Millions of Americans have health care coverage through the Medicare program. Medicare coverage usually works quite well for most people, and many medical services and procedures are covered under Medicare plans. However, there are some things that original Medicare does not cover. Some of the items not covered might not be a big deal for you, but others might end up costing you a lot of money. So, what are the things that Medicare does not cover? Keep reading as we give you all the details about what is not covered by Medicare and some ways you can get those things covered!
What Does Medicare Not Cover?
If you have Original Medicare for your health insurance, you will find that some everyday items and services are not covered. Some of these things are used frequently, so you will need to make sure that you are planning for those medical expenses. Here are ten of the most common things not covered by Medicare.
— Routine Dental Care
Original Medicare does not cover routine dental care. This type of care includes regular cleanings, fillings, extractions, or other services performed by your dental provider. Although regular dental work is not a covered service, there are some exceptions when Medicare will cover dental services. If the dental work is medically necessary to perform another covered service, then Medicare will cover the dental work. Consider the following example.
Suppose you are in a car wreck and require emergency jaw surgery. However, a tooth extraction must be performed as part of the jaw surgery. Although tooth extractions are not normally covered by Medicare, they would be covered in this situation.
— Eye Exams
Routine eye exams and vision screenings are not covered by Medicare. Likewise, fittings for contact lenses or eyeglasses are also not covered. Although routine eye services are not covered, some medically necessary services are covered through Medicare. For example, Medicare will cover cataract surgery. Medicare will typically pay for the removal of the cataract, a basic lens implant, and one pair of prescription eyeglasses after the surgery. If your doctor recommends an advanced lens implant, then Medicare will likely not cover the additional cost of the advanced lens. You would need to speak with your Medicare plan provider to discuss any coinsurance amounts and out-of-pocket costs for which you might be responsible.
— Long-Term Care Or Custodial Care
Many people wonder, “Does Medicare pay for an assisted living facility?” The answer is no. This type of care might include both medical and non-medical care. In many cases, these facilities offer assistance with activities of daily living, like bathing, eating, dressing, or getting out of bed. Medicare does not cover these types of services, regardless of where the activities take place. The services may be provided in a nursing home, assisted living facility, or even at your home. Either way, Medicare does not pay for it, and neither do most health plans. Medicare does, however, pay for hospice care in most cases, as well as short-term care in a skilled nursing facility.
— Dentures
Dentures can be quite expensive, but Medicare does not cover their cost. Many people on Medicare health plans find themselves in need of dentures at some point in their lives. Depending on the type of dentures that you need, you could find that the cost ranges into the thousands for a complete set of dentures. Unfortunately, you will be stuck paying for them totally out of your own pocket if you only have Original Medicare. If you suspect that you might need dentures in the future, you should consider enrolling in a Medicare Advantage plan that provides this benefit. Some Advantage plans provide coverage for dentures, so it might make sense for you to enroll in a plan that offers this coverage.
— Hearing Aids
Unfortunately, hearing aids are not covered by Medicare. Anyone who has any experience with these devices knows that they can be extremely expensive. Not only does Medicare not cover hearing aids, but fittings for the devices and hearing exams are also not covered. You will need to pay 100% of the cost of hearing aids and the exams associated with them. Perhaps you are wondering why hearing aids are not covered by Medicare Part B since this coverage pays for durable medical equipment. Hearing aids are not considered durable medical equipment. Instead, they are classified as elective medical devices.
— Cosmetic Surgery
Although Medicare covers many types of surgery, it does not cover cosmetic surgery. Medicare beneficiaries will need to pay for cosmetic surgery out of their own pocket. These types of procedures might include a facelift, nose job, breast augmentation, tummy tuck, or others. This limitation is not just specific to Medicare, either. Almost no medical insurance companies will pay for cosmetic surgery. Medical insurance coverage is almost always limited to medically necessary procedures, and cosmetic surgery is considered purely elective. There is usually no medical reason that people need to get cosmetic surgery, so Medicare will not provide coverage for elective procedures like cosmetic surgery. In some cases, like severe burns or car accidents, Medicare will pay for reconstructive surgery for a reasonable period of time after the accident.
— Massage Therapy
Some people require massage therapy for sore muscles or other issues. Medicare does not cover massage therapy. In addition, Medicare also does not usually cover acupuncture and it does not provide coverage for many chiropractic services. While Medicare will cover manual manipulation of the spine by a chiropractor, it does not pay for other services or tests, like X-rays, massage therapy, and others. In very limited cases, Medicare will cover acupuncture for chronic low back pain.
— Routine Physical Exams
You might think that Medicare would cover a routine physical exam, but that is not the case! Medicare does not cover routine physical exams without any specific symptoms or patient complaints. However, Medicare will pay for an annual wellness visit. Many preventive services are covered, and the annual wellness visit is one of those. While it might sound similar, there is a difference between a routine physical exam and an annual wellness visit. Medicare will also pay for an initial preventive physical exam (IPPE) or a “Welcome to Medicare” visit.
