Joanne: We often talk about the A, B, Cs, and Ds and the other letters of the alphabet that relate to Medicare coverage, but what do these various parts of Medicare actually cover? And perhaps more importantly, what do they not cover? Keep listening as we aim to answer those questions 

Cameron: right now. And before we start, my name is Cameron Giardini and together with my cohost, Joanne Giardini Russell, we operate Giardini Medicare, which is an independent insurance agency based out of Southeast Michigan.

Although we are based in Michigan, we work virtually over the phone to directly help consumers in about 13 different states find the right Medicare coverage for them. If we do not work in your state, we will connect you with another trusted independent agent who will be able to help you find the right coverage that you want.

Even if you choose not to work with us, we know that the information in this podcast will help you have a successful and stress-free transition to Medicare. Also, just an added note, we now have a free online course that you can register for, for all things Medicare when it comes to different topics, and you can find that by going to gmedcourse.com. So, in this episode, we will talk about Part A coverage. We will also talk, of course, about Part B coverage to go with it, and we will talk about Medicare Advantage coverage and Part D coverage, which is prescription drug coverage. We will continue with Medigap coverage, also known as Medicare supplements, and then we will finish things off.

by talking about what Medicare doesn't cover and possibly some additional coverages that can help while you're enrolled in Medicare. First, 

Joanne (2): let's get into some Medicare coverage sources and disclaimers. So, although we always want to bring you as much information as possible, we can't tell you everything that Medicare covers.

It's impossible, and it would just take too long. Also, we can't tell you exactly what services will be covered because it'll really come down to many factors, especially. Medical necessity. Medicare.gov defines medical necessity as health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards couple of examples to bring that to life. Okay. Example number one is medications like Ozempic. You may hear about those in the news a lot lately. They may be covered by Part D prescription coverage plans when they're prescribed for diabetes. But, not when they're prescribed for just weight loss.

Example number two, Medicare won't cover Botox for cosmetic purposes, but it does sometimes cover it for some medical treatments. So, here are some Medicare coverage sources that may help you, and you can find all of these in our online course that we mentioned at gmedcourse.com. But they're going to lead you to there's an app for your smartphone, and it's it's called the What's covered app.

Download this app, or you can go online by searching medicare dot gov forward slash coverage and that you App or the Medicare.gov website lets you search by specific treatments and procedures. Just type in what you're looking for. If it's colonoscopy, type in colonoscopy, and I'll talk about what's covered.

The second source is the Medicare new handbook. If you start on page 25 of the 2023 handbook, there's a really long list of Medicare-covered topics and procedures. There are also really detailed sources. We're not going to get into much of that here, but there's a super detailed CMS Medicare coverage database and the Medicare Benefit Policy Manual.

These are for the people who really want to go deep diving in, but we're going to link to those in the show notes if that's you. And these sources are very, very detailed and are likely way more than you need to know. But again, some people like that. Yeah, 

Cameron (2): Absolutely. A lot of it's going to just come down to you talking with your doctor.

And again, going back to that medical necessity, like Joanne discussed. So just a couple more important points and disclaimers saying something might be covered by Medicare. It does not mean the full cost of the service is covered. For example, you may have an outpatient surgery that is technically covered by Medicare.

However, you will 20 percent co-insurance out of pocket to pay for that surgery. With Medicare Part B, if you only have original Medicare, or you might have an inpatient hospital stay covered under Part A, which in 2023 would require you to pay the Part A deductible of $1600, you also have to use Medicare approved and contracted providers and facilities for Medicare to cover procedures.

So if you receive a procedure that is normally covered by Medicare, But not from a Medicare-approved provider, the service is not going to be covered by Medicare itself. To find Medicare contracted providers and locations, you can use the Find a Provider online tool, which can be found on Medicare.gov's website, and you can also confirm with your providers that they accept Original Medicare.

So, I'll start by talking about what does Medicare Part A cover. Medicare Part A is also referred to as hospital insurance, and this covers inpatient hospital stays, which are typically related to room and board coverage, it also includes coverage for a semi-private room, meals, general nursing, and drugs as part of your inpatient treatment, and as well as other hospital services and supplies.

However, Medicare Part A does not cover private duty nursing a television or a phone in your room if they charge separately for these items. Now Medicare Part A, although it is called hospital insurance, it is not only limited to inpatient hospital coverage. So Medicare Part A will also cover inpatient care in a skilled nursing facility.

But not for long-term or custodial care. It's important to note that this coverage is typically for a limited time following a hospital stay, and there is up to 100 days of coverage during each benefit period that Medicare will cover for those services. Two other important skill nursing facility coverage criteria are One, you typically have to be transferred to a participating skilled nursing facility within 30 days after discharge from the hospital.

