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.

The Comprehensive Coverage of Medigap Plan F

What Does Medigap Plan F Cover?

Medigap Plan F has been the best-selling Medicare supplement plan since Congress standardized the plans in 1991. The reason is simple – Plan F offers the most comprehensive coverage of any Medigap plan.

When you look down the Medicare comparison chart that shows all the available plans side by side, you will see that every box is checked on the Plan F. The comparison chart is published by Medicare. Here is that chart in case you haven’t seen it lately:


Even with the growth of new popular plans, such as the Plan G and the Plan N, the Medigap Plan F continues to grow in coverage each year. In the latest report from AHIP that shows the trends in Medigap, the Plan F still led the way – accounting for 57% of all the Medigap plans in force. The latest available report is from 2015 data. In the previous year (2014), that number was 56%.

The growth of Medigap Plan F is not slowing down. When people new to Medicare get inundated with mail and phone calls about Medicare options, many will look at the above chart, see that Plan F has the most comprehensive coverage, and choose to enroll in Plan F without ever consulting someone about it.


What a Plan F Medicare Supplement Covers

Some people refer to Plan F as the “Cadillac” plan. Any services that Medicare covers will have the “gaps” filled in with Plan F. That is where the name “Medigap” comes from. Medigap plans fill the void left by Medicare Part A and Part B. Some Medigap plans offer less coverage for less premium. But most people that choose Plan F due to the fact that they can go for a doctor’s visit, or even a hospital stay, and walk out without having to pay anything out of pocket for any Medicare services.

With a Plan F, your healthcare budgeting is very easy. You pay your monthly premium and your Medigap Plan F will pick up the difference with Medicare. It is important to note that Medicare will not approve cosmetic procedures and services. They will not cover dental, vision, or hearing. Medicare will also not approve cosmetic surgeries that they deem “not medically necessary.” Your Medigap plan will only pay on what Medicare approves. The Medigap plans also do not cover prescription drugs. A standalone drug plan will be needed to cover those costs.

The Plan F Medicare supplement does cover every deductible, co-pay, coinsurance, and excess charges that fall under Part A and B of Medicare.


Plan F Medicare Supplement Coverage Under Part A

Medigap Plan F will cover the Part A deductibles, coinsurance, and co-pays. Part A of Medicare covers inpatient care. That includes hospital stays, limited skilled nursing stays, hospice care, and some home health care.The Part A deductible ($1,316 in 2017) covers you for a 60-day period. Regardless of how many times you may go in and out of the hospital during that 60 days, there is only one deductible for that time period. If you have to be re-admitted after the 60 days is up, there is another Part A deductible that must be paid. In a perfect storm, that Part A deductible could be paid up FIVE TIMES in one year!

The Part A deductible ($1,316 in 2017) covers you for a 60-day period. Regardless of how many times you may go in and out of the hospital during that 60 days, there is only one deductible for that time period. If you have to be re-admitted after the 60 days is up, there is another Part A deductible that must be paid. In a perfect storm, that Part A deductible could be paid up FIVE TIMES in one year!

We have never heard of a situation where that actually occurred, but it is possible. The Plan F will pay that deductible no matter how many times it is due every year.

Here is a breakdown of the expenses that Medigap Plan F will cover under Part A:

  • Part A hospital deductible, co-pays, and coinsurance
  • An additional 365 days of hospital costs after Medicare benefits are exhausted
  • Part A Hospice care coinsurance or copayment
  • Some home health benefits
  • The first three pints of blood (Medicare covers blood after that)
  • Other Medicare approved expenses associated with Part A hospitalization


Plan F Medicare Supplement Coverage Under Part B

Plan F also covers the deductible, coinsurance, and excess charges under Part B. Medicare Part B is the part of Medicare that covers outpatient services. That would include doctor visits, outpatient surgeries, and some home health care services.

Under Part B, you have an annual deductible. In 2017, that deductible is $183. After that Medicare pays 80% and your Plan F Medicare supplement will pay the other 20%.

