What Medicare Does Not Cover, and How to Bridge the Gaps

We recently looked at some of the unexpected services Medicare does cover, including acupuncture. Now for the catch: there are also several things many people assume Medicare pays for that it simply does not. Finding that out at the pharmacy counter or front desk is never pleasant.

Below is a rundown of what Original Medicare (Parts A and B) leaves out, based on Medicare’s own “Medicare & You” handbook, along with possible ways to handle each gap. One quick note before we begin: Medicare Advantage, Medicaid, and some other coverage options may help fill certain holes, so it is worth checking what you already have.

1. Long-term care

This is the biggest exclusion. Medicare does not pay for non-medical long-term care, whether it is in a nursing home, an assisted living facility, an adult day program, or even at home. Help with daily activities such as bathing, dressing, and using the bathroom is also excluded. Medigap and most other health insurance plans do not cover it either. Medicare does, however, cover certain medical home health services, which is a separate benefit.

2. Most dental care

In most cases, Original Medicare does not cover routine dental services such as cleanings, fillings, extractions, or dentures. There is a narrow exception when dental work is closely connected to certain covered medical treatments, such as a heart valve replacement, an organ transplant, cancer treatment, or dialysis for kidney failure.

3. Eye exams for glasses or contacts

If you need an annual exam to update your prescription, Original Medicare generally will not pay for it, and it also will not cover glasses or contact lenses themselves. The main exception is after cataract surgery that implants a new lens: Medicare covers one pair of standard-frame glasses or one set of contact lenses.

4. Hearing aids

Original Medicare does not cover hearing aids or the exams needed to fit them. It does, though, cover diagnostic hearing and balance tests when a doctor orders them to determine whether treatment is needed. You can also see an audiologist once a year without a doctor’s order for gradual hearing loss. After the Part B deductible, you pay 20% of the Medicare-approved amount.

5. The standard annual physical

The full head-to-toe physical many people received through an employer plan is not covered by Original Medicare. If you schedule a “physical,” you may end up paying for it yourself.

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6. Doctors who have opted out of Medicare

This can be an easy detail to miss. Some doctors choose to opt out of Medicare altogether. If you see one of them, Medicare will not pay for the visit, even if the care would normally be covered, unless it is an emergency or urgent situation. You and the doctor may sign a private contract and agree on a price, but that bill is entirely your responsibility.

Doctors who opt out make that choice for two years, and it renews automatically, so a doctor who opted out earlier may still be outside the Medicare system.

7. Health care outside the U.S.

If you are planning a trip abroad, do not assume Medicare will follow you. In general, it does not cover health care outside the United States, except in limited situations. For Medicare purposes, the U.S. includes the 50 states, Washington, D.C., Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

And a few more expenses you may have to pay yourself

The bottom line

Understanding what Medicare leaves out is half the battle. If any of these gaps matter to you, especially long-term care, use Open Enrollment to compare plans that may help fill them and start planning ahead as soon as possible.

For the other side of the story, take a look at the surprising things Medicare does cover.