For many people at retirement age, having Medicare benefits means the difference between getting quality health care and not being able to visit a doctor. Over 64 million people in the United States depend on Medicare for their health care coverage. 22 million of these people have a Medicare Advantage policy because they want extra coverage for services and treatments that Original Medicare Parts A and B do not provide.
Original Medicare Parts A and B do not cover treatments or services that are not certified to be medically necessary. Your health care provider must determine that any care you receive is medically necessary before your Medicare benefits cover the cost.
If you are close to the age of 65 and soon to be eligible for Medicare insurance, you may be doing some homework on Medicare coverage. In most cases, it is equally as important to know what Original Medicare covers and what these benefits do not cover. When you have this information, you can make an informed decision about whether having a Medicare Advantage, or Medicare supplement plan is a better option for you than Original Medicare benefits alone.
Medicare Part A Gaps in Coverage
Long-term Custodial Care
Long-term, or custodial care that takes place either in a skilled nursing facility or in your own home, is not included in Medicare insurance coverage. Part A insurance does cover short-term stays in skilled nursing care facilities and home health care on a part-time, or intermittent, basis. But even this short-term care does not include custodial care services.
Custodial care includes things like meal preparation and feeding, bathing, dressing, or personal hygiene care.
In cases of home health care, Medicare does not pay for the following services:
• 24-hour care
• Meals delivered to the home
• Homemaker services such as shopping, cleaning, or laundry care
• Custodial or personal care
Skilled nursing home care, even on a short term basis, is not covered if your only needs are custodial care.
Once your hospice care benefits begin, Medicare does not cover the following:
• Treatment to cure our terminal illness or any related conditions.
• Any prescription drugs meant to cure the illness, other than drugs administered for pain relief or symptom control.
• Care that comes from someone outside the hospice facility providing your care.
• Room and board for instances where you receive hospice care at home or in a skilled nursing facility.
• When you are in hospice care, Medicare does not cover care in a hospital either as an inpatient or outpatient, or ambulance services unless your hospice team makes the arrangements, or if you need this care for reasons that are not related to the terminal illness.
During an inpatient hospital stay, most expenses fall under Part A coverage. But some are covered by Part B. In hospital stays, your benefits do not cover:
• Private-duty nursing care
• A private room, unless this is medically necessary
• Television or telephone in the room when not included in the room charge
• Personal care items
Medicare Part B Gaps in Coverage
Part B (medical insurance) does not cover the following services and treatments:
1. Routine dental care and dentures are not included in Medicare insurance coverage. Examples of this sort of care include:
• Dentures, dental plates, other orthodontic or dental devices
However, if you need certain emergency or difficult dental procedures that take place while you are a hospital inpatient, Part A covers the cost.
2. Eye exams and eyeglasses or contact lenses are not covered. Some vision care is covered in cases of diabetes, glaucoma, and macular degeneration.
3. Typical cosmetic surgeries are not included in Medicare coverage. Medicare does cover cosmetic surgery if it is medically necessary due to accidental injury, or to improve function of a malformation. Medicare also covers breast reconstruction surgery in cases of mastectomy due to breast cancer.
4. Acupuncture is not covered by Medicare.
5. Hearing exams and hearing aids are not covered in routine circumstances. Diagnostic hearing exams needed to determine the cause of another condition are covered.
6. Routine foot care such as corn or callus removal or toenail cutting is not covered. However, if you need foot care that Medicare considers medically necessary due to illness or conditions like diabetes for example, it does cover the care.
Prescription drug coverage
Unless you have a separate Part D policy, Original Medicare does not cover self-administered prescription drug costs. Your prescription drugs needed during hospital inpatient stays are covered by Part A. Drugs covered under Part B are those that your health care provider administers in a medical office or facility.