Here is a breakdown of the services that Medigap Plan F will cover under Part B:

  • Medicare Part B deductible and coinsurance
  • Medicare approved doctor’s office fees
  • Medicare Part B deductible
  • Medicare Part B excess charges
  • Other Medicare approved expenses associated with Part B coverage

It is important to note that the above synopsis of the Plan F coverage does not apply to residents of Massachusetts, Minnesota, and Wisconsin. Residents of those states have different coverage rules for Medigap. For more information, visit this site on the website.


Medigap Plan F Additional Benefits

One of the biggest differences between Medigap plans and Medicare Advantage plans is what they cover outside the USA. Medicare Advantage offers NO COVERAGE outside the US. Medigap Plan F does offer coverage of 80% of approved coverages for foreign travel emergency. If you travel outside the US or enjoy taking cruises, you should avoid Medicare Advantage in favor of Medigap. There are some plan limitations, but you get the peace of mind in knowing you can travel without having to worry whether you get injured or sick while in another country.

Some limited skilled nursing care is available under Medigap Plan F. Medicare pays for the first 20 days if have a qualifying stay in a skilled nursing facility. Starting day 21 and going through day 100, there is a daily co-payment for care. Plan F will cover that daily co-payment.

An important note about coverage beyond 100 days in a skilled nursing facility – Medicare will approve no expenses beyond day 100, therefore, your Medigap plan will not pay, either. This is one reason it is important to have a long-term care policy in place. Remember – if Medicare does not approve the service, your Medigap Plan F won’t cover it.


High-deductible Plan F Options

There is a variation of the Plan F you should be aware of. It is a high-deductible Plan F. It causes confusion quite often, and there are unscrupulous agents who will enroll people in this plan because the premium is incredibly cheap compared to a normal Medigap Plan F. The problem is that those agents will not tell their clients about the deductible.

The high-deductible Plan F, also known as HDF, has an annual deductible, as the name implies. You must pay that deductible each year before the plan pays anything. In 2017, that deductible is $2,200. Make sure if you are enrolling in a Plan F that you know whether it is the HDF or just a regular Medigap Plan F. The coverage is identical once you meet that annual deductible.

Medicare really should put that plan under a different letter. It can cause confusion and lead to regret when a person realizes how the plan works. Considering how Medigap plans can be underwritten if you are outside of your Open Enrollment or Guarantee Issue Period, it could cause a lot of problems if you find out you’re in the wrong plan too late.


Medigap Plan F vs Other Medigap Plans

There are cases where other plans may be better for you. By taking on some out-of-pocket expenses – like paying the Part B deductible under Plan G – you could significantly lower your premium. Plan N is another viable option to reduce costs.

The Plan F has the most comprehensive coverage. But that might not make it the best value for your situation. Compare the benefits and costs to the other available plans. An independent agent can help you shop all the plans at once.


Costs of Plan F Medicare Supplements

Medigap plans are standardized. This means they are identical from one company to another. The plan structure must adhere to the chart at the top of the article. A Plan F from one company is identical to every other company’s Plan F. The big difference is in premium.

Some of the bigger, more expensive companies like UnitedHealthcare and Humana may offer additional benefits like gym memberships or prescription discount cards (which are unnecessary and useless since we now have a Part D prescription drug program under Medicare). These added benefits are not worth the higher premium.

Your best bet is to find a good, solid company with an “A” rating from the rating companies. AM Best is the standard for company ratings. There is no need to pay $30-60 more per month for identical coverage just to get a Silver Sneakers membership. Paying more for a big-name company is not in your best interest when the coverage is identical. Also, find a company with a lower premium and then pay for the gym membership out of your pocket. That way you can save money and pocket the difference.

The Medigap Plan F can vary in prices by over $150 in some cases for the exact same coverage. There is no good reasoning for that difference. The insurance companies are doing fine without you paying them extra. Medicare supplements are one area where you can shop mostly on price.