For the over 60 million Americans enrolled in Medicare, understanding what their plan covers is vital information.
Deciphering the rules, regulations, limitations, and endless small print of coverage can be overwhelming, even for experts who are steeped in the details of Medicare.
The basics of Medicare
There are four parts to Medicare. Medicare Parts A and B together are often referred to as “Original Medicare.”
Medicare Part A is the hospital insurance portion of Original Medicare. Medicare Part B is the medical insurance piece of Original Medicare. Part B covers things like doctors’ visits, outpatient care, ambulance services, and more.
Michael Stahl, executive vice president of Health Markets, an independent health insurance agency experienced with the intricacies of Medicare, knows it can be confusing navigating the Medicare maze.
Medicare Advantage (or Part C) is an alternative to Original Medicare (Parts A & B) that is offered by Medicare-approved private insurers. It must cover everything that Original Medicare covers. And in some cases, Medicare Advantage plans cover some of the services below that Original Medicare does not.
Finally, Medicare Prescription Drug Plans (or Medicare Part D) are available to anyone who is eligible for Medicare.
“It can be overwhelming with all the information out there on TV, online and in your mailbox,” Stahl told Considerable.
It’s easy to assume that Original Medicare (Parts A & B) will cover all or most of your medical needs, but that isn’t necessarily true. Gaps in coverage can cost you money out of pocket, whether it’s for emergency treatment or routine maintenance.
To start your research, check out these healthcare services Medicare doesn’t cover.
1. Dental care
If you’re hoping to get routine dental care, including annual cleanings, fillings, bridges, crowns, or oral exams, you won’t be able to do it on Medicare.
There are some exceptions: For example, Medicare may cover tooth extraction to prepare a jaw for radiation treatment of jaw-related neoplastic diseases. In addition, Medicare may also cover jaw reconstruction surgery after an accident, or an oral exam that is necessary before a heart or kidney transplant.
2. Hearing aids
Hearing aids, routine hearing exams, and exams for fitting hearing aids are not covered by Medicare. Medicare will cover diagnostic hearing and balance exams when ordered by a doctor for medical reasons, but you’ll still be responsible for paying some of the costs unless you have a supplemental plan.
3. Cosmetic surgery
Bad news for an increasing number of aging Americans: Unless the surgery increases the functionality of a body part, it’s not covered.
4. Alternative medicine
Many patients swear by the efficacy of non-traditional treatments, but Medicare doesn’t cover them. That eliminates acupuncture, other experimental procedures, and medical marijuana.
Massage therapy is also not covered, even if prescribed by a doctor.
Chiropractic treatment may be partially covered in instances when a bone has slipped out of place in your spine, but you’ll still be looking at covering 20% of the costs.
5. Routine vision care
Medicare doesn’t cover routine vision care, but under certain conditions you may be eligible certain treatments.
Medicare Part B covers some surgical, preventive and diagnostic eye exams:
- Yearly eye exam but only for those with diabetes.
- Glaucoma tests for people at high risk for glaucoma.
- Macular degeneration for those with this condition.
- Cataract surgery (including a pair of corrective lenses if required after surgery).
For more details about vision coverage, take a look here.
6. Routine foot care
If you have hammertoes or an assortment of other problems affecting the structure of your foot, you may be covered — but for pedicures, massages, and corn or callus removal, you’re out of luck.
The coverage provided by Medicare Part B includes diabetes-related nerve damage to the foot, and medically necessary treatments for deformities and diseases like bunions and heel spurs. Even in these cases, you’re still responsible for 20% of the costs, plus the deductible.
7. 24-hour home care
Medicare may cover some part-time or intermittent nursing or health aide services, but it doesn’t extend to 24-hour care at home.
Complicating matters further: If the patient requires full-time care, they may not be eligible for many home health benefits, including skilled nursing care, health aides, medical supplies, and occupational, physical, and speech therapy.
8. Long-term, or custodial care
Long-term care, also called custodial care, refers to a range of services including nursing-home care.
Medicare covers nursing-home residents’ medical needs, but it won’t pay for assistance with basic personal tasks of everyday life. Look at Medicare Advantage plans for more options.
9. Skilled nursing care
While Medicare does cover nursing care in a skilled nursing facility for a short period of time (typically 20 days) for patients who qualify, coverage for longer stays or for services not included in your Medicare plan vanishes or becomes more pricey after that initial period.
Take a look at the requirements to get a better idea of what medicare covers and what it doesn’t.
10. Foreign travel
Next time you’re able to travel abroad, you’d better get some specific coverage for your trip. That’s because unless you fall into a very specific category of traveler in Canada or Mexico, you’ll be without health insurance on your trip.
The link above goes into detail about scenarios in which you might be covered by Medicare in a foreign hospital, but the parameters are tight. If you’re planning a trip abroad you should definitely look into adding coverage just to be safe.
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It’s a good idea to get familiar with Medicare.gov, which has lots of information and can answer a lot of common questions quickly. To find out what your specific plan covers (and does not cover) Medicare released a new app called “What’s Covered” that can help folks get more information.
Finally: Do some Medicare research, and talk to a professional about your options.
Stahl recommends getting as much knowledge as possible when making decisions regarding Medicare and your health coverage.
“Take advantage of working with a licensed agent or even various informative websites so you feel armed with information and prepared to make decisions.
“[T]here are a number of nuances with what different Medicare plans provide,” Stahl said. “I always advise that individuals sit down with a licensed, non-biased health insurance agent who can review what is or is not covered and offer a variety of options to choose from in terms of carriers, so you can choose the plan that best fits your medical needs and budget.”