According to Medicare.gov, “medically necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” In any of those circumstances, if your condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat those.

Medicare uses certain criteria from National and Local providers to deem certain procedures either Medically Necessary or Non Medically Necessary. Contrary to popular belief, Medicare is NOT trying to find a reason NOT to cover something. The reverse couldn’t be more true. What they are doing is trying their best to weed out the abuse of Medicare by PROVIDERS, not Patients. Some things happen that just shouldn’t, and Most if not all of the Non Medically Necessary items are just things that the taxpayer should not have to pick up the bill for. Here are some examples:

• Times where your hospital service surpasses the Medicare-approved stay length
• Physical therapy treatment that surpasses Medicare’s usage limit
• Hospital-administered treatment that could have been delivered in a lower-cost setting
• Prescription of drugs to treat fertility, sexual or erectile dysfunction, weight loss or weight gain, and cosmetic purposes

If you have Original Medicare and a supplement (or Medigap coverage) your supplement has to pay its part if Medicare deems a procedure Medically Necessary. On the contrary, if Medicare doesn’t pay because a procedure is Non Medically Necessary, your supplement will not either.

The important thing to consider here is the Provider. No matter the procedure, or reason for the office visit, Providers are well versed in the difference of Medically Necessary versus Non. It is VERY important to ask questions to your doctor about procedures and how you insurance will cover it. The Provider can tell you right up front if Medicare will approve the claim or not. Or, at least they should. Don’t be afraid to ask questions of your provider. Talk to the insurance biller in the Doctors office if you need to. If for some reason your Doctors office or hospital cannot tell you if your recommended procedure is Medically Necessary, you should not agree to the procedure until you find out whether it is or isn’t.

A vast majority of the time, Medically Necessary just means common sense. If your Provider is wanting to perform a Non Medically Necessary procedure, I would certainly consider a 2nd or 3rd opinion.

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A lot of folks that turn 65 and qualify for Medicare don’t like the fact that Medicare doesn’t cover Dental or Vision services. The main reason being that the insurance they had before turning 65 was a Group Employer Based Plan that had a Dental and/or Vision insurance option. Most opted into the Dental and Vision because it would provide coverage for their entire family for a very low monthly premium, and it was easy to pay – directly from their paycheck.

Most folks don’t really know what Dental and Vision is, what it covers, or what it doesn’t cover. Group dental and vision plans are based on the group participation, so the premiums are less. There really isn’t much coverage there when you look close. Let’s do that: Dental Insurance plans are all basically the same with minor differences in coverage from company to company.

All Dental plans have:
-Waiting periods for major services coverage such as root canals, bridge work, crowns, et cetera)
-Limited coverage on cleanings and x-rays that are typically limited to one or two visits a year with a co-payment.
-An annual maximum benefit typically between $1000-$1500. There’s no coverage after that amount.
-Limited networks of Dentists.
-Very little to no Orthodontic or Oral Surgery coverage.

Vision Plans aren’t much better. One question I get in EVERY workshop usually goes like this, “If Medicare doesn’t cover Vision – Is there any coverage for Cataracts, or eye diseases?” Well, the truth is that Vision Insurance is only “good” for one thing – Eyeglasses. Medical issues with your eyes, be it Cataracts, Glaucoma, Macular Degeneration, Astigmatism are ALL covered by Original Medicare and your supplement. Or, if you have a Medicare Advantage Plan, you are covered there too.

Vision insurance gives very limited coverage on eyeglasses and contacts. Also, it will give you limited coverage on the refraction portion of an eye exam. The medical portion of the eye exam that checks for diseases, damage, retina, et cetera; are all covered by Medicare.

I like to put it this way – The taxpayer will make sure your eyes are healthy, but they will not buy you the most expensive pair to Ray-Bans. Although, Medicare will pay for a pair of glasses for beneficiaries after cataract surgery. Usually a prescription will change after that so Medicare will foot the bill on eyeglasses then.

Private Dental and Vision plans are typically costly when compared to what you are paying for. Premiums are usually between $20 and $50 per month. Most folks only use it to have their teeth cleaned twice a year. In that event, you are paying much more in premiums that you would be if you just paid the dentist direct.

