Medicare covers most medically necessary care as prescribed by a qualified healthcare provider, but it doesn't pay for most dental or vision services.
If you are enrolled in Original Medicare, you can select doctors, specialists, hospitals and other providers that accept Medicare insurance coverage for care and supplies. While Medicare covers much of the cost of medically necessary services and care, it doesn’t cover everything you may need.
There are several factors you should consider before making any final decisions about your healthcare coverage. One thing to understand is what is and isn’t covered by Original Medicare and what you’ll pay for care.
What Services Are not Covered by Medicare Parts A and B?
To know if Medicare covers what you need, first talk to your doctor or healthcare provider about what services or supplies you need and why. Or, you can contact Medicare directly.
Unless you have additional insurance or opt for a Medicare Advantage or other Medicare health plan with additional coverage, here are items and services Original Medicare won’t cover:
- Long-term care. This applies to both medical and non-medical care provided to those who are unable to perform basic daily activities on their own. While Original Medicare does cover some skilled nursing facility services (if tied to a qualifying hospital stay), it does not cover the cost of residency or day-to-day custodial care in nursing homes or assisted living facilities.
- Routine dental care, including exams, cleanings, x-rays and dentures.
- Cosmetic surgery that is not medically necessary. Exceptions include surgery to treat severe burns or repair following a serious accident, or if the surgery is to help improve the function of a malformed body part.
- Routine eye exams or eyeglasses, including exams for prescribing or fitting glasses. The exception is eye exams after you’ve been diagnosed with diabetes or glaucoma, or have had cataract surgery.
- Acupuncture or other alternative medicine services. This includes experimental procedures and treatments and chiropractic services.
- Hearing exams or hearing aids, including the exam for prescribing or fitting hearing aids.
- Routine foot care, such as nail trimming or corn/callus removal. You may be covered if you have foot problems caused by conditions like diabetes, cancer, malnutrition or other qualifying scenarios, though a doctor or podiatrist must provide evidence that the foot care is medically necessary and not routine.
- Coverage while traveling outside of the U.S. Except under very limited circumstances, any hospital stay or medical visit will not be covered. Consider purchasing additional travel insurance that covers medical expenses in case of an emergency.
- Outpatient prescription drugs.
- Personal care, such as assistance dressing, cooking, running errands, bathing, etc.
- Custodial care, which is personal care that requires no trained medical professional to assist in daily living, such as housekeeping, laundry and meal prep.
- Medically unnecessary or unreasonable services or supplies. This may include home safety items like grab bars, stair lifts, bathtub seats, medical emergency alert systems, etc. These items may only be covered if a doctor prescribes them.
Even with Parts A and B coverage you are still responsible for your monthly premium, annual deductible, and any copays or coinsurance for services. You will have to pay your full deductible before coverage kicks in, and also have to pay for a portion of a hospital stay or other services. For example, in most cases Part B coverage is only 80 percent of the cost, and the other 20 percent you will pay out-of-pocket after you pay your deductible.
There are also often caveats to your coverage, such as though Medicare pays for hospital stays, it will only pay for a certain number of days.
What Does Medicare Cover?
Many services you’ll need are covered by Medicare Parts A and B.
Part A, your hospital insurance, covers:
- Inpatient hospital care. However, simply because you stay the night in a hospital doesn’t mean you’re an “inpatient.” Be sure you’re admitted to the hospital via a doctor’s order or coverage may vary. Part A covers any medical supplies, services or prescription drugs you receive while a patient in the hospital.
- Skilled nursing facilities. If you have a qualifying hospital stay (three days) and your doctor has decided you need daily skilled care that must be given by a skilled nursing or therapy staff, you are covered for up to 100 days during each illness stay. Some covered services include a semi-private room, meals, nursing care, therapy, medications, medical supplies and equipment.
- Hospice. Your hospice and regular doctor must certify you are terminally ill with a life expectancy of six months or less, you must accept palliative comfort care instead of care to cure your illness, and you must sign a statement choosing hospice care instead of other benefits to treat your illness and related conditions.
- Lab tests
- Home health care
- Physical and occupational therapy
Part B, your medical insurance, covers:
- Doctor and other health care provider services required to diagnose and/or treat your medical illness or conditions.
- Medically necessary services or supplies that are needed to diagnose or treat your medical condition.
- Outpatient care. If you are not formally admitted to the hospital (transitioning to inpatient care), services such as lab tests, x-rays, and outpatient surgery would be covered here.
- Durable medical equipment (DME), such as walkers, wheelchairs, canes, etc.
