Answers Provided by a Medigap Plan Representative
You can never know too much about Medicare, and here are some frequently asked questions and answers to get you started.
Click on any of the following questions to see the answer.
- What services Are NOT covered by Medicare Part A?
- Should I sign up for Medicare Parts A and B if I’m still working?
- What diabetic supplies does Medicare cover?
- What’s the difference between Medicare and Medicaid?
- What is the Medicare coverage for eye care and eyeglasses?
- What is “assignment” in the Original Medicare plan and why is it important?
- When does Medicare cover ambulance trips?
- Which preventive services are covered by Medicare?
- Why are preventive services important?
What services are NOT covered by Medicare Part A?
Medicare Part A DOES NOT cover the following:
- Private duty nursing.
- A television or telephone in your room or personal care items like razors or slipper socks.
- A private room that isn’t medically necessary.
- Custodial care, assisted living, adult daycare, or reimbursement for family members.
- The first three pints of blood unless the blood deductible has been met.
The doctor services you get while in a hospital may be filed under Medicare Part B.
Should I sign up for Medicare Part A and B if I’m still working?
Even if you keep working after you turn 65, you should sign up for Medicare Part A. If you have health coverage through your employer or union, Part A may still help pay some of the costs not covered by your group health plan. Call the Social Security Administration at 1-800-772-1213 to sign up. However, you may want to wait to sign up for Medicare Part B if you or your spouse are working and you have group health coverage through one of your employers or unions. (See the note below if you work for a small company.) You would have to pay the monthly Medicare Part B premium, but the Medicare Part B benefits could be of limited value to you as long as the group health plan remained the primary payer of your medical bills. In addition, you would start your six-month Medigap open enrollment period during a time when it wouldn’t be of most use to you.
Note: If you’re 65 or older and working for a company with fewer than 20 employees, you should talk to your employee health benefits administrator before making any decision not to enroll in Medicare Part B. If your employer has fewer than 20 employees, Medicare is the primary payer and your group health insurance would be the secondary payer.
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What diabetic supplies does Medicare cover?
- Blood glucose test strips
- Blood glucose monitors
- Lancets and lancet devices
- Glucose control solutions for checking the accuracy of test strips and monitors
- Therapeutic shoes or inserts
To make sure your Medicare diabetes medical supplies are covered:
- Only accept supplies you have ordered. Medicare won’t pay for supplies you didn’t request.
- Make sure you request your supply refills. Medicare won’t pay for supplies automatically sent from the supplier to you.
- Don’t submit the claim yourself. Medicare-enrolled pharmacies and suppliers must submit all claims for diabetic testing supplies.
Medicare doesn’t cover insulin (unless used with an insulin pump), insulin pens, syringes, needles, alcohol swabs, gauze, eye exams for glasses, or routine or yearly physical exams. If you use an external insulin pump, insulin and the pump may be covered as durable medical equipment. Insulin and certain medical supplies used to inject insulin are covered under certain Medicare prescription drug plans.
Make sure your supplier is enrolled in Medicare and has a Medicare supplier number. Each supplier has to meet strict standards to qualify for a Medicare supplier number, and Medicare won’t pay your claim if your supplier doesn’t have a supplier number. This applies even if your supplier is a large chain or department store that sells more than just durable medical equipment (DME).
What’s the difference between Medicare and Medicaid?
While Medicaid and Medicare sound similar, they’re in fact very different programs. One difference is that Medicaid is a state-governed program while Medicare is a federal program. Here are some other differences:
Medicaid is a state-governed program to aid people of low income, including:
- Pregnant women
- Children under the age of 19
- People 65 and over
- People who are blind
- People who are disabled
- People who need nursing home care
Medicare is a federal program (applied for at the local Social Security office) for:
- People 65 and over
- People of any age who have kidney failure or long term kidney disease
- People who are permanently disabled and cannot work
Some people qualify for both Medicaid and Medicare, and Medicaid is sometimes used to help pay Medicare premiums. People who qualify for both programs are considered “dual eligible.”
What is the Medicare coverage for eye care and eyeglasses?
Eye care following cataract surgery:
Medicare generally doesn‘t cover eyeglasses or contact lenses. However, following cataract surgery with an intraocular lens, Medicare helps pay for cataract glasses, contact lenses, or intraocular lenses provided by an ophthalmologist. Only standard frames are covered. Services provided by an optometrist may also be covered if the optometrist is licensed to provide this service in your state.
Lenses are covered even if you had the surgery before enrolling in Medicare. Payment may be made for lenses for both eyes even if cataract surgery involved only one eye. Medicare covers one pair of glasses or contact lenses for patients who’ve had cataract surgery and an intraocular lens implant. Medicare will cover these items even if the patient had surgery before Medicare benefits began. An order (prescription) signed and dated by the treating doctor must be on file with the supplier.
