Life After 50 Expo

Dear Marci,

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Dear Marci,
 
I am making decisions about Medicare coverage options, and one of my friends told me that I should ask the plans that I’m considering whether they have any supplemental benefits. What are supplemental benefits?
 
-Emmy (Houston, TX)
 
Dear Emmy,
 
A supplemental benefit is an item or service covered by a Medicare Advantage Plan that is not covered by Original Medicare. These items or services do not need to be provided by Medicare providers or at Medicare-certified facilities. Instead, to receive these items or services, you need to follow your plan’s rules. Some commonly offered supplemental benefits are:
 Dental careVision careHearing aidsGym membership 
For the most part, supplemental benefits must be primarily health-related. Beginning in 2020, however, Medicare Advantage Plans can begin covering supplemental benefits that are not primarily health-related for beneficiaries who have chronic illnesses. These benefits can address social determinants of health for people with chronic disease. A social determinant of health is a part of your life that can affect your health in some way, such as not having access to transportation. Examples of the kind of benefits that plans can now cover are:
 Meal deliveryTransportation for non-medical needsHome air cleanersPest remediationHeart-healthy food or produce 
In order to be eligible for this new category of supplemental benefits, you must be considered chronically ill. This means that you:
 Have at least one medically complex chronic condition that is life-threatening or significantly limits your health or functionMedically complex chronic conditions include cardiovascular disorders, diabetes, chronic lung disorders, neurologic disorders, chronic heart failure, chronic and disabling mental health conditions, cancer, dementia, chronic alcohol or drug dependence, autoimmune disorders, stroke, end-stage renal disease (ESRD), severe hematologic disorders, end-stage liver disease, and HIV/AIDS.Have a high risk of hospitalization or other negative health outcomes, andRequire intensive care coordination 
If you meet the above criteria, a Medicare Advantage Plan may offer you one of these new benefits if it has a reasonable expectation of improving or maintaining your health or function.
 
Since Medicare Advantage Plans will be able to create sets of supplemental benefits for people with specific chronic illnesses, not every member of a Medicare Advantage Plan will have access to the same set of benefits. For example, a plan might cover services like home air cleaning and carpet shampooing to its members who have asthma. A member of that plan who has asthma may be able to get these services covered, while a member who does not have asthma may not.
 
Before enrolling in a Medicare Advantage Plan that has these new supplemental benefits, check if you meet the plan’s criteria for coverage. Contact your plan to find out how to access these and other supplemental benefits.
 
-Marci

Dear Marci,

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Dear Marci,

I’m new to Medicare and would like to know about what benefits are covered. Does Medicare cover dental care?

-Anthony (Providence, RI)

Medicare does not cover dental services that you need primarily for the health of your teeth, including but not limited to:

  • Routine checkups
  • Cleanings
  • Fillings
  • Dentures (complete or partial/bridge)
  • Tooth extractions (having your teeth pulled) in most cases

If you receive dental services, you will be responsible for the full cost of your care unless you have private dental coverage or are utilizing a low-cost dental resource. Again, Medicare will not pay for or reimburse you for dental services you receive primarily for the health of your teeth.
Note: Some Medicare Advantage Plans cover routine dental services, such as checkups or cleanings. If you have a Medicare Advantage Plan, contact your plan to learn about dental services that may be covered.

While Medicare does not pay for dental care needed primarily for the health of your teeth, it does offer very limited coverage for dental care needed to protect your general health, or for dental care needed in order for another Medicare-covered health service to be successful. For instance, Medicare may cover:

  • An oral examination in the hospital before a kidney transplant
  • An oral examination in a rural clinic or Federally Qualified Health Center (FQHC) before a heart valve replacement
  • Dental services needed for radiation treatment for certain jaw-related diseases (like oral cancer)
  • Ridge reconstruction (reconstruction of part of the jaw) performed when a facial tumor is removed
  • Surgery to treat fractures of the jaw or face
  • Dental splints and wiring needed after jaw surgery

It is important to know that while Medicare may cover these initial dental services, Medicare will not pay for any follow-up dental care after the underlying health condition has been treated. For example, if you were in a car accident and needed a tooth extraction as part of surgery to repair a facial injury, Medicare may cover your tooth extraction—but it will not pay for any other dental care you may need later because you had the tooth removed.

