Medicare provides essential health coverage for Americans 65 and older and some younger people with disabilities. But Medicare does not cover everything. There are some key exclusions and gaps in Medicare coverage that beneficiaries should be aware of.
Let's look at 7 common services and items that Medicare does not cover and explain why these Medicare exclusions exist.
1. Long-Term Care
One significant thing Medicare does not cover is long-term care, sometimes called custodial care. This includes assistance with activities of daily living such as bathing, dressing, using the toilet, eating, and moving around. Long-term care is not considered medically necessary treatment by Medicare.
Medicare does not help cover long-term nursing home stays or home health aides to help with daily living activities on an ongoing basis. You cannot rely on Medicare to cover the typical costs of assisted living facilities.
Medicare Part A will pay for skilled nursing facility care only in certain situations for a limited time. To qualify for skilled nursing care coverage, you must first have a 3-day minimum medically necessary inpatient hospital stay.
Medicare will then cover up to 100 days of skilled nursing care per benefit period. You must meet eligibility criteria like continuing to require skilled care and rehab services daily. Custodial long-term care does not qualify.
If you need assistance on a regular basis, you will need to pay for long-term care costs yourself or look into long-term care insurance policies to cover expenses. Long-term care costs can be extremely expensive, so this is a major coverage gap in Medicare.
2. Routine Dental Care
Medicare does not cover routine dental care like dental cleanings, exams, x-rays, fillings, tooth extractions, dentures, and other basic services. Dental care is excluded from what Medicare Part A covers and Medicare Part B cover.
Medicare will pay only for certain limited dental services like:
These dental procedures must be medically necessary and connected to treatment of a covered medical condition. Routine preventive dental work and treatment for tooth decay, gum disease, denture fitting, and other standard dental needs are not covered.
Some Medicare Advantage Plans offer extra dental benefits beyond what Medicare covers. You may be able to find a Medicare Advantage Plan that includes routine dental coverage for additional premiums.
But if you stick with Original Medicare, you will need a separate dental insurance policy or pay cash for any dental work not related to very specific medical treatments.
3. Routine Vision Care
Similar to dental care, Medicare does not cover routine vision care including eye exams and corrective lenses. Some vision screening tests are covered if you are at high risk for conditions like glaucoma or diabetic retinopathy.
But standard vision exams for glasses or contacts, treatment for eye conditions like pink eye, cataract surgery, and costs of prescription eyeglasses and contact lenses are not covered.
Certain medical conditions impacting vision like macular degeneration may qualify for some Medicare coverage of vision-related medical treatment. But routine vision care is excluded.
Many Medicare Advantage Plans may provide extra benefits covering basic vision exams, eyeglasses, and contacts every year or two. Stand-alone Part D prescription plans also cover some vision costs.
To get routine vision care covered, you will most likely need to enroll in a Medicare Advantage or Part D prescription drug coverage vision plan for additional premiums. Or you can purchase a separate vision insurance plan.
4. Hearing Aids
Hearing aids and exams for fitting hearing aids are generally not covered by Medicare. Basic hearing screenings and diagnostic exams if you have symptoms indicating an ear condition or hearing loss may be covered.
But Medicare does not cover routine hearing tests or the hearing aids and batteries themselves. Some Medicare Advantage Plans offer supplemental hearing aid coverage, but it is limited.
You may get a set allowance towards hearing aids like $500-$1,000 per year or a discount on hearing aids purchased through the plan's contracted providers. But hearing aid costs can run $2,000-$7,000 for two high-quality devices, so the coverage still leaves substantial out-of-pocket expenses.
Look carefully at what any Medicare Advantage Plan provides for hearing coverage before enrolling. Expect to pay for hearing aids and fitting exams yourself unless you have a secondary insurance policy that covers hearing costs.
