What Medicare Doesn’t Cover

Medicare is pretty black and white about what they do and do not cover. Many will find it surprising that services like long-term care and prescription drugs are not covered. These can often be substantial expenses that one may face, and that may be a big reason why you won’t find them covered on Original Medicare. The good news is that they can often be covered either through a separate insurance policy or through Medi-Cal. Below we list what’s not covered under Original Medicare and where/how to find coverage for it.





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Non-medical Home Health

Original Medicare will not cover any home health services that are not medically necessary. This includes having someone help you with bathing, going to the bathroom, cleaning the house, shopping, or any other service that can fall under assisted living with home health. This would also include any nursing homes or assisted living facilities. To get coverage for these services you have to pay out-of-pocket, have a long-term health policy, or have Medi-Cal.

If you have Medi-Cal, then you will likely get coverage through IN-HOME SUPPORTIVE SERVICES (IHSS); however, you will need to apply for this. Either your doctor can help you or you can go to the local office in your city.

Ancillary Services

There are many services considered “extra” that aren’t covered under Original Medicare. These include:

Dental:

Most dental care, including dentures, dental procedures or cleanings, fillings, dental plates, tooth extractions, and check-ups are not covered by Medicare. Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you’re in a hospital. Part A can pay for inpatient hospital care if you need to have emergency or complicated dental procedures, even though the dental care isn’t covered. Most common ways to get dental coverage are from: a Medicare Advantage plan as an “extra” benefit, from a Medicare Supplement (Medigap) plan as an “add-on”, or as a stand-alone dental plan.

Cosmetic surgery:

Pretty much no one in the Medicare space will cover this for you. If it is considered cosmetic in any way, you can often expect to pay the full cost of the service.

Hearing aids:

Medicare won’t cover hearing aids. You can get coverage from the following sources:

  1. A Medicare Advantage plan

  2. Many Medicare Advantage plans will offer coverage for hearing aids in the form of either an allowance or a deductible. To learn more, please refer to our class on “ What is Medicare Advantage?”.

  3. Certain Medicare Supplement F Plans

  4. There are certain Medigap Plan F’s that will include hearing aid coverage. They will often have the words “extra” or “innovative” in the title. To learn more, please refer to our class on “ What is Medicare Supplement?”.

  5. Medi-Cal

  6. Medi-Cal provides a very basic level of hearing aid coverage. Each year they will cover up to $1,510 for hearing aids. This will not cover anything fancy or even mid-level. To get coverage for higher quality hearing aids, you may want to explore the other options on this list.

  7. Lions Club

  8. Most local Lion’s Clubs have a hearing aid program where individuals who are low-income can apply for support. Often those who just missed the income limits for Medi-Cal may qualify. Once accepted, you will pay a small fee and receive a quality pair of hearing aids. Contact your local Lion’s Club for more information.

Eye exams for prescription glasses and lenses:

Medicare doesn’t cover routine vision exams to check for vision correction or glasses. These services can be covered through a Medicare Advantage plan, and certain Medicare F Plans. Medi-Cal will pay for the exam, but not the glasses.

Routine foot care:

Routine foot care includes, but is not limited to, the treatment of bunions (except capsular or bone surgery thereof), calluses, clavus, corns, hyperkeratosis and keratotic lesions, keratoderma, nails (except surgery for ingrown nails), plantar keratosis, tyloma or tylomata, and tylosis. The reduction of nails, including the trimming of nails, is also considered routine foot care. Often diabetics will benefit from these types of services.

Original Medicare won’t cover this service, which means any Medicare Supplement won’t cover it as well. To get coverage for this, you will need to either enroll into a Medicare Advantage plan or have Medi-Cal.

Acupuncture:

The only way to get coverage for acupuncture is through a Medicare Advantage plan. No Medicare Supplement plan nor even Medi-Cal will cover this service.

Part D

Original Medicare does not include prescription drug coverage. Some medications may be covered when administered within a doctors office. Outside of the doctors office, any pharmacy filled medications will require a prescription drug plan (PDP) to be purchased from a private company. Medicare requires you to have prescription drug coverage or pay a penalty when you do enroll at a later date.

Any Medicare beneficiary who does not enroll into a PDP and does not have Creditable Coverage will incur a 1% penalty of the National Drug Premium average for every month without Creditable Drug Coverage. If you have any of the following examples of Creditable Coverage, then you are not required to buy a PDP. If you are uncertain if your coverage is “Creditable”, then you may want to contact your coverage provider and ask. They are required to let you know.

Examples of Creditable Coverage:

✓ Group/Employer Coverage

✓ VA

✓ TriCare

If you are interested in getting coverage for anything listed above, please contact us at the option that best suits you. We can support you in exploring your options and finding the coverage that fits your needs.

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