SENIOR BLOG & INFO PLACE: WHAT THE MEDICARE RED, WHITE, & BLUE WON'T DO:

WHY MEDIGAP SUPPLEMENTS & PART D or ADVANTAGE C PLANS are needed..

What the Red White Blue card won't do:
Medicare has saved the lives of countless seniors & keeps them healthy. But it was never intended to pay all, Medicare pays for only some of the health care services you need. As a Medicare member the careful consideration should be given to the Medicare covered services, non-coverage gaps, and cost-shares. The typical 80/20 cost sharing is for only the "MEDICARE APPROVED" services and procedures. Along with the many procedures, services, deductibles & co-insurance costs, you need to know :

WHAT MEDICARE A and B DOESN'T COVER

Drugs, Pharmaceuticals, & Medicines: Medicare Parts A and B do not cover any prescription medications purchased from the retail drug store pharmacy. Only drugs administered during an admitted hospital stay or by the doctor in their office during an office visit are covered. Only a Medicare Part D or Advantage C (MAPD with a D) plan will cover these at your retail or mail-order pharmacy. This is the reason you need a Part D drug plan.

Medicare Excess Charges: An excess charge is the amount a doctor or other health care provider is legally permitted to charge above the Medicare-approved amount, the difference is called the "excess charge." If something goes wrong or the doctor feels there was extra work he may charge extra. You are responsible for this Part B extra-excess amount. The excess amount can be 15% greater than approved Medicare Average Cost (MAC) and must be approved. These charges can occur in the hospital, as an out-patient, or in the doctor's office. Plan B Excess Charges are only covered with the Supplements F & G types and with Advantage C Plans by the maximum out-of-pocket limit (see MOOP) amount.

Skilled Nursing/Rehabilitative Care: Medicare only pays for what is termed, "medically necessary skilled nursing care" from a facility or home care service. After the 20th day of confinement you pay the cost at $148.00 per day, (2013) for up to 100 days. Medicare doesn't provide any skilled nursing or rehabilitation coverage for services that exceed 100 consecutive days and there is a 60 day reserve life-time limitation. Medicare rules say all coverage must be preceded by at least a 3 day hospital stay. There can be multiple benefit and non-coverage periods each calender year. These are the reasons you need LTC insurance coverage.

Personal Care Assistance: The cost of hiring help for bathing, toileting & dressing are not covered unless you are home bound or in a skilled nursing facility receiving skilled nursing care. Housekeeping services, grocery shopping, meal preparation and cleaning, are covered only if you are receiving hospice care, which has it's own limited coverage. Generally, Medicare will not cover the above activities of daily living (ADL's) unless preceded by a hospital stay with skilled nursing facility (SNF) care ordered by a physician. The 20/100 day rules and ADL needs are the reasons you need LTC insurance coverage.

Hospice Care: Medicare won't cover treatment or medication to stop the terminal illness. Care or any services, and room & board from a non-Medicare approved Hospice provider isn't paid. Care in an emergency room, inpatient facility care, ambulance transportation, or unrelated to your terminal illness is not covered. Sometimes Medicare will cover services if they have been ordered by the hospice team.

Alternative Medicine: Complementary and alternative medicine (CAM) are non-standard services and procedures not covered. Medicare does not cover acupuncture, chiropractic services (only spine subluxation is covered), vitamin, holistic, herbal, or other types of alternative or complementary care. The key words to know, "non-FDA approved procedures or medicines" you pay out of pocket.

Cosmetic Surgery: Medicare will not pay for your elective cosmetic procedures, although some surgeries may be covered if necessary to repair a malformation due a disease or accident. So your tucks, implants, body-lifts, wrinkle-removers, facial day-lifts, and lasers-jobs are out of your own pocket.

Vision, Hearing, Foot, & Dental Care: Medicare only covers these areas when there is disease or resulting from an accident. Hearing aids, hearing exams, routine eye, foot, dentures and dental care are not covered. But Medicare will cover 1 pair of glasses after cataract surgery and hearing implants to treat a severe hearing loss. Vision, hearing, podiatry, and dental care would be covered if it resulted in a hospital stay. Preventive and normal exams are not covered unless it is one the newly covered screenings. Unfortunately for seniors, no orthopedic shoes, glasses, dentures, cosmetic-smiles, and hearing-aids are covered.

Miscellaneous Hospital Costs: Forget "All-Inclusive," Inpatient charges for a private hospital room not covered. In-room television, telephone, cable, pay-per-view movies, rent-a-Pods, room wi-fi or internet access will not be covered by Medicare. The hospital "goody-bag" isn't covered.

Other Excluded Costs: Medicare does not pay for any medically unnecessary services or items, non-emergency transportation, all air transportation, senior day-care services, any private duty nursing, convenience/personal care items, experimental procedures, spa/fitness/exercise memberships, non-essential durable medical devices; non-FDA approved procedures or medicines, or even the extra copies of x-rays/MRIs/lab tests. Excessive preventative screenings are not covered, most have 2 or 5 year periods.

Overseas Coverage: Medicare will not pay for health care you receive outside of the United States. All Medicare payees must be in the US. Only Medicare secondary Medigap-Supplements and Advantage provider plans will offer limited accidental and limited emergency coverage outside our US borders, check your plan's benefits. The good news: Puerto Rico, U.S. Virgin Islands, Guam, American Samoa and Northern Mariana Islands are considered US.

Help with Claims and Appeals: Medicare does have a claims and appeals committee for services that are not covered or for questionable claims. Read here about: Medicare Claims and Appeals at Medicare.gov. There are exceptions to these exclusions, if you are enrolled in a Medicare Advantage C-plan, Insurance company's Medigap Supplement and (or) Medicare Plan D these providers are your first call resources for an appeal. The appeal outcomes very depending on the Medicare coverage you own plan-type and cost-sharing. Find the complete list of these costs at MEDICARE.GOV or "Medicare and You 2013". Also see "Your Medicare Benefits" . You may always call 800-MEDICARE (800-633-4227), use your Medicare Advantage/Drug plan administrator, Supplement insurance company, and if you are part of our "Senior Family", call us for direction/help.

SENIOR FAMILY ALLIANCE is a broker and independent agent for 7 Medicare Provider companies offering more than 190 Medicare Plans, Medigap and Advantage, Prescription Drug, Dental, Vision, and Hearing Plans.