What Medicare Does Not Cover

Medicare Parts A and B, or Original Medicare, provides broad health coverage but doesn’t cover everything. For instance, Original Medicare generally does not cover long-term care, most dental care, eye exams for prescription glasses, hearing aids or cosmetic surgery.

To cover these gaps, you might need to look into separate insurance policies like Medicare Advantage, supplemental insurance plans like Medigap or sign up for other state or federal programs like Medicaid if you qualify. These plans can ensure protection against unexpected health care costs.

Medicare Parts A and B cover many health care needs. Part A generally handles hospital stays, skilled nursing facility care, hospice and some home health services. Meanwhile, Part B covers doctor visits, outpatient care, medical supplies and preventive services.

However, Original Medicare excludes some items and services from coverage. These include medically unnecessary services, items and services not directly linked to medical care, certain bundled services and services already reimbursable by other organizations. Knowing these exclusions helps you understand what additional coverage you might need or costs you may need to pay out of pocket.

Medicare generally covers only the services or supplies necessary to diagnose or treat a health condition. It may not cover services in settings that are more expensive than needed or treatments and tests that go beyond what is medically reasonable.

• Services Provided in a High-Cost Setting: If a service could have been provided in a less expensive setting, like at home or in a nursing home, Medicare might not cover it. The setting must match the medical need.
• Exceeding Duration Limits: Hospital stays or services that exceed Medicare's time limits may not be covered. This includes staying in the hospital longer than Medicare deems necessary for a particular diagnosis.
• Over-Utilization of Services: Services that exceed what is considered medically reasonable are generally not covered. This includes overly frequent evaluation and management services surpassing a condition's norm.
• Excessive Procedures: Excessive therapy sessions or diagnostic procedures not justified by the patient’s condition are usually not covered.
• Unnecessary Screenings and Tests: Medicare will not cover screenings, examinations and treatments that are not related to any symptoms or diagnosis the patient has, except for certain approved preventive screenings.
• Services Not Related to Medical Needs: Procedures or treatments that do not directly address a medical condition, such as transcendental meditation for a condition that does not require therapy, are not covered.

Note that Medicare may include coverage for preventive services, Transitional Care Management (TCM) after hospitalization, Chronic Care Management (CCM) for ongoing conditions and Advance Care Planning discussions, which are crucial for effective health management and avoiding unexpected costs.

Medicare has specific guidelines about what it does not cover, focusing primarily on services and items within the scope of primary care. These exclusions help Original Medicare concentrate resources on essential health services. Among the excluded categories are long-term daily care services, most dental care, hearing and vision care and cosmetic procedures unrelated to medical treatments.

Original Medicare focuses on short-term care for recovery rather than ongoing support, so it does not cover long-term care, which is often necessary for ongoing assistance with daily activities like bathing, dressing and eating. This type of care is typically provided in nursing homes or assisted living facilities and can also include home-based services.

However, Medicare covers the first 100 days of skilled nursing facility care following a three-day hospital stay. Medicare may also cover short-term stays in rehabilitation facilities for recovery care, such as after a hip replacement.

Additionally, there are exceptions where Medicare may cover certain Part B services if Part A coverage is denied for being too custodial.

Original Medicare typically does not cover routine eye exams or glasses, so if you just need a checkup for new glasses, you'll have to pay for it yourself. However, Medicare does cover some eye care services if they are linked to medical issues. For example, if you have diabetes, Medicare covers yearly exams for diabetic retinopathy. Similarly, Medicare will pay for an annual screening if you are at high risk for glaucoma.

Additionally, Medicare Part B covers cataract surgery that implants an intraocular lens. After this type of surgery, Medicare will also help pay for corrective eyeglasses or contact lenses.

Original Medicare generally does not cover dental care, which means you are responsible for the cost of most dental services, including cleanings, fillings, tooth extractions and dentures.

However, there are specific situations where dental services are covered if they're part of another medically necessary procedure. For example, if you're hospitalized and need dental services to treat a condition such as a fractured jaw or if dental exams are required to prepare for certain surgeries like renal transplant surgery or heart valve replacement, Medicare may cover these.

While Original Medicare does cover medical conditions related to your ears, it does not cover routine hearing tests or hearing aids under the original Medicare or Medigap plans. If you need hearing aids, you'll have to find other ways to cover the cost.

Medicare generally doesn't cover health care services outside the United States, with a few exceptions for emergencies.

If you find yourself in an emergency abroad, Medicare might cover your inpatient hospital services if the foreign hospital is closer or more accessible from the emergency site than the nearest U.S. hospital. This coverage applies under specific conditions, such as if you were traveling directly between the U.S. and another state via Canada without unreasonable delays and an emergency occurred.

Medicare may also cover physician and ambulance services linked to covered inpatient hospital stays abroad, provided the physician is legally authorized to practice in that country, and the ambulance service meets Medicare's criteria.

Medicare typically doesn't cover routine foot care or most foot care devices. This includes everyday foot care like cutting nails, removing corns and calluses or using skin creams to maintain skin tone when there's no underlying medical condition. Also, treatments for flat feet and most types of orthopedic shoes are not covered.

However, there are exceptions where Medicare will cover certain foot care services and devices if deemed medically necessary. For instance, orthopedic shoes that are part of a leg brace or therapeutic shoes for people with diabetes may be covered.

Under Medicare, certain services are "bundled" together, meaning the payment covers all related services you might need during a treatment or health event. This approach is part of an effort to encourage efficient, coordinated care. For example, all related services during surgery — from the anesthesia to the post-operative care —are included in one payment.

However, there are services and supplies that Medicare does not cover because they are included as part of the basic allowance of another service or because they are denied as bundled, such as:

• Standby physician services during procedures
• Indirect prolonged care not directly related to the treatment
• Fragmented services that are considered part of the initial treatment
• Certain administrative services or supplies

Medicare typically does not cover items and services if other coverage or settlements pay for them, such as auto or liability insurance or workers' compensation. This prevents overlapping payments and ensures that Medicare acts as a secondary payer when other insurers are liable.

Always inform your health care providers about any potential coverage from other insurance plans that might apply to your treatment, especially in cases of accidents or injuries related to work.

Note that if other insurers deny a claim or delay payment, Medicare might make a conditional payment to cover immediate costs. This helps prevent financial hardship during claim disputes. However, if the primary insurer later pays, you or they must reimburse Medicare.

Understanding the boundaries of Medicare’s coverage can help you manage your health care effectively. If Medicare does not cover a service due to reimbursement by another entity, be sure to communicate with your providers to ensure they understand which costs will be covered by which insurer. Some of these situations you might find yourself in include:

When Medicare does not cover a service or item you need, there are several steps you can take to find support and manage costs. It’s wise to know your options, such as reviewing your Medicare Summary Notices to understand the coverage decision, appealing if you believe there has been an error and exploring other insurance plans like Medicare Advantage or Medigap.