What Does Medicare Not Cover?

Original Medicare (also known as Traditional Medicare) is composed of two parts, Medicare Part A and Medicare Part B. Part A is your inpatient insurance and Medicare Part B medical insurance for outpatient and physician services. Medicare Part A helps pay your Medicare bills for inpatient hospital care, inpatient in a skilled nursing facility or any other inpatient medical facility. Medicare Part B helps pay your Medicare bills for outpatient and physician services in addition to durable medical equipment and lab tests. It is Medicare’s intent to cover procedures or services that are medically necessary and they lean on your doctor to help determine medical necessity.

Medicare was never intended to be stand-alone medical insurance. It is designed to be the primary foundation of a health insurance program from which the consumer can build upon and construct the full insurance coverage desired. You should be aware of what Medicare does not cover so that you can fill in those gaps to construct a more robust insurance program for your needs.

Important categories of insurance not covered by Original Medicare include dental services, prescription drugs (except Part B drugs), hearing care, long-term care, custodial care, annual physicals, cosmetic surgery, vision care and more. Each of these categories of coverage has exceptions which will be covered in more detail in this article. in addition, we will guide you to what insurance you should consider to protect yourself from expenses in each of these categories.

To best understand what your Medicare does not cover, the reader should focus on “Why” the procedure is recommended more than the procedure itself. Many procedures you may think are not covered by Medicare, are covered under select circumstances.

Our Medicare Advocate services, free to all clients, help you understand what should be covered by Medicare as well as managing potential billing errors.

Medicare Deductibles and Copays

Medicare Part A & Part B are the foundation of your Medicare coverage, but both have either significant deductibles, coinsurance or copays that are the consumers financial responsibility. In addition, it is critical to understand that Original Medicare’s biggest weakness is that your Medicare coverage does not have a maximum annual out of pocket expenses limit. Without building on your Original Medicare, the consumer is still exposed to unlimited financial risk for medical expenses.

In the October or November of each year Medicare announces the new deductibles, copays and coinsurance for Original Medicare for the year to come. These are often referred to as gaps in your coverage. You can find the latest details on the Original Medicare on the Resources page of my website.

Medigap Plans

The best medical insurance to cover these gaps in Original Medicare is with Medigap plans, also referred to as a Medicare supplement. Supplement plans can limit your annual out of pocket costs to under $250. There are 10 different plans offering supplemental coverage to your Original Medicare. You can view the benefits of these supplement plans at this link. The cost of this coverage is completely dependent on where you live, your age, gender and so on. To receive a free, no obligation personalized quote just use this Medicare supplement quote request form to provide us the information we need to develop a quote for you. To learn more about these Medicare supplement plans, see my video Medicare Supplement Plans Explained.

Does Medicare Cover Prescription Drugs?

Original Medicare doesn’t cover prescription drugs. Medicare prescription drug coverage is offered through Medicare Part D drug plans. There are two ways a consumer can purchase drug coverage through Part D; either through a stand-alone Part D drug plan or through Medicare Advantage Plans that have bundled Part D coverage.

Stand-Alone Part D

The stand-alone Part D drug coverage is designed to work hand-in-glove with Original Medicare and a supplement. The consumer can shop each year for the Part D plan that best suits their needs without disturbing their primary health insurance plan.

Bundled in Medicare Advantage

Some Medicare Advantage plans have bundled prescription drug coverage. These are referred to as Medicare Advantage Prescription Drug Plans (MAPD). While these plans help with drug costs just as much as a stand-alone plan, there are a few drawbacks to be aware of.

First, with any Medicare Advantage plan HMO or PPO the consumer cannot purchase a stand-alone Part D plan. Medicare does not allow combining a stand alone Part D plan with a Medicare Advantage plan HMO or PPO.

Second, because the benefits of Part D and Medicare Advantage Plans change each year, if you have a Medicare Advantage Plan and need to change your Part D coverage, you will have to change your primary health insurance coverage as well. They are bundled.

To see the plans available in your area, and learn even more about Medicare Part D, we have created a special website for consumers to shop and enroll in Part D. You can input your own prescriptions into this HIPAA compliant site to find which prescription drug plan will offer you the lowest price for your prescriptions and learn all you need to know to understand this coverage.

Does Medicare Cover Dental?

Medicare doesn’t cover most dental care. This includes cleanings, fillings dentures, crowns and so one. There are some exceptions to this under very limited circumstances which include some dental services prior to an organ transplant, as part of cancer treatment or reconstructive surgery after an accident are all covered by Medicare Part A hospital insurance. But these exceptions are limited to the specific reasons you may need such services.

Thankfully, there are several ways a consumer can add dental coverage.

Dental Insurance

Dental insurance plans have advanced a lot in recent years. They offer much more coverage at very reasonable costs. Our webpage on dental insurance details the features of dental insurance plans and how we can help you find the one right for you.

Dental Discount Plans

For some, a dental discount plan make more sense than dental insurance. Dental discount plans are offered by the same insurance companies that also provide dental insurance. These plans are very low cost, typically paid annually and have many limits (the fine print) that need to be considered. You can review the dental discount plans available to you from this link. But please read the fine print of the plans or you may find the dental procedure you thought was covered, isn’t.

