Medicare FAQ

1. Why does Medicare have coverage exclusions?

Medicare is health insurance that exists because of Federal Laws that were passed to create it. Initially, as created in 1965, it consisted of Part A (hospital benefits) and Part B (medical benefits) and reflected the restrictions and limitations of most health insurance at that time. Additions have been made over time, including prescription drug coverage through Part D. The federal law that created Medicare benefits has specific provisions that exclude coverage for certain things, like dental care and routine vision services. Other services that are not covered by Medicare, like certain long-term care services, are excluded because they do not meet the definition of health care service in the law. Just because something is not covered by Medicare does not mean that it is not needed. As we talk about types of care that Medicare doesn't cover, we will include some resources and information about other ways of accessing or paying for these services.

2. What should I know about dental care and Medicare coverage?

Dental care is excluded from Medicare coverage. Medicare does not cover dental services that you need primarily for the health of your teeth, including but not limited to:

• Routine checkups
• Cleanings
• Fillings
• Dentures (complete or partial/bridge)
• Tooth extractions (having your teeth pulled) in most cases

If you receive dental services, you will be responsible for the full cost of your care unless you have private dental coverage or are utilizing a low-cost dental resource (see question 4). Medicare will not pay for or reimburse you for almost any dental services.

Note: Some Medicare Advantage Plans cover routine dental services, such as checkups or cleanings (see question 6). If you have a Medicare Advantage Plan, contact your plan to learn about dental services that may be covered.

3. Are there any situations in which Medicare will cover dental services?

While Medicare does not pay for dental care needed primarily for the health of your teeth, it does offer very limited coverage for dental care needed to protect your general health in certain ways, or for dental care needed in order for another Medicare-covered health service to be successful.

For instance, Medicare may cover:

• An oral examination in the hospital before a kidney transplant
• An oral examination in a rural clinic or Federally Qualified Health Center (FQHC) before a heart valve replacement
• Dental services needed for radiation treatment for certain jaw-related diseases (like oral cancer)
• Ridge reconstruction (reconstruction of part of the jaw) performed when a facial tumor is removed
• Surgery to treat fractures of the jaw or face
• Dental splints and wiring needed after jaw surgery

It is important to know that while Medicare may cover these limited dental services, Medicare will not pay for any follow-up dental care after the underlying health condition has been treated. For example, if you were in a car accident and needed a tooth extraction as part of surgery to repair a facial injury, Medicare may cover your tooth extraction-but it will not pay for any other dental care you may need later because you had the tooth removed.

Medicare also covers some dental-related hospitalizations. For example, Medicare may cover:

• Observation you require during a dental procedure because you have a health-threatening condition that makes receiving the dental care outside of the hospital dangerous

In these cases, Medicare will cover the costs of hospitalization (including room and board, anesthesia, and x-rays). It will not cover the dentist fee for treatment or fees for other physicians, such as radiologists or anesthesiologists. Further, while Medicare may cover inpatient hospital care in these cases, it never covers dental services specifically excluded from Original Medicare (like dentures), even if you are in the hospital. If you need dental care, look into resources or other forms of insurance that may help pay for dental services. You can also use FAIR Health's consumer cost lookup tool to get an estimate for the amounts dental professionals usually charge in your area for different services.

4. How can I get dental coverage?

If you need dental coverage, you may be able to get assistance through the programs listed below.

