Just like any other program, Medicare has coverage limitations. It continues to add more items and services to its coverage, but there are still many exclusions. This article provides a list of some of the more significant exclusions. It is NOT a comprehensive list.
First and foremost, Medicare does not cover all your healthcare needs. Over the years, it has added many items and services to the coverage and continues to evolve but the program has limits and exclusions.
Keep in mind that if you have Medicaid or a private Medicare health plan or other coverage, additional benefits/services may be included in your coverage even if they are not covered by Medicare Part A and Part B.
Medicare Part A and Part B do NOT cover the following items and services (this is NOT a comprehensive list)
Prescription drugs are not covered though there are a few exceptions including, but not limited to, drugs provided during an inpatient stay at a hospital or SNF (skilled nursing facility), drugs provided during an outpatient stay which are not self-administered and drugs included as part of services provided by a doctor. If in doubt, you should confirm coverage with your doctor or hospital.
You can add prescription drug coverage by joining a Medicare Part D plan (Prescription Drug Plan or PDP).
Most Dental care
Routine dental fillings and cleanings are not covered, nor are dentures, braces, brackets, retainers and other types of dental devices. However, Part A might pay for certain dental services received while hospitalized during an emergency.
Eye tests related to prescribing glasses
Though eye sight is a common problem among the elderly, Medicare does not cover eye examinations for prescribing glasses and contact lenses. However, if you undergo cataract surgery that implants an intraocular lens, you will be provided with one pair of eye glasses or one set of contact lenses under Medicare.
Hearing aids and tests for fitting them
Hearing and balance exams are covered but only if your doctor deems them necessary. You will have to pay for hearing aid devices or for tests that are required to select and fit them.
Cosmetic surgery is not covered by Medicare unless it is essential to improve the functioning of a malformed body part or to treat an accidental injury. Elective cosmetic procedures such as breast enhancement; facial contouring; facial rejuvenation; tummy tuck, liposuction, etc. are excluded. However, if you have had a mastectomy to treat breast cancer, then Medicare covers prostheses for breast reconstruction.
Medicare or Medicare Supplement policies do not pay for long-term care also known as custodial care. If you have a chronic illness or disability and need long-term care (such as dressing, cleaning, bathing and help in using the bathroom and other daily activities), you will have to make your own arrangements as Medicare excludes such services. You may be eligible for ‘custodial care’ through Medicaid or under long-term care insurance for which you will have to pay a premium.
However, if you are an inpatient and transferred from an intensive or critical care unit and need respiratory therapy, pain management or head trauma treatment for an average duration of 25 days, you can avail the same in long-term care hospitals (LTCHs) which are certified as acute-care hospitals.
It is also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice or direct care. Medicare doesn’t cover membership fees for concierge care which is when a doctor or group of doctors charges you a membership fee before they will see you or accept you into their practice.
Miscellaneous hospital costs
Medicare does not pay for a private hospital room, or in-room television or telephone unless of course, the hospital provides it free of charge. Medicare does not pay for non-emergency transportation or copies of X-rays.
Medicare is for treatment within the United States and usually does not pay for health care received outside of the United States.
Medicare does not cover acupuncture which is considered alternative medicine.
There are other exclusions as well. The ones mentioned above do not form a comprehensive list but should give you a general idea of what sort of services are NOT covered by Medicare.
Click here to learn more about Medicare, its various Parts, different enrollment periods and your costs.
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Last Updated: 01-10-2021