescription drugs (Part D), 1% of the “national base beneficiary premium” is multiplied by the number of full, uncovered months they were eligible to get the penalty. The eligible full, uncovered months should be the time when they didn’t job Part D and weren’t covered under a creditable prescription drug coverage.
Understanding these penalties is also crucial to avoid unexpected increases in healthcare costs. Enrolling during an initial enrollment period is crucial unless beneficiaries have other creditable coverage, such as employer or union coverage.
The Medicare Savings Programs (MSPs)
Medicare Savings Programs (MSPs) are often underutilized resources. They’re designed to help low-income beneficiaries cover some of their Medicare expenses, such as premiums, deductibles, and coinsurance.
There are several types of MSPs. Check them out here:
- Specified Low-Income Medicare Beneficiary (SLMB) Program: It only assists with outpatient service (Part B) for individuals whose income slightly exceeds the QMB criteria. Although it doesn’t offer as broad a coverage as the QMB program, it can still provide substantial relief for those struggling with Medicare costs. The income limits for this program are also slightly higher than those for QMB.
- Qualified Medicare Beneficiary (QMB) Program: It’s the most comprehensive MSP. It helps with inpatient care (Part A) and outpatient services (Part B) premiums and covers all deductibles, copayments, and coinsurance fees that Medicare-approved services incur. To qualify, individuals must have an income and resources below a certain threshold.Â
- Qualified Disabled and Working Individuals (QDWI) Program: It assists with paying Part A premiums for specific disabled individuals under 65 who have returned to work and lost their benefits of having no premiums for Part A. It’s particularly tailored to those who are working and have a disability, but its income limits are higher than those for the QMB, SLMB, and QI programs.
- Qualifying Individual (QI) Program: It’s available to individuals with slightly higher incomes than those eligible for the SLMB program. It assists with Part B premiums only. Unlike the QMB and SLMB programs, QI applicants must apply yearly for benefits, and the grants are awarded to whoever applied first, with priority given to the previous year’s beneficiaries. This program has higher income limits than the SLMB program but requires individuals to have income and resources under a specific threshold.
As noticed, eligibility for MSPs is determined based on income and resource tests, which can vary by state due to differences in cost of living and specific state supplements. If interested in applying, contact the nearest state Medicaid office directly.
Telehealth Services Coverage
In recent years, Medicare has expanded its coverage to include telehealth services. This shift allows patients to receive various medical services from the comfort of their homes through telecommunication technologies, such as video conferencing and mobile health apps. This includes routine office visits, mental health counseling, and preventive health screenings.
The move to include telehealth services under Medicare Part B coverage aims to provide greater accessibility to healthcare, especially for those living in rural areas or with transportation difficulties. It also offers a safer alternative for receiving care when visiting a healthcare provider in person might pose a risk, such as during flu outbreaks or the COVID-19 pandemic.
Final Thoughts
Medicare has several benefits. Beneficiaries only need to be aware of them and leverage them fully. If unsure or confused, seeking professional guidance is always highly recommended. They help ensure beneficiaries can maximize the benefits available to them.
Specified Low-Income Medicare Beneficiary (SLMB) Program: It only assists with outpatient service (Part B) for individuals whose income slightly exceeds the QMB criteria. Although it doesn’t offer as broad a coverage as the QMB program, it can still provide substantial relief for those struggling with Medicare costs. The income limits for this program are also slightly higher than those for QMB.
The Specified Low-Income Medicare Beneficiary (SLMB) Program primarily focuses on aiding individuals with outpatient services (Part B) under Medicare, especially those whose income marginally surpasses the criteria for the Qualified Medicare Beneficiary (QMB) program. While SLMB doesn’t offer the extensive coverage of QMB, it can still deliver significant assistance to individuals grappling with Medicare expenses, aligning with the principles of the 8-minute rule. Additionally, the income thresholds for eligibility in the SLMB program are slightly more lenient compared to those for QMB.