• Medicare Advantage Plans: Some Medicare Advantage Plans offer routine dental coverage (see question 6). Contact your plan to learn about services it may cover, any rules or restrictions, and costs. If you are considering joining Medicare Advantage, make sure the plan suits your other care needs.
• Medicaid: In some states, Medicaid covers some dental services. You may qualify for Medicaid if you have a low income and minimal assets. Contact your local Medicaid office for more information.
• Private Dental Plans: You can purchase a separate dental plan from a private company.
• Reduced-Cost or Free Dental Clinics: These clinics are available in many states. Use resources available at NeedyMeds, healthcare.gov, freeclinics.com, and hhs.gov for more information.
• Local Hospitals: Call the hospitals in your area to ask if they offer dental clinics, how you can become a patient there, which services they offer and at what cost, and if payment plans
  are available.
• Federally Qualified Health Centers (FQHCs): FQHCs are health care facilities located in medically underserved areas. People with Medicare are eligible to receive services from an FQHC. Some FQHCs may offer dental care.
• Community Health Centers (CHCs): CHCs provide free or reduced-cost health services, including dental care. CHCs are funded by the Health Resources & Services Administration (HRSA).
• Donated Dental Service Programs: These programs operate in certain states. Dentists in these programs offer free dental services if you qualify.
• Dental Schools: Some dental schools provide low-cost dental care. Dental students work with patients under the supervision of experienced, licensed dentists.
• Program of All-Inclusive Care for the Elderly (PACE): PACE is a program available in some states to people with Medicare and Medicaid who need a nursing home level of care.

5. What should I know about vision care and Medicare coverage?

Routine eye care services, such as regular eye exams, are excluded from Medicare coverage. However, Medicare does cover certain eye care services if you have a chronic eye condition, such as cataracts or glaucoma. Medicare covers:

• Surgical procedures to help repair the function of the eye due to chronic eye conditions. For example, Medicare will cover surgery to remove a cataract and replace your eye's lens with a fabricated intraocular lens.
• Eyeglasses or contacts if you had an intraocular lens placed in your eye after cataract surgery. In this case, Medicare will cover a standard pair of untinted prescription eyeglasses or contacts if you need them. If it is medically necessary, Medicare may pay for customized eyeglasses or contact lenses.
• An eye exam to diagnose potential vision problems. If you are having vision problems that may indicate a serious eye condition, Medicare will cover an exam. Your exam is covered even if it turns out you do not have a vision problem.

Medicare only covers routine eye care in the following circumstances:

• If you have diabetes, Medicare covers an annual eye exam by a state-authorized eye doctor to check for diabetes-related vision problems.
• If you are at high risk for glaucoma, Medicare covers an annual eye exam by a state-authorized eye doctor.

You are considered to be at high risk if you:

• Have diabetes
• Have a family history of glaucoma
• Are African American and age so+
• Or, are Hispanic American and age 65+

6. Can Medicare Advantage Plans cover dental and vision care?

Medicare Advantage Plans can cover dental and vision services as supplemental benefits. A supplemental benefit is an item or service covered by a Medicare Advantage Plan that is not covered by Original Medicare. These benefits do not need to be provided by Medicare providers or at Medicare-certified facilities. Instead, to receive these items or services, you need to follow your plan's rules. Some commonly offered supplemental benefits are dental care, vision care, hearing aids, and gym memberships.

Most supplemental benefits must be primarily health-related.* These benefits can either be:

• Optional, meaning that they are offered to everyone who is enrolled in a plan, and you can choose to purchase the benefits if you want to, or
• Mandatory, meaning that they are covered for everyone enrolled in a plan and you cannot decline the coverage (even if you do not need to use the service)

Before joining a Medicare Advantage Plan for its supplemental dental or vision benefits, make sure you fully understand what services are covered and what rules you must follow to receive coverage. Also make sure the plan fits your other health needs.

*Medicare Advantage Plans can also offer coverage of supplemental benefits that are not primarily health-related for beneficiaries who have chronic illnesses.

7. What should I know about Medicare and long-term care?

Long-term care (LTC), also called long-term services and supports (LTSS), refers to a range of services that help you perform everyday activities. LTC can be provided in a nursing home, assisted living facility, or other setting, and may include medical care, therapy, 24-hour care, personal care, and custodial care (homemaker services). Medicare usually does not cover non-medical LTC services.

However, if you need this assistance, there are other organizations and forms of insurance you can try:

• Medicaid is a state and federal program that provides health coverage if you have a limited income. Medicaid is the country's largest payer of LTSS and willpay for nursing home care. Medicaid benefits also coordinate with Medicare.
• An Area Agency on Aging (AAA) may be able to provide counseling and connect you with services in your area.
• Local senior centers may have programs that can deliver meals, provide transportation and shopping assistance, and offer case management. To find senior centers in your area, callyour local AAA.
• Faith-based organizations and charities may offer services, financial assistance, and/or referrals to other organizations in your area.
• Geriatric care managers are health and human services professionals who work privately with you and your family to create a plan of care that meets your needs.