- Home health care.
- Ambulance services.
- Inpatient and outpatient mental health care.
- Limited outpatient prescription drugs.
- Some preventive services, including an annual wellness visit, screenings for conditions such as depression, cardiovascular disease, colorectal cancer, diabetes, lung cancer, mammograms, and more. Flu shots, Hepatitis B shots, and Pneumococcal shots are also covered.
Unfortunately, if you need a service that’s not covered, you’ll have to pay for it out-of-pocket. Understanding what is and isn’t covered can help save you time and money down the road.
What Prescription Drug Coverage Does Medicare Provide?
Original Medicare does not typically cover most prescription drugs under Part A or Part B, though you can purchase a separate prescription drug plan or Part D. Part D drug coverage is optional, but if you enroll in Medicare and don’t sign up for Part D until a later date, you may face a monetary penalty (unless you had other creditable coverage).
You can sign up for Part D coverage:
- When you enroll with Medicare or lose other drug coverage.
- If you have Medicare Part B.
- If you live within the service area of a Part D plan.
Your plan will provide you with a formulary, or list or covered drugs, which you can share with your doctor to ensure your prescriptions will be covered.
You will have to pay a monthly premium for your plan, and some plans also charge an annual deductible, as well as copays or coinsurance for your prescription fills depending on the Tier the drugs fall into. Generic drugs are the least expensive, while new or specialty, brand name drugs are the most expensive.
If you are enrolled in a Medicare Advantage plan, your prescription drug coverage may be included in the plan for no extra cost, though most also have a deductible and/or copay/coinsurance. Talk with your plan to understand your coverage and costs.
What Is Covered Under My Medicare Advantage (MA) Plan?
Medicare Advantage plans (Part C) must provide everything Original Medicare does (except for hospice care), but they also provide additional coverage beyond what Original Medicare provides. This may include:
- Annual vision exam
- Annual hearing exam, as well as hearing aid coverage
- Emergency coverage abroad or while outside of the U.S.
- Routine and additional dental coverage
- Wellness programs or fitness center memberships
- Prescription drug coverage
Some plans even offer $0 monthly premiums and lower deductibles, copays or coinsurance than Original Medicare. They also limit your maximum out-of-pocket expenses, so once you spend that, you pay no additional dollars for medical coverage for the rest of the year.
There are both positives and negatives to MA plans. If you’re considering a Medicare Advantage plan, compare all of your options and the coverage that is most important to you. Some plans have specific service areas or providers, so take that into consideration as well. Plan coverage and costs can change each year, so be sure to review your coverage every annual enrollment period.
What Is Medigap?
Medigap policies help fill the “gaps” of Original Medicare coverage. Typically, they cover the cost of deductibles or copays/coinsurance associated with Medicare that you would pay out of pocket without Medigap. Some Medigap policies even cover services Original Medicare doesn’t cover, like emergency care if you travel outside the U.S.
To qualify, you must have Medicare Parts A and B, and pay the Medigap company a monthly premium for the policy in addition to your Part B premium. If you have a Medigap policy, Medicare will pay its share of the Medicare-approved amount for a medical service. Then, the Medigap policy pays its share.
You can buy a Medigap policy from a private company in your state who sells them, though keep in mind they do not cover everything. It’s important to note that Medigap plans do not cover prescription drugs. You will need to purchase a separate Part D plan. Some other services not covered by Medigap policies typically include long-term care, vision, dental, hearing aids, or glasses.
How Do I Know if a Service Is Covered?
First, ask your doctor if a service is covered. You can also contact Medicare directly.
Or, go online to Medicare.gov/coverage, where there is a “Is my test, item or service covered?” tool. Enter the item in question, search, and Medicare will tell you if it’s covered or not and at what percentage.
Knowing what is and isn’t covered by Medicare and your Part D plan is important to help keep dollars in your wallet. If you receive a service or treatment that isn’t covered, you will likely have to pay the full cost out-of-pocket.
If you need a procedure or treatment that is not covered, your healthcare provider should let you know and, in most cases, you’ll have to sign a release prior to receiving treatment acknowledging you know it’s not covered.
What if Medicare Won't Pay?
If you believe a service or treatment should be covered, or something you received was denied, you can file an appeal with Medicare to attempt to get coverage. Your doctor may have to submit testimony as part of the appeal process that the service or equipment you want covered is medically necessary and cannot be received in any other way.
However, just because you file an appeal doesn’t mean you’re guaranteed coverage. If your appeal is denied, you will be required to pay for the service out of your pocket.
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