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Understanding Your Medicare Coverage as Senior Healthcare Changes

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Don Makos of MB Senior Solutions (MBSS) recently shared the story of an older adult who came into the MBSS offices looking for information and advice on how to pay for two medications that their doctor had prescribed—Advair and Nexium.

Senior healtcare can have hidden expenses for older adults who aren't familiar with their coverage.This individual had no idea that differences in Medicare coverage could turn the out-of-pocket expense for the medicines into a $2500 expenditure.


At ERH, we’ve found the same to be true among older adults who participate in our services as well as residents of our retirement communities.

The fact is that a majority of seniors don’t know what their Medicare plan actually covers. They don’t really read about their coverage when they sign up, and they don’t keep up with the changes and reforms.

They don’t start asking questions until they need their Medicare to cover a medical expense, when it’s too late to make sure they have the coverage they need and out-of-pocket start adding up.

We’d like to see this aspect of senior healthcare change. We believe that being informed is a part of what living well is all about, so we’re shedding some light on Medicare coverage.

Medicare, Hospitalization, and Rehabilitation Care

If you need rehabilitation or physical therapy for some reason at some time in the future, or if you have a major surgery or experience a life-altering event, you can’t expect your Medicare plan to cover the expense as part of your hospitalization.

The number of hospitals that operate their own skilled nursing care, assisted living, home-healthcare services is actually shrinking. Many of the hospitals that had historically offered such services, including the Mercy Health system right here in Cincinnati, are getting rid of their post-acute care providers.

Instead of recovery programs led by the hospital, older adults are being discharged to senior living communities or nursing homes to convalesce in a skilled nursing program— which carries more out-of-pocket expenses on top of any that were paid for the original hospitalization.

Long-term Care in Your Medicare Plan

We’ve found that there’s a lot of confusion about what kind of long-term care coverage (i.e. skilled nursing care and other home services) is offered by traditional Medicare or Medicare Advantage plans.

Most older adults and their adult children are confident that Medicare will cover their expenses should they, or their loved ones, ever need to receive care for an extended period. Unfortunately, this is not the case.

In reality, Medicare only pays for long-term care services under 3 circumstances:

  • You have had a recent prior hospital stay of at least three days
  • You are admitted to a Medicare-certified nursing facility within 30 days of your prior hospital stay
  • You need skilled care, such as nursing services, physical therapy, or other types of therapy

If you meet all these conditions, Medicare will pay for some of your costs for up to 100 days.

  • 100 percent of your costs for the first 20 days.
  • Expenses over $140/day for days 21 through 100

After 100 days, Medicare stops coverage, and you are responsible for 100 percent of costs.

Preventative Care and the Affordable Care Changes to Medicare

Older adults who also have or have recently transferred to Medicare from traditional insurance may notice that a subtle difference in the tone senior healthcare takes in plans from these providers.

In traditional insurance, there is a heavy emphasis placed on providing preventative care, on procedures that prevent illness, to get better rates and coverage. Medicare has traditionally been more reactive, treating illness as they arise.

With the introduction of the Affordable Care Act, however, we’ve begun to see more preventative care benefits added to Medicare programs.

Most older adults don’t even know that they exist. In the first year that these benefits were offered, only 9% of seniors who were eligible for the new benefits took advantages of them. Recent studies show that only half of all older adults enrolled in Medicare are even aware that preventative care benefits exist!


Image Credit: Match Financial

Bryan Reynolds
August 09, 2013
Bryan Reynolds is the Vice President of Marketing and Public Relations for Episcopal Retirement Services (ERS). Bryan is responsible for developing and implementing ERS' digital marketing strategy, and overseeing the website, social media outlets, audio and video content and online advertising. After originally attending The Ohio State University, he graduated from the College-Conservatory of Music at the University of Cincinnati, where he earned a Bachelor of fine arts focused on electronic media. Bryan loves to share his passion for technology by assisting older adults with their computer and mobile devices. He has taught several classes within ERS communities as well as at the Osher Lifelong Learning Institute run by the University of Cincinnati. He also participates on the Technology Team at ERS to help provide direction. Bryan and his wife Krista currently reside in Lebanon, Ohio with their 5 children.

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