Why won’t Medicare cover dental, hearing or vision expenses?

Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.

Marcia – Ariz.:  I started on Medicare Nov. 1 after years with group health and dental insurance. Ironically, I developed my first dental issue in December that required treatment by a periodontist. Why isn’t oral surgery covered by Medicare? I’m very surprised that the dental profession hasn’t lobbied for inclusion. What do older people need? Dental care, annual physicals, vision exams — all excluded (to some degree) by Medicare. How does this make sense, and is there any hope for future coverage?

Robert – Fla.: I am a 72-year old senior citizen who will have to have approximately $13,000 in required dental work this year. Dental is not covered by Medicare. Can I open and create a health savings account or something like it in order to take advantage of pretax dollars?

Phil Moeller: The failure of Medicare to cover most dental, hearing and vision expenses is perhaps its greatest failing. Other critics might point to the fact that it does not cover long-term care expenses either. And my favorite personal rant is reserved for its failure to cover nearly all medical expenses incurred outside the United States, even though such care these days is often superior and much cheaper than in the U.S. These omissions have been in place since Medicare was created in 1965, so it’s not as if some new problem has emerged. What has become clearer, however, is that huge and growing numbers of seniors face substantial dental, hearing and vision expenses. Failure to receive adequate care in any of these areas will eventually have a big impact on overall health care and thus on health claims that Medicare does cover.

Unfortunately, nearly all of the talk in Washington these days is about how to restrain Medicare expenses, not add to them. Until we have a working Congress again and more acceptance of the legitimate needs of our aging population, I just don’t see Medicare’s serious coverage omissions being reversed.

As to Robert’s question, health saving account plans are only available to people with active employer health coverage (retiree health plans do not qualify). Further, anyone receiving Social Security (which I hope Robert is doing at age 72) is ineligible for a health saving account. Robert’s best bet is to see if some or all of his dental expenses can be deducted on his federal taxes. Only the portion of such expenses exceeding 7.5 percent of his taxable income will be deductible. But this threshold will rise to 10 percent next year for people 65 and older, so in this respect, Robert may have his best shot this year to have Uncle Sam help pay for some of his dental and other deductible medical expenses.

Kathy – Ky.: In June 2015, I was able to get Medicare on my ex-spouse, because I was disabled — I qualified after getting 24 months of disability benefits as an ex-spouse. Also, I was 62 and allowed to remarry and still collect my ex’s benefits. But in June, I decided that the Obamacare policy I had was better than Medicare. My Obamacare insurer said they would reopen the case and give me a six-month extension while they were processing it. But the insurer said last November that they were dropping my plan. So I went back to Medicare that month and filed again for coverage. They said I had to start all over again and resubmit forms, and it’s taking forever. Does this have anything to do with the new changes to Social Security laws? All I know is that I now have no insurance. Is there any way to speed this up?

Phil Moeller: I don’t care if the rules formally dictate a do-over. This is awful and you deserve better treatment. This delay, however, has nothing directly to do with the new Social Security laws. It may have everything to do with the fact that the Social Security Administration is criminally understaffed. Such shortages prevent the administration from being able to adequately train the people it does have to understand and carry out their obligations. These duties include managing access to Medicare and deciding when a person is insured by the program. In this regard, the new rules are adding a whole new set of complicated provisions onto an agency that can’t even handle its current workload. You should get in touch with either the Medicare Rights Center or the State Health Insurance Assistance Program (both free services to consumers) and find a counselor who can help you expedite your access to Medicare.

Glen – Miss.: I am planning to retire at the end of April 2016. I will be 66 on April 12 of this year. How soon do I need to apply for Medicare? And where do I go to apply for Medicare?

Lynne – S.C.: I will be turning 65 on May 7, 2016, but I’m not retiring until age 66. I now have Tricare Prime, but I will be getting Tricare for Life. When do I need to sign up for Medicare and Social Security? I’m very confused.

