Originally published 7/8/22, updated 10/2/23.
For the first time, we have five generations in the workforce and 25% are in the Baby Boomer generation. And while these older employees bring a wealth of knowledge and experience to the workplace, they’re entering new territory when it comes to what healthcare options are available to them. Unfortunately, Medicare coverage isn’t always consistent or clear, and getting answers about its costs can be a challenge.
That’s why it’s so important for benefits pros to take time now to prepare employees for the potential costs of healthcare in their retirement (or if they sign up for Medicare while they’re still employed). But how can you prepare employees when there are so few clear-cut answers about Medicare benefits?
Quick refresher: What are the different types of Medicare?
Eligible folks are likely confused about which types of Medicare they should enroll in. So let’s take a quick minute for a Medicare explainer. (Feel free to copy-paste these definitions into your educational materials!)
The most commonly known type is Original Medicare, which is a fee-for-service health plan that consists of two parts:
- Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare. There’s no monthly premium for Part A for most beneficiaries.
- Part B (Medical Insurance): Covers certain doctors’ services, outpatient care, medical supplies, and preventive services. There is a monthly premium for this coverage.
While this distinction helps, Medicare beneficiaries might easily be led astray. For example, Part B covers “certain other medical and health services not covered by Medicare Part A.”
That could easily lead eligible folks to believe that anything that’s not an inpatient-related service is fair game for Medicare Part B coverage. But they’d be wrong. The key test for coverage under Medicare Part B is whether Medicare deems a service or supply to be either “medically necessary” or “preventive.” Clear as mud?
Don’t worry. In this guide, we’ll explore how Medicare defines those terms, and review some common questions about services that are and aren’t covered by Part B.
What does “medically necessary” mean?
Healthcare.gov defines “medically necessary” services as those “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” CMS further notes that “medically necessary services and supplies” must meet four criteria:
- They are proper and needed for the diagnosis or treatment of a medical condition.
- They are provided for the diagnosis, direct care, and treatment of a medical condition.
- They meet the standards of good medical practice in the local area.
- They are not mainly for the patient’s or doctor’s convenience.
That doesn’t clear it up much, does it?
In general, Medicare Part B will cover most medically necessary doctor visits (if the doctor is Medicare-approved), outpatient hospital care, and screenings.
But when is something truly medically necessary? Perhaps it’s easier to look at what CMS has deemed to be not medically necessary. The list of services that aren’t medically necessary includes:
- Services given in a hospital that, based on the beneficiary’s condition, could have been furnished in a lower-cost outpatient setting
- Hospital services that exceed Medicare’s length-of-stay limitations
- Evaluation and management services that exceed those considered medically reasonable and necessary
- Therapy or diagnostic procedures that exceed Medicare usage limits
- Screening tests, examinations, and therapies for which the beneficiary has no documented symptoms or conditions, except for certain screening tests, examinations, and therapies
- Services not called for based on the beneficiary’s diagnosis (for example, acupuncture and transcendental meditation)
- Items and services administered to a beneficiary to cause or aid in causing death
While those exclusions narrow down potential coverage, it’s still not always clear to people whether Medicare will cover a service or supply that they feel they need. Let’s turn next to the second prong of Medicare Part B coverage: preventive care.
What does Medicare consider “preventive services”?
Medicare defines “preventive services” as any health care designed to prevent an illness or detect it at an early stage. The list of covered preventive services is long and varied, ranging from annual wellness checks to screening for alcohol misuse and nutrition therapy services to cancer screening. Medicare will also pay for one “Welcome to Medicare” preventive visit, which includes a review of the patient’s medical and social history as well as education and counseling about available preventive services.
Let’s look at some of the most common questions that beneficiaries may have about their Medicare coverage.
Does Medicare cover dental care?
Generally, Medicare does not cover dental care. It won’t pay for oral surgery or dental procedures like cleanings, fillings, or extractions. It also won’t cover dentures or other dental devices. Medicare Part A will pay for certain dental services that occur in a hospital such as an emergency or complicated dental procedure. Beneficiaries who want dental coverage should look into enrolling in Medicare Part C (a Medicare Advantage Plan) or a standalone dental plan.
Does Medicare cover dentures?
