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What caregivers need to know about Medicare’s coverage

Whether Medicare will cover the services your loved one needs depends on whether the care is custodial or medical. Here's what that means.

Maurie Backman | August 24, 2022

If you’re a caregiver for a parent, spouse, or loved one who’s eligible for Medicare, it’s important for you to know what to expect.

Medicare will generally pay for services related to your loved one’s specific illnesses or injuries, but it generally won’t help cover the cost of supportive care for everyday living. Understanding this distinction will help you navigate your choices and know what level of care you may need to provide on your own.

What services and care will Medicare pay for?

As a general rule, Medicare will pay for:

  • Hospital stays related to injuries or illness
  • Skilled nursing care to treat or aid in the recovery of an injury or illness
  • Physical and occupational therapy following an injury or illness
  • Hospice care
  • Home health care that’s medical in nature (related to a specific injury or illness)
  • Outpatient services, including doctor visits, diagnostic exams, and preventive care
  • Prescription medications
  • Medical supplies, like oxygen and catheters
  • Durable medical equipment, including wheelchairs and walkers, provided that equipment is deemed medically necessary

Deductibles, coinsurance, and copayments may apply to the services above. The specifics will depend on what care is provided and whether the beneficiary has Original Medicare (with or without supplemental coverage) or Medicare Advantage.

What services and care won't Medicare pay for?

On the other hand, Medicare generally will not pay for:

When determining whether it will cover a given service, the primary distinction Medicare makes is whether the care in question is custodial or medical. Custodial care refers to assistance with everyday living activities, like bathing and dressing. If the need for help with these activities does not arise from a specific injury or illness, Medicare will not pick up the tab.

Which Medicare coverage is right for my loved one?

A big part of caring for a loved one involves finding that person the right Medicare plan. Medicare Parts A, B, and D cover hospital care, outpatient services, and medications, respectively. And Part C, Medicare Advantage, is a cost-effective alternative that offers at least the same level of coverage as Original Medicare, but often, much more.

There are a number of Advantage plans that offer supplemental benefits for enrollees with chronic conditions, including some in-home support services, home modifications (like ramps and shower or bathtub rails), and transportation services, so it’s worth exploring your options under Advantage and seeing if there’s a plan that best suits your loved one’s needs.

It’s important to understand, however, that Advantage plans will tend to have more limited provider networks, and higher out-of-pocket costs than a person would have if they enrolled in Original Medicare plus a Medigap plan and Part D plan. Here’s a guide to understanding the pros and cons of each option.

Keep in mind that you’ll have the option to change your loved one’s coverage during Medicare’s annual open enrollment, which runs from Oct. 15 through Dec. 7 each year. During that time, you can switch from one Part D plan to another, or sign up for an Advantage plan if Original Medicare isn’t meeting your loved one’s needs.

There’s also a Medicare Advantage open enrollment period that runs annually from Jan. 1 through Mar. 31 every year. If your loved one is already signed up for an Advantage plan, you can see if there’s a better plan available and make that switch. You can also revert back to Original Medicare during that time if you feel an Advantage plan isn’t the best choice for your loved one.

But it’s also important to understand that there’s no annual enrollment period for Medigap plans. These plans have a one-time enrollment opportunity that lasts for six months when you’re first enrolled in Part B and at least 65 years old. After that window ends, there are only very limited opportunities to enroll in a Medigap plan without medical underwriting. Since supplemental coverage is fairly essential when a person is enrolled in Original Medicare, you’ll want to keep in mind that people cannot just switch back and forth between Medicare Advantage and Medigap (to supplement Original Medicare) plans.

Original Medicare plus Medigap plus Part D will generally be more expensive than Medicare Advantage, but will also tend to provide more comprehensive coverage. But that comprehensive coverage may be challenging to obtain if you’re trying to enroll later on, after the person’s original Medigap open enrollment period has ended. This is why some people opt for Original Medicare plus Medigap when they first enroll in Medicare, even if they don’t have significant medical needs at that point.

How can I get help paying for services Medicare won’t cover?

Both Original Medicare and Medicare Advantage have an appeals process. If either plan rejects a claim for services or medical equipment that your loved one needs, you can file an appeal to have that decision reversed.

Furthermore, if there’s a medication your loved one needs that isn’t covered by Medicare, or whose copays are astronomical, you can apply for patient assistance directly through that drug’s manufacturer. RxAssist is an online resource that can help you identify where these programs exist.

It could also pay to see if your loved one qualifies for long-term care insurance. Though premiums can be costly, having a policy in place gives your family financial protection in the event your loved one requires full-time care in a nursing home or assisted living facility that you can’t provide on your own. Long-term care insurance is something that you’ll need to sort out before it’s needed, however. You won’t be able to buy a policy to cover a current or imminent need for custodial care.

How to get the help you need as a caregiver

Being a caregiver isn’t easy. Thankfully, there are a number of resources available to help provide the support you need. First, there’s SHIP, a free benefits counseling service for Medicare beneficiaries and their caregivers. The Center for Medicare Advocacy is another good resource for caregivers. Finally, you can visit the Administration for Community Living, which offers a host of information for caregivers grappling with the challenge of aging loved ones, or the American Society on Aging for an extensive list of caregiver support services.

Maurie Backman has been writing professionally for well over a decade, and her coverage area runs the gamut from healthcare to personal finance to career advice. Much of her writing these days revolves around retirement and its various components and challenges, including healthcare, Medicare, Social Security, and money management.

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