By the time you turn 65, you probably have a good feel for what health insurance does and does not cover. But Medicare is a different beast – and there are some surprising things that do not fall under Medicare’s umbrella.
Medicare is the federal government’s health insurance coverage for people age 65 and older, and other people living with disabilities and certain chronic conditions. Here are seven things Medicare does not cover:
1. Deductibles and coinsurance
If you opt for Original Medicare, both Medicare Part A (hospital insurance) and Part B (medical insurance) require out-of-pocket spending in the form of deductibles and coinsurance. If you have medical needs, this can get pricey, and there’s no out-of-pocket cap on Original Medicare spending.
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“Many people on traditional Medicare get a Medigap plan to help cover those costs and make their out-of-pocket costs more predictable,” says Gretchen Jacobson, vice president of Medicare for The Commonwealth Fund, a private foundation with the mission of promoting a high-performing health care system.
If you enroll in a Medicare Advantage plan, which is offered by private insurance companies that contract with the federal government, you’ll also be responsible for any deductibles, copays or coinsurance required when you seek health care. Although there’s an out-of-pocket maximum for Medicare Advantage, that limit can be as high as $ 7,550 in 2022.
2. Routine dental care
Although Medicare Part A covers some dental services you may get as part of a hospital stay, basic dental care like cleanings, X-rays and fillings aren’t covered. If you want coverage, you’ll have to purchase a separate dental policy.
You may be able to get some coverage by purchasing a Medicare Advantage plan with dental benefits. “But those benefits can be limited, or Medicare Advantage plans can ask you to pay extra for those benefits,” says Lina Walker, vice president of health security for AARP’s Public Policy Institute.
3. Eye exams
Medicare does not cover eye exams for glasses or contacts, or the eyeglasses or contacts themselves. Medicare Part B does cover one pair of glasses or contacts if you have cataract surgery. (After the Part B deductible of $ 233 in 2022, you’ll pay 20% of costs.)
4. Hearing aids
Medicare also does not cover hearing aids or the exams required for hearing aids. While there’s some language in the Build Back Better Act to add hearing aid coverage to Medicare, the act has not made it through Congress. Medicare does cover diagnostic hearing exams if your doctor thinks you need them.
5. Prescription drugs
Original Medicare Parts A and B do not offer coverage for prescription drugs. If you want prescription drug coverage, you must buy a Medicare Part D plan from a private insurance company or get prescription drug coverage from a Medicare Advantage plan that includes it.
Medicare drug coverage is optional, but if you choose to skip it and you do not have other creditable drug coverage, you’ll pay a late enrollment penalty if you decide to enroll at a future time. You’ll pay this penalty for as long as you have Medicare drug coverage, so it’s worthwhile to make sure you get and keep qualified coverage once you’re eligible.
6. Long-term care
A person turning 65 today has about a 7-in-10 chance of needing long-term care at some point in the future, according to the Department of Health and Human Services, and it can be a big expense. But Medicare does not cover long-term care if it’s the only care you need.
“This is an area where there might be some confusion, because people have heard that Medicare covers nursing services,” Walker says. Medicare does cover skilled nursing facility care if your doctor recommends it after a qualifying three-day inpatient hospital stay. In these circumstances, Medicare covers the first 100 days of care along with a daily coinsurance charge. After that, you’re responsible for all costs.
Medicare Advantage plans may offer some additional limited benefits. “Some Medicare Advantage plans are providing in-home help, but there’s pretty limited coverage at this point, and relatively few plans are providing that,” Jacobson says.
7. Overseas health care
If you’re outside of the US and certain US territories, Medicare does not cover health care or supplies except in some very specific circumstances. (For instance, if you’re passing through Canada between Alaska and another state when you have a medical emergency, and a Canadian hospital is closer than a US hospital, Medicare may cover your care.) Otherwise, you’ll need to find supplemental coverage for travel or purchase insurance in the country you’re living in.
This is a key point if you’re planning to move out of the country. If you ever change your mind and want to return to the US and re-enroll in Medicare, you may be subject to Part B penalties. “It’s important, before they move, that they find out what the implications will be for them if they were to give up Medicare,” Walker says.