About 10,000 people turn 65 every day in the US. Presuming the majority of us all have contributed to it for years through our payroll taxes. For us as older adults become eligible to take advantage of the federal health insurance upon hitting the 65-year milestone. This is good news. But, for many, it comes with the surprise that there are Services That Original Medicare does not cover. They will still have to pay for many medical services from their pocket.
A study conducted by Fidelity a couple of years ago offered estimates of health care spending by retirees. According to the study, a 65-year-old couple retiring in 2020 would pay about $295,000 on average over their lifetime.
Wondering what you (or a loved one) would pay this much for? Medicare premiums, deductibles, copays, and services that Original Medicare does not cover.
What Does Original Medicare Not Cover?
Original Medicare is meant to cover your basic medical expenses. Hence, there are many things that your Medicare plan does not pay for unless you get some additional coverage. Today we will talk about the nine healthcare items and/or services that Original Medicare does not cover. As well as what will we will likely need.
1. Prescription Drugs
Medicare Part A and Part B do not cover prescription drugs. However, there are a few conditions where you may get outpatient prescription drug coverage under Medicare Part B. These are the drugs administered at a doctor’s office or hospital outpatient setting. These include injectable drugs, antigens, and drugs administered through durable medical equipment. Some drugs for osteoporosis, end-stage renal disease, and blood clotting factors fall into this category. By doing this they are covered by Medicare Part B. Deductible applies in these situations as well.
Those who do not qualify for this coverage but regularly need (other) prescription drugs can buy coverage for them separately. This can be done through Medicare Part D or Medicare Advantage. Compare the coverage and cost of both plans to find the best option for yourself.
Pro Tip:
Evaluate your need for prescription drug coverage before your 65th birthday. This way you can enroll in it alongside Original Medicare. While you can enroll in the Medicare Prescription Drug Coverage plan later as well. You can do this during the Annual Enrollment Period, it’s best to do when your first sign up for Medicare. You may have to pay the penalty for delaying enrollment in Part D.
2. Most Dental Care Services
Original Medicare does not pay for most services related to the routine care or treatment of teeth and structures directly supporting the teeth. Simply put, It won’t pay for your routine dental exams, cleanings, fillings, root canals, dentures, and most tooth extractions. The only situations where your Original Medicare plan may cover your dental services are when you need:
- An oral exam is performed as part of inpatient care, at a federally-qualified health center or a rural health center before undergoing a renal transplant or heart valve replacement surgery.
- A dental X-ray to treat a fractured facial bone or jaw.
- Tooth extraction in preparation for neoplastic disease radiation treatment.
- A non-covered dental treatment or service as an integral part of a covered procedure. For example, teeth wiring that is performed as part of jaw fracture treatment is paid for by Original Medicare.
Since routine dental checkups are a vital part of overall health care maintenance and the cost of dental care can significantly increase your out-of-pocket expenses, it’s good to have dental coverage.
There are two key options for it. Choose a Medicare Advantage plan that includes dental coverage or buy stand-alone dental insurance. Medicare Advantage plans may seem like great options, but they come with an annual coverage cap for dental care services and treatments. It’s important to check that to figure out if the plan will cover all your dental care expenses or if you would still be paying some money from your pocket. Stand-alone dental insurance plans generally make a better alternative. But, you do you. Do your research to find the best dental care coverage option for yourself.
3. Routine Eye Exams and Glasses
Bad news for people who wear glasses (most seniors, if not all) – Original Medicare doesn’t pay for your regular eye exams or glasses unless you have diabetes or have had certain kinds of cataract surgery. For people with diabetes, it pays for the annual eye exams, and for those who have undergone cataract surgery, it pays for one pair of eyeglasses or contact lenses.
Having said that, if you have certain eye conditions, Medicare Part B does offer coverage for diagnostic tests and treatment procedures you may require. These include:
- Cataract removal surgery
- Glaucoma tests (only for people who are at high risk)
- Tests and treatment procedures for macular degeneration
Even though covered, these vision care services will be entitled to copayments, and the Part B deductible also applies.
Knowing that vision deterioration is an integral part of the aging process, it’s good for seniors to have comprehensive vision care coverage. For that, there are two primary options available – buy a Medicare Advantage plan that includes vision coverage or buy a supplemental policy for it. If you buy supplemental insurance, you can either get a stand-alone vision care insurance policy or get one that offers vision and dental coverage (there are such policies available).
4. Routine Hearing Exams and Aids
If aging has affected your hearing, you may need regular exams and are required to use a hearing aid to maintain your quality of life. However, you will have to pay for them from your pocket as these aren’t covered under Original Medicare. The only situations where Part B may pay a part for a diagnostic hearing and balance exam are when it is ordered by a doctor in an emergency and/or to determine your need for medical treatment. An example of when Medicare will pay for a diagnostic hearing exam is when it is ordered to determine the cause of dizziness experienced by a patient.
For others, some Medicare Advantage plans offer hearing aids coverage and may also pay for your fitting exams.
5. Long-Term Care
Research tells that about 70% of older adults, i.e., those above 65, will need long-term care services at some point in their life. However, most retirees rely upon Medicare for their health care expenses, only offering limited coverage.
Under Original Medicare, you’re only covered for a specific number of days (100) at skilled nursing or assisted living facilities for certain services.
Original Medicare coverage does not include custodial care, which most seniors likely need help with as they age. Assistance with everyday activities such as going to the toilet, bathing, and dressing all qualify as custodial care and are not paid for by it. You need to purchase a separate long-term care policy to cover these costs.
While you may want to wait till you need these services to enroll in a long-term care policy, you will have to pay high premiums if you do so. Enrolling in a long-term care plan when you’re younger and healthy will get you better rates.
