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What Medicare Does Not Cover: A List of Exclusions

August 22, 2023

What Medicare Does Not Cover: A List of Exclusions

Medicare is a government-run health insurance program that primarily covers the older population of 65 years and above. The program has been designed to offer healthcare coverage for people above retirement age and for those who have certain disabilities. Medicare coverage has parts A, B, C, and D. These parts cater to different aspects of healthcare and cover a varying range of services. Additionally, you should also be aware of what Medicare does not cover.

Original Medicare refers to the standard federal health insurance program that's available to U.S. citizens and legal permanent residents who are age 65 or older. This program is administered by the federal government and is commonly called Medicare Part A and Part B.

Medicare Part A generally covers hospital stays, skilled nursing facilities, hospice care, and home health care, while Part B covers medical services such as doctor visits, preventive care, and medical equipment. Original Medicare is fee-for-service insurance which means that you're free to choose any healthcare provider or hospital that accepts Medicare without being restricted to a network of providers.

However, Original Medicare does not cover all healthcare costs, and beneficiaries are required to pay out-of-pocket expenses such as deductibles, coinsurance, and copayments. In addition, Original Medicare does not cover prescription drugs, so beneficiaries may need to purchase a separate Part D prescription drug plan to get Medicare coverage for medications.

Although Medicare Parts A and B serve a vital role for the elderly population, there are many services that aren't covered. If you need services that Part A or Part B doesn't cover, you'll have to pay for them yourself unless:

  • You have other coverage like Medicaid or other health insurance to cover the costs.
  • You're in a Medicare Advantage Plan or Medicare Cost Plan that covers these services. Medicare Advantage Plans and Medicare Cost Plans may cover some extra benefits, like fitness programs and vision, hearing, and dental services.
  • You enroll for Original Medicare and purchase a medicare supplement policy, also called Medigap, which covers many of those expenses. 

As a result, many seniors purchase Medicare Part C, also known as Medicare Advantage, to receive additional healthcare benefits through a private insurance company. These plans are required to cover all services covered by Original Medicare but often offer additional benefits. Let's take a closer look at what Medicare does not cover.

Long-Term Care

Long-term care is an essential consideration when it comes to healthcare planning, but what many people don't realize is that Medicare doesn't cover the majority of things that fall under this category. Long-term care is a type of healthcare service that provides ongoing assistance and support to elderly individuals or those with chronic conditions. It can include various services such as nursing home care, home health aides, and assisted living facilities. One of the most common exclusions for long-term care is custodial care. This type of care involves assistance with daily living activities like eating, bathing, and dressing but is not considered medically necessary. This includes stays in nursing homes and assisted living facilities. Medicare only covers custodial care if it's provided as part of skilled nursing care and only for a limited time.

Similarly, another common exclusion for long-term care is homemaker services. This type of care involves help with household tasks such as cooking and cleaning. Medicare doesn't cover these services unless they're provided as part of skilled nursing care. Furthermore, Medicare generally doesn't cover long-term care services for chronic conditions like Alzheimer's disease or other forms of dementia unless they're provided as part of hospice care.

Dental Care

Dental care is an important aspect of overall health and wellness, but unfortunately, it's not fully covered under Original Medicare. While Medicare provides coverage for many medical services, it does not cover routine dental care, such as cleanings, fillings, or extractions.

One of the most common exclusions from Medicare coverage is routine dental care. This includes preventive services like cleanings, as well as restorative services like fillings, extractions, and root canals. In addition to routine dental care, Medicare also does not cover certain types of oral surgery, such as implants or orthodontics.

Also included on the list of what Medicare does not cover are dentures. Medicare does not provide coverage for dentures unless they're necessary due to medical conditions. It's crucial for seniors to be aware of these exclusions and plan accordingly for dental care needs.

As a solution to this, most Medicare Advantage plans include dental benefits. The majority of these plans typically cover preventive and comprehensive dental services.

Eye Exams

While many seniors rely on regular eye exams to maintain their visual health, Medicare does not cover all aspects of these appointments. One of the most important exclusions to note is that Medicare generally does not cover routine eye exams. This means that if you're getting an exam simply to check your vision and don't have any existing eye conditions or symptoms, you'll likely have to pay out of pocket.

