One of the things that makes the Medicare program such a useful health care solution for seniors and eligible citizens is the comprehensive coverage that it offers. While this is an obvious plus, there are some things that Medicare insurance doesn’t usually cover. There are also some things that it only partially covers. We talk a lot about what Medicare insurance covers on the Shop & Enroll blog, but discussing what generally isn’t covered is equally important, if not more important.
This article is primarily discussing the coverage of Original Medicare (Parts A and B). If you’re curious to see what insurance plans and coverage options are available in your area, please speak to a licensed independent agent.
Hearing Aids
Hearing loss is a condition about one in three seniors ages 65 to 74 around the country face. In fact, by the time they’re 75, nearly half of all seniors experience some form of hearing loss. This can make being able to get a hearing aid vital to maintaining a good quality of life. Unfortunately, the Medicare program rarely covers hearing aids, hearing exams, and hearing aid fittings. Specifically, Original Medicare only covers hearing aids if they’re bone-anchored hearing aids (BAHA), since those types of hearing aids are now considered prosthetics. Medicare Supplements also rarely, if ever, cover hearing aids.
Can I Get It Covered?
If you find yourself needing hearing aids, there are a few places you can turn. Medicaid may offer hearing aid coverage, depending on the state and if you qualify for coverage. Some private charities and associations, like the Starkey Group, can offer financial aid. The Hearing Loss Association of America also offers information about how to get financial aid for those in need.
Routine Dental Work and Dentures
Routine dental work is not covered by Original Medicare. This means you’ll likely be paying out of pocket for dentist visits, cleanings, and even dentures if you have Medicare.
Can I Get It Covered?
The only way that Original Medicare may cover dental work is if it’s part of something that Original Medicare normally covers, like surgery as part of inpatient care, or it’s considered medically necessary. In a circumstance where there is some coverage of dental care, a Medicare Supplement may help by possibly covering deductibles and coinsurances. Depending on which state you live in and if you qualify, you may receive some coverage for dental treatment and dentures through Medicaid.
Routine Vision Care
So, we’ve discussed dental and hearing, and how they’re generally not covered by the Medicare program. But, is eye care covered? Unfortunately, that’s also a no, if you’re referring to routine care. Services and checkups, like regular eye exams or glasses or contact lens fittings, generally aren’t covered by Original Medicare. The same goes for Medigap plans, which do not cover routine vision services. This means that 100 percent of the costs of these regular checkups and fittings will be out-of-pocket expenses for you.
Can I Get It Covered?
Original Medicare does cover certain preventative and diagnostic exams for conditions like glaucoma, diabetes, and macular degeneration. It can also cover things like medically-necessary cataract surgery. Medical necessity is a key factor in whether or not a service will be covered, generally. Some organizations like EyeCare America can also connect qualifying individuals with low or no out-of-pocket cost eye exams.
Custodial Long-Term Care Services
There may come a point in your life when you require help with daily tasks beyond what your family and friends can provide. You may eventually need long-term care services. If you need help with everyday tasks like eating, washing, and dressing, this would be considered custodial long-term care. Since this type of help is not considered medically necessary, Original Medicare won’t assist with paying for this type of long-term care. It may assist with the costs of a skilled nursing facility services, like a semi-private room or prescription drugs, if they become medically-necessary but the custodial care is still your responsibility.
Can I Get It Covered?
Luckily, unlike other options in this article, there are ways to get help from Original Medicare for long-term care. If you qualify for PACE or hospice care, certain long-term care needs may be covered. Original Medicare may also assist with long-term care hospitals or some home health services. Medicaid can help cover some costs of long-term care as well. Alternatively, you can enroll in a long-term care insurance plan to have all your bases covered.
Cosmetic Surgery
Cosmetic surgery usually isn’t covered by Original Medicare. In fact, there are very few circumstances where cosmetic surgery is covered. Most cosmetic surgery is considered to be elective or non-essential surgery since it’s not medically-necessary and often done to fix a certain perceived physical imperfection. This differs from plastic surgery, which is often focused on reconstruction or defects due to birth disorders, trauma, or disease.
Can I Get It Covered?
The difference between cosmetic surgery and plastic surgery can make a large difference in your coverage. Original Medicare will cover cosmetic or plastic surgery if it’s caused by an accidental injury or to improve function of a malformed body part. It may also cover breast prostheses if you’ve had a mastectomy due to breast cancer. Some companies also offer cosmetic surgery insurance, though this is rare and should be thoroughly researched before purchasing. The non-essential nature of most cosmetic surgery procedures makes coverage for it rare, meaning you’ll likely be footing the entire bill.
Care Outside of the U.S.
Let’s say you’re on vacation and you get sick. You need health care. Does Medicare insurance cover you? If you happen to be inside the United States, generally speaking, you should be able to get coverage, depending on the service. Original Medicare is accepted throughout the country. With Medicare Advantage, the answer is a little murkier since they have plan networks. If you’re venturing outside of the country, though, you won’t likely receive the same Medicare insurance coverage you’re used to, if any.
Can I Get It Covered?
There are a few instances where Medicare insurance can cover some of your expenses outside of the United States, though they are very specific. These are:
- If you have a health emergency in the U.S., but the nearest hospital that can assist you is in another country.
- If you’re in Canada while traveling the most direct route between Alaska and the continental U.S. when the emergency occurs. In this case, a Canadian hospital must be the closest hospital and your trip must not be taking any “unreasonable delay[s].”
- If you live in the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition. In this instance, a medical emergency is not required for coverage.
Otherwise, you’ll likely be covering your own bills. You may be able to get a travel insurance plan, though not all of them cover health care, so read the coverage closely before enrolling in a plan. Finally, some Medicare Supplements, which can be wise if you’re planning on traveling abroad.
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Medicare, and specifically Original Medicare, covers many of the crucial health care needs of seniors and eligible Americans around the country. But, it can’t cover everything. Luckily, if you do need one of the health care services or items that aren’t traditionally covered by Original Medicare, there’s often a way to get some financial assistance. This way, you can afford the care you need without your quality of life being impacted. While this could mean that Original Medicare isn’t the only insurance you may need depending on your circumstances, it’s good to know that there are options out there.