Medicaid is another option to pay for long-term care, but it’s not an option for all seniors, as it’s only available to those with limited income.
6. Medical Services Outside the US
Medicare does not pay for medical treatment you receive outside the United States unless it was given under a few specific scenarios. These include:
- Treatment given in a medical emergency occurred within the US, but a foreign hospital was closer than the American hospital.
- Treatment was given in a medical emergency encountered while traveling to Canada through the most direct route and the Canadian hospital was closer than an American hospital.
- Treatment given in a medical emergency encountered while onboard a ship that left the port no more than six hours ago or reaching a US port within the next six hours.
Simply put, there are very limited scenarios where your Original Medicare plan would pay for medical services or treatments received outside the US. While this may not be a big issue for most people, those who frequently travel internationally may want to purchase a Medigap plan to cover their health care costs overseas. Although a Medicare Supplement is designed to build upon your Original coverage, many of its plans offer additional coverages, including foreign travel emergency health care coverage.
Check out our blog Medicare Supplement Cheat Sheet to know what Medigap plans offer foreign travel health coverage and how much of your cost they will pay off.[1]
Some Medicare Advantage plans also offer emergency care coverage abroad. Buying a separate travel insurance policy is another option to cover your medical expenses on foreign land.
7. Cosmetic Surgeries
Most health insurance does not cover cosmetic surgeries. Medicare is no exception in most situations. It does, however, offer coverage for cosmetic surgeries in the following situations:
- Breast prostheses are performed after mastectomy as part of a breast cancer treatment plan
- Cosmetic surgery becomes medically necessary to fully recover from an accidental injury, it covers 80% of the cost.
- Where cosmetic surgery is deemed necessary by doctors to improve a malformed body parts function. Rhinoplasties that are performed to correct congenital birth defects or functional impairment caused due to an accident fall into this category. The original Medicare plan covers 80% of the approved cost for such surgeries. You may also get coverage for surgeries performed to fix chronic nasal obstructions that cannot be effectively treated via non-surgical methods.
These are the few scenarios where Medicare will pay for your cosmetic surgeries. However, it never pays for a surgery performed purely for cosmetic purposes.
8. Alternative Treatments
Even if your doctor prescribes them, Medicare, in most cases, does not pay for treatments and procedures that fall under the category of alternative medicine. These include, but are not limited to, massage therapies, various experimental procedures, and medical marijuana. Acupuncture and chiropractic services are only covered under very specific conditions.
You will get Medicare coverage for acupuncture for chronic lower back pain if it meets Medicare’s definition of chronic back pain. Medicare defines chronic back pain as the one that:
- Has no identifiable systemic cause; cannot be associated with systemic diseases.
- Not associated with surgery or pregnancy.
- Lasts for 12 weeks or longer.
If your back pain meets these conditions, your Original Medicare plan will pay for a maximum of 12 acupuncture sessions within 90 days period. You may get coverage for additional eight sessions if you experience/exhibit improvement, but you won’t get coverage for more than 20 acupuncture sessions in a year.
It has only started offering this acupuncture coverage from January 2020.
You can only get Medicare coverage for chiropractic services when one or more of your spinal bones have slipped out of position – a condition called subluxation – and chiropractic spinal manipulation is deemed medically necessary to fix the problem. Even in that case, Medicare will pay 80% of the approved cost; you will be responsible for the remaining 20% and deductible.
9. Foot Care
Several people need regular foot checkups and/or foot care services to maintain healthy feet and overall health maintenance. These may include:
- Flat feet treatment
- Nail debridement services
- Care and treatment for calluses and corns
- Orthopedic shoes
- Diabetic foot exam
Unfortunately, it doesn’t cover any of these foot treatments or care services; you will have to pay for them on your own.
What Does Original Medicare Pay for?
Now we know what Original Medicare doesn’t cover. What medical treatments and health care services does it actually pays for.
For those who may not know, let’s take a quick look at Original Medicare coverage.
Original Medicare Coverage
Parts A and B are what make up Medicare. Each of these comes with its own set of coverage rules, guidelines, and limitations.
Medicare Part A Coverage
Medicare Part A is the responsible for the hospital side. This can be misleading because Part A pays for more than just hospital. Although inpatient care in a hospital is a major part of Medicare Part A coverage. It is not the only thing Part A pays for. Here’s all that Medicare Part A offers coverage for:
- Inpatient care at a hospital, including all services from lab tests to surgeries.
- A short-term stay at skilled nursing facilities
- Nursing home care when it doesn’t include custodial care
- Hospice care
- Certain home health care services
The best part about Medicare Part A is that it comes for free to those who (or their partners) paid their Medicare taxes during employment years.
Medicare Part B Coverage
Also known as “Medical Insurance,” Medicare Part B offers coverage for:
- Outpatient care.
- Medical services are necessary to diagnose and treat various health conditions.
- A range of preventive care services is necessary to avoid various diseases or detect them early. Example are vaccines and mammograms.
- Home health care.
- Durable medical equipment that a doctor believes is necessary for the Medicare beneficiary. These may include wheelchairs, walkers, hospital beds, etc.
- Ambulance services
- Mental healthcare
- Clinical research
Unlike Medicare Part A, Part B doesn’t come free to anyone. Every Medicare beneficiary has to pay a premium for Medicare Part B.
How to Determine Your Medicare Coverage – The Easy Way
These details should be enough to tell you what medical and health care services your Medicare plan covers. Get in touch with us and talk to our Medicare experts for any other help, advice, or suggestions regarding Medicare. We’ll be happy to assist you to acquire comprehensive health coverage as per your needs.