As mentioned above, Medicare does not cover dentures or other dental devices, but beneficiaries who want dental coverage should look into enrolling in Medicare Part C or a standalone dental plan.
Does Medicare cover eye exams?
Even though routine eye exams may be considered “preventive,” they aren’t covered by Medicare. Beneficiaries also have to pay the full cost of any eyeglasses or contact lenses.
As with dental insurance, beneficiaries who want vision coverage will need to seek out Part C coverage or a supplemental plan.
Does Medicare cover eyeglasses?
Typically Medicare does not cover eyeglasses or contact lenses. Beneficiaries with Medicare Part B coverage can get help with paying for corrective lenses if they have cataract surgery that implants an intraocular lens. Medicare will only pay for contact lenses and eyeglasses from a supplier enrolled in Medicare.
Does Medicare cover cataract surgery?
Outpatient cataract removal surgery using traditional surgical techniques or lasers does fall within the coverage of Medicare Part B so long as it is deemed medically necessary. Medicare will pay 80% of the cost of pre-operative exams, cataract removal surgery, lens implantation, and post-operative exams. After surgery, Medicare will also cover the cost of one pair of glasses or contact lenses.
Does Medicare pay for hearing aids?
If a patient’s healthcare provider orders testing, Medicare will cover diagnostic hearing tests to determine whether they need treatment for hearing loss. It will also pay for the treatment of a hearing-related condition. However, Medicare won’t cover exams for fitting hearing aids or pay for the hearing aids themselves. Beneficiaries who want specific hearing aid coverage will need to obtain separate insurance.
Does Medicare cover the shingles vaccine?
Medicare Part B covers some vaccines, including those for COVID-19, flu, pneumonia, and hepatitis B. However, the shingles vaccine isn’t one of them, even though it’s a preventive service. For coverage of the shingles vaccine, beneficiaries will have to sign up for Medicare Part D, which is the prescription drug benefit program.
Does Medicare cover COVID-19 testing?
Medicare Part B covers FDA-authorized COVID-19 diagnostic tests for as long as the public health emergency lasts. Additionally, Medicare covers up to eight over-the-counter COVID-19 tests each month at no cost to the beneficiary. Qualifying tests can be found at any participating eligible pharmacy or health care provider.
Does Medicare cover chiropractic services?
Medicare covers 80% of the cost of chiropractic services for medically necessary spine manipulation to treat back pain. More specifically, the treatment must manually adjust the spine to treat a subluxation, which happens when a vertebra is out of position. Medicare won’t cover the cost of maintenance chiropractic treatments, massage therapy, or X-rays.
Does Medicare cover acupuncture?
Medicare Part B covers up to 12 acupuncture visits over the course of 90 days for chronic low back pain—Medicare will not cover acupuncture for any condition other than chronic low back pain. If a patient shows signs of improvement, Medicare covers an additional eight sessions, and a maximum of 20 acupuncture treatments are allowed in a 12-month period. If the patient does not improve after the first 12 acupuncture visits, Medicare will not cover additional treatments.
Does Medicare cover physical therapy?
Medicare Part B will help pay for outpatient physical therapy if a doctor or healthcare provider—that includes a nurse practitioner, clinical nurse specialist, or physician assistant—certifies that a patient needs physical therapy services.
Does Medicare cover a colonoscopy?
Medicare does cover screening colonoscopies for individuals with a high risk for colorectal cancer once every 24 months. Medicare covers the test once every 120 months for individuals who are not high risk, or every 48 months after a previous flexible sigmoidoscopy (a procedure that only looks inside the lower part of the colon versus a colonoscopy that looks at the entire large intestine).
If a patient has a non-invasive stool-based screening test and receives a positive result, Medicare covers the follow-up colonoscopy as a screening test at no cost.
Preparing Medicare-eligible folks for the next step
It’s never too early to prepare aging folks for the future. And with the limitations of Medicare Part B, beneficiaries should be forewarned that they’ll need supplemental coverage if they want dental and vision benefits or prescription drug coverage after they’ve enrolled in Medicare Part B. As employees near 65, they need sound advice from a voice they trust. ALEX Medicare provides educational resources about Medicare and can help eligible folks understand their options. With ALEX Medicare, they can put together a smart benefits strategy that gives them the medical, dental, vision, and voluntary benefits coverage they want while optimizing their costs.