What Medicare Does Not Cover

As important as Medicare is, it does not cover all your health care needs. It has been estimated that Medicare will pay for only half of all your retirement health care expenses! And the portion it does pay is shrinking. Medicare beneficiaries now pay a greater percentage of their incomes for out of pocket health care costs than they did before Medicare was passed in 1965. Because of this, an important part of retirement planning includes understanding how Medicare works, what it does and does not cover, and how much you should budget for your out of pocket health care costs. Medicare pays for just a portion of your health care costs.

Medicare is designed to cover acute care or the care necessary to diagnose or treat an illness or injury. This means several types of expenses are not be covered. For example, many beneficiaries new to Medicare are surprised to find out that, with one exception, annual or routine physical examinations are not covered. The one exception is the “Welcome to Medicare” physical examination you may take within six months of joining Medicare. Vision and dental care as well as long term care expenses are not covered by Medicare.

In this article, you will learn what Medicare does not cover. With this knowledge you can better protect yourself from large health care costs that can deplete your retirement nest egg and alter your life style.

You pay for what isn’t covered - While there are some exceptions in each category, in general Medicare beneficiaries must pay the cost of:

1. The premiums, deductibles and coinsurance amounts that are part of the original Medicare program.
2. First three pints of blood.
3. Eye care, eyeglasses and dental bills including dentures.
4. Foot care, orthopedic shoes, cosmetic surgery, chiropractic services, acupuncture.
5. Syringes or insulin (unless insulin pump used) but refer to coverage for diabetes screening and diabetes self management programs.
6. Shots to prevent illness (with exceptions for flu shots, Hepatitis B, pneumococcal shots).
7. Health care while you are traveling outside the U.S.
8. “Wellness programs” - with the exception of the one-time “Welcome to Medicare” physical examination, original Medicare does not cover the cost of “wellness programs” including routine or yearly physical exams. There are certain preventive screenings covered by Part B. Ask your doctor if you are eligible to receive the services.
9. Doctors who do not accept Medicare assignment may charge up to 15% more for their services which you are expected to pay (these are known as the Medicare Part B Excess Charges).
10. The cost of long term custodial care. While Medicare does cover the cost of a limited stay in a skilled nursing facility (if certain criteria are met) it does not, in general, pay for custodial care. More than 90% of long term care is custodial care which is assistance with activities of daily living (ADLs) or the personal assistance needed by someone with a cognitive impairment. See the section on The Basics of Long Term Care.

Planning for what Medicare does not cover

The chart below recommends steps you can take to better prepare yourself for what Medicare fails to cover:

What Medicare does not cover…	What to do…
Premiums, deductibles and coinsurance amounts	Consider purchasing a Medicare Supplement (Medigap) policy. See the section on Medicare Supplement plans. Low income seniors may be eligible for assistance with paying the premium, deductibles and/or coinsurance through the Qualified Medicare Beneficiary (QMB); Specified Low-Income Medicare Beneficiary (SLMB); Qualifying Indiviudual (QI) programs. The amount of assistance you are eligible for depends on your level of income. If you think you need assistance call 1-800-MEDICARE (1-800-633-4227).
First three points of blood.	Purchase a Medigap policy which will pay for the first three pints of blood.
Eye care, eyeglasses and dental bills including dentures, hearing tests and hearing aids	Some Medicare Advantage plans offer limited vision coverage such as an eye exam every two years and/ or free regular hearing exams plus discounts on hearing aids, dental discounts; otherwise, budget to pay out of pocket. Consider discount programs or insurance programs offered through private insurers. Always shop carefully for discount cards – most are not worth the fee! A discount card is not an insurance plan. You pay for the services received but at a discounted price.
Foot care, orthopedic shoes, cosmetic surgery, chiropractic services, acupuncture.	Medicare pays for a limited amount of chiropractic care. Some Medicare Advantage plans pay for some of these types of care. Budget to pay out of pocket or consider discount programs or insurance programs offered through private insurers. Always shop carefully for discount cards – most are not worth the fee! A discount card is not an insurance plan. You pay for the services received but at a discounted price.
Syringes or insulin (unless insulin pump used) but refer to coverage for diabetes screening and diabetes self management programs.	Understand the exceptions and preventive screening provisions for diabetes. Join a Part D prescription drug plan – check the formulary to determine if insulin is covered and the other terms of the plan. Consider a Medicare Advantage Special Needs Plan (SNP) for diabetics.
Shots to prevent illness (with exceptions for flu shots, Hepatitis B, pneumococcal shots).	Understand the exceptions – many shots are covered. Talk with your doctor.
Health care while you are traveling outside the U.S.	Most Medicare Supplement plans provide for foreign travel emergency care – but only for the first two months of a trip. Some Medicare Advantage plans also provide limited coverage for emergency care and low cost immunizations for foreign travel.
Wellness programs, annual checkups	Make sure to take advantage of the “Welcome to Medicare” physical exam within the first 6 months of participation in Medicare Part B. Most Medicare Advantage plans pay for routine physical exams and offer more extensive wellness programs.
Medicare Part B Excess Charges	Purchase a Medigap policy which pays the excess charges. Consider a Medicare Advantage managed care plan.
Long term custodial care	Consider purchasing long term care insurance. Work with a knowledgeable professional who will find an affordable plan with a financially strong insurance company.

In addition, if you are a veteran, benefits may be available – call the U.S. Department of Veterans Affairs (VA) at 1-800-827-1000. You may also be eligible for benefits under TRICARE (1-888-363-5433 - the health program for active duty service members) or TRICARE for Life (1-866-773-0404 – medical coverage for Medicare entitled uniformed services retirees, eligible family members, survivors and certain former spouses). Retired Federal employees may be eligible for benefits under the Federal Employee Health Benefits Program (FEHBP).

For More Information

Every state offers assistance through SHIP (Senior Health Insurance Program). Check the telephone directory or the back cover of your current copy of Medicare & You or go to www.medicare.gov.