And two, you may have heard about this before, but you also want to make sure the three-day rule is met before. Skilled nursing facility admission. This means as a patient, you have to have a medically necessary three consecutive day inpatient hospital stay. And this does not include the discharge day or the pre-admission time spent in the emergency room.

And more importantly, it doesn't include the time spent in outpatient observation. Again, the key is that observation status does not meet this three-day. Now, when it comes to hospice care, this is also another covered service under Medicare Part A. If you are terminally ill and have six months or less to live, you can get hospice care to help manage your pain and support your family.

This can be received at home or in a hospice facility. Medicare Part A does provide coverage for home healthcare services as well, but these are usually a little bit limited. They must be ordered by your doctor, and they need to be medically necessary. Covered services can include intermittent skilled nursing care, physical therapy, speech-language pathology services, and continued occupational therapy services.

It does not include Covered 24-hour home care. It doesn't include meals delivered to your home or homemaker services like shopping, cleaning, and laundry. A lot of people ask us, well, Medicare cover custodial, and things like that around the house, and the answer is no. So, moving on to a slightly more straightforward coverage.

Let's talk about part B. coverage. 

Joanne (2): When it comes to Medicare coverage, most people actually think about Part B coverage as coverage. This is essentially the medical insurance portion of original Medicare, and it's so it's probably more familiar or similar to what you have, and it covers a wide range of medical services and supplies that are essential for prevention.

Again, this is not an all-inclusive list, but here are some examples of Part B covered services. First, we have doctor and clinical lab services. This includes outpatient doctor visits, specialist visits, lab testing services, and preventive screenings. Then there's outpatient care. This covers services that you get as an outpatient from a hospital or a clinic, like an emergency department service, or observation service, Cameron just mentioned that, related to hospitals, skilled nursing stays, surgical procedures, and anesthesia and lab tests linked to your care. There are also preventive services. Part B is going to cover preventive measures like vaccinations, such as the flu shot, the hepatitis B shot, pneumonia shot, COVID shots, screenings for conditions such as cancer, for example, a mammogram, diabetes testing, heart disease, counseling to prevent tobacco use and alcohol misuse.

There's also durable medical equipment, which we often call DME. This can include items like wheelchairs, walkers, hospital beds for use at home, oxygen equipment, infusion pumps, and supplies, including insulin pumps, CPAP machines, and the supplies for the CPAP machine, walkers. Blood sugar meters, and even more.

A side note: there are some equipment like CPAP machines and oxygen machines that are actually covered as rentals, at least in the beginning. There's. also mental health services. So Part B can cover outpatient mental health services, including therapy,

Cameron: And to continue talking about Part B coverage, you can also get coverage through Part B for physical, occupational, and speech therapy. These are typically covered when prescribed by a doctor and provided by a licensed healthcare professional. Like always, Medicare will only cover therapy services that are considered reasonable and necessary.

And when it comes under Part B, these are typically going to be those services in an outpatient setting that you might be used to when it comes to therapy. Another thing Part B typically covers is ambulance services. However, this is when other transportation could endanger your health. Ambulance services might then be covered.

Medicare will only cover ambulance services to the nearest appropriate medical facility that's able to get you the care that you need. So don't. Just call ambulances to do any service if it's not actually medically necessary, and you can't ask it to just take you wherever you'd like. There are limitations to all of these coverages, as we've talked about.

Joanne: And people do that, and they wonder why it's not covered. 

Cameron: Yes, it is. Uh, unfortunately, it is a common topic when it comes to Part B. Now, Part B might also cover certain prescription drugs. This might sound kind of strange because you think that's under Part D coverage, but in reality, Part B covers a limited number of prescription drugs.

Typically, those that you wouldn't give to yourself, like. Drugs are given at a doctor's office. Think infusions or certain injections in this case as well as prescriptions that are infused through an item of durable medical equipment, which, like Joanne mentioned, an insulin pump and the insulin it uses is a good example of that.

Now lastly, part B might also cover clinical research. It can help cover the cost of participating in qualifying clinical research studies. These might be studies that test how well different types of medical care work and compare them. Overall, the coverage for all of the services we mentioned for Part A and Part B will depend on many factors, including medical necessity and more.

Again, this podcast should not be used to determine whether or not a service will be covered. But instead, it's just going to give you an overview of original Medicare coverage. Make sure to check with your doctor or healthcare providers to see if the care you need is likely to be covered by Medicare.

Because I promise if you go in and say, Joanne and Cameron told me this is covered, they're not going to care. So make sure you check with the actual medical providers and make sure everything is medically necessary based on their guidelines. So, shifting now away from Original Medicare, Joanne can talk about Part D coverage with Medicare.