Phil Moeller: Glen’s window for applying for Medicare has nothing to do with his age and everything to do with the date he is no longer covered by an active employer health plan. So long as he is covered by such a plan (and he must be covered as an active employee and not as a retiree), he does not need to get Medicare and is probably better off sticking with his current plan. When he does lose access to that plan, he will have a special enrollment period lasting eight months. However, he should look into Medicare even before his employer plan stops covering him. Having a break in health insurance coverage is a very risky gamble.

Lynne’s window for signing up for Medicare has already begun. Because she needs it at age 65, she is subject to the program’s initial enrollment period. It is seven months long and begins three months before she turns 65, continues through her birthday month and ends three months thereafter. She would face late-enrollment penalties for failing to get Medicare by the end of August. But the more serious penalty she faces is not having coverage if she encounters a meaningful health care need. And there is a growing gap in coverage dates the later she waits to apply during her initial enrollment period. Many people are unpleasantly surprised by these gaps:

Month 1 – Coverage effective month 4.
Month 2 – Coverage effective month 4.
Month 3 – Coverage effective month 4.
Month 4 (birthday month) – Coverage effective month 5.
Month 5 – Coverage effective month 7.
Month 6 – Coverage effective month 9.
Month 7 – Coverage effective month 10.

Michael – Ind.: I turned 64 on Jan. 24, 2016. My wife turned 65 on Jan. 23. She and our 19-year-old son are covered under my employer’s health care policy.  My wife started taking Social Security payments at age 62 in 2013. My son received Social Security payments for a few years before turning 18. I believe my wife has three months to enroll in Medicare Part A (month when turning 65 plus three months). Am I right? If she doesn’t enroll in Medicare Part A now, will she later have to pay a penalty in higher premiums?

Phil Moeller:  So long as you continue to have active coverage (and not retiree coverage) from your employer’s health plan, your wife need not sign up for Medicare, no matter how old she is. Because your wife is already taking her Social Security benefits, the agency is supposed to automatically enroll her in at least Medicare Part A when she turns 65 and send her a Medicare card. This card also may indicate the agency has enrolled her in Part B of Medicare as well as Part A. She does not need Part B at this time and should call the agency (1-800-MEDICARE) to make sure her Part B enrollment is reversed. Part A is free to your wife (and anyone else who qualifies for Social Security benefits). She definitely should keep Part A, because it may be able to pay for some expenses not fully covered by your employer health plan. There will be no late-enrollment penalties for her, of course, because she is already enrolled in Part A.

Kathi – Ga.: My mom is 90 and lives with me. She suffers from mild dementia, weakened legs and a minimal appetite. There are several days during the month where I am required to be out of the home all day and other times when I must be gone for part of the day. She has a Medicare Advantage plan. I am wondering whether this will cover a home health aide to just be here when I’m not.

Phil Moeller: Unfortunately, Medicare will not cover these expenses, and I haven’t heard of any Medicare Advantage plans that will do so. Her needs fall under the category of “custodial” care. This kind of care would be covered by a private long-term care insurance policy, but it’s not covered by Medicare. The agency would cover skilled home care for your mom if her doctor says that such care is medically necessary. Even so, this benefit is generally available for only limited periods, and the doctor would need to re-certify her need for care for each additional period.

Wendy – Wash.: My husband is not yet 65, but he has Medicare because he is disabled and receiving Social Security payments. This year, there are no supplemental or gap insurance policies available for him to purchase in our remote county, so we did not enroll him in anything additional. Will this result in penalties in the future?

Phil Moeller: There is no formal penalty for dropping a Medigap plan and later buying another policy. However, there could be a practical penalty when he gets a new policy, because his new insurer might be able to charge him substantially more for the policy than he has been paying. However, because there is no plan offered this year where you live, the state of Washington — states regulate Medigap policies, not the federal government — might well provide him protected access to a new policy that will protect him from such rates. I’d call the SHIP office nearest you and ask a counselor there about Washington’s rules for your husband’s situation. Good luck!