Chronic Conditions & Medicare - How to Prepare for Uncovered Costs

The number of Americans with a chronic condition continues to rise as the American population grays. About 85 percent of older adults have at least one chronic condition and 60 percent have two, according to the U.S. Centers for Disease Control and Prevention (CDC). 

Chronic conditions generally last more than one year and require ongoing care. Examples include asthma, diabetes, cancer, COPD and cardiovascular disease. They’re often expensive to treat and present many financial challenges to patients. And while Medicare or Medicare Advantage won’t exempt you from a plan because of a chronic condition, you may run into some coverage limits.

For instance, Medicare tends to deny treatment beyond maintenance therapy for patients with chronic conditions like Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis (ALS), HIV/AIDS and multiple sclerosis because their underlying condition won’t improve. In other words, trying a new or more aggressive type of treatment may result in some out-of-pocket expenses.  

“One of the best ways to control your Medicare costs is to work with your doctor to manage your disease,” says Bernard Kaminetsky, MD, medical director, MDVIP. “An uncontrolled condition can lead to a wide range of unexpected costs.”

Understanding what’s covered under Medicare can help you prepare for uncovered expenses. If services and treatments you feel you need aren’t covered, look into buying a supplement plan and/or long-term care policy. And if you travel regularly, a Medicare Advantage plan may make more sense because it covers emergencies worldwide. Here’s a basic overview of coverage for handful of common conditions based on information from United Medicare Advisors and Medicare Matters.

Medicare Coverage Overview for Common Chronic Conditions

Alzheimer’s Disease
Covers: diagnosis-related services such as office visits, tests and PET scans (in certain cases); treatment-related services such as office visits to psychiatrists, psychologists and social workers, physical exams; durable medical equipment (DME) like walkers, wheelchairs and oxygen equipment; medications to help memory, judgement and attention; home health/home social service visits and hospice care.

Doesn’t Cover: long-term care, assisted living facilities, adult daycare, personal care and hygiene services, 

Arthritis (Rheumatoid)
Covers: diagnostic tests for rheumatoid arthritis, office visits, physical/occupational therapy, hospitalizations, surgeries and skilled nursing care

Doesn’t Cover: nutritional supplements, including vitamins and other forms of alternative treatment

Asthma
Covers: asthma medications, nebulizers, oxygen equipment, doctor visits, hospitalizations, vaccinations (influenza, pneumonia and hepatitis B), smoking cessation counseling  

Doesn’t cover: private duty nurses 

Cancer
Covers: hospitalizations, office visits, second opinions on surgery, medications including chemotherapy and anti-nausea medication, radiation, home health including aides, visiting nurses and rehabilitation specialists, mental health services, hospice and other types of end-of-life care  

Doesn’t Cover: nutritional supplements, long-term nursing home care, adult day care, assisted living facilities, personal care, hygiene services or medical marijuana 

Depression
Covers: partial hospitalizations, annual screening, group/private therapy sessions, counseling visits with mental health provider (psychologist, psychiatrist, social worker, nurse practitioner, physician assistant), medication management, various antidepressants

Doesn’t cover: private duty nursing

Diabetes (1 and 2) 
Covers: up to two screenings per year; hemoglobin A1C tests, medical nutrition therapy services, blood testing kits, podiatry exams, orthopedic footwear prescribed by a physician or podiatrist, glaucoma tests, diabetes drugs, insulin, supplies such as strips, external pumps and insulin for the pumps, flu and pneumonia shots

Doesn’t cover: weight loss programs, more than one physical exam per year, routine vision services and supplies

Additional Services
Typical hearing, dental or vision care exams and expenses aren’t covered by Medicare. A supplement plan may help you pay for some procedures, particularly if you have glaucoma or cataracts, but you may need dental/vision/hearing coverage for senior to help pick up costs for dental work, hearing aids, glasses or contacts.

Understanding Observation Status vs. Admission Status 

Another important step to take is understanding the difference observation status and admission status, in case you’re ever hospitalized. If you go to a hospital for care, a triage nurse will you’re assigned a status – observation or admitted (inpatient) – based on the Medicare Benefit Policy Manual. The status helps hospital staff determine the level of care you need and dictates how Medicare will bill you.

Observation patients are generally too sick for a clinic or doctor’s office, but not sick enough to stay in the hospital or require the intense, hospital-level care needed by an admitted inpatient. You can also be classed as observation when medical professionals aren’t quite sure how sick you are. For instance, if you begin experiencing chest pain, is it a heart attack or indigestion? 

Here’s the problem: If you’re billed as an inpatient, but the Center for Medicare and Medicaid Services (CMS) or your Medicare Advantage carrier determines you should have been in observation status, they may refuse to pay the claim. And if you’re an observation patient when you should have been inpatient, you’ll pay out-of-pocket for services that should have been covered under Medicare Part A or your Medicare Advantage plan. Observation status will also cost you more for nursing home and rehabilitative services.

Hospitals do their best to classify patients correctly and often go to bat for patients if their claims are denied due to wrong status. As a general guide, CMS established the Two-Midnight Rule, which states if a patient is expected to stay in the hospital for a period longer than two midnights, they should be admitted.

The bottom line is to make sure you are properly classified. Ask questions. For example, if your status is observational, ask what types of symptoms, tests and treatments would switch that classification to inpatient? See if you (or a loved one or patient advocate) can schedule an appointment with a biller who might be able to provide an estimate of your out-of-pocket expenses.

Managing your Medicare expenses with a chronic condition is never easy. But working with your primary care physician to manage your condition, help you live a healthy lifestyle and refer you to appropriate specialists can help minimize your costs.

If you need a primary care physician, check out MDVIP. Physicians in MDVIP-affiliated practices can customize a wellness plan for you. Find an MDVIP affiliate near you and begin your partnership in health »