I have Medicare, and I’m interested in getting services like dental, transportation, and home-delivered meals. Do I need a Medicare Advantage Plan to get these supplemental benefits? Is there a way to get these services if I have Original Medicare?
A supplemental benefit is an item or service covered by a Medicare Advantage Plan that is not covered by Original Medicare. These items or services do not need to be provided by Medicare providers or at Medicare-certified facilities. To receive them, you just need to follow your plan’s rules. Some commonly offered supplemental benefits are dental care, vision care, hearing aids, and gym memberships. Supplemental benefits must be primarily health-related, with some exceptions for people with chronic conditions. Some supplemental benefits are offered to everyone who is enrolled in a plan, but for an additional premium, such as to add dental coverage. Other benefits may be covered for everyone enrolled in the plan, regardless of whether you use the benefit, such as a gym membership.
Medicare Advantage Plans can also cover supplemental benefits that are not primarily health-related for beneficiaries who have chronic illnesses. These benefits should address environmental factors that may affect the health, functioning, quality of life, and risk levels of beneficiaries with chronic conditions. Some examples of these benefits are meal delivery, transportation for non-medical needs, and home air cleaners. In order to be eligible for this category of supplemental benefits, you must be considered chronically ill. This means that you:
- Have at least one medically complex chronic condition that is life-threatening or significantly limits your health or function
- Have a high risk of hospitalization or other negative health outcomes, and
- Require intensive care coordination
If you meet these criteria, a Medicare Advantage Plan may offer you one of these benefits if it has a reasonable expectation of improving or maintaining your health or function. Medicare Advantage Plans will be able to create sets of supplemental benefits for people with specific chronic illnesses, which means not every member of a Medicare Advantage Plan will have access to the same set of supplemental benefits. For example, a plan might cover services like home air cleaning and carpet shampooing for members with severe asthma. A member of that plan who has severe asthma may be able to get that service covered, while a member who does not have asthma, or whose asthma is mild, may not.
In some cases, there may be no Medicare Advantage Plan in your area that covers the supplemental benefits that you need, or you might find that Original Medicare offers better coverage of services that are important to you. You may still be able to access services that Original Medicare does not cover.
- Medigaps: Generally, Medigaps, which are insurance policies that supplement Original Medicare, pay second to Medicare when Medicare covers a service and pays first. All Medigaps also offer additional days of inpatient hospital care beyond what is covered by Original Medicare, and some cover emergency medical services received outside of the United States, which are not covered by Original Medicare. Medigaps can also offer fitness benefits or other targeted supplemental coverage in some states.
- Medicaid: Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets. In some states, Medicaid covers services that are not covered by Medicare, including dental, vision, long-term care, and transportation. A state may also have a Medicaid waiver program that covers additional services, too. To learn more about your state’s Medicaid program, contact your local State Health Assistance Program (SHIP). Contact information for your SHIP is on the last page of this document.
- Reduced-cost or free clinics: You may be able to access the services you need through a free or reduced-cost clinic in your area. Use resources available at needymeds.org, healthcare.gov, freeclinics.com, and hhs.gov for more information.
- Donated dental service programs or dental schools: Donated dental services programs operate in some states. Dentists in these programs offer free dental services if you qualify. You may also be able to get low-cost dental care at a dental school, where dental students work with patients under the supervision of experienced, licensed dentists.
- Administration for Community Living (ACL) eldercare locator: Visit eldercare.acl.gov to learn about other resources in your community, such as long-term care and legal aid.
As always please contact your Total Benefit Solutions, Inc benefit specialist at (215)355-2121 for a more specific answer or more information!