What Does Medicare Not Cover?

Key Takeaways

• Medicare does not cover services, medications or equipment that are not medically necessary.

• The list of items not covered by Medicare includes routine dental care, dentures, dermatology, eye exams for glasses and hearing aids.

• Private insurers offer Medicare Advantage (Part C) . It provides at least the same coverage as Parts A and B. Part C often includes benefits that Original Medicare does not.

• Prescription drug coverage is not provided as a part of Original Medicare (Parts A and B) but can be added as a standalone Part D plan .

• Medicare does not cover annual physicals but provides an Annual Wellness Visit that focuses on your current health and preventive care .

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  Asking the question “What does Medicare not cover?” can be just as important as learning what does Medicare cover. Medicare provides a wealth of benefits aimed at improving your health, now and in the future. But it doesn’t cover everything. Some services, like cosmetic surgery, not being covered may not surprise you. But there are other excluded services that you’ll want to know about. To help you understand what to expect from your benefits, here’s a rundown of what is not covered by Medicare.

  

What is Not Covered by Medicare?

Rest assured that your Medicare coverage is going to meet the majority of your healthcare needs. But Medicare enrollment doesn’t qualify you to receive any healthcare-related service or item you want. Medicare coverage comes with a few standard stipulations; the service or equipment must be medically necessary, and the doctor must accept Medicare assignment. To have equipment covered by Medicare, you must receive it from a Medicare-approved supplier. Under these guidelines, Original Medicare (Parts A and B) generally does not include dental coverage, eye exams for glasses or hearing aids — among other things. Medicare will cover them if you need prescription drugs, but you’ll need to enroll in a separate Medicare Prescription Drug Plan (Part D).

Medicare Advantage (Part C) plans often cover services and items that Original Medicare doesn’t. Medicare Advantage replaces Original Medicare (Part A and B) but offers the same Part A and B benefits or coverage as Original Medicare. Along with receiving Part A and B benefits, Medicare Part C often bundles additional dental, hearing, vision and prescription drug coverage.

What does Medicare Part B Not Cover?

Medicare Part B provides the medical insurance portion of your coverage. The medical part of Medicare helps pay for doctor visits and services, durable medical equipment and other medically necessary services you need while outside of a medical facility (outpatient). Several items and benefits may seem to meet Medicare’s qualifications for coverage but don’t. Knowing what Medicare Part B does not cover can help you plan and find separate coverage before needing it.

Medical services not covered by Part B

• Cosmetic surgery

• Long-term care

• Nursing home custodial care

• Vision and eye exams

• Routine dental care

• Routine foot care

• Dermatology

• Most chiropractic care

Medical equipment not covered by Part B

• Hearing aids

• Blood pressure monitors

• Adult diapers

• Dentures

• Dental implants

If you receive any of these services, you may need to pay full price if you’re enrolled in Original Medicare — even if your doctor says you need them. If you need any of these services or equipment, talk to your doctor to see if it’s covered.

How Medicare does (and does not) cover mobility equipment

If you or a loved one need mobility equipment, Medicare will not cover all options equally. Instead, Medicare and your doctor will take a hard look at your condition and prescribe the type of equipment you need. In other words, if you’re stable enough to use a cane but want a motorized scooter, Medicare generally won’t cover the scooter. There are some exceptions and guidelines Medicare Part B uses to determine what type of mobility equipment it will cover.

Manual wheelchair 

If you can’t use a cane or walker safely, but you have enough upper body strength or have someone available to help, you may qualify for a manual wheelchair.

Power-operated vehicle/scooter 

If you can’t use a cane or walker or operate a manual wheelchair, you may qualify for a power-operated scooter. To qualify, you must be able to get in and out of it safely and strong enough to sit up and safely operate the controls.

Power wheelchair 

If you can’t use a manual wheelchair in your home or don’t qualify for a power-operated scooter because you aren’t strong enough to sit up or work the scooter controls safely, you may be eligible for a power wheelchair.

Note: Before you get either a power wheelchair or scooter, you must have a face-to-face exam with your doctor.

What is Not Covered Under Medicare Preventive Care Benefits?

Aside from simply treating illnesses and injuries you already have, Medicare offers a robust system of preventive services aimed at improving your health outcomes over time. With screenings and other proactive services, Medicare beneficiaries can find health issues early before becoming more serious and costly.

One service many Medicare beneficiaries expect to find, but don’t, is their annual physical. Under current Medicare guidelines, the traditional annual check-up is not covered. But that doesn’t mean your health isn’t monitored every year.

Within 12 months of enrolling in Medicare Part B, you’ll have a Welcome to Medicare preventive visit with a doctor. Your doctor will check your height, weight, blood pressure and other measurements during this appointment. You’ll also receive a vision test and discuss your medical history.  All Medicare beneficiaries are allowed one Welcome to Medicare preventive visit.

Then one time per year, you’ll have an Annual Wellness Visit. Like with an annual physical, your doctor will check for issues and determine if any further preventive services are needed to keep you as healthy as possible. While not technically a physical, you’ll receive a similar level of managed care.

Are there Prescription Drugs Not Covered by Medicare?

Yes, much like medical services, Medicare will only cover medically necessary prescription drugs. Drugs not covered by Medicare can include weight loss or sexual health medications. But Medicare’s prescription drug coverage exclusion can also extend to brand-name drugs with suitable generic options available at lower prices. The main takeaway is that Medicare generally covers medications you need, but you may need to look past the brand names. Discuss your medications with your doctor if you have any questions.

How Much Does Medicare Cover?

While the focus here has been on which type of care is not provided by Medicare, beneficiaries receive an impressive array of services, treatments and equipment. With Original Medicare (Parts A and B), you’ll receive preventive care to keep you healthy, and inpatient and outpatient services when you do need medical treatments. Depending on what you need, Medicare will cover it at different levels. For example, Part B often covers 80% of approved costs (after you’ve met your deductible), while Part A has a different price structure.

Those with Medicare Advantage (Part C) receive at least the same coverage as Parts A and B and often have more benefits included. Part C plans also have different costs.

No matter what form of Medicare you have, whether or not your service or item is covered comes down to a few primary details.

Which type of care is not covered by Medicare?

When figuring out if what you need is covered, remember these general rules:

• Your item or service must be deemed medically necessary by a doctor or provider.

• That doctor or provider must accept Medicare assignment.

• Each item must be medically necessary and obtained through a Medicare-approved supplier.

Unfortunately, Original Medicare typically does not pay for home modifications. However, there are some exceptions to this rule. Medicare may pay for part of the modification process provided it’s required for medical reasons and prescribed by a doctor. You may be able to receive assistance from Medicare in determining what home modifications are medically required. Medicare Part B will pay for an occupational therapist to evaluate a home and determine what changes are required. But in most cases, home modifications are not covered by Medicare.

If you have any more questions about what is and isn’t covered by Medicare, give GoHealth a call. Our licensed insurance agents can look at your policy and discuss your needs. Then, we’ll see if your plan offers what you need. If not, we’ll find plans that do.

Sources

• Medicare Wheelchair & Scooter Benefit. CMS.gov

• Your Guide to Medicare Preventive Services . Medicare.gov.

• ITEMS & SERVICES NOT COVERED UNDER MEDICARE . CMS.gov.

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