7 Essential Services Medicare Should Cover But Does Not

How to Get the Care You Need

Medicare is not an all-encompassing service, and it certainly isn't free. Not only do you have to pay deductibles, copayments, coinsurance, and premiums, but you may be on the hook to pay for more services than you expect. You might be surprised by the essential services that Medicare does not cover.

1

Medicare Does Not Cover Routine Dental Exams or Dentures

Dentist showing teeth dentures to a female patient
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People with poor dentition or who are edentulous (missing teeth) are at risk for malnutrition. The American College of Prosthodontists reports that 30 percent of seniors over 65 years old do not have any natural teeth. There can be a number of causes for this, ranging from gum disease to trauma.

That puts a significant segment of the Medicare population at risk. Despite that, Medicare does not cover routine dental care like cleanings, fillings, root canals, tooth extractions, or dentures (false teeth). Other dental treatments like bridges, crowns, and plates are also excluded. That leaves seniors with a hefty out of pocket cost to maintain a reasonable quality of life.

The Healthcare Bluebook—a company which provides cost estimates for health services nationwide—estimates the fair price for a complete set of dentures (upper and lower teeth) to be approximately $1,300. Immediate dentures or partial dentures, depending on the type of material used, may range from $950 to $1,450. That is a lot of money for someone on a fixed income. Some people may turn to dental insurance, but that can be pricey in itself. Medicaid is an option for people who are dual eligible.

What Medicare does cover for dental care is extremely limited. People who are about to have surgery, specifically heart valve replacement or a kidney transplant, may have an oral examination to make sure they are safe for surgery. Dental services may be approved if they help treat specific jaw-related conditions. For example, Medicare will cover these services if they are needed to reconstruct the jaw after a facial tumor is removed or to repair a fracture of the jaw.

2

Medicare Does Not Cover Eye Exams or Corrective Lenses

Glasses Contact Lens Medicare
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One in three people has impaired vision by the time they turn 65. That number increases every year of life. Of the 43.9 million Medicare beneficiaries in 2015, approximately 40.5 million reported use of eyeglasses.

Poor vision impacts health in a number of ways. It can decrease someone's ability to perform basic activities of daily living like bathing, dressing, or even taking their medication. After all, it may become difficult to read medication labels and bottles. More complicated activities like cooking or driving could become dangerous. Vision impairment can also affect people on a psychosocial level. It has been associated with higher rates of depression.

People with vision impairment are also at greater risk for falls. The Centers for Disease Control and Prevention reports that one in four seniors falls every year resulting in three million emergency department visits, 800,000 hospitalizations, and 28,000 deaths.

Despite all the evidence that supports the need for vision care in seniors, Medicare does not cover routine eye exams or corrective lenses. Eyeglasses and contact lenses must be paid for out pocket. That is the case at least if you have Original Medicare (Part A and Part B). It may be possible to find a Medicare Advantage plan that offers coverage, and people who are dual eligible can turn to Medicaid to foot the bill.

That does not mean that Original Medicare does not cover any vision screening at all. It does, but only for people at risk. Specifically, it covers the following services for people with these conditions:

  • Age-related macular degeneration: If you have AMD, Medicare will pay for treatment, including surgical procedures and some injectable medications.
  • Cataracts: Medicare covers cataract surgery with implantation of an intraocular lens. This is the rare time that Medicare will also cover a pair of corrective lenses, albeit through a Medicare-approved supplier.
  • Diabetes: If you have diabetes, Medicare covers an annual ophthalmology exam to screen for diabetic retinopathy.
  • Glaucoma: If you have a family history for glaucoma, have diabetes, are an African American over 50 years old, or are a Hispanic American 65 and older, you are considered to be at risk for glaucoma. Medicare will pay for screening every 12 months.
3

Medicare Does Not Cover Hearing Tests or Hearing Aids

Hearing Aids Medicare
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According to the National Institutes of Health, one-third of people between 65 and 74 years old and half the people over 75 years old have hearing loss. Depending on the severity of the impairment, this could put some people at risk. It may be difficult to interact with others or to respond to warning signs in their environment like car horns and fire alarms. There are also studies that correlate hearing loss with an increased risk for dementia.

People who lose their hearing can lead perfectly healthy lives. What they need is a diagnosis and a plan to manage their condition so they can maximize their quality of life.

Despite the high proportion of Medicare beneficiaries with hearing loss, Medicare does not cover routine hearing exams. It will only pay for a test if they specifically complain of symptoms and the test is considered necessary to diagnose an underlying condition. This is unfortunate because many seniors gradually lose their hearing and will not report symptoms until they are far along. By then, they may already have psychosocial issues relating to the condition.

Unfortunately, even if a diagnostic test confirms that someone has hearing loss, Medicare won't pay for an exam to fit hearing aids and it surely won't pay for the hearing aids themselves. Hearing aids on average cost anywhere from $1,000 to $4,000 depending on the type and brand. The cost can be prohibitive for many seniors.

While Medicaid may pay for hearing aids, this is not the case in all states. You will need to check with your state Medicaid program to find out more. Otherwise, if you need hearing aids, a Medicare Advantage plan that covers them may be worth the added expense.

