What Medicare Does Not Cover

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Medicare is pretty black and white about what they do and do not cover. Many will find it surprising that services like long-term care, dental, and prescription drugs are services that Medicare does not cover. These can often be substantial expenses that one may face, and that may be a big reason why you won’t find them covered on Original Medicare.

The good news is that all of these benefits can often be covered either through a separate insurance policy or through Medicaid.

Non-medical Home Health

Original Medicare will not cover any home health services that are not medically necessary. This includes having someone help you with bathing, going to the bathroom, cleaning the house, shopping, or any other service that can fall under assisted living with home health. This would also include any nursing homes or assisted living facilities. To get coverage for these services you have to pay out-of-pocket, have a long-term health policy, or have Medi-Cal. 

If you have Medi-Cal, then you will likely get coverage through IN-HOME SUPPORTIVE SERVICES (IHSS); however, you will need to apply for this. Either your doctor can help you or you can go to the local office in your city. 

Ancillary Services

There are many services considered “extra” that aren’t covered under Original Medicare. These include:

Dental

Most dental care, including dentures, dental procedures or cleanings, fillings, dental plates, tooth extractions, and check-ups are not covered by Medicare. Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you’re in a hospital. Part A can pay for inpatient hospital care if you need to have emergency or complicated dental procedures, even though the dental care isn’t covered. Most common ways to get dental coverage are from: a Medicare Advantage plan as an “extra” benefit, from a Medicare Supplement (Medigap) plan as an “add-on”, or as a stand-alone dental plan. 

Cosmetic surgery

Pretty much no one in the Medicare space will cover this for you. If it is considered cosmetic in any way, you can often expect to pay the full cost of the service. 

Hearing aids

Medicare won’t cover hearing aids. You can get coverage from the following sources:

• Medicare Advantage Plans: Many Medicare Advantage plans will offer coverage for hearing aids in the form of either an allowance or a deductible
• Medicare Supplement Plans (Medigap): There are certain Medigap Plan F’s and G’s that will include hearing aid coverage. They will often have the words “extra” or “innovative” in the title.
• Stand alone Hearing aid plan
• Medicaid: Medicaid (aka MEdi-Cal) provides a very basic level of hearing aid coverage. Each year they will cover up to $1,510 for hearing aids. This will not cover anything fancy or even mid-level. To get coverage for higher quality hearing aids, you may want to explore the other options on this list.
• Lions Club: Most local Lion’s Clubs have a hearing aid program where individuals who are low-income can apply for support. Often those who just missed the income limits for Medi-Cal may qualify. Once accepted, you will pay a small fee and receive a quality pair of hearing aids. Contact your local Lion’s Club for more information. 

Eye Exams and Prescription Glasses and Lenses

Medicare doesn’t cover routine vision exams to check for vision correction nor does it cover glasses and contacts. This is considered routine vision and not medical vision services. They will still cover medical services like glaucoma, cataracts, ect.

You can get coverage for routine vision from the following sources:

• Medicare Advantage Plans: Many Medicare Advantage plans will often offer coverage for glasses, contacts, and exams.
• Medicare Supplement Plans (Medigap): There are certain Medigap Plan F’s and G’s that will include vision coverage. They will often have the words “extra” or “innovative” in the title.
• Stand alone Vision plan
• Medicaid: Medicaid (aka MEdi-Cal) provides a very basic level of vision coverage. Each year they will cover one vision exam, but they will not pay for glasses or contacts. To get coverage for glasses and contacts, you may want to explore the other options on this list.

Routine foot care

Routine foot care includes, but is not limited to, the treatment of bunions (except capsular or bone surgery thereof), calluses, clavus, corns, hyperkeratosis and keratotic lesions, keratoderma, nails (except surgery for ingrown nails), plantar keratosis, tyloma or tylomata, and tylosis. The reduction of nails, including the trimming of nails, is also considered routine foot care. Often diabetics will benefit from these types of services. 

Original Medicare won’t cover this service, which means any Medicare Supplement won’t cover it as well. To get coverage for this, you will need to either enroll into a Medicare Advantage plan or have Medi-Cal. 

Acupuncture

The only way to get coverage for acupuncture is through a Medicare Advantage plan. No Medicare Supplement plan nor even Medi-Cal will cover this service. Although, some supplement plans will have a discounted network coverage for acupuncture.

Chiropractic

The only way to get coverage for Chiropractic is through a Medicare Advantage plan. No Medicare Supplement plan nor even Medi-Cal will cover this service. Although, some supplement plans will have a discounted network coverage for chiropractic.

Part D

If you’re on Medicare, you may be wondering what prescription drug coverage is and how it works.

Part D was created by the Medicare Modernization Act of 2003 (MMA) to provide prescription drug coverage for Medicare beneficiaries who chose not to enroll in a prescription drug plan (PDP). This program is optional, though it is highly recommended that all Medicare beneficiaries enroll in a PDP if they wish to receive their prescriptions at little or no cost.

Original Medicare does not include prescription drug coverage. Some medications may be covered when administered within a doctors office.

If you are uncertain if your coverage is “Creditable”, then you may want to contact your coverage provider and ask. They are required to let you know. 

If you are not enrolled in a PDP, you must purchase one from a private company. Your premium will vary depending on your income and location, but it will likely range from $7-150 per month with the average being $34.50 a month.

Examples of Creditable Coverage

• Group/Employer Coverage
• VA
• TriCare

If you do not have any Creditable Coverage (which includes many types of health insurance plans), then you will incur a penalty when you do enroll at a later date. Any Medicare beneficiary who does not enroll into a PDP and does not have Creditable Coverage will incur a 1% penalty of the National Drug Premium average for every month without Creditable Drug Coverage.

Why Speaking To A Local Medicare Agent Can Help

Some people do fall through the cracks and go without prescription drug coverage for extended periods of time. If this happens, you will want to sign up for a plan as soon as possible to avoid penalties. You may also want to talk with your doctor or pharmacist about other medications you are taking to see if they have any less expensive options.

If you’re thinking of signing up for Medicare or have already done so, it’s important to understand all of the benefits that you have access to. Once you have a clear picture of what your plan covers, you can make the decision about what type of coverage will best meet your needs.

For instance, if you would like more prescription drug coverage than Original Medicare provides, then a Medigap Insurance policy may be a good choice for you. A Medicare Broker will help you find the best path which is why it is always best to speak to them; it will always be free.

By weighing the pros and cons of all available options and carefully considering all essential factors, deciding on which option is right for you should be easy.