Similarly, Medicare does not cover glasses or contacts, even if they're prescribed as part of an eye exam. These items are typically considered elective and not medically necessary, and as such, they are not covered by Medicare. Another exclusion to keep in mind is that Medicare generally does not cover eye exams related to fitting or adjusting glasses or contact lenses.

There are many Medicare Advantage plans available that include vision care. These plans typically cover a yearly exam and an allowance for eyewear. There are also options to increase vision coverage within those plans.

Cosmetic Surgery

Cosmetic surgery is a type of treatment that aims to improve an individual's physical appearance. As a result, most cosmetic surgery is considered purely elective and is typically not covered by Medicare. On the list of what Medicare does not cover are procedures like facelifts and liposuction. These treatments are not covered unless they relate to an underlying medical condition. Further, Medicare does not cover procedures that are considered experimental or investigational. This can include certain types of laser therapies, Lipodissolve treatments, and stem cell injections.

While Medicare usually doesn’t pay for cosmetic surgery, there are some exceptions where services might be covered. If you need it because of accidental injury or to improve the function of a malformed body part, it could be considered a covered service. Medicare also covers breast prostheses for breast reconstruction if you had a mastectomy due to breast cancer.

Medicare requires prior authorization before you get these hospital outpatient services that are sometimes considered cosmetic:

  • Blepharoplasty: Surgery on your eyelid to remove “droopy,” fatty, or excess tissue.
  • Botulinum toxin injections (or “Botox”): Injections used to treat muscle disorders like spasms and twitches.
  • Panniculectomy: Surgery to remove excess skin and tissue from your lower abdomen.
  • Rhinoplasty (or “nose job”): Surgery to change the shape of your nose.
  • Vein ablation: Surgery to close off veins.

Routine Physical Exams

Alt Text: A Medicare beneficiary has her blood pressure checked during her annual Medicare wellness visit.

While Medicare provides coverage for many services, there are some exclusions when it comes to exams. One common exclusion is that Medicare does not cover routine physicals. An annual physical, also known as a yearly check-up or medical exam, is a comprehensive evaluation of an individual's overall health and wellness status. It usually involves several medical tests such as blood tests, blood pressure, and other vital sign measurements, as well as a physical examination conducted by a medical professional.

Annual routine physicals are on the list of what Medicare does not cover. However, Medicare benefits will provide for an annual "wellness visit." Your visit may include the following:

  • Routine measurements (like height, weight, and blood pressure)
  • A review of your medical and family history
  • A review of your current prescriptions
  • Personalized health advice
  • Advance care planning
  • Cognitive assessment to look for signs of dementia, including Alzheimer’s disease

Medicare also covers some preventive services, such as mammograms, colonoscopies, and flu shots, that healthcare professionals recommend to prevent or detect specific illnesses or conditions. Routine physical exams, including blood tests and other diagnostic tests that are performed without any specific symptom or concern, are considered "screening services" and are not covered by Medicare.

Some Medicare Advantage plans may offer additional benefits beyond what's covered by traditional Medicare, and individuals need to evaluate their options to choose a plan that meets their needs.

Hearing Aids and Fitting Exams

While Medicare covers many health-related services, hearing aids and fitting exams are not included in the coverage. Original Medicare only covers hearing and balance exams if they're deemed medically necessary due to other health conditions. Moreover, Medicare does not cover the cost of hearing aid fittings, adjustments, or maintenance.

Medicare Parts A and B don’t cover the cost of hearing aids, fittings for hearing aids, or hearing exams that are specifically for the purpose of buying a hearing aid. However, Medicare covers hearing exams for diagnostic purposes as long as you have a referral from your doctor. Some Medicare Advantage plans offer coverage for hearing services and, in many cases, will cover some of the cost of hearing aids.

Understanding what Medicare does not cover is crucial for beneficiaries to avoid unexpected out-of-pocket expenses. Overall, it's paramount to review the list of common exclusions and consider additional coverage options to ensure comprehensive healthcare coverage. It's necessary to consult with your healthcare provider annually to discuss your health and any conditions or treatments that might require additional Medicare or health insurance coverage.

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