Roughly 56 million Americans rely on Medicare to help cover the cost of their doctor visits, hospitalizations and prescription drugs. But like most forms of health insurance, the program won’t cover everything. The services Medicare won’t help pay for often come as a surprise and can leave people with hefty medical bills.
Here are six services Medicare doesn’t fully cover.
Long-Term Nursing Home Care
“People just sort of assume that if you have Medicare it will be covered,” says Keith Lind, senior strategic policy advisor in AARP’s Public Policy Institute.
In fact, Lind says his research shows that about half of all Medicare costs are paid by beneficiaries out of their own pocket – and a big portion is for long-term care. Medicare will pay for some shorter-term nursing home care, but only up to 100 days following a three-day inpatient hospital stay.
But beware: A common practice is to hospitalize patients for several nights in what’s called an observation unit, which is considered outpatient care. Unless you’re admitted as an inpatient, you won’t qualify for needed nursing home care following your hospital stay.
“The trap for the unaware is that you have to have a three-day hospitalization to go to a skilled nursing facility,” Lind says. “People in observation are surprised they won’t be covered.”
Once admitted to the hospital, it’s important to confirm directly with your medical care team that you are being cared for as an inpatient, rather than under observation.
Traditional Medicare does not cover the cost of routine dental care, including dental cleanings, oral exams, fillings and extractions. Eye glasses and contact lenses aren’t covered either.
Medicare will help pay for some services, however, as long as they are considered medically necessary. For example, cataract surgery and one pair of glasses following the procedure are covered, although you must pay 20 percent of the cost, including a Part B deductible.
And, according to David A. Lipschutz, senior policy attorney with the Center for Medicare Advocacy, there are narrow criteria that allow for dental care coverage in extreme cases. A serious infection in the mouth or a jaw disorder that requires inpatient hospitalization, say due to a cancer diagnosis, may qualify for coverage under Medicare.
Many Medicare Advantage plans, which are Medicare policies administered by private insurers, may offer benefits to help cover the cost of routine dental and vision care.
But Lipschutz cautions that these extra benefits, while nice to have, tend to be quite limited. For that reason, make sure to keep your broader health care needs in mind and consider all costs before choosing Medicare Advantage over traditional Medicare.
With traditional Medicare, you can get coverage for treatment if you’re hospitalized or need to see a doctor while you’re away from home inside the U.S. People covered by Medicare Advantage policies, however, generally need to see doctors within their plan’s network for full coverage. If your plan is a preferred provider organization, or PPO, you may get help from your insurer paying for services outside of its provider network, although at a lower rate. If your plan is an HMO, however, you could be on the hook for the entire bill, as these policies generally don’t pay for care delivered by health care providers who don’t participate in the network.
When it comes to travel overseas, Medicare rarely covers the cost of medical services, except under special circumstances in Canada or for care delivered on a cruise ship within six hours of a U.S. port.
Many Medigap plans, supplemental insurance that helps cover the cost of care that Medicare doesn’t, will pay 80 percent of billed charges for emergency care that’s deemed to be medically necessary and is delivered within the first two months of a trip outside the U.S. You’ll first need to meet a $250 annual deductible. There’s also a lifetime limit of $50,000 for foreign travel emergency care.
“Some Medicare Advantage plans provide some foreign coverage, but you have to look for it specifically,” Lind says.
And sometimes Medicare Advantage plans offer worldwide coverage for emergencies, but not all plans offer the same extra services or define emergency in the same way.
Medicare will cover the cost of diagnostic hearing exams, as long as they’re ordered by your doctor to determine if medical treatment is needed. The program will also pay for cochlear implants to repair damage to the inner ear.
But Medicare doesn’t cover routine hearing exams, hearing aids or exams for fitting hearing aids, which can be quite expensive when you’re paying for them out of pocket.
“The inpatient stay is covered during the most acute states when medical complications are more probable,” Lind says.
A five-day limit on inpatient care for alcoholism and drug addiction may be extended depending on the patient’s condition. Generally, between 16 and 19 days of rehab services are covered.
But as more people seek help as a result of an opioid addiction epidemic that has ravaged many communities throughout the country, Medicare in most cases does not cover the cost of methadone, a commonly used medication to treat opioid dependence.
“Medicare won’t cover methadone for opioid addiction, only for certain pain treatment,” Lipschutz says.
Alternative or Cosmetic Medicine
Alternative treatments such as acupuncture or chiropractics are not typically covered by Medicare. Chiropractic care is covered only in cases in which a licensed chiropractor manually manipulates the spine to correct a condition that causes one or more of the bones of the spine to become dislocated.
The Medicare plans represented are PDP, HMO, PPO or PFFS plans with a Medicare contract. Enrollment in plans depends on contract renewal.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800- MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
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