6 Things Medicare Doesn’t Cover

The Medicare program offers great coverage for older adults. While Medicare may differ from typical employer health plans, most beneficiaries are satisfied with their healthcare choices. That's a positive note.

However, it's also important to know that Medicare has its limitations. Not all the benefits you might have enjoyed with private group health insurance are covered by Part A and Part B of Medicare. Transitioning to Medicare during retirement could leave you with a few unexpected gaps if you're not well-informed.

Let's dive into the six things Medicare doesn't cover.

1. Long-Term Care

While Medicare offers coverage for care within skilled nursing facilities under specific conditions, this is different from actual long-term care.

Research shows that about 70% of individuals who turn 65 in a given year will likely need long-term care at some stage in their later years. On average, women may require roughly 3.5 years of such long-term care, whereas men might need around two years.

Medicare provides coverage for up to 100 days within a skilled nursing facility per benefit period. To qualify for this coverage, you must have had a preceding inpatient hospital stay, necessitating a more intensive level of care than just assistance with daily tasks. If the care you require is solely custodial—like assistance with daily routines—Medicare's coverage won't apply.

For those days between 21 and 100 within a skilled nursing facility that Medicare covers, there's a significant copayment of $204 per day as of 2024. This translates to more than $14,000 for a single qualifying stay. While a Medigap plan might cover this copayment, it won't address long-term care services outside Medicare's coverage scope.

Since you can’t rely on Medicare for long-term care coverage, consider exploring private long-term care insurance options to manage supportive care expenses. Securing long-term care coverage earlier can result in more affordable premiums. Additionally, investing in health savings accounts or similar tax-advantaged plans can earmark funds for extended care. One benefit of these accounts over insurance is flexibility: the funds are at your discretion, and any remaining amount can potentially benefit your heirs.

2. Prescription Medications

More than 90% of older adults rely on at least one prescribed medication, with 54% managing four or more medicines daily. However, Original Medicare (Part A and Part B) doesn't typically cover most of the prescription drugs you consume outside medical facilities. Generally, only drugs administered via injection or infusion during outpatient visits fall under Part B coverage.

Interestingly, while the costs of generic drugs have seen a decline over the last five years, expenses for brand-name and specialized medications surged.

If you opt for Medigap to supplement your Original Medicare, remember that you're still responsible for your prescription drug expenses. Medigap doesn't step in for out-of-pocket costs related to medications unless they are approved by Part A or Part B.

You’ll need to enroll in a Part D prescription drug plan to get prescription coverage. If you decide to enroll in Medicare Advantage, make sure prescription coverage is included in your plan.

3. Foreign Travel Coverage

When traveling outside of the U.S., it's important to realize that Original Medicare doesn't extend coverage for health-related incidents, even in emergencies, with a few specific exceptions. For example, if you're traveling between Alaska and the lower 48 and require emergency care while exploring Canada, Medicare might consider covering your medical needs. Also, if you’re close to a foreign medical facility, and it is more feasible than a U.S.-based one due to your location, Medicare may reimburse you.

However, for most scenarios abroad, the financial responsibility rests on you. This can be particularly concerning for frequent travelers, as unforeseen medical emergencies can result in staggering bills running into hundreds of thousands.

To get foreign travel coverage, you might consider enrolling in a Medigap plan. Some Medigap plans offer limited coverage for emergency situations during overseas travel, albeit with a lifetime cap set at $50,000.

Many Medicare Advantage plans also include coverage for international care, but the responsibility still remains on you to manage payments abroad, as foreign providers might not cooperate with your plan's billing process.

Considering these limitations, sometimes travel health insurance policy is often advisable for those planning international travels. These policies are usually cost-effective and cover a broad spectrum of scenarios—from medical evacuations to incidental challenges like lost baggage or trip cancellations.

4. Routine Dental Treatment

Our teeth are like tires on a car. After enough wear and tear, they need to be replaced! Dental issues like dry mouth, gum problems, decay, and oral infections tend to increase as we get older. Maintaining consistent dental hygiene during retirement is important for oral health, as well as our overall health.

What’s surprising is that, like the other things we’ve mentioned so far, Medicare doesn’t have much dental coverage. Routine dental check-ups aren't covered by Medicare Part A or Part B. Treatments related to cavities, broken teeth, and other dental concerns aren't covered either. Medicare's scope extends to dental services deemed medically necessary for treating specific health conditions. For example, if oral cancer necessitates dental treatment as part of the therapeutic process, Medicare might offer coverage. In addition, Medicare might cover routine dental evaluations if deemed essential before procedures like heart surgery.

There are lots of dental plans tailored for older adults available in today's market. These range from discounted plans targeting routine services to comprehensive dental coverage options. If you intend to have regular dental check-ups—a recommended practice—it's advisable to consider adding dental insurance to your portfolio.

Medicare Advantage plans also often incorporate dental care benefits. When dental benefits are part of the package, they often cover routine examinations and cleanings entirely or with a minimal copayment. Moreover, many plans contribute a predefined amount towards procedures like fillings, crowns, and extractions. If your current plan lacks dental coverage, there might be options to incorporate it for an added monthly premium.

5. Routine Vision Services

Under Medicare, services like routine eye examinations, eyeglasses, or contact lenses typically fall outside the coverage spectrum. However, if a cataract diagnosis occurs, Medicare steps in to cover the surgical procedure and a single pair of corrective eyewear. Yet, ongoing standard vision care remains an out-of-pocket expense. Similar to other Medicare exclusions, Medigap coverage doesn't extend to routine vision care.

Medicare Advantage plans often include routine vision care either as a core benefit or as an optional add-on for an extra monthly fee. Depending on your location, you might have access to vision discount plans that come at minimal or no cost, offering another avenue to manage vision-related expenses.

6. Hearing Services

It's notable that among individuals aged 65 to 74, approximately one-third experience hearing impairment, with this number escalating to half among those aged 75 and beyond. Surprisingly, not many insurance policies incorporate coverage for hearing aids, leading to an average out-of-pocket expenditure of around $2,700 for a pair.

Like vision services, hearing care isn’t covered by Medicare If you have hearing challenges, you're responsible for the full costs for hearing tests, hearing aid fittings, and the actual devices. And again, Medigap won’t cover these services either.

If you decide to enroll in Medicare Advantage, you might have hearing benefits, including hearing tests and hearing aids.

Find the Coverage You Need

Choosing your Medicare plans requires a thoughtful comparison of your choices. While some individuals might find Original Medicare coupled with Medigap, along with additional plans for vision, dental, and hearing, to be the optimal choice, others might lean towards the comprehensive coverage offered by a Medicare Advantage plan.

Be sure to evaluate factors like premiums, deductibles, copayments, and the scope of benefits provided. Your decision should also factor in your lifestyle and preferences. For instance, Medicare Advantage plans often confine benefits to designated provider networks and specific service regions. If frequent travel is part of your lifestyle, such limitations might not align with your needs. Additionally, remember that even with a Medicare Advantage plan, the obligation to continue paying your Part B premium persists.