Medicare beneficiaries receive comprehensive coverage for most health issues and the treatment of acute illness, but there are some expenses Medicare doesn’t cover. To make sure you are covered for some of these services, you may choose to purchase additional insurance, maintain coverage offered by a current or former employer, enroll in Medicaid if you’re eligible, or select a Medicare Advantage plan.
Here’s what you need to know:
What services aren't covered by Original Medicare – and are unlikely to be covered in Medicare Advantage?
The following are not covered by Medicare Part A or Part B and are unlikely to be covered by Medicare Advantage plans:
- Routine care for the feet – services such as cleaning and caring for nails, or the removal of corns and calluses, are not covered by Medicare. (Medicare does cover feet exams every six months in some circumstances. Treatment of foot injuries or diseases is also covered.)
- Cosmetic surgery – unless it’s necessary because of an injury or to improve the function of a malformed body part. (Medicare will pay for breast reconstruction following a medically necessary mastectomy.)
- Orthopedic shoes – unless they’re required as part of a leg brace. (In addition, Medicare does cover therapeutic shoes and inserts.)
- Services ordered by a chiropractor (e.g. x-rays, acupuncture, or massage therapy)
- Custodial long-term care – Original Medicare (and Medicare Advantage) will pay for custodial care that’s provided at the same time as skilled medical care. But if the person only needs custodial care — help with activities of daily living such as bathing and dressing — Medicare will not pay for those services. Medicaid will pay for custodial long-term care, and millions of older Americans have coverage under both Medicare and Medicaid. However, Medicaid eligibility is limited to those with very limited assets and income. Private long-term care insurance is another alternative, but the coverage can be expensive or unavailable, depending on the person’s age and medical history.
Medicare has strict rules about services it will cover, and it excludes some services from coverage. These rules are specified by law, so while many commercial insurance plans that cover people who aren’t eligible for Medicare can make exceptions to their rules – and choose to cover certain services in certain circumstances – Original Medicare (Part A and Part B) can’t usually do this.
What services are not covered by Original Medicare but may be covered by Medicare Advantage plans?
Medicare Advantage plans may cover the following services that are excluded by Original Medicare:
- Routine acupuncture – although Original Medicare does pay for up to 20 acupuncture visits annually to treat chronic lower back pain.
- Hearing aids and hearing exams. Hearing aids can now be purchased over the counter. This can be an affordable alternative if you’re dealing with hearing loss and don’t have any health benefits that will cover the cost of hearing aids.
- Dental care – although Original Medicare will pay for certain dental services provided during an inpatient hospital stay, or for specific inpatient or outpatient dental services that are “directly related to certain covered medical treatments.”
- Routine care for the eyes and eyeglasses – although Original Medicare does pay for a pair of eyeglasses or contacts following cataract surgery to implant an intraocular lens.
- Medicare care outside the U.S. Original Medicare will only cover health care received outside the U.S. in very limited circumstances. But Medigap plans C, D, F, G, M, and N will pay a portion of the cost of emergency medical care during a trip outside the U.S.
Medicare Advantage plans are required to cover all of the services that Original Medicare covers (out-of-pocket costs differ). In addition, it’s very common for Medicare Advantage plans to also offer supplemental coverage for services that aren’t covered by Original Medicare. The most widely available supplemental benefits are vision, hearing, dental, and fitness programs, but there are a variety of other supplemental benefits that Medicare Advantage plans can offer.
There’s a lot of variation from one Medicare Advantage plan to another when it comes to supplemental coverage. There’s also variation in terms of how mandatory coverage (Part A and Part B services) is provided, with differences in out-of-pocket costs, provider networks, prior authorization rules, and managed care designs (HMO, PPO, etc.). So picking a Medicare Advantage plan requires careful consideration.
You’ll want to prioritize the most important aspects, such as total out-of-pocket costs, access to medical providers, and coverage of the medications you need (most Medicare Advantage plans include Part D drug coverage). After you’ve narrowed down your options, comparing the supplemental benefits offered by each plan can be a good way to figure out which plan will provide you with the best overall value. The annual open enrollment period (October 15 to December 7) is your opportunity to switch plans if you’d like to do so. If you’re already enrolled in a Medicare Advantage plan, you also have an opportunity to switch to a different Advantage plan (or to Original Medicare) during the Medicare Advantage Open Enrollment Period (January 1 to March 31).
Medicare beneficiaries who don’t want to use Medicare Advantage may choose to purchase private dental or vision insurance to have coverage for these services. And as noted above, certain Medigap plans provide supplemental coverage for medical emergencies during a trip abroad.
Which services are covered by Medicare Part D?
These services are only covered under private Part D prescription drug plans (including Medicare Advantage Prescription Drug plans):
- Vaccinations other than flu, pneumonia, COVID-19, and Hepatitis B – Other vaccinations are covered by Medicare Part D prescription drug plans. Since 2023, as a result of the Inflation Reduction Act, recommended vaccines covered under Part D have not had any copays, deductibles, or coinsurance. This means Medicare beneficiaries with Part D coverage no longer have to pay anything to get their recommended Tdap and shingles vaccines.
- Outpatient prescription drugs – other than medications used with an item of durable medical equipment, injectable and infused drugs, oral end-stage renal disease (ESRD) drugs under certain circumstances, and a few other medications. (Other outpatient medications are covered by Medicare Part D.)
Before the Affordable Care Act (ACA), preventive screening exams generally were not covered by Medicare, but numerous screening tests are now covered under Medicare Part B because of the ACA.
To cover long-term care, some Medicare enrollees purchase private long-term care insurance, although this can be quite expensive. Medicaid provides coverage for long-term care services in every state, along with various other services Medicare doesn’t pay for, like non-emergency medical transportation.
What if Medicare won’t pay for your care
If Medicare decides not to pay for a service you need, you can appeal (although you’ll appeal to your insurer if you have a Medicare Advantage plan). But if the service isn’t covered at all under Medicare, then an appeal probably won’t benefit you.
