For Baby Boomers Seeking Information on Medicare Coverage

Most people think Medicare is the cure-all for healthcare. In fact, Medicare is a government program paid by taxpayers meant to provide benefits to eligible individuals. It normally starts at age 65 or earlier for individuals with End Stage Renal Disease or those with other lifetime disabilities. As with most government programs, the program is plagued by waste and fraud.

An example of such waste and fraud took place when a few months ago I received in the mail a gadget that would send to the cloud and ultimately to my physician’s office my glucose levels. The service was wasteful, bordering on fraud, as I did not request it nor–thankfully–am I diabetic. When I called the company that sent it, initially they seemed eager to assist me but when I said I wanted to return the gadget, all the courteous assistance meant nothing. Several weeks went by and nothing arrived in the mail indicating they wanted the equipment back. After three different phone call requests, each weeks apart, it was clear that my phone calls were ignored. It took an angry phone call to get my call transferred to someone with the authority to ship me a return label. Still, to return the equipment I had to drive to a shipping office of FedEx to dispatch the unneeded, unsolicited equipment back to the provider.

Imagine the revenues from hundreds if not thousands of these artifacts reporting results that get billed to Medicare first for the hardware itself and then for processing the data received at the cloud as transmitted several times a day. Imagine the doctors’ offices billing Medicare first for tallying the results and then for calling the patients to tell them they receive the reports. Hundreds of thousands of dollars–if not millions–paid by the taxes working Americans pay to fund Medicare.

When in 1966 the Congress of the United States passed the Medicare law, reportedly there were Americans unable to receive quality healthcare because their income was too low to cover the costs of catastrophic illness. It seemed like a good idea at the time.  Since Medicare became law, through the years politicians have expanded the number of people to qualify for the benefit.

In 1964, a doctor’s visit would cost anywhere between $10 and $30. A hospital stay per day would cost $200. A day in the Intensive Care Unit of the average hospital would cost $350. Surgeons and anesthesiologists would charge reasonably for their services amounts insurance companies were contracted to pay on behalf of their premium paying customers. Health insurance premiums were an average of $50 per month. No networks existed. Everyone was free to go where they felt well cared for. points out that $100 in 1964 adjusted for inflation would be equal to $843 in 2021. This means that a $10 office visit then would be today an $84.30 office visit; a $200 daily hospital room back then would be $1,686 today, and a $350 Intensive Care Unit would be $2,950. A $50 a month health insurance premium today would be $421.50. However, these quoted figures reflect the inflation caused by the government’s meddling. No one can assert what today’s cost of living would be if the government remained in its place, ensuring a level playing field for everyone to participate in commerce unhindered by monopolies and free of the political distortions that affect the markets and restrict the free-flow of commerce.

Since those days, Medicare became the arbiter of healthcare services, regulating what is acceptable in healthcare and determining by payment codes what every conceivable healthcare procedure may cost. These parameters  have increased the cost of healthcare in the nation. Today the average family pays 8% of their annual salary for health insurance and they are still burdened with $6,000 annual deductibles and huge annual out of pocket costs. Thanks for nothing, politicians.

When the government meddles in the free markets, everyone loses except the bureaucrats, the politicians, and those who milk the system for personal gain. Today the nation is engulfed in costs spiraling out of control for medical services, a situation further aggravated every time the government meddles further. The Affordable Care Act–Obamacare for most–has become the Unaffordable Care Act for those who work and pay the premiums themselves. Those who live off the rest of the taxpayers by necessity or by personal choice get their premiums paid and their out of pockets reduced to negligible levels.

The Center for Medicare and Medicaid Services–CMS–is the final judge of what coverage is afforded, whether by private insurance or by government disbursement.

As the government’s current (2021) website states, Medicare coverage is based on 3 main factors:

    1. Federal and state laws.
    2. National coverage decisions made by Medicare about whether something is covered.
    3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Having expressed my thoughts on all of the above, we now address the scope of coverage Medicare affords its beneficiaries as follows.

Original Medicare

    • Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).
    • You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
    • You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
    • To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also shop for and buy supplemental coverage.

Note that if you don’t get Medicare drug coverage when you’re first eligible, you may have to pay more to get this coverage later. This could mean you’ll have a lifetime premium penalty for your Medicare drug coverage.

The basics on Medicare coverage are simple.

Medicare Part A covers:

Medicare Part B covers medically necessary services–services and supplies needed to diagnose or treat medical conditions and that meet accepted standards of medical practice–and preventive services to detect illnesses at an early stage when treatment is most likely to work best.

Medicare Part B covers:

However, there are four services that Medicare does not cover.

First: Prescription Drugs: Original Medicare doesn’t provide coverage for prescription drugs, but you’re able to purchase separate prescription drug coverage, called a Part D Plan.

You could also choose to enroll in a Medicare Advantage plan that will cover both medical and drug costs, but this choice restricts you to a geographical area of service and limits your choice of providers to a pre-determined network. Nonetheless, Medicare Advantage plans still carry an out of pocket cost to beneficiaries. For 2022, the maximum out of pocket limit for beneficiaries who elect Medicare Advantage plans is $7,559 per person.

Your other option is to choose to remain with free Medicare and purchase a Medicare Supplement plan of insurance where any doctor or other healthcare provider accepting Medicare may address your issues without restrictions as to networks or geographical location. Medicare Supplement plans have an annual out of pocket maximum set by the Congress of the United States. For 2022, the maximum out of pocket is $2,490 for a High Deductible Plan G, which carries the lowest monthly premium of all Medicare Supplement plans.

Second: Long-Term Care: while Medicare provides some coverage for nursing services, things like custodial care, bathing assistance and dressing assistance are not covered. Long-term-care insurance is the best option to cover costs like these.

Third: Deductibles and Copays: even though Medicare Part A and Part B offer some coverage for hospital stay and doctors’ services, you are still responsible for all deductibles and copayments.

Getting a Medicare Advantage plan with $0 copay and $0 deductible could help you avoid these costs even if you give up your freedom to access any healthcare provider accepting Medicare and if you limit your healthcare services to a geographical area and a pre-determined network of care.

Fourth: Dental Care: routine dental visits, cleanings, filling, dentures, and most tooth extractions are not covered by Medicare.

Enrolling in a Medicare Advantage plan with dental coverage could be beneficial only if paying an insurance premium allowing you access to a dentist of your choice is not financially feasible for you.

I hope  you enjoyed my blog today. Please leave me your thoughts in the comments. Thank you for your time.

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