So, 

Joanne (2): again, although the Original Medicare Part A and Part B may cover some prescriptions in limited situations like we just mentioned, when it comes to coverage for the most common prescription medications, that's where Part D as in dog of Medicare is going to come into play. So Part D is going to provide coverage for most outpatient prescriptions that you fill at a retail pharmacy.

Think of the CVSs and the Walgreens of the world. Part D is not a part of Original Medicare. That's Part A and Part B. But it's instead provided by private insurance companies that contract with Medicare to offer those prescription drug plans to you. Although these plans are provided by private companies, according to the Center for Medicare Advocacy, these companies are both regulated.

A Part D plan's formulary is the key to finding out which prescription medications are going to be covered by that particular plan. These are easy to find online. You can find physical versions of the plan. Hard copies can be mailed to you. But in our opinion, using the online Medicare.gov Plan Finder tool is a really great way to find the medications that are covered by the different Part D prescription plan.

It's not as hard as it sounds, but you can go online, and you can run your own prescription medication plans. The key here to remember is that the different insurance companies and the plans do not cover the same prescriptions, meaning they don't cover them the same. They might cover similar or the same prescriptions, but they may not cover them in the same manner.

Also, what you pay for prescriptions can vary drastically from one plan to the next, since medications are categorized by a tiering system, and that varies from plan to plan as well. According to the Medicare Right Center, all Part D plans must cover at least two drugs from the following categories. HIV, AIDS, treatment, antidepressants.

antipsychotic medications, anti-convulsive treatments for seizure disorders, immunosuppressant drugs, and anti-cancer drugs, unless those are covered under Part B. What are some medications that are not covered by Part D? According to the Medicare Rights Center. Medicare typically does not cover the following types of prescription medications.

These are drugs to treat anorexia, weight loss or weight gain, fertility drugs, drugs for cosmetic purposes or hair growth, drugs only for cold or cough symptoms, non-prescription over-the-counter drugs, prescription vitamins, and drugs for erectile dysfunction. The source for this list is going to also be in the show notes below.

Cameron (2): Yeah, it's a lot of information about Part D, but it's also good to know because a lot of people. Especially recently, with Ozempic and other things are kind of surprised to see Medicare Part D not covering all the prescriptions they expect. So another type of Medicare coverage that you might run into are Medicare Supplement Plans also known as Medigap Plans.

And these are sold by private insurance companies, and they are designed to help fill the financial gaps left by Original Medicare and to cover some or all of the cost sharing not covered by Original Medicare, which are things like those copays, coinsurance, and deductibles we talked about earlier with both Part A and Part B.

 An important thing to know about Medigap plans is they provide secondary coverage to Original Medicare. This means that if Medicare approves a medical treatment or procedure, the Medigap plan has to pay the remaining portion that they are obligated to pay based on the plan that you have. So, for example, Plan G will cover 20 percent co-insurance that Part B does not cover.

So, if you have a Part B-covered service, your Plan G has to cover it in full if you have met the Part B deductible. Even more importantly, these plans, they can't stop you from having a procedure. Because, again, they are secondary. So if Medicare approves something, they have to pay their legally obligated portion.

Medigap plans are standardized by plan letters, and currently, there are 10 plan options in the market ranging from plan A to N, and you have probably heard of popular ones like plan F, plan G, and plan N. Medigap plan letters do impact what a Medigap plan will cover financially for your healthcare, but they don't actually impact the services that will be approved by Medicare.

For example, a plan A, a Medigap plan A, does not cover the part A deductible. Oddly enough, I know it's confusing, but that's how it works. This does not mean you won't have Part A hospital coverage. It just means you'll have to pay the full deductible out of pocket. Again, that's not really a popular plan.

It's just more of an example of how these plans can work. The standardized Medigap plans do provide some coverage for foreign travel emergency situations outside of the U.S. S. And I just talked to somebody about this today. They were asking about, you know, a trip to Europe for a couple of weeks, but I told them, and it's important to remember this coverage with the Medigap, it has a lifetime limit of 50,000 dollars for foreign travel emergency coverage.

So be very careful if you're only relying on that. Some Medigap companies go even further, and they provide additional benefits not covered by Medicare. This can include. Coverage for routine physicals or other non-Medicare covered preventive services, and even coverage like dental, vision, hearing, and possibly more.

Now, on the complete opposite side of the spectrum, Joanne will talk about Medicare Advantage plans, which are sometimes called Part C.

Joanne (2): Right. We're going to totally shift gears here. We've talked a lot about original Medicare coverage, but now we're going to talk about Medicare Advantage coverage.

