What Does Medicare Not Cover? 10 Things You Should Know

What are 10 common things Original Medicare does not cover?

Original Medicare means Part A, hospital insurance, and Part B, medical insurance. It covers many medically necessary and preventive services, but it has important exclusions.

1. Long-term care or custodial care: This usually means help with daily activities such as bathing, dressing, or eating when that is the only care you need.
2. Most dental care: Routine cleanings, fillings, tooth extractions, dentures, and implants are not covered in most cases.
3. Routine vision services: Eye exams for prescription eyeglasses are generally not covered by Original Medicare.
4. Hearing aids: Original Medicare does not cover hearing aids or exams for fitting them.
5. Most cosmetic surgery: Cosmetic procedures usually are not covered unless an exception applies, such as surgery needed because of accidental injury or to improve the function of a malformed body part.
6. Massage therapy: Massage therapy is listed as a service Original Medicare does not cover.
7. Routine physical exams: Original Medicare does not cover routine physical exams, even though it may cover certain preventive services under separate rules.
8. Concierge membership fees: Medicare does not cover membership fees charged by concierge or retainer-based medical practices.
9. Care from providers who opt out of Medicare: In many cases, you pay for covered items or services from a doctor or provider who has opted out of Medicare, except for emergency or urgent needs.
10. Most care outside the U.S.: Medicare usually does not cover health care when you travel outside the United States, with limited exceptions.

What does “not covered” mean for your costs?

If Medicare does not cover a service, you generally pay the full cost yourself unless another source of coverage applies. Examples may include a Medicare Advantage Plan, a Medicare Cost Plan, PACE, Medicaid, employer or retiree coverage, or a separate policy that covers the service.

Medicare Advantage Plans must cover almost all medically necessary services that Original Medicare covers, but they may also offer extra benefits that Original Medicare does not cover, such as certain dental, vision, or hearing benefits. These extra benefits vary by plan and may have limits, networks, prior authorization rules, or copayments.

Are dental, vision, and hearing ever covered by Medicare?

Sometimes, but the details matter. In most cases, Original Medicare does not cover routine dental services such as cleanings, fillings, extractions, dentures, or implants. Medicare may cover certain dental services when they are closely related to a covered medical treatment.

Original Medicare also generally does not cover eye exams for prescription eyeglasses, hearing aids, or exams for fitting hearing aids. Some Medicare Advantage Plans may offer extra dental, vision, or hearing benefits, but the coverage is plan-specific.

Does Medicare cover nursing home or long-term care?

Medicare does not provide broad long-term care coverage. Long-term care, also called custodial care or long-term services and supports, can include help with daily living needs over an extended period.

Medicare may cover skilled nursing facility care or home health care when Medicare requirements are met, but that is different from paying for a long-term nursing home stay when custodial care is the only care needed. If long-term care is a concern, check Medicaid eligibility rules in your state and any separate long-term care coverage you may have.

What exceptions apply to cosmetic surgery, travel, and concierge care?

Cosmetic surgery is usually not covered, but Medicare may cover certain procedures when they are medically necessary under Medicare rules. Examples include surgery needed because of accidental injury, surgery to improve the function of a malformed body part, or breast reconstruction after a mastectomy for breast cancer.

Medicare usually does not cover care outside the U.S. Some limited foreign travel situations may qualify, and some Medigap policies may help with emergency care outside the U.S. Concierge care is different: Medicare does not pay the membership fee, though doctors who accept Medicare assignment must still follow Medicare rules for Medicare-covered services.

How can you check before getting a service?

Before scheduling care, ask the provider whether the service is covered by Medicare, whether the provider accepts Medicare, and whether the provider accepts assignment. If a provider has opted out of Medicare, ask what private payment agreement you would be signing.

If you are in a Medicare Advantage Plan, contact your plan before getting non-emergency care. Ask whether the service is covered, whether you need prior authorization, whether the provider is in network, and what your expected out-of-pocket cost may be.

Official Sources