Although Medicare does not pay for hearing aids, it does cover cochlear implants if you meet certain criteria. The catch? One of those criteria is that hearing aids were not effective! For clarification, the procedure is not on the inpatient-only list and will be covered under your Part B (not your Part A) benefit.

4

Medicare Does Not Cover Long-Term Nursing Home Care

Nursing Home Medicare
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Not everyone is capable of taking care of themselves as they grow older. They may become frail and weak or they could suffer from chronic medical conditions. While some people can turn to family and friends to help them, many people do not have that option. Even fewer people have enough resources to pay for a nursing home out of pocket, especially when you consider that the average cost for a nursing home in 2017 was $7,148 per month for a shared room and $8,121 for a private room.

Alzheimer's disease affects 5.7 million people every year and that number is expected to increase to 14 million by 2050. As it stands, it is the sixth leading cause of death in the United States. The condition leaves a lot of Medicare beneficiaries in need of long-term care.

Unfortunately, Medicare does not play for long-term stays in a nursing home. While it will pay for short-term placement in a skilled nursing facility after a hospitalization, it only pays for a limited number of days.

It is no surprise that many people must turn to Medicaid for nursing home care. Eligibility for Medicaid is usually based on income alone, but when it comes to nursing home care, your assets are also taken into consideration. Many seniors spend down their assets to qualify for Medicaid's long-term care benefit. This could affect how many assets their spouse is able to keep. For this reason and others, it may be in your best interest to talk to an elder care lawyer for advice to protect those assets. 

5

Medicare Does Not Cover Custodial Care

Custodial Care Hygiene Basic Needs
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Not everyone who needs help taking care of themselves goes to a nursing home. Many people live at home or in assisted-living facilities. Regardless of where they live, they may need help performing activities of daily living. This may include anything from bathing to eating to dressing to toileting.

Medicare distinguishes between two types of care: skilled care and custodial care. Skilled care is performed by a licensed medical professional. For example, physical therapy, occupational therapy, and speech therapy are considered skilled services. Skilled nursing care also falls into this category. These services will be covered by Medicare, regardless of location, but only if they are considered medically necessary and are ordered by a physician.

Custodial care, on the other hand, can be performed by anyone. The care is not medical in nature person and does not require a license. A nurse's aide, for example, may assist with the activities of daily living listed above. Flat out, Medicare will not pay for these services.

It does not make much sense. If Medicare paid for custodial care and the basic needs of its beneficiaries, it could decrease the number of complications from chronic medical conditions and decrease the need for nursing home care.

6

Medicare Does Not Cover White Canes for the Visually Impaired

White Canes Blind Medicare
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Medicare does not pay for services it does not consider to be medically necessary. That is why it is so surprising that the program does not cover white canes for people who are blind or otherwise visually impaired. This is especially ironic since the United States observes White Cane Safety Day every year on October 15.

Unlike other canes that are used to keep your balance or support your weight while walking, these canes are intended to help people who are visually impaired navigate their environment. It is a tool that not only allows for independent mobility, but it promotes safety. It is a signal to people in the community that a person using one has visual difficulties. In fact, there are laws in all 50 states that require drivers to yield the right of way to people with white canes.

It is fortunate that there are other places people can turn to for white canes. The National Federation of the Blind offers free white canes to anyone who needs one and has given out more than 64,000 canes since 2008.

Not only does Medicare not cover white canes, but it will not pay for service animals that could help people with visual impairments live more independent lives. Specifically, it does not include the cost of obtaining, feeding, or providing veterinary care for the animal. If you or someone you know is interested in a service animal and you qualify, you may consider turning to Social Security Disability Service Animal Assistance Programs.

7

Medicare Does Not Cover Most Foreign Travel

Overseas Foreign Travel
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Many people talk about traveling the world when they retire. While finances may prohibit some people from chasing that dream, access to health care may be another sticking point.

Original Medicare does not cover health care in another country unless very specific criteria are met. It pays for emergency services when you travel to/from Alaska through Canada, when you are on a cruise ship within six hours of a United States port, or when the nearest hospital is over the border to the United States.

There is one exception that extends Medicare coverage beyond emergency care. Someone who lives near the border to the United States may choose to use a hospital facility in another country if it is closer to their home than United States facilities.

Medicare Advantage plans may or may not provide a good alternative. These plans work within local networks. That means they contract with a select group of local medical providers and facilities. Whenever you receive care outside of that network, your plan will either charge you more or not pay at all. This can make it expensive to travel even within the United States, nevermind in a foreign country. That said, some Medicare Advantage plans may offer a benefit for emergency travel coverage. 

Alternatively, you may turn to Medicare Supplement Insurance (also known as a Medigap plan). Select plans have a foreign travel benefit that pays 80 percent of emergency costs for the first 60 days you are out of the country. Keep in mind there is a cap on how much foreign care a Medigap plan will cover over your lifetime. In 2018, the cap is set to $50,000.

A Word from Verywell

Medicare does not cover everything. In fact, it leaves many of life's essentials on the table. Many preventive services, including routine dental, eye, and hearing exams are not included as a standard benefit. Even people who are physically or mentally unable to care for themselves cannot rely on Medicare to support their need for custodial or nursing home care. Make a plan so that you can get the services you need when you need them.

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