Key Points:
Original Medicare is robust, but has a few grey areas that could lead to surprise bills
Part A & B have grey areas with Cataracts, Vitamin Deficiency Tests, Cruise Ships and Chiropractic Services
Part D has grey areas with weight loss medications and erectile dysfunction medications
What are some surprise bills you could have while on Medicare? What are some things that are covered by Medicare but not in every situation? We have helped thousands of people with their Medicare, and in this article, we’re going to use our expertise to help you avoid any surprise bills while on Original Medicare.
Non Standard Cataract Lenses
The first thing we’re going to talk about is Non Standard Cataract lenses. One of the more confusing parts of Original Medicare is that vision is not covered, but your eyes are. Treatment for conditions like Cataracts, Retinopathy for diabetics, and more are indeed covered by Original Medicare. Your annual eye exams and glasses, however, are not.
You should know that newer non- standard Cataract lenses are not covered by Original Medicare yet. You still can 100% get cataract surgery and some more traditional lenses that will help treat your condition while on Original Medicare. Just because the ophthalmologist says it is “dated” does not mean it won’t help you.
Often people go to get cataract surgery and their surgeon or Ophthalmologist will tell them, “you can get a Medicare covered lens, or you can spend an extra few thousand dollars on the Cadillac version of the lenses”. Whether you do this or not is up to you, but you can still get quality Medicare-covered cataract lenses.
Vitamin Deficiencies in Blood Work
Original Medicare covers many routine blood tests. Tests like A1C or blood sugar, cholesterol and lipids, HIV, Hepatitis, PSA, STD’s and much more are covered with little to no issue. One of the main ways people get blindsided with blood work is with Vitamin B & D tests.
While it is possible to get Vitamin B and D tests covered by Medicare, you must meet specific criteria. It IS NOT part of a routine blood test in most cases.
To get a Vitamin B or D test, it must be deemed “medically necessary”. This tends to mean you need to have a specific condition like kidney disease or Osteoporosis to get this regularly covered. Medicare deems these tests unnecessary without these conditions because there are other ways a doctor can determine if you have these vitamin deficiencies.
Let’s give a real-world example. We have had some of our clients get sent to a lab work office by their doctor. They are simply getting a normal annual blood test. The lab service front desk then gives them a seemingly boilerplate document that requires a signature. We all have seen these before and signed them thinking it’s a standard medical release.
What they end up doing is signing a waiver that says, “I understand I may get some medical work done that is not covered by Medicare, and I am financially responsible.” The lab service does the blood work and adds in Vitamin B and D tests. They then send a bill for several hundred dollars to the client. The clients are shocked but are unfortunately locked into this bill.
Here is a pamphlet from Quest Diagnostics diving in further. (https://www.questdiagnostics.com/content/dam/corporate/restricted/documents/mlcp/mlcp/jm-palmetto/jm_palmetto-mlcp-l33418-vitamin_d/JM-Palmetto---L33418---Vitamin-D.pdf)
Cruise Ships
Many Medicare enrollees love going on cruises. And Original Medicare with a Medicare Supplement does indeed have a partial benefit while traveling overseas. What you should know is this often DOES NOT WORK WITH Cruise Ships.
Medicare’s own laws say that they will not pay for any medically necessary procedures performed on a ship 6 hours outside of a port. Even if it’s an emergency. There is some wiggle room if you are within 6 hours of a port.
But the issue we have seen is that many of the doctors and nurses hired by cruise ships don’t take Medicare. Medicare covers 95% of doctors across the US, but once you enter a cruise ship that is likely no longer the case. We had a client get medically evacuated by a helicopter while on a cruise ship and was later served a $50,000 bill. They learned the hard way Medicare would not cover them on a cruise ship in most cases. They luckily had gotten traveler’s insurance beforehand, which we always recommend when leaving the US!
Source:
Chiropractic Services
We have a lot of clients who love their chiropractor and go to see theirs regularly. The issue is Medicare doesn’t cover a vast majority of Chiropractic services.
Medicare WILL cover chiropractic adjustments if deemed medically necessary. They will not, however, cover anything a chiropractor orders. Chiropractic massages, ultrasounds, X-rays and more, will NOT be covered by Medicare.
Many people are blindsided by surprise chiropractic bills when their chiropractor orders things outside of the scope of what Medicare allows. They will say, “I thought Medicare covers chiropractic!”. They do cover adjustments, and basically nothing else. I linked Medicare’s official page on the subject in the about section below:
Part D Grey Areas
We’ve just covered a few things that Original Medicare doesn’t cover, and now we’re going to give you the bonus of a few grey areas within Medicare Part D. You can get Medicare Part D on Original Medicare or with a Medicare Advantage plan. If you have either of these the concepts are for all and intents and purposes very similar.
Weight Loss Medications
One of the biggest new medications of the last few years is Semaglutide, otherwise known as Ozempic or Wegovy. Ozempic was initially made for diabetics to help them lose weight. Wegovy is a very similar compound that is designed to help anyone lose weight. Many of our clients have been prescribed either of these prescriptions to help with their weight loss journey. That is, until they see the $15,000 annual bill.
Medicare at the moment does not cover any medications for weight loss. If you are prescribed either of these explicitly for weight loss, it will not be covered. And the cost is in the tens of thousands of dollars at full price.
The way you can get coverage for Ozempic is if you are diabetic. Because it serves your diabetes AND helps you lose weight, Medicare Part D will cover it. It is still expensive, but you’re looking at around $2000 a year as opposed to $15,000+.
Erectile Dysfunction Medication
Our final Medicare coverage grey area is Erectile Dysfunction medications. SOME Medicare Part D plans do cover Erectile Dysfunction medications like Viagra and Cialis. But they are often labeled Tier 4 or 5 medications, which leads to high copays. We’re talking hundreds or thousands of dollars over the course of the year.
The secret for any ED medication is to use a service like GoodRX or Singlecare. The copays with these free coupon programs are much lower compared to Medicare 99% of the time. When you remove ED medication from your overall Part D calculation by using GoodRX or Singlecare, you save money on your ED medication and on your Medicare Part D plan.
We hope you enjoyed this video on a few random things Medicare doesn’t cover or some grey areas that could lead to high bills. If you have any other examples we missed, leave us a comment down below and we’d be happy to dive into it in a future video.
Contact Us
If you ever need any help with your Medicare and avoiding surprise bills, feel free to reach out to us here at NJ Life and Health. We can help you avoid surprise bills and fully understand your plans. Call our Toms River, NJ office at 848-226-6897 or visit our website at www.njlifeandhealth.com.