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What kinds of health-related services are not covered by Medicare?

Josh Schultz | May 31, 2020

Q: What kinds of health-related services are not covered by Medicare?

A: 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. Here’s what you need to know:

What services aren't covered by either Original Medicare – and are unlikely to be covered in Medicare Advantage?

The following are never covered by Medicare Part A or Part B and are unlikely to be covered by Medicare Advantage plans:

Medicare has strict rules about services it will cover, and it excludes many services from coverage. These rules are specified in the law, so while many commercial insurance plans that cover people who aren’t eligible for Medicare are able to 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 not covered by Original Medicare may be covered by Medicare Advantage plans?

Medicare Advantage plans may cover the following services that are excluded by Original Medicare:

Because the insurers offering these plans are paid based on what Original Medicare would pay for care, they usually don’t cover additional types of medical care not reimbursed by Original Medicare (e.g. diabetic foot care).

Medicare beneficiaries who don’t want to use Medicare Advantage may choose to purchase private dental or vision insurance so they have coverage for these services.

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, and Hepatitis B – (other vaccinations are covered by Medicare Part D prescription drug plans). When a coronavirus vaccine is developed, Medicare Part B will cover it.
  • Outpatient prescription drugsother 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, preventive screening exams generally were not covered by Medicare, but numerous screening tests are now covered under Medicare Part B because of the law.

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, and covers a number of other things 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.

Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals.In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive.

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