Many people expect Medicare to work like the health insurance they had before retirement. It can provide important coverage for hospital and medical care, but it does not pay for every health-related expense.
Understanding what Medicare does not cover can help you plan before unexpected bills arrive. This is especially important when you are first enrolling, because some coverage choices are easier to make during your initial enrollment period.
When people say “Medicare,” they often mean Original Medicare, which includes Part A for hospital care and Part B for medical care. Original Medicare may cover many medically necessary services, but there are several common gaps to know about.
Does Medicare cover routine dental care?
Original Medicare generally does not cover routine dental care. That may include regular exams, cleanings, fillings, dentures, and most tooth extractions.
Medicare can cover certain dental services when they are part of a covered medical treatment. For example, it may cover some dental care that is needed before a covered organ transplant or another hospital-based procedure. These situations are limited, so it is wise to ask your dentist and Medicare provider about coverage before treatment.
If routine dental care matters to you, you may consider a separate dental plan or paying for care directly. Some Medicare Advantage plans may include routine dental benefits. Those benefits can vary by plan, carrier, service area, and state, so review the plan details carefully.
Does Medicare pay for eye exams and glasses?
Original Medicare generally does not cover routine eye exams for glasses or contact lenses. It also usually does not pay for standard eyeglass frames, lenses, or contact lenses.
However, Medicare Part B may cover certain eye-related services when they are medically necessary. Examples may include cataract surgery, glaucoma tests for people at higher risk, diabetic eye exams, and treatment for eye diseases or injuries.
After covered cataract surgery, Medicare may help pay for one pair of basic corrective lenses or one set of contact lenses. You may still have deductibles, coinsurance, or costs for upgrades.
For routine vision needs, a separate vision plan may be an option. Medicare Advantage plans may also offer vision benefits, although the amount and type of coverage can differ from one plan to another.
What about hearing exams and hearing aids?
Hearing is another area that often surprises new Medicare beneficiaries. Original Medicare generally does not cover routine hearing exams or hearing aids.
Part B may cover a diagnostic hearing and balance exam if your doctor or other qualified provider orders it to help find a medical problem. For example, an exam may be covered when you have dizziness, hearing loss connected to an illness, or balance concerns. Even then, you may have your share of the Medicare-approved cost.
Hearing aids themselves are generally not covered by Original Medicare. Some Medicare Advantage plans may include hearing benefits or allowances, but it is important to understand the plan’s provider network, approved devices, copays, and benefit limits.
Does Medicare cover long-term care?
Original Medicare does not generally pay for long-term custodial care. Custodial care means help with everyday activities such as bathing, dressing, eating, using the bathroom, or getting around safely.
This is different from skilled nursing care. Medicare may cover a limited stay in a skilled nursing facility when you meet certain conditions and need skilled care after a qualifying hospital stay. Coverage is not designed to pay for an extended stay when someone mainly needs daily personal assistance.
Long-term care can be provided at home, in assisted living, or in a nursing facility. People may use personal savings, long-term care insurance, family support, Medicaid if they qualify, or other resources to help with these needs. Planning early may give you more choices.
Prescription drugs are not included in Original Medicare
Original Medicare usually does not cover most prescription drugs you pick up at a retail pharmacy. To get outpatient prescription coverage, many people enroll in a standalone Medicare Part D prescription drug plan.
Part D plans have their own drug lists, called formularies. A plan may cover your medication but place it in a different cost tier than another plan. Pharmacy networks, deductibles, copays, and coverage rules can also vary.
Medicare Advantage plans often include prescription drug coverage, although not every plan does. If you are considering a Medicare Advantage plan, check whether your prescriptions are covered and whether your preferred pharmacy is in the plan’s network.
Other common services Medicare may not fully cover
Original Medicare may have limited coverage or no routine coverage for several other services. These can include:
- Routine foot care, such as nail trimming or treatment of corns and calluses, unless it is medically necessary for certain conditions
- Care outside the United States, except in a few limited situations
- Most cosmetic surgery, unless it is needed because of an injury, illness, or another covered medical reason
- Routine physical exams, although Medicare does cover certain preventive visits and screenings
- Personal comfort items during a hospital stay, such as private rooms when they are not medically necessary
Medicare also does not eliminate all out-of-pocket costs for covered services. With Original Medicare, you may still have deductibles, copayments, and coinsurance. There is generally no annual out-of-pocket maximum under Original Medicare alone.
How can you prepare for Medicare coverage gaps?
Start by thinking about the care you use now and may expect to use in the future. Make a list of your prescription drugs, doctors, specialists, dental needs, vision needs, and hearing needs. This list can make comparing coverage options much easier.
A Medicare Supplement insurance plan, also called Medigap, can help pay certain out-of-pocket costs left by Original Medicare, such as some deductibles and coinsurance. It does not typically add routine dental, vision, hearing aid, or long-term care benefits. You would usually need separate coverage or a separate plan for those services.
Medicare Advantage can be another way to receive Medicare-covered services through a private insurance plan. Many plans may offer additional benefits such as dental, vision, or hearing coverage. In exchange, these plans often have provider networks and plan rules that you should review closely.
The best approach depends on your doctors, medications, budget, travel habits, and comfort with networks. Benefits, premiums, and availability can vary by plan, carrier, county, and state.
If you would like help understanding how Original Medicare, Part D, Medicare Advantage, and Medicare Supplement plans may fit your needs, reach out to Eric for free, no-pressure guidance. With 25 years of experience, he can help you review your options clearly and at your own pace.