In certain areas, you can dial 2-1-1 to ask for referrals to community services. You can also contact your State Health Insurance Assistance Program (SHIP) for assistance and counseling. You can find your local SHIP by going to www.shiphelp.orgor calling 877-839-2675. If you are unsure what kind of care you need, you may want to start by asking your provider.

8. Does Medicare cover stays in nursing homes and assisted living facilities?

Medicare Part A covers up to 100 days of skilled nursing facility (SNF) care in certain circumstances. Medicare will not cover the cost of your stay if you need additional days in a SNF or LTC in a different kind of facility (such as an assisted living facility). If you have significant LTC needs, you may want to explore other kinds of insurance that may provide you with more comprehensive coverage:

• Medicaid is a state and federal program that provides health coverage if you have a limited income. Medicaid is the country's largest payer of LTSS and will pay for nursing home care. Medicaid benefits also coordinate with Medicare.
• Long-term care insurance generally covers nursing home stays and can limit your health care costs. However, it can be very expensive, and you can only purchase certain LTC policies if you are in good health.
  

9. Can I receive personal or custodial care at home?

Medicare covers home health care through its home health benefit if you meet the eligibility requirements. You must need skilled nursing or therapy care to qualify for Medicare's home health benefit. If you are eligible, Medicare may also cover other services, such as personal care, that are provided along with your skilled nursing or therapy services.

If you need home health care and/or personal care services but do not need what Medicare defines as skilled care, Medicare will not pay for those services. If you are not eligible for Medicare-covered home care, you may want to consider other options, such as the following:

• Medicaid is a state and federal program that provides health coverage if you have a limited income. Medicaid benefits coordinate with Medicare.
• Program for All-Inclusive Care for the Elderly (PACE) is a state-sponsored program that covers home care.
• Home care organizations in your area may provide services at low or reduced costs.
• Eldercare locator is a public resource created by the U.S. Administration on Aging. It connects older adults and their families to local resources and help. You can find the Eldercare locator at www.eldercare.acl.gov or by calling 800-677-1116.
• Medicare's hospice program provides certain home care services. You are eligible for hospice if you are terminally ill.
  

You can also contact your SHIP for assistance and counseling. Find your local SHIP at www. shiphelp.org or by calling 877-839-2675. You may want to consider speaking to a home health agency to learn more about costs if you must pay out of pocket.

10 Does Medicare cover respite care?

Medicare only covers respite care (care that allows your caregiver to rest while you temporarily stay in a hospital or other facility) under the hospice benefit. If you are not eligible for Medicare-covered respite care through hospice, you may want to consider other options, such as the following:

• An Area Agency on Aging (AAA) or the National Adult Day Services Association (NADSA) may be able to connect you with services in your area.
• Adult day service organizations (also known as adult day care) generally offer supervision and meals during the day.
• Respite care organizations in your area may provide services at low or reduced costs.

11. What are helpful resources and contacts for help with Medicare and dental, vision, and long-term care?

• Your doctor or other provider: First speak to your health care provider about what dental, vision, and long-term care you need.
• State Health Insurance Assistance Program (SHIP): Contact your local SHIP to learn more about what dental, vision, or long-term care resources may be available, or for general Medicare counseling. Find your local SH IP by calling 877-839-2675 or visiting www.shiphelp.org.
• Local Medicaid office: Contact your local Medicaid office to learn about Medicaid eligibility requirements and about the application process. Remember that Medicaid coverage can help you access dental, vision, and long-term care.
• Private plans: You can contact private plans (such as dental plans, long-term care insurance, or Medicare Advantage Plans) to learn about their coverage and costs and see if their plans may be a good fit for you.
• Eldercare locator: Use the Eldercare locator to be connected with local resources and help. This is a public resource created by the U.S. Administration on Aging for older adults and their families. Visit www.eldercare.acl.gov or call 800-677-1116.