13 Things Original Medicare Does Not Cover in 2020
There is a long list of things that Medicare will not pay for. So, what does Medicare not cover? Find that information here, plus several alternative options for better coverage.
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Most seniors depend on Medicare for health insurance, but you may be surprised to find out that there is a lot that Original Medicare does not cover. Many of these non-covered items are essential to your health and well-being.
Unfortunately, that leaves you with a difficult choice: forgo needed care, or shell out the money to pay for it completely on your own. Without careful planning, such out-of-pocket costs could leave you in a real financial lurch.
The key to ensuring that you get the care that you need, at a cost you can afford, is to know the ins and outs of what Medicare Part A and Part B does and does not cover. That way, you can decide whether you will need additional coverage to supplement your Original Medicare coverage. By reading the information below, you will find out where the holes are in your Medicare coverage, and discover how to plug them.
What Does Medicare Part A and B Not Cover?
Some healthcare services are simply not a recognized Medicare benefit, as they are excluded by law. Because these services are not part of Original Medicare (Part A and Part B), you must pay out of pocket in order to receive them.
Some examples of such services are as follows:
1. Custodial care: Personal care that does not require medical staff. Some examples of custodial care are walking, getting out of bed, dressing and cleaning.
2. Routine physical checkups: Doctor appointments made based on no specific signs, symptoms, or complaints. This does not include preventive care, which is covered.
3. Eyeglasses and vision exams: Original Medicare only covers medical eye exams to diagnose and treat an eye disease, like glaucoma or cataracts. Medicare also covers one pair of glasses after cataract surgery.
4. Hearing aids and examinations
5. Immunizations: Exceptions include immunizations that are:
Related to an injury or exposure to a disease (like rabies)
Specifically covered by law (like flu shots).
6. Cosmetic procedures: Like most health insurance, Original Medicare will not pay when the main purpose for a procedure is to improve or change your appearance.
7. Dental services: Original Medicare will not cover routine dental care or dentures. Exceptions include an x-ray of a fractured jaw or facial bone, or a tooth extraction that is required to prepare the jaw for surgery.
8. Some foot care products and services: Original Medicare will not pay for routine or preventive foot care, treatment of flat foot, or orthopedic shoes. Some exceptions include therapeutic shoes furnished to diabetics, treatment of foot warts, and a few more.
9. Investigational devices: These include devices that are still undergoing clinical trials to determine their effectiveness and/or safety.
10. Services required because of non-covered services: If you had complications related to a non-covered service while still in the hospital, Original Medicare would not cover treatment.
11. Items and services obtained outside the US: While some Medicare supplements cover care in other countries, Original Medicare only covers care in the following areas:
Northern Mariana Islands
The U.S. Virgin Islands
12. Services paid for by someone else, or services you received for free: This includes free services (like those obtained from a nonprofit), or services paid for by another type of insurance (i.e. automobile or worker's comp)
13. Services that are not deemed medically necessary: What does "medically necessary" mean? According to Medicare, medically necessary services or supplies are those that are "needed to diagnose or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine." For example, if you broke your leg and needed physical therapy, that is covered. However, if you keep going to therapy after you have sufficiently recovered, Original Medicare would not pay for that.
Do Medicare Parts C and D Cover What Original Medicare Does Not?
Because of the limitations of Original Medicare, many enrollees choose to boost their coverage by signing up for a Medicare Supplement plan. Supplements come in many different forms, each having their own levels of coverage and costs. Two options for covering services that Medicare Parts A and B do not cover are Medicare Parts C and D.
Medicare Part C
Part C plans are also called Medicare Advantage plans. These plans are optional, and they replace your Original Medicare coverage. They cover all of the same services as Parts A and B, and most of these plans also provide extra coverage.
Many Medicare Advantage plans cover vision, hearing, and dental services. Some may even cover services like gym memberships, transportation to doctor visits, and adult daycare. Many plans also include prescription drug coverage. If one does not include such coverage, you can always enroll in Medicare Part D.
Like most health insurance, including Original Medicare, Medicare Advantage plans usually will not cover services that are not deemed as being medically necessary.
Medicare Part D: Prescription Drug Plans
Medicare Part D, also called prescription drug plans, cover your prescription drug costs. Like Medicare Advantage, there are many plans to choose from, each with a different amount of drug coverage and varying costs.
Each plan has its own formulary — a list of what medications the plan covers and the prices of each. The formulary consists of "tiers" (levels) that the drugs covered are arranged in. The specific amount that you will pay out-of-pocket (your copay) for a given drug depends upon its tier. Below is an example:
Tier 1, lowest copay: This tier usually includes preferred generic drugs
Tier 2, medium copay: Non-preferred generics and preferred brand name medications
Tier 3, higher copay: Non-preferred generics/brand name drugs. Sometimes, new drugs, or drugs that are similar to a Tier 1 or Tier 2 drug are also placed here.
Tier 4, highest copay: Very expensive, specialty drugs
Medicare Part D plans will not cover a drug that does not appear on their formulary. In that case, you will likely have to pay full price — unless you qualify for an exception.
There is a long list of services that Medicare just does not cover. While supplements can give you coverage for many of these services, it is important to remember that no plan covers everything (although some do come pretty close).
If you are worried about paying out of pocket for the care that you need, you're not alone. A licensed Medicare insurance agent can help you find the type of coverage that best fits your needs.
Andrea Bonner is a healthcare writer with more than 10 years of experience covering senior health. She is from the Raleigh-Durham area in North Carolina.