Be sure your supplier is a participating supplier in the Medicare program before getting any durable medical equipment. If the supplier is a participating supplier, it must accept assignment. If the supplier is enrolled in Medicare but isn’t participating, it has the option of accepting assignment. If the supplier isn’t enrolled in Medicare, Medicare won’t pay your claim.
Medicare covers glaucoma screening once every 12 months for people with Medicare at high risk for glaucoma. This includes people with diabetes, a family history of glaucoma, or African-Americans age 50 and older. The screening must be done or supervised by an eye doctor legally allowed to perform this service in your state.
Treatment of Macular Degeneration:
Medicare covers a treatment called ocular photodynamic therapy (OTP) with verteporfin for some patients with age-related macular degeneration.
Eye prostheses are covered for patients with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal. The RT and LT modifiers must be used with all HCPCS codes in this policy. Polishing and resurfacing is covered twice per year. One enlargement or reduction of the prosthesis is covered without documentation. Additional enlargements or reductions are rarely medically necessary and are covered only when information in the medical record supports the medical necessity. This information must be available to the DMERC on request. Replacement of an ocular prosthesis is governed by the five-year reasonable useful lifetime rule. Replacement of a prosthesis or prosthetic component before five years is covered if the prosthesis is irreparably damaged, lost, or stolen.
Routine Eye Care
Medicare doesn’t cover routine eye exams.
What is “assignment” in the Original Medicare plan and why is it important?
Assignment is an agreement between Medicare and doctors, other health care providers, and suppliers of health care equipment and supplies (including wheelchairs, oxygen, braces, and ostomy supplies). Doctors and suppliers who agree to accept assignment accept the Medicare-approved amount as payment in full for Medicare Part B services and supplies. You pay the coinsurance and deductible amounts. In some cases (for example, if you have both Medicare and Medicaid), your health care providers and suppliers must accept assignment.
If assignment isn’t accepted, charges are often higher and you may pay more. In addition, you may be required to pay the entire charge at the time of service. If this is the case, Medicare will then send you its share of the charge. The limiting charge (highest amount a doctor or other health care provider not accepting assignment can bill you) is set at 15% more than the Medicare-approved amount. Note that the limiting charge only applies to certain services and not to supplies or equipment.
When does Medicare cover ambulance trips?
Medicare pays for limited ambulance services. If you go to a hospital or skilled nursing facility (SNF), ambulance services are covered only if transportation in any other type of vehicle could endanger your health. Generally, transportation from a hospital or SNF isn’t covered. If the care you need isn’t available locally, Medicare helps pay for necessary ambulance transportation to the nearest facility that can provide the care you need. If you choose to go to another facility farther away, Medicare payment is based on the cost of transportation to the nearest facility. All ambulance suppliers must accept assignment.
Medicare does not pay for ambulance transportation to a doctor’s office.
Air ambulance cost is paid only in emergency situations. If you use an air ambulance although land transportation won’t seriously endanger your life or health, Medicare pays only the land ambulance rate, leaving you responsible for the difference.
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Which Preventive Services are covered by Medicare?
- “Welcome to Medicare” Physical Exam
- Cardiovascular Screening
- Screening Mammography
- Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
- Colon Cancer Screening (includes Fecal Occult Blood, Sigmoidoscopy, Colonoscopy, and Barium Enema)
- Prostate Cancer Screening (PSA)
- Pneumococcal Vaccine
- Diabetes Screening, Supplies, and Self-Management Training
- Smoking Cessation
- Abdominal Aortic Aneurysm
The following preventive services are covered but not listed on MyMedicare.gov:
- Glaucoma Tests
- Flu Shots
- Hepatitis B Vaccine
- Bone Mass Measurements
Why are preventive services important?
Preventive services can find health problems early when treatment is most effective, and can even prevent disease or illness in some cases. Medicare pays for many preventive services to keep you healthy. Talk to your doctor or health care provider to find out what tests you need and how often you need them to stay healthy.
Special note about dental care, hearing aids, and eyeglasses:
Unfortunately, Medicare doesn’t cover routine dental care, hearing aids, or eyeglasses. These services or items are statutorily excluded from coverage.
There are, however, a few exceptions to the statutory exclusion for dental care. A non-covered dental service MAY be covered if it is:
- The result of a covered dental service.
- A necessary part of the same covered dental service.
- Performed by the same Medicare-approved dentist.
- A procedure involving extraction of teeth to prepare the jaw for radiation treatment secondary to cancer.
- A dental examination in advance of a kidney transplant.
That’s a lot to remember! It’s important to know the ins and outs of Medicare, and we’re eager to serve you in any way we can. We’re especially eager to get to work finding the Medicare supplement insurance that will best fill the gaps in your Medicare coverage. MedicareMall is the expert at shopping the market on your behalf, and we have over two decades of experience helping people like you find the Medicare Advantage and Medicare supplement plans that provide the best coverage at the best price. Contact us now and we’ll guide you through the Medicare maze and find the Medigap plan that best meets your needs and budget.