Medicare also covers some dental-related hospitalizations. For example, Medicare may cover:

  • Observation you require during a dental procedure because you have a health-threatening condition

In these cases, Medicare will cover the costs of hospitalization (including room and board, anesthesia, and x-rays). It will not cover the dentist fee for treatment or fees for other physicians, such as radiologists or anesthesiologists. Further, while Medicare may cover inpatient hospital care in these cases, it never covers dental services specifically excluded from Original Medicare (like dentures), even if you are in the hospital.

If you need dental care, look into resources or other forms of insurance that may help pay for dental services. You can also use FAIR Health’s consumer cost lookup tool to get an estimate for the amounts dental professionals usually charge in your area for different services.

-Marci

Dear Marci,

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Dear Marci,

My husband has a major surgery coming up, and his doctor said that after the surgery, he might need inpatient rehabilitation hospital care. Will his Original Medicare cover this?

-June (Fargo, ND)

Dear June,

Rehabilitation hospitals are specialty hospitals or parts of acute care hospitals that offer intensive inpatient rehabilitation therapy. Someone may need inpatient care in a rehabilitation hospital if they are recovering from a serious illness, surgery, or injury and require a high level of specialized care that generally cannot be provided in another setting (such as in your home or a skilled nursing facility).

Examples of common conditions that may qualify someone for care in a rehabilitation hospital include stroke, spinal cord injury, and brain injury. Your husband may not qualify for care if, as an example, he is recovering from hip or knee replacement and has no other complicating condition.
Medicare-covered services offered by rehabilitation hospitals include:

  • Medical care and rehabilitation nursing
  • Physical, occupational, or speech therapy
  • Social worker assistance
  • Psychological services
  • Orthotic and prosthetic services

In order for your husband to qualify for a Medicare-covered stay in a rehabilitation hospital, his doctor must that that this care is medically necessary, meaning he must require all of the following services to ensure safe and effective treatment:

  • 24-hour access to a doctor (meaning your husband requires frequent, direct doctor involvement, at least every 2-3 days)
  • 24-hour access to a registered nurse with specialized training in rehabilitation
  • Intensive therapy, which general means at least three hours of therapy per day (but exceptions can be made on a case-by-case basis—your husband may still qualify if he is not healthy enough to withstand three hours of therapy per day)
  • And, a coordinated team of providers including, at minimum, a doctor, a rehabilitation nurse, and one therapist

Your husband’s doctor must also expect that his condition will improve enough to allow him to function more independently after a rehabilitation hospital stay. For example, therapy may help him regain the ability to eat, bathe, and dress on his own, or live at home rather than living in a living facility.

If your husband qualifies for Medicare-covered care in a rehabilitation hospital, his out-of-pocket costs will be the same as for any other inpatient hospital stay. Keep in mind that if he enters a rehabilitation hospital after being an inpatient at a different facility, he will still be in the same benefit period. If he does not qualify for a Medicare-covered stay in an inpatient rehabilitation hospital, he may qualify for rehabilitation care from a skilled nursing facility, a home health agency, or an outpatient setting.

-Marci

Dear Marci,

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Dear Marci,

I will be having my hip replaced this year, and my doctor told me I will need to stay in the hospital and then likely recover in a skilled nursing facility (SNF). I have Original Medicare. How does it cover inpatient services like this?

-Fiona (Culver City, CA)

Dear Fiona,

Inpatient hospital care and care in a skilled nursing facility (SNF) are both Medicare Part A-covered services.

Part A covers medically necessary inpatient hospital care, which is care that you receive as a formally admitted hospital inpatient. You must be formally admitted into the hospital by a physician in order for your care to be considered inpatient hospital care. You may face different costs if you are a hospital outpatient, meaning you receive services at the hospital but are not formally admitted.

