When Medicare Coverage Is Not Enough | BAYADA Blog

While we were working and paying into the federal Medicare insurance program for decades, it was under the assumption that it would cover all our medical expenses in retirement. But now that we seniors have reached the age of our reward, it seems one of the most confusing and daunting tasks we face is understanding what Medicare pays for, and what it does not.

Here is a quick, but far from exhaustive, primer on Medicare insurance:

• Medicare Part A covers inpatient hospitalizations, skilled nursing visits, hospice, and/or rehabilitation care for a maximum benefit of 100 lifetime days.
• Medicare Part B covers physician office visits and outpatient care. 
• Medicare Part C is a combination of Part A & B plus some additional benefits such as dental, hearing, wellness checks, and drug costs. This additional coverage can be purchased through an insurance company that has been approved by Medicare, such as Aetna, Humana, and others. 
• MEDIGAP policies supplement Medicare and will pay the difference between what traditional Medicare covers and the actual cost of services, such as co-pays and deductibles.

What kinds of care require private pay or non-Medicare insurance?

Medicare covers health care for short-term, acute (sudden) illnesses such as a stroke, heart attack, injury, or surgery. It also covers dialysis.  

The more important question though, when one is planning for financial security, is to understand what Medicare will not pay for, such as: 

• Routine eye exams and optician visits
• Hearing aids
• Medical care while travelling overseas
• Routine podiatry care
• Dental care (Pay attention to this expense; it takes many seniors by surprise.)
• Cosmetic surgery
• Care related to a chronic (long-lasting) or multiple chronic conditions such as diabetes, congestive heart failure, Parkinson’s disease, or vascular disease.
• Nursing home care, assisted living facilities, or home health care services*

* It is important to understand and plan for one of these three options, because personal care probably, even eventually, will become a need at some stage in life, particularly over age 85. 

What coverage does long-term care insurance provide?

Long-term care insurance will partially or fully cover the expense of any of the three personal care options above (nursing home care, assisted living facilities, or home health care services). The amount insurance will pay depends on:

• The cost of one’s policy
• The selected “period of elimination” (how many initial months you choose to pay out-of-pocket before insurance kicks in)
• The duration and amount of the lifetime benefit

The decision as to which setting is best varies from person to person and should be based on need, preference, and ability to pay:

Assisted living community: This can be the right option for people who are social and in relatively good medical condition, or for those who may not have the necessary social supports and relationships nearby to support a decision to stay at home. When needed, additional one-on-one nursing or personal care services can be provided by a home health care agency such as BAYADA while living in an assisted living community.

Nursing homes: If around-the-clock skilled nursing care is needed, there is no substitute for a skilled nursing facility.

Home: Study after study show that seniors overwhelmingly desire to “age in place” in the comfort and familiarity of their own home. About 90 percent of Americans shared this preference before the COVID-19 pandemic, and even more do now.

The benefits of home health care—the preferred choice

The good news is that staying safe, comfortable, and independent at home is possible with the help of in-home personal care and companionship services. The one-on-one attention of a dedicated home health aide is especially important to help keep people with dementia safe, giving their families the peace of mind they need when they can’t be there.

Whether you need occasional services, regular help, or live-in care, home health care providers like BAYADA can help you live your best life at home by assisting you with:

• Dressing and grooming
• Bathing and toileting
• Walking, moving, and transferring (including safe use of wheelchairs, walkers, or lifts)
• Basic exercise
• Reminders about medications and appointments
• Meal preparation, help with eating, and nutritious food choices
• Light housekeeping and errands
• Companionship at home and in the community

Since Medicare doesn’t cover the costs of ongoing personal care and companionship services, people opt for either paying privately or using their long-term care insurance policy’s home health care benefit.

Please contact your local BAYADA Home Health Care office or call (888) 876-0111 for more information on paying for short- or long-term care in your own home. A BAYADA insurance specialist can help explain your personal coverage and help facilitate billing if you choose to receive home health care services. 

originally published: September 2020
updated: January 2022