Services that may be nice but aren’t necessary
You probably aren’t surprised to know that you can’t get a face-lift or a tummy tuck at taxpayers’ expense. Surgery solely for cosmetic purposes is one of the absolute no-no’s of Medicare coverage. (Medicare does cover bariatric surgery to reduce the size of the stomach in very obese people, but this procedure is to lessen their risk of serious health disorders and not to improve their looks.)
Acupuncture and other alternative medical practices are barred under traditional Medicare. Physical fitness classes and gym memberships are also excluded. But some of these services (notably gym memberships) are covered as extras in some Medicare Advantage plans.
Even something as relatively mainstream as chiropractic care may be excluded from Medicare coverage in many circumstances. Chiropractors help lessen the pain of spine and joint problems, most often by the manipulation of bones. Medicare covers manipulative treatment from a licensed chiropractic physician when you’re injured or in pain because of a problem with the spine and provided that the treatment is clearly improving your condition. But Medicare doesn’t pay for the manipulation of other joints (such as shoulders and knees) or for other types of chiropractic care such as massage or traction. And it doesn’t pay for maintenance care to keep you stable if you aren’t demonstrably improving.
Finally, in the hospital, Medicare doesn’t cover a private room (unless sharing one would be medically inadvisable), private nursing, or conveniences like a telephone or television if these items are billed separately.
If you’ve had a hip replacement but fall again and need another, Medicare isn’t going to turn around and deny you coverage for the second one. If you’re fighting your third bout of pneumonia, Medicare isn’t going to shut you out of the hospital because of the first two episodes. If you’re in your 90s and have heart failure or cancer, Medicare isn’t going to refuse you treatment because you’re too old. For all the loose and cruelly inaccurate talk about “death panels” and “rationing” that still circulates in mass emails meant to exploit older people’s fears of being denied coverage, Medicare simply doesn’t – and can’t, by law – ration care like that. “Medical necessity” is what usually counts.
At the same time, Medicare has always placed limits on certain areas of coverage – and although Washington policymakers may regard these caps as reasonable attempts to rein in runaway costs and guard against fraud, the limits can adversely affect some patients. So on the basis that forewarned is forearmed, the following sections provide an overview of the four main areas where coverage comes with limits: stays in the hospital, stays in a skilled nursing facility, mental health benefits, and therapy services.
Limits on hospital stays
Most people these days don’t spend more than a few days in the hospital, and the fear of catching a really bad hospital infection – known as a leading cause of death – is enough to make anyone want out of there as soon as possible. So the chances that you’ll exhaust Medicare coverage during a hospital stay are remote. Still, in case you get sick enough to need a long spell in the hospital, the following sections clue you in to how the limits work.
If you’re enrolled in traditional Medicare
If you need to stay for a long period in the hospital for one spell of illness that’s known as a benefit period, Medicare will cover 100 percent of your nursing and living costs for the first 60 days after you’ve met a deductible. For days 61 to 90, you’re required to pay a daily co-pay. (I explain these costs in Chapter 3, and I go into detail about benefit periods in Chapter 14.)
No limit caps the number of benefit periods you can have, provided that 60 days have elapsed between each one. But if you still need to be in the hospital longer than 90 days in any one benefit period, you must either pay the full cost yourself or draw on up to 60 more days for which you pay hefty daily co-pays. These 60 days are called lifetime reserve days. You can use as many as you want or save some in case you need them in the future. But, as the phrase implies, when you’ve used them, they’re gone for good.
However, all Medigap supplemental insurance policies (explained in Chapter 4) extend Part A hospital coverage for up to an additional 365 days in your lifetime after Medicare benefits are exhausted. And most Medigap policies pay for the Part A hospital deductible too. If you’re enrolled in Medicaid (state medical assistance), this program usually covers the co-pays for lifetime reserve days.
If you’re enrolled in a Medicare Advantage health plan
Medicare Advantage plans usually have a simpler system for charging for hospital stays. Often they charge a daily co-pay for the first several days and nothing for the remaining days. Most plans set no limits on the number of days they cover, so you don’t need to draw on lifetime reserve days. But some plans do set limits, although sometimes they charge no co-pays for the lifetime reserve days. Comparing the differences between Medicare Advantage plans and traditional Medicare when it comes to hospital stays is an important topic that I discuss in Chapters 9 and 11.
Limits on skilled nursing facility stays
If you need continuing skilled nursing care after you’ve been in the hospital and meet certain conditions (as explained earlier in this chapter and in Chapter 14), Medicare covers a stay in a skilled nursing facility – but it comes with limits. Beyond 100 days in each benefit period, you’d pay the full cost unless you have additional insurance. Some or all of these costs may be covered if you have additional insurance coverage through Medicaid, employer health benefits, long-term care insurance, or Medigap supplemental insurance. Check your policy to find out. Most Medicare Advantage plans also limit coverage to 100 days in a benefit period.
Limits on mental health benefits
Like many other insurance plans, Medicare treats care for mental health disorders differently from other health problems. This kind of discrimination is less common than it used to be in Medicare, but some limits are still placed on mental health benefits, as described in the following sections.
Outpatient psychiatric services
In the past, traditional Medicare charged more than twice as much for seeing a mental health professional as an outpatient than for seeing any other kind of doctor – co-pays of 50 percent of the cost of a visit rather than 20 percent. But since 2010, under a law passed in 2008, those co-pay costs have gradually come down. Today, you pay the standard 20 percent co-pay for outpatient psychiatric care, and Medicare pays the rest. If you have Medigap insurance, these co-pays are covered. If you’re in a Medicare Advantage plan, you pay what your plan requires.
Psychiatric care in a hospital
The 2008 health care law didn’t change a discriminatory situation in which Medicare patients are limited to 190 days over their lifetime for receiving inpatient treatment in psychiatric hospitals – those that specialize in mental health conditions. Yet Medicare places no such limit on care in general hospitals. So any days you spend in a non-psychiatric hospital – even if you’re being treated for a mental health condition – don’t count toward the 190-day lifetime limit.
