Key Takeaways:

• Medicare covers many essential services, but it’s easy to assume something is included when it’s not.
• Regularly reviewing your coverage and knowing the right questions to ask can help you avoid surprises and get the care you need.

Why You Need to Double-Check Your Medicare Coverage

Navigating Medicare can sometimes feel like wading through a maze. It’s packed with different parts, detailed coverage rules, and a few hidden surprises. Understanding what is and isn’t covered can make a big difference in managing your health and your finances. Whether you’re new to Medicare or a long-time beneficiary, staying proactive and informed is key.

What You Think Might Be Covered but Isn’t

Many people are surprised to learn that Medicare doesn’t cover everything they assumed it would. This can lead to unexpected costs and frustration. Let’s break down some common services people overlook and how you can prepare for them.

A Close Look at Part A and Part B: The Basics Explained

Before we dive into what’s missing, let’s go over what you can expect from Original Medicare—Part A and Part B. These are the two pillars of Medicare and offer a lot of essential benefits.

Part A: The Hospital Safety Net

Part A is your hospital insurance. It covers inpatient hospital stays, skilled nursing facility care (with some conditions), hospice care, and certain home health services. If you’ve worked long enough, you won’t pay a monthly premium, but there’s an annual deductible. Part A covers your basic room and board, but if you’re expecting private rooms or specialized amenities, those come at an extra cost.

It’s worth mentioning that while Part A covers skilled nursing care after a qualifying hospital stay, it doesn’t include long-term custodial care. This is an important point, as many people mistakenly think Medicare will cover nursing home stays indefinitely. Nope—it only covers short-term, medically necessary care.

Part B: Outpatient and Preventive Services

Part B is your go-to for outpatient services. This includes doctor visits, outpatient procedures, preventive services, and some types of home health care. You’ll pay a monthly premium for Part B, as well as an annual deductible. After that, Medicare typically covers 80% of the approved amount, leaving you to handle the remaining 20%.

Preventive care like annual wellness visits and screenings are covered, which is great news for catching health problems early. But what about follow-ups or treatments after a screening? Those could come with out-of-pocket costs if they’re not fully covered under Part B.

The Gaps in Original Medicare You Need to Know About

Medicare covers a lot, but it doesn’t cover everything. Here’s what’s missing and why you need to plan for it.

Routine Dental, Vision, and Hearing Care

One of the most overlooked gaps in Medicare coverage is routine dental, vision, and hearing care. That means regular dental checkups, eyeglasses, and hearing aids aren’t covered under Part A or Part B. Considering how common these services are, many beneficiaries are surprised by this exclusion. If you rely on these types of care, it’s wise to explore supplemental insurance options or budget for out-of-pocket expenses.

Long-Term Custodial Care

Medicare is not a long-term care solution. While it may cover short-term stays in a skilled nursing facility after a hospital discharge, it won’t cover non-skilled, custodial care. So if you need help with daily activities like dressing, bathing, or eating over an extended period, you’ll need to look into other ways to fund it, such as long-term care insurance or personal savings.

Overseas Coverage

If you love to travel, here’s a point that might be a surprise: Medicare doesn’t typically cover you when you’re outside the United States. There are a few exceptions, like if you’re on a ship within six hours of a U.S. port, but generally, you’ll need a separate travel medical insurance plan to cover any emergencies or routine care while abroad.

The Role of Part C (Medicare Advantage)

Medicare Advantage plans, also known as Part C, combine Part A and Part B and often come with additional perks. These plans are managed by private companies approved by Medicare and may include extra benefits such as dental, vision, or hearing coverage.

The Good News

The big advantage of Part C is that it often wraps various types of coverage into one plan. Some even include prescription drug coverage, so it’s a one-stop shop for many of your medical needs. And if you’re someone who prefers predictable costs, the annual out-of-pocket maximums that come with Part C plans can provide peace of mind.

What to Double-Check

However, don’t assume all Part C plans are created equal. Networks can be restrictive, meaning you may need referrals or have limited choices in healthcare providers. Make sure to check if your preferred doctors and specialists are included before making any decisions.

Part D: The Prescription Drug Catch

Prescription drug coverage falls under Part D, which is optional but important for many beneficiaries. Plans can differ widely, so reviewing what’s on the formulary list (the list of covered drugs) each year is a must.

Understanding Formulary Tiers

Part D plans use a tiered system to classify medications. The same drug might have different copay amounts depending on its tier. Generic drugs usually cost less, while specialty or brand-name medications can be pricier. It’s essential to understand which tier your medications fall into and whether any step therapy or prior authorizations are required.

The Donut Hole

Medicare’s “donut hole” is a term that describes a temporary limit on what Part D plans will cover for drug costs. While recent changes have lessened the impact of this gap, you could still be responsible for a higher share of drug costs once your spending hits a certain point.

Essential Questions to Ask About Your Medicare Coverage

Getting the most from Medicare means staying informed. Here are some questions you should ask:

1. What Are My Out-of-Pocket Costs?
This includes your deductibles, copays, and coinsurance amounts. It’s essential to know what your maximum financial responsibility could be each year.

2. Is My Preferred Doctor in My Network?
This is especially important if you have a Medicare Advantage plan. Double-check the network to avoid unexpected charges or having to switch providers.

3. Are My Prescriptions Covered?
With Part D or Medicare Advantage plans that include drug coverage, make sure your current medications are on the formulary. If they’re not, ask about alternatives or check if a different plan would better suit your needs.

4. What Preventive Services Are Included?
Understand which preventive services are fully covered under Part B and which may involve some cost-sharing.

5. Will I Be Covered When Traveling?
Whether you’re going out of state or overseas, knowing your coverage limitations can help you plan better.

Annual Review: The Smart Way to Stay Ahead

One of the best habits you can adopt as a Medicare beneficiary is reviewing your coverage each year. The Annual Enrollment Period (October 15 to December 7) is the perfect time to assess your current plan and make changes if needed. Even if your plan worked perfectly last year, things change—networks, formularies, and benefits are updated yearly.

Taking the time to go over your plan can help you avoid surprises and make sure you’re still in the best position for the coming year. Remember to evaluate your health needs and how they might have changed over the past 12 months.

Preparing for the Unexpected

Medicare provides substantial coverage, but it’s not exhaustive. Preparing for gaps, whether through additional insurance, savings, or a mix of both, can make all the difference in how smoothly your health care needs are met.

Stay proactive, ask questions, and don’t assume anything when it comes to your coverage. Double-checking now could save you from unwanted stress and expenses later.