5. Cosmetic Procedures
Medicare does not cover cosmetic or aesthetic procedures solely to improve appearance. This includes things like:
Reconstructive procedures following an injury or to correct significant deformities may be covered. And if a cosmetic procedure is medically necessary, like breast reduction surgery for back pain, Medicare can cover the costs.
But any procedure done purely for cosmetic reasons to enhance or alter normal structures of the body is excluded. Medicare will not pay for elective plastic surgery procedures to improve appearance and self-esteem.
Keep in mind that just because a procedure is listed as cosmetic does not mean Medicare will never cover it. Your doctor will need to demonstrate the medical necessity for Medicare to consider covering costs of procedures that can also have cosmetic components.
Acupuncture involves stimulating specific points on the body by inserting thin needles into the skin. It is commonly used to treat pain and nausea.
However, acupuncture is generally not covered by Medicare since it is considered an alternative medical treatment. Medicare typically only covers acupuncture for lower back pain studies in clinical research trials or when provided during an inpatient hospital stay.
Routine acupuncture treatments in an outpatient setting are not reimbursable services under Medicare. Medicare Advantage Plans sometimes offer supplemental coverage for a limited number of acupuncture visits annually.
But in most cases, you will pay out-of-pocket for ongoing acupuncture care and cannot rely on Medicare to cover the costs. Acupuncture can provide medical benefits to some patients for certain conditions when performed by a licensed professional. But it falls outside what Medicare has defined as reasonable and necessary care worthy of reimbursement.
7. Services Outside the U.S.
Medicare does not provide coverage for care received outside the United States and its territories. A few exceptions exist in limited circumstances.
For example, Medicare may cover services in Canada or Mexico if the hospital is closer to your home than any U.S. hospital that could treat your medical condition. Medicare may also cover foreign hospital services if you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another U.S. state when a medical emergency occurs that requires immediate admission to a hospital.
But in most situations, Medicare will not pay for care during trips abroad or medical services provided outside U.S. borders. You will need to purchase a travel insurance policy that covers foreign medical care.
Make sure you understand exactly what Medicare does and does not cover before seeking any non-emergency treatment. Never assume that Medicare has you covered outside the country or for common exclusions like routine dental and vision care.
Summary of Exclusions
In conclusion, some significant exclusions from original Medicare coverage include:
While Medicare covers a wide array of healthcare services, these are some surprising exclusions beneficiaries should be familiar with. Knowing what Medicare does not cover can help you plan for inevitable out-of-pocket costs and determine if additional insurance coverage is needed.
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What is the difference between Medicare Parts A and B?
Medicare Part A covers inpatient hospital stays and skilled nursing facility care, while Medicare Part B covers doctor visits, outpatient care, preventive services, and some home health care. Both are part of traditional Medicare, but generally speaking, Part A covers inpatient services and Part B covers outpatient services.
What expenses does an Medigap policy help cover?
A Medigap policy is a private insurance policy that helps cover some of the costs that aren’t covered by Original Medicare, like copays, coinsurance, and deductibles. Most Medigap Plans cover the Medicare Part A hospital deductible as well as all or part of the Medicare Part B deductible.
What does Medicare Part D cover?
Medicare Part D is prescription drug coverage. It helps cover the cost of prescription drugs. Part D is run by approved private insurance companies that offer drug plans approved by Medicare. These plans may have formularies and tiered costs. They cover both brand-name and generic medications.
What costs are not covered by traditional Medicare?
Some of the main costs not covered by traditional Medicare include long-term care, dental care, eye exams and glasses, and hearing aids. Medicare also does not cover most care received outside of the United States. Beneficiaries are responsible for these costs not covered by Medicare out of pocket.
How do I enroll in Medicare?
Most people enroll in Medicare automatically at age 65. If you are already receiving Social Security benefits, you will be enrolled automatically in Medicare Parts A and B on your 65th birthday. For those eligible for Medicare who are not yet receiving Social Security, you must sign up during an Initial Enrollment Period that includes your birthday month and the three months after.