Vision services are on a changing trend as well. Here in Bowling Green, we have two different eye centers that provide very inexpensive plans. Like $59 for an eye exam and 2 pair of glasses. You cannot purchase insurance for that, and your copay’s are more than $59 usually with the coverage. These specialty shops are popping up all over our area and doing well.

In my opinion, you should really talk to one person before purchasing dental coverage – your dentist. If your dentist feels that you may be looking at long term major dental work, it may be right for you. If you go for a few cleanings a year and an x-ray, you may be better off just working something out with the dentist.

I do carry a number of the most popular plans for dental and vision. I do have several clients that carry that type of coverage. I just don’t think it’s something that EVERYONE needs or should have.

If you have questions or want an explanation of dental and vision coverage, look at the following:
Respond to what you’ve read here.
Contact Brian here.
Sign up for a Turning 65 Medicare workshop here.

Sometimes the wrong word is chosen to describe something.  I don’t know if it is because there is no better “word” available, or the describer wants to make a bigger “statement” by using a certain word.  For example… Medicare says you will be PENALIZED, or there will be a PENALTY if you do not sign up for Medicare when you should. If you remember who “Uncle Charlie” is, Uncle Charlie loves this one because it’s “scary” and off course, no one wants to be penalized for anything.  So Uncle Charlie really goes overboard with this one and of course, we all believe our Uncle Charlies.

In my opinion, the word Penalty is the wrong word to use.  The Penalty comes into play when you do not sign up for Medicare Part B, or a Medicare Part D drug plan when you become eligible.  If you put that off to sometime in the future (when you need it), you will not be able to just sign up when you want to and there will be a Penalty accessed in the form of higher premiums than you would have paid if you signed up on time.  Here is the catch though – This is INSURANCE. Medicare is Health Insurance. It is not a Freebie, it is not a giveaway program, It’s Insurance. It’s something you pay for all your working life and something you continue to pay for after you get it.  So, lets forget about the word Medicare and just think of it as insurance.

What are the reasons you would NOT sign up for Medicare at age 65?

• You are currently actively employed and covered under an employee group plan?
• Your spouse is actively employed and has you covered under their group plan?
• You are still working just to keep your spouse insured because they are much younger than you?
• You are covered under a retiree group plan that does not require you to enroll?

OR…

• Maybe you are the picture of health?
• Maybe you don’t go to the Doctor?
• Maybe you don’t take any medications?
• Maybe you believe you will never use Medicare, so why have it?

See, whether there is a Penalty accessed depends on the reason why you do not take Medicare at 65.    If you have had alternate coverage prior to taking Medicare Part B no matter what your age is, there is NO penalty.  But if you wait until you get sick or are facing large medical expenses that you did not plan for, well, you will pay more for your insurance.  So, let me ask a few questions so you can look at this in perspective.

1. Do you own a home?
2. Have you owned that home for longer than 5 years?
3. Do you have Home Owners Insurance on that home?
4. How many claims have you had in the past 5 years?

If you answered that last question “Zero”, then Cancel Your Home Owners Insurance!  You don’t need it! Why pay for it if you’ve never used it?

Of course, you wouldn’t do that.  That would not be smart. But it’s the same concept.  You don’t wait until the tree falls on your home before you go get home owners insurance.  You also don’t wait until you get sick before you go get health insurance. It works the same way.  If you did wait until the tree fell, wouldn’t you pay more for the insurance? – Yes, you would, if you could get it.  Well, if you wait until you get sick to buy health insurance – you will also pay more for it.

This shouldn’t be called a Penalty.  The government should just say “If you wait until you need Medicare before you enroll in Medicare, you will pay a higher premium”.  Sounds simple enough, and if it was put to most folks that way, there would be a whole lot less worrying about Penalties. Take your Medicare benefits when you are supposed to so that when you need it, it’s there for you, and don’t worry about Penalties.

Respond to what you’ve read here.
Contact Brian here.
Sign up for a Turning 65 Medicare workshop here.