Many Medicare Advantage plans (also called Medicare Part C) offer dental care. Each plan is different and the benefits offered can change each calendar year or even be canceled. Dental coverage within an Advantage Plan is not like having your own dental policy. However, we have this extra service improve each year to where it can be competitive coverage to your own plan.

Does Medicare Cover Vision Care?

Medicare doesn’t cover corrective vision or routine eye exams, eye glasses or contact lenses. However, there are many exceptions to this rule.

Many people confuse Medicare’s coverage (or lack thereof) of corrective vision services and the coverage provided for eye disease and conditions. Medicare will cover cataract surgery and recovery including corrective lenses. Medicare also covers exams, services and treatment for glaucoma, macular degeneration and other eye diseases or medical conditions.

Like everything else with Medicare, the key is “Why?”. It’s the answer to the question “Why?” that determines medical necessity. Why does a person need the service? Diabetics, for example, have a special need to test for retinopathy. Thus, for a diabetic, such exams become medically necessary and thus covered by Medicare. Cataract surgery becomes necessary when cataracts when it becomes difficult to carry out normal activities of daily living or they interfere with treatment of eye disease.

Vision insurance for corrective vision treatment can be purchased as a stand-alone policy or in combination with dental insurance coverage. Some Medicare Part C plans also include minimal vision insurance coverage.

Does Medicare Cover Hearing Tests?

Medicare doesn’t cover routine hearing exams. However, Medicare does cover diagnostic hearing and balance exams (Audiology Services) if your licensed medical provider orders them to determine if you need medical treatment. In addition, Medicare doesn’t cover hearing aids or exams required for fitting.

Recently, a new category of hearing aids have become available called Over-the-Counter Hearing Aids. These hearing aids can be acquired without a doctor’s prescription, and have many of the same features as prescription hearing aids. However, you will need to fit them yourself.

How to Insure for Hearing Exams

You can purchase insurance to help pay for hearing exams and hearing aids. Most people find the best coverage within dental plans that include vision and hearing care coverage. These insurance plans are typically referred to as DVH plans, short for dental, vision and hearing.

In addition, some Medicare Advantage Plans offer limited coverage for hearing care.

Does Medicare Cover Annual Physicals?

Original Medicare does cover preventive care health care services. All Medicare preventive services are free to Medicare beneficiaries without copay and exempt from deductibles. However, preventive care under Traditional Medicare is not referred to as a physical.

When you are within your first twelve months of Medicare Part B coverage, your first preventive care health care visit is referred to as a “Welcome to Medicare” visit. After your first twelve months on Medicare Part B, you are allowed to have one preventive care visit every twelve months. It is important to understand medicare wellness services are not based on the calendar year. They are based on a rolling twelve month period that starts the day your Medicare Part B becomes effective.

After your Welcome to Medicare visit, the annual preventive care visits are referred to as “Wellness Visits.” The terminology is important because a physical is billed using a billing code not covered by Medicare.

Guide to Medicare’s Preventive Services

For a detailed list of what preventive care Medicare covers and how often, please look for the “Guide to Medicare’s Preventive Services” on this page.

Does Medicare Cover Long Term Care?

Medicare doesn’t cover long term care. Medicare was never intended to provide coverage for long-term care needs even though long term health care treatment is very important.

Inpatient services, covered by Medicare Part A, are limited 150-days. That is extended to one-year with a supplement or an Advantage plan. Skilled nursing care is limited to 100-days. Custodial care is not covered.

Some people confuse Skilled Nursing Care with nursing home coverage. They are not the same. Nursing home health care includes care for people who simply need help with their activities of daily living.

Private insurers offer long-term care plans. These plans cover care in nursing homes, custodial care and other long-term care needs. There are multiple ways a person can get long-term insurance including a stand-alone, as a rider on life insurance or an asset based policy where a single premium purchases coverage. Without long term care insurance, nursing home stays are not financially reasonable for most people.

Does Medicare Cover Cosmetic Surgery?

Like most health insurance, Medicare views cosmetic surgery as not medically necessary and thus not worthy of insurance coverage. However, there are important exceptions which can include treatment for burns, repairing a face after an accident or therapeutic surgery that can serve a cosmetic purpose.

Medicare Doesn’t Cover Foot Care?

Because most foot care is outpatient care, it would generally fall under Medicare Part B medical insurance. But Medicare does not cover routine foot care, including flat foot treatment, removing calluses, coms and so on. Orthopedic shoes are generally not covered as well.

That said, this is one category of outpatient care where there are more exceptions to the rule than the list of what is excluded. If you are using a Medicare Advantage plan, any care would require prior authorization which reduces the probability of the insurance covering your needs.

The list of exceptions include treatment related to diabetes, Multiple Sclerosis, traumatic injury, hereditary disorders, leprosy, infection and much more. It’s best to ask your specialists if your insurance will cover the medical bills related to your necessary medical services.

Medicare Coverage of Acupuncture

On a good note, Medicare recently approved the coverage of acupuncture on a limited basis.  Only acupuncture to treat chronic lower back pain is approved.  We have an entire blog post about Medicare and acupuncture – click here.  

Conclusion

The above is not intended to be a full list of what Medicare does not cover. Please remember, the common thread for exceptions is in answering the question of Why? Emergency care is always an exception, for example. Your Medicare plan is intended to cover everything that is medically necessary.