There are several significant medical expenses that Original Medicare, the federal program for Americans 65 and older, doesn’t cover.
However, there are some exceptions to these rules. These include prescription drugs and some dental services.
1. Excessive Therapies or Diagnostic Procedures
Medicare doesn’t pay for excessive therapies or diagnostic procedures unless the patient is already suffering from symptoms and has been diagnosed by a doctor. Examples include surgery for a benign lesion or MRIs recommended by the American Cancer Society or National Institutes of Health. This is important to remember because it can help you budget and avoid unexpected medical bills.
Another change that will take effect in 2023 is that all Part D enrollees will be able to receive the vaccine recommended by the Advisory Committee on Immunization Practices, or ACIP, for free. Additionally, the Inflation Reduction Act will require pharmaceutical manufacturers that market both Part D prescription drugs and Part B drugs to pay a rebate to Medicare if they raise their drug prices more than the rate of general inflation.
3. Copayments or Coinsurance
While Medicare plans do not cover everything, they pay for some uncovered costs. These costs include deductibles, copayments, and coinsurance. They vary among different Medicare plans, and each project has its details.
Deductibles are the annual amounts you must spend out-of-pocket before your insurance plan begins to cover treatments. They generally range from $1,600 to $226 in 2023.
Copayments are flat fees you pay for certain healthcare services. They can be a good choice for people on tight budgets or who want to know their out-of-pocket expenses before they visit the doctor.
However, copayments can be expensive if you visit an out-of-network provider or have multiple doctor visits within the same year. Fortunately, many health plans now offer in-network options for most services, so you don’t have to pay as much out of pocket at your doctors’ offices.
Additionally, copayments on prescription drugs can be confusing because they vary depending on the drug’s tier in the formulary. For example, some Medicare plans offer five or more levels of prescription drug coverage.
The bottom tier of drugs typically requires a fixed copayment, while the top level requires a percentage of the cost to be paid out-of-pocket by the patient. In addition, several plans have copayments for specialty medications unavailable at all retail pharmacies.
Coinsurance can be a better option for people who expect a lot of medical needs in the coming year, need to see multiple specialists, or have several different medications covered at once. It also helps people meet their deductibles faster and avoid a higher out-of-pocket maximum. It’s essential to check a plan’s benefits summary for the specifics on coinsurance.
4. Inpatient Hospital Care
Knowing your coverage and what services are covered is essential whether or not you have health insurance. If you’re concerned about paying for medical costs, it may be wise to consider getting supplemental insurance or indemnity insurance.
Medicare will only cover specific inpatient hospital care if you have the necessary health insurance. This includes medically necessary surgery, treatment for severe illnesses like the flu or stroke, birthing/childbirth, and rehabilitation services.
Inpatient hospital care is usually more expensive than outpatient care because it requires extended stays. It also uses more resources, such as beds, personnel, and equipment, to provide higher medical care.
While there are many types of inpatient hospital care, the most common is for a person to be admitted overnight or for extended periods to undergo surgery or a severe illness requiring intensive healthcare professional monitoring.
This can be great, as it allows a doctor to monitor the patient and ensure their health improves closely. However, inpatient care is more expensive than outpatient care and can be costly if you don’t have insurance.
If you are admitted as an inpatient, it’s helpful to understand your copays and how much you’ll have to pay for these services. Some plans have a flat per-stay or per-day fee, while others have a sliding scale.
Another way to reduce the cost of inpatient hospital care is to look into Medicare Advantage plans. These plans typically have lower out-of-pocket costs for hospital stays and may even offer payment relief for patients without insurance.
If you’re considering enrolling in a Medicare Advantage plan, reading the contract is helpful. This will give you a better idea of what Medicare will and won’t cover and help you choose the best plan for your needs.
5. Non-Medicare Providers
Non-Medicare providers are healthcare professionals who do not accept Medicare assignments or refuse to bill Medicare for services. They may also be known as non-par (non-participating) providers.
The number of physicians and other healthcare professionals who opt out of Medicare varies by state. Still, it is much less common than the percentage of providers participating in the program or not accepting Medicare assignments. For example, fewer than 2 percent of non-pediatric physicians in 47 states have opted out of Medicare as of September 2020.
While Medicare does not pay for all items and services provided by non-Medicare providers, it does reimburse these healthcare professionals at the same rate as participating healthcare professionals. In addition, these physicians do not have to participate in a particular Medicare program, such as the Physician Quality Reporting System, to receive reimbursement for their work.
There are many reasons a healthcare professional might decide to disenroll from Medicare, and the choice is based on the provider’s circumstances. For instance, a doctor might choose to do this if the Medicare payment is lower than if they had enrolled in a Medicare plan or signed a participating agreement with Medicare.
For non-Medicare medical doctors, this can mean a year’s income loss. However, the Medicare fee schedule allows non-participating doctors to charge their patients an additional amount that is not more than 115% of the Medicare-approved fee for their service.
These fees are called limiting charges. In 2023, Medicare will only pay up to 95% of the limiting charge amount for non-PAR providers who do not accept assignments. This means the patient will be responsible for the difference between the Medicare allowed amount and the limiting charge, plus any applicable coinsurance or deductible.