Medicare Advantage is also known to some people as Part C, but it's technically not a part of Medicare. There are plans that are sold by Medicare-approved private insurance companies, and they are considered a private alternative to original Medicare. What they do is they bundle all of the benefits from Part A, Part B, and typically for Part D, which is drug coverage, and they bundle it into one package.

According to Medicare, Medicare Advantage plans must cover all of the services that original Medicare covers except hospice care. That is still provided by Original Medicare Part A, and they have to cover emergency and urgent care even outside of the plan's network. So we often say that what Medicare Advantage plans cover is the same as Original Medicare, but it's how they're covered and how it's delivered to you is really where the differences come into play. This is because Medicare Advantage plans are managed care programs provided by private insurance companies, and they're responsible for administering your Medicare coverage while you are enrolled in one of their plans. Because of this, Medicare Advantage plans typically structure things. They have structured costs.

They have fees and copays and things like that. They have networks, and they have rules that are completely different than original Medicare Part A and Part B. Please note, though, when we talk about this, even though you are getting your services in a different fashion, you will still be paying your Medicare Part B premium.

That is commonly misunderstood. For example, Medicare Advantage plans are typically PPO or HMO plans with networks of providers you may have to stay within, which does not happen with Original Medicare. Medicare Advantage plans also often change that 20 percent co-insurance that you do have with Part B of Original Medicare, and they turn that sort of into set co-pays.

And that actually can be a good thing. Instead of a 20 percent co-insurance, you might have a $5 or $10 co-pay with the Medicare Advantage plan. Medicare Advantage plans also may impose restrictions in the forms of prior authorization for some treatments and procedures before they will cover that, unlike Original Medicare.

So, although Medicare Advantage plans have to cover the same services as original Medicare, a 2022 Office of Inspector General report found that 13 percent of prior authorization denials from Medicare Advantage plans met the Medicare coverage rules and should have been covered. So, it is very, very different in how it's delivered.

Lastly, Medicare Advantage plans often provide coverage for extra benefits that are not covered by original Medicare. CMS will not let us discuss specifics of any of these coverages, but if you've seen a commercial about extra benefits with Medicare, they are almost certainly talking about Medicare 

Cameron (2): Advantage plans.

Yeah, absolutely. These are only becoming more popular. So it's always good to understand how Medicare Advantage coverage differs from original Medicare with or without Medigap coverage. And just like Joanne said, the key here is that Medicare Advantage plans do have to cover the same services as original Medicare, which is true.

But again, how do they bundle those Benefits? How do they administer the plan? It can, and it will act differently than with original Medicare. So it's not saying it's bad, but know that it's not always as simple as saying it's just like original Medicare. 'cause it's certainly not. So, what does Medicare not cover?

Like other topics in this episode, we're not going to cover every single service that Medicare does not cover, but we will discuss many of the more common things that Medicare does not typically cover. Keep in mind, in this case, we are again referring to Original Medicare, which is Part A and Part B.

So, according to CMS and Medicare.gov, here are services typically not covered by Medicare. So, the first ones are medically unreasonable and unnecessary services and supplies to diagnose and treat a Medicare patient's condition. Also, services performed at a provider that is not contracted with or has opted out of Medicare.

Well, not typically be covered by Medicare itself. Also, Medicare does not cover long-term care or custodial care. Most dental care, eye exams for glasses, dentures, cosmetic surgery, massage therapy, hearing aids, items, and services outside of the U.S., as well as routine physicals and more

we're going to link to a full CMS guidebook about non-Medicare covered procedures in the show notes, and you can also find more of that in our online course at gmedcourse.com. From that list, we find that many consumers are actually surprised that Medicare does not cover routine dental, vision, and hearing coverage.

Also, many are surprised to find that although Medicare does pay for an annual wellness visit, it does not cover a routine annual physical that you might have been accustomed to. Routine physicals are commonly perceived as more in-depth than wellness visits, and CMS defines a physical as an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, condition, or injury.

So I would say when people start Medicare, the biggest reason we see one of their claims being denied is due to them having a routine physical that is billed as a routine physical by the provider and that is not going to be covered by the Original Medicare. So trying to understand the various parts of Medicare and what each one does or does not cover can seem overwhelming.

But at the end of the day, remember that Medicare is just another form of health insurance. It may be different than what you've had in the past, but many of our clients do not run into coverage issues when services are coded correctly and are shown to be necessary. And if you do run into issues, it kind of goes back to things being coded incorrectly.

 And usually, we can sort things out and help find the root of the problem. As always, please leave us a review on your podcast app and subscribe so you can listen to future episodes. You can find more Medicare content from us by going to YouTube or TikTok and searching Giardini Medicare.

You can also go to our online course and register for free at gmedcourse.com and then Last but not least, if you want to give us any feedback or questions, please send an email to info at g medicare team. com. But thank you for listening, and have a great day.