Six Common Medical Situations Medicare Will Not Cover

Nearly 56 million Americans depend on the Medicare program to help cover the cost of their doctor visits, in-patient admissions, and prescription drugs. However, like most forms of health insurance, Medicare will not cover everything. The gaps in coverage left by Medicare can leave you with large out of pocket costs.

Even with the comprehensive coverage that comes from enrolling in a Medicare supplement, also known as Medigap, you are only covered for the gaps on Medicare-approved procedures and services. If Medicare doesn’t approve it, your Medigap plan won’t either. Medicare Advantage plans may help with some of these services, but the coverage is very limited and restricted to certain networks.

Medicare will not pay for what they consider to be cosmetic services. Here are six services Medicare will not cover.

 

Long-Term Nursing Home Care

Many Medicare beneficiaries assume Medicare and their supplemental insurance will cover long-term nursing care expenses.

“People just sort of assume that if you have Medicare it will be covered,” says Keith Lind, senior strategic policy advisor in AARP’s Public Policy Institute.

In fact, Lind says his research shows that about half of all Medicare costs are paid by beneficiaries out of their own pocket – and a big portion is for long-term care. Medicare will pay for some shorter-term nursing home care, but only up to 100 days following a three-day inpatient hospital stay. In addition, that approval is only for the skilled level of nursing care.

There is a new practice that hospitals are utilizing to skirt Medicare rules. A common practice is to keep patients in the hospital for several nights in what is known as an observation unit. This practice causes the hospital stay to be classified as outpatient care. Unless you’re admitted for inpatient care, you will not qualify for Medicare to pay for any nursing home care following your hospital stay.

“The trap for the unaware is that you have to have a three-day hospitalization to go to a skilled nursing facility,” Lind says. “People in observation are surprised they won’t be covered.”

If you require a stay in the hospital, be sure to confirm that you are indeed being treated as an inpatient stay.

 

Dental and Vision Care

Original Medicare does not cover the cost of routine dental care. This would include dental cleanings, oral exams, fillings, and extractions. Eyeglasses and contact lenses are not covered by Medicare, either.

Medicare will help pay for some services only if they are considered medically necessary. For example, cataract surgery and one pair of glasses following the procedure are covered. This service would fall under Medicare Part B. Therefore, you are subject to pay 20 percent of the cost, including a Part B deductible unless you have a Medigap plan that will cover those co-payments and deductibles.

And, according to David A. Lipschutz, senior policy attorney with the Center for Medicare Advocacy, there are narrow criteria that allow for dental care coverage in extreme cases. A serious infection in the mouth or a jaw disorder due to a cancer diagnosis or other serious medical situation that requires hospitalization may qualify for coverage under Medicare.

There are some great insurance plans available that will help cover dental services. Some even cover dental, vision, and hearing all in one policy. It is a good idea to shop these plans to see if one will fit your needs and budget. Dental services can get quite expensive.

Medicare Advantage plans sometimes have dental and vision coverage. But Lipschutz cautions that these extra benefits, while nice to have, tend to be quite limited. For that reason, make sure to keep your broader health care needs in mind and consider all costs before choosing Medicare Advantage over traditional Medicare.

 

Out-of-Area Care

Under original Medicare, you can get coverage for treatment if you’re hospitalized or need to see a doctor while you are outside of the United States. People covered by Medicare Advantage policies will not be covered while traveling abroad, except for a few plans that offer emergency care only in limited form.

All Medigap plans will pay 80 percent of billed charges for emergency care that is considered medically necessary and is delivered within the first two months of a trip outside the US. This coverage has a $250 annual deductible and a lifetime limit of $50,000 for foreign travel emergency care.

 

 

Hearing Aids

Medicare will cover the cost of diagnostic hearing exams, as long as they’re ordered by your doctor to determine if medical treatment is needed. Medicare will also cover cochlear implants that repairs damage to the inner ear. However, Medicare doesn’t cover routine hearing exams, hearing aids or exams for fitting hearing aids. These can be quite expensive when you’re paying for them out of pocket.

 

Opioid Dependence

Medicare will cover both inpatient and outpatient detox for alcoholism and drug addiction in certain situations. The coverage is very limited. There is a five-day limit on inpatient treatment for alcoholism and drug addiction. That could be extended depending on the patient’s condition. Generally, between 16 and 19 days of rehab services are covered.

“The inpatient stay is covered during the most acute states when medical complications are more probable,” Lind says.

There has been an increase in opioid dependence in the US lately. It has been featured in the news and addressed by President Donald Trump. Medicare will not cover the cost of methadone except in rare cases. Methadone is a medication commonly prescribed to treat opioid dependence.

“Medicare will not cover methadone for opioid addiction, only for certain pain treatment,” Lipschutz says.

 

Alternative or Cosmetic Medicine

Medicare will not cover alternative medical treatments such as acupuncture. Chiropractic care is covered only in cases in which a licensed chiropractor manually manipulates the spine to correct a condition that causes one or more of the bones of the spine to become dislocated.

Procedures such as face-lifts, Botox or filler injections to smooth wrinkles or other procedures done to improve appearances and with no medical need are never covered by Medicare.

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