What Medicare Does Not Cover

You may be surprised to discover that budgeting for health care is still necessary once you’re on Medicare, especially for those on a limited income.

(Getty Images)

It’s important to educate yourself on what is, and isn’t, paid for by Medicare so that you’re not caught off guard by medical bills. Here are the things that Medicare doesn’t cover.

What Medicare Doesn’t Cover

Examples of items and services that fall into this category include excessive therapies or diagnostic procedures, or exams and treatments for which the patient has no symptoms or diagnoses.

Casey Schwarz, senior counsel, education and federal policy at MedicareRights.org, explains that people who are eligible for Medicare but are currently covered by an employer health plan have to think about their loved ones, as well as themselves.

“Oftentimes employer coverage is family coverage, meaning it covers you and your spouse and dependents. Medicare is coverage just for you. So for some people, it makes sense to keep their employer plan even if Medicare is going to be the primary payer because they want to keep the coverage for their spouse and children.”

Many people fail to budget for deductibles and copayments. In 2022, original Medicare members have to pay a $1,556 Part A deductible before their coverage kicks in. That is in addition to a $233 deductible for Part B. After the Part B deductible has been fulfilled, Medicare will cover 80% of doctor services, lab tests and X-rays.

Joel Mekler, a health benefits professional, Medicare expert and writer of the “Medicare Moments” weekly column in the New Castle (Pennsylvania) News, says, “The sky is the limit as far as potential out-of-pocket costs unless someone goes for a Medicare supplement or Medigap plan. And Medigap plans essentially fill a lot of those gaps in original Medicare. It would cover the Part A hospital deductible, the Part B deductible plus coinsurance and copayments.”

Original Medicare covers 90 days of hospitalization with deductibles and copays per benefit period, explains Jaime Fenimore, a Medicare specialist and broker based in Pittsburgh, Pennsylvania.

Over your lifetime, original Medicare will only cover some of the costs of hospitalization once you exceed 90 days of hospitalization during a benefit period. After 90 days, you dip into your so-called “lifetime reserve days,” which have higher copays.

“To understand lifetime reserve days, one must first understand how Medicare defines a benefit period,” says Fenimore. “A benefit period begins the day you are admitted as an inpatient to the hospital or a skilled nursing facility and ends when you have not gotten any inpatient care for 60 days in a row.”

In other words, if you’re hospitalized on May 1 and then again on June 15, you’re still in the same benefit period because both incidents are less than 60 days apart. And you’ll only have to pay your deductible once.

However, Medicare will add the length of stay of both hospitalizations during that benefit period, and if they equal more than 90 days, you’ll begin to use your lifetime reserve days. These 60 lifetime reserve days are one-time use only. Once they’re used, they’re gone for good.

Original Medicare does not provide coverage for routine dental exams, dental work or dentures. Unless you have diabetes or need eyeglasses following specific types of cataract surgery, original Medicare also does not cover vision care, including eye exams, eyeglasses or corrective contacts.

Most Medicare Advantage plans do cover some vision services, however. Similarly, while original Medicare will not assist with the cost of hearing exams or hearing aids, some Medicare Advantage plans may.

Although Medicare Advantage plans often cover things like some vision, dental and hearing care that original Medicare doesn’t, there might still be annual limits, such as the common dental limit of $1,500 per year, or the benefits might need to be received from a limited list of providers in order to be covered. Medicare Advantage members might opt to also purchase a separate dental plan.

If podiatrist visits are a regular part of your care schedule, you’ll need to set aside money to cover the cost of these appointments out of pocket, unless they’re medically necessary, since Medicare doesn’t cover these services if they’re not medically necessary. Regular foot care services that aren’t covered include treatment of flat foot, corn and callus removal, nail care, creams to maintain skin tone and orthopedic shoes.

Medicare does not generally cover long-term nursing home care. However, even though the nursing home won’t be paid for by Medicare, you can’t drop your coverage once you’re admitted. You’ll still use your Medicare for many services including hospital care and medical supplies while you’re in the nursing home, as well as physician visits.

Most nursing homes do accept Medicaid so if you’re dual eligible and receive both Medicaid and Medicare, you’ll likely be covered for admission. Some people on Medicare elect to purchase a separate long-term care insurance policy to cover this level of care.

If you’re a frequent international flyer, you might want to consider that, in most cases, original Medicare will not cover care outside of the U.S. However, several available Medigap plans will cover 80% of these international medical costs. Some, but not all, Medicare Advantage plans will also cover necessary emergency medical care outside of the country.

Medicare will not cover cosmetic surgery costs, with a few exceptions. For instance, Medicare might elect to cover the prompt repair of severe burns, facial injuries after a serious car accident or other surgeries for therapeutic reasons that also happen to serve a cosmetic purpose.

If you have any questions about what services are covered by your Medicare plan, it’s best to call the customer service phone number on the back of your insurance card. Another incredibly helpful service is State Health Insurance Assistance Programs, which provide free and unbiased assistance and advice on a wide range of Medicare-related topics. With a little extra research, you can avoid costly and unnecessary medical bills.

By Percy