If you are a hospital inpatient, Part A covers:A semi-private hospital room and mealsGeneral nursing careMedically necessary medicationsOther hospital services and suppliesMedicare does not cover:Private duty nursingA private room (unless medically necessary or if it is the only room available)Personal care items (such as razors or socks)A television or telephone in your roomAfter meeting your Part A deductible, Original Medicare pays in full for the first 60 days of your benefit period. After day 60, you will pay a daily hospital coinsurance. Part B continues to cover any outpatient provider services you receive while in the hospital. You usually owe a separate 20% coinsurance for these services.
SNF care is post-hospital care provided at a SNF. Skilled nursing care includes services such as administration of medications, tube feedings, and wound care. Keep in mind that SNFs can be part of nursing homes or hospitals.
Medicare Part A may cover your SNF care if:You were formally admitted as an inpatient to a hospital for at least three consecutive daysYou enter a Medicare-certified SNF within 30 days of leaving the hospital, and receive care for the same condition that you were treated for during your hospital stayAnd, you need skilled nursing care seven days per week or skilled therapy services at least five days per weekNote: the day you become an inpatient counts toward your three-day inpatient stay to qualify for Medicare-covered SNF care. However, the day you are discharged from the hospital does not count toward your qualifying days. Also remember that time spent receiving emergency room care or under observation status does not count toward the three-day hospital inpatient requirements for SNF coverage.

If you meet all of the above requirements, Medicare should cover the SNF care you need to improve your condition, maintain your ability to function, or prevent your health from getting worse.

During a Medicare-covered SNF stay, Part A covers:A semi-private room and mealsSkilled nursing care provided by nursing staffTherapy, including physical therapy, speech therapy, and occupational therapyMedical social services and dietary counselingMedicationsMedical equipment and suppliesAmbulance transportation to the nearest provider or needed services, when other modes of transportation would endanger your health.For each benefit period, Part A covers the full cost of your first 20 days in a SNF. For days 21-100, Part A covers part of the cost and you pay a daily coinsurance. If you need more than 100 days of SNF care in a benefit period, you will need to pay out of pocket.

-Marci

Dear Marci,

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Dear Marci,

I volunteer at a local senior center and I have Medicare myself. With Medicare’s Fall Open Enrollment coming up, I know that Medicare plans will be advertising. What rules do these plans have to follow? What should we do if plans break these rules?

-Cindy (Bridgeport, CT)

Dear Cindy,

Insurance companies selling Medicare private plans (which include Part D and Medicare Advantage plans) must follow certain rules when promoting their products. These rules are meant to prevent plans from presenting misleading information about a plan’s costs or benefits. This is also known as marketing fraud.

Medicare private plans are allowed to conduct certain activities. For instance, companies can market their plans through direct mail, radio, television, and print advertisements. Plans can also send emails, but they must provide an opt-out option in the email for people who do not wish to receive them. Agents can also visit your home if you invite them for a marketing appointment.

Insurance agents cannot:Call you if you do not give them permission to do soVisit you in your home, nursing home, or other place of residence without your invitationAsk for your financial or personal information (like your Social Security number, Medicare number, or bank information) if they call youProvide gifts or prizes worth more than $15 to encourage you to enroll. Gifts or prizes that are worth more than $15 must be made available to the general public, not just to people with MedicareDisregard federal and state consumer protection laws for telemarketing, the National Do-Not-Call registry, or do-not-call-again requestsMarket their plans at education events or in health care settings (except in common areas)Sell you life insurance or other non-health products at the same appointment (known as cross-selling), unless you request information about such productsCompare their plan to another plan by name in advertising materialsUse the term “Medicare-endorsed” or suggest that their plan is a preferred Medicare planPlans can use Medicare in their names as long as it follows the plan name (for example, the Acme Medicare plan) and the usage does not suggest that Medicare endorses that particular plan above other Medicare plansImply that they are calling on behalf of MedicareIf you feel a plan or agent has violated Medicare’s marketing rules, you should save all documented proof, when available, such as an agent’s business card, the plan’s marketing materials, and your phone call records. Report the activity to 1-800-MEDICARE or your local Senior Medicare Patrol (SMP). To contact your SMP, call 877-808-2468 or visit www.smpresource.org.

-Marci