Medicare provides invaluable health coverage for Americans 65 and over, as well as younger individuals with certain disabilities. But Medicare does not cover all health care services. There are some significant gaps that seniors should be aware of as they consider coordinating supplemental coverage.
Below we will look at 6 major categories of services that are not covered by original Medicare Parts A and B. Understanding these gaps can help you plan for out-of-pocket costs.
1. Routine Dental Care
One of the biggest gaps in Original Medicare is coverage for dental services. Medicare does not cover routine dental care like:
Dental fillings and crowns
Medicare Part A will only cover dental services that are required as part of an inpatient hospital stay, such as reconstructive surgery after an accident. Medicare Part B also only covers dental services required for certain covered medical treatments, like tooth extractions prior to radiation treatment for oral cancers.
But any preventative, restorative, or cosmetic dental work is generally excluded. Basic dental care must be paid completely out-of-pocket by seniors on Medicare.
Options to obtain dental coverage include:
Purchasing a stand-alone dental insurance plan
Enrolling in a Medicare Advantage Plan that includes dental benefits
Seeing if you qualify for dental coverage through Medicaid
Looking into dental discount plans and clinics for discounted rates
Without additional dental coverage, individuals face paying full price for cleanings, fillings, crowns, dentures, and other dental work needed to maintain good oral health.
2. Routine Vision Care
Similar to dental care, Medicare does not cover routine eye care and vision services like:
Eye exams for glasses/contacts
Contact lens supplies
Medicare Part B only covers vision services related to medical conditions affecting the eyes. This includes annual eye exams for those with diabetes and diagnosis/treatment of medical eye diseases like glaucoma, cataracts, and macular degeneration.
But Medicare does not cover routine vision needs like annual eye exams for glasses or contacts, or the eyeglasses or contacts themselves.
Options for obtaining routine vision coverage include:
Purchasing supplemental vision insurance
Enrolling in a Medicare Advantage Plan that covers vision services
Paying for exams and eyewear out-of-pocket
Seeing if you qualify for free/discounted eyewear through programs like Vision USA
Without additional coverage, Medicare beneficiaries may pay several hundred dollars per year for an exam and new eyeglasses or contacts.
3. Hearing Aids and Exams
Hearing aid costs are not covered by original Medicare. This includes:
Routine hearing exams
Hearing aid evaluations/fittings
Batteries and other hearing aid supplies
The only hearing-related services covered by Medicare Part B are exams to diagnose and treat hearing issues related to illness or injury. Any routine hearing tests or hearing aids must be paid for by beneficiaries.
Options to get coverage for hearing services include:
Enrolling in a Medicare Advantage Plan that includes hearing benefits
Buying separate hearing insurance
Asking your hearing aid provider about financing plans
Checking if you qualify for free hearing aids through Medicaid
Seeing if any local organizations offer free/discounted hearing aids
Hearing aids typically cost $2,000 - $4,000 per pair without coverage. So this is an expensive gap in original Medicare.
4. Long-Term Care
Medicare does not cover long-term custodial care in nursing homes, assisted living facilities, or at home. This type of ongoing assistance with activities of daily living, like bathing, dressing, using the bathroom, and eating, is not considered a medical necessity and so is not covered.
Medicare Part A will pay for a limited nursing home stay of up to 100 days following a hospitalization. But once rehabilitation is complete and skilled care is no longer medically necessary, Medicare will not continue paying for long-term care.
Ways to get long-term care coverage include:
Purchasing private long-term care insurance
Qualifying for Medicaid through both financial and medical eligibility (covers nursing home care)
Paying privately for home health aides, assisted living, and nursing homes
Long-term care costs can easily exceed $100,000 per year depending on the level of assistance required and setting. This makes planning ahead very important.
5. Most Dental Care
As noted under routine dental care, dental implants, dentures, bridges, crowns, and other major dental services are generally not covered by Medicare.
The only dental care potentially covered is:
Surgery on the jaw or related structures
Setting fractures of the jaw or facial bones
Extracting teeth prior to radiation treatment of neoplastic diseases
So Medicare will only pay for certain dental services that are medically necessary and involve general health issues. Any routine or restorative dental work is not covered.
6. Cosmetic Procedures
Medicare does not cover cosmetic or aesthetic procedures purely meant to improve appearance. This includes:
Laser skin treatments
The only exception is if a cosmetic procedure is medically needed, such as reconstructive surgery after an injury or to correct functional impairment. Medicare may then cover certain plastic surgery procedures under Part A or Part B.
But any cosmetic treatments done purely for appearance reasons would not be covered and would need to be paid privately.
Supplemental Insurance Options
To help cover these common gaps in original Medicare, many beneficiaries enroll in additional insurance plans:
Medicare Supplement (Medigap) Plans help pay Medicare out-of-pocket costs like coinsurance and deductibles. But they do not cover most of the services above.
Medicare Part D Plans add prescription drug coverage, but do not cover the other gaps.
Medicare Advantage Plans often include some of the above benefits like dental, vision, and hearing. $0 premium plans may provide the most value.
Individual supplemental policies can be purchased for things like dental/vision insurance or long-term care coverage.
Understanding these limitations allows Medicare beneficiaries to plan ahead and coordinate supplemental policies or programs to cover non-Medicare services and minimize out-of-pocket expenses.
In summary, original Medicare does not cover several key healthcare services seniors commonly need. Understanding gaps around routine dental, vision, and hearing care can help you prepare for these costs. Also recognizing that Medicare excludes long-term custodial care and cosmetic treatments allows you to plan accordingly.
Carefully reviewing your supplemental coverage options like Medicare Advantage and individual vision/dental policies enables coordinating the right additional benefits around the original Medicare foundation. Planning ahead and utilizing all available public and private insurance will help you maximize affordable healthcare coverage as you age.
We’re Here to Help
You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Bourgeois Insurance a Call at (985) 803-8999. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.
What are the 6 things Medicare does not cover?
Medicare does not cover long-term care, dental care, eye exams for eyeglasses, hearing aids, routine foot care, and cosmetic surgery.
Does Medicare cover cataract surgery?
Yes, Original Medicare covers cataract surgery if it is medically necessary. Part B covers the cost of the surgery and any necessary follow-up care.
Does Medicare cover routine vision care?
No, Medicare generally does not cover routine vision care, such as eye exams for eyeglasses or contact lenses.
Does Medicare cover the cost of part d prescription drugs?
Medicare coverage does cover prescription drugs through Part D prescription drug plans. These plans are offered by private insurance companies.
Will Medicare cover everything?
No, Medicare does not cover everything. While it provides coverage for many healthcare services, there are limitations and certain services that are not covered.
Does Medicare cover long-term care?
No, Medicare does not cover long-term care, such as nursing home care. However, it may cover limited stays in a skilled nursing facility under certain conditions.
Do Medicare Advantage Plans cover more than Original Medicare?
Yes, Medicare Advantage Plans may offer additional benefits beyond what is covered by Original Medicare. These can include prescription drug coverage and additional services.
Can I sign up for Medicare if I am eligible?
Yes, if you are eligible for Medicare, you can enroll in the program during specific enrollment periods. It is recommended to sign up during your initial enrollment period to avoid any coverage gaps.
Does Medicare cover routine eye exams?
No, Medicare does not cover routine eye exams for eyeglasses or contact lenses. However, it may cover eye exams if they are medically necessary, such as for the diagnosis of an eye disease.
Do Medicare Part B deductibles apply to prescription drugs?
No, the Part B deductible does not apply to prescription drugs. It only applies to certain medical services and supplies covered by Part B.
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