— Prescription Drugs
This might come as a surprise, but Original Medicare does not provide coverage for prescription drugs. Remember that Original Medicare only includes Medicare Part A and Medicare Part B coverage. Medicare Part D, or prescription drug coverage, is not automatically included. Most people choose to enroll in either a Medicare Part D plan or a Medicare Advantage plan to gain access to a prescription drug plan. The cost of medications can be extremely high, so getting any kind of medicine without insurance coverage could be expensive. Part D plans still include deductibles, copays, and coinsurance payments, but those expenses are usually cheaper than trying to pay for your prescriptions out-of-pocket.
— Spouse Or Family Medical Expenses
Enrollment in Medicare means that only you will have coverage through your plan. Medicare does not provide coverage for spousal expenses or family medical expenses. Many health insurance plans provide spousal or family coverage. However, Medicare does not. You can only enroll in Medicare if you are eligible for enrollment, and each person needs to enroll individually. If you need to enroll other family members in coverage who are not eligible for Medicare, you will need to look elsewhere. Depending on your income, they might qualify for Medicaid coverage. You might also check the health insurance marketplace or attempt to enroll them in an employer-sponsored plan if you or your spouse are still working.
Services That Medicare Covers
Now that you know some common items that are not covered by Medicare, you might be wondering, “What does Medicare cover?” Medicare covers a wide range of items, and each part of Medicare covers slightly different items. Here is an overview of the things covered by Medicare.
— Medicare Part A
Medicare Part A is commonly known as hospital insurance, and it provides coverage for inpatient care. Coverage under Part A includes inpatient hospital stays, care in a skilled nursing facility, home health care, hospice care, and some nursing home care. Care in a nursing home must meet the definition of a skilled nursing facility, and the care must be short-term care instead of long-term care.
— Medicare Part B
Medicare Part B is more traditional health insurance coverage. Part B covers doctor visits, outpatient services, durable medical equipment, ambulance services, and other medically necessary services. It provides limited coverage for prescription drugs when they are associated with an outpatient service. Part B also provides preventive services, like vaccines, wellness visits, and other items.
— Medicare Part C
Medicare Part C is another term for a Medicare Advantage plan. Part C plans are managed and administered by private insurance companies, so these companies get to set their own rules about coverage and costs. Each plan must provide the same minimum level of coverage provided by Original Medicare, but many plans offer additional benefits. These extra benefits might include gym memberships, prescription drug coverage, and other perks. If you choose not to enroll in a Part C plan, you might enroll in a Medicare supplement plan to help with out-of-pocket expenses not covered under Original Medicare.
— Medicare Part D Prescription Drug Plans
If you decide not to enroll in a Medicare Advantage plan that includes prescription coverage, you might elect to enroll in a standalone Part D drug plan. These plans offer coverage for prescription medications. Since these plans are managed by private insurance companies, you will need to refer to your specific plan documentation for details on costs, such as monthly premiums, deductibles, and copayments.
How To Get Coverage For Services Not Covered By Medicare
So, how can you get coverage for services not covered by Original Medicare? There are a couple of different ways to do that. First, you might choose to enroll in a Medicare Advantage plan. These plans must include at least the same minimum level of coverage as provided by Medicare. However, most Advantage plans include much more coverage beyond traditional Medicare benefits. Some Advantage plans cover dentures, hearing aids, dental care, vision care, and many other services not covered by Medicare. You can visit the plan finder tool at Medicare.gov to find a Medicare Advantage plan in your area that fits your needs.
You might also choose to enroll in Medicare supplement insurance. These plans are also called Medigap plans. They help cover out-of-pocket costs not covered by Medicare, such as deductibles, copays, and coinsurance amounts. However, you should know that a Medigap plan will not cover items that are not covered by Medicare. For example, Medigap would not cover the cost of your hearing aids since hearing aids are not covered by Medicare.
The Bottom Line
While Medicare covers many types of medical services, there are several items not covered by Medicare. Items that are not covered include dental care, vision care, hearing aids, dentures, and long-term care. If you need coverage for these types of things, you will need to find a Medicare Advantage plan that offers this coverage.
Frequently Asked Questions
Does Medicare cover surgery?
Yes, Medicare covers most surgeries, including both inpatient and outpatient surgeries. As long as the surgery is medically necessary, then Medicare will usually provide coverage. Even though Medicare does not pay for vision care, it does cover cataract surgery. However, Medicare will not pay for elective surgeries, such as cosmetic surgery.
What are the limitations of Medicare?
Medicare has some limitations, and coverage limits are one of the most significant. There are many things that Medicare does not cover, and some of the items not covered by Medicare are extremely important. For example, Medicare does not cover dental care or vision exams. Medicare also does not cover prescription drugs. Many people turn to a Medicare Advantage plan to overcome some of the limitations of Original Medicare.
What is not typically covered by Medicare?
Typically, any service that is not medically necessary is not covered by Medicare. This may include elective procedures such as cosmetic surgery. Even items like hearing aids are not considered medically necessary. Instead, these are considered elective medical devices. Medicare also does not cover routine dental care or vision care. Finally, Medicare does not cover any medical expenses for your spouse or other family members.
