- Original Medicare does not cover some fundamental health care costs.
- Medigap and Medicare Part D prescription plans help fill coverage gaps. Medicare Advantage plans replace Original Medicare altogether.
- Original Medicare does not cover treatment outside of the U.S., except under very limited circumstances.
Understanding Coverage Gaps in Original Medicare
Many retirees think Medicare covers most health care expenses.
In reality, Medicare Part A and Part B — otherwise known as Original Medicare — has several coverage gaps.
In general, Original Medicare does not cover:
- Prescription drugs
- Long-term care (such as extended nursing home stays or custodial care)
- Hearing aids
- Most vision care, notably eyeglasses and contacts
- Most dental care, notably dentures
- Most cosmetic surgery
- Massage therapy
- Sterilization, including a hysterectomy (unless it's deemed medically necessary)
- Medical marijuana
- Medical expenses outside the United States
There are some exceptions, but beneficiaries should be aware of what is not covered by Medicare and plan accordingly.
A Medicare Advantage plan, also known as Part C, acts as an all-in-one alternative to Original Medicare and is offered by government-approved private insurance companies.
Medicare Advantage plans must provide the same base level of care as Medicare Part A and Part B but may also bundle other benefits, such as prescription drugs, dental, vision and hearing, into a single plan.
However, coverage for these additional services may be limited.
In 2020, the average spending for a person with Medicare coverage was $10,739, according to a June 2022 analysis by the Kaiser Family Foundation — a leading nonprofit focused on national health policy issues.
Long-term care, certain medical supplies, prescription drugs and dental services accounted for the biggest out-of-pocket costs, the study found.
It’s important to note that Medicare Part B includes a standard monthly premium of $164.90 in 2023. There are also deductibles, coinsurance and copayments, which can further drive up out-of-pocket expenses for beneficiaries.
The easiest way to look up services and procedures covered by Medicare is by using Medicare's coverage tool, an online resource that allows you to enter the test, item or service you need and shows you the details of your coverage, including any costs that may arise from exceptional circumstances.
Don't Leave Your Health to Chance
Find a local Medicare plan that fits your needs by connecting with a licensed insurance agent.
Get FREE Help Now
Prescription Drug Coverage
Original Medicare does not cover most prescription drugs.
However, You Can Get Drug Coverage One of Two Ways
- With a standalone Medicare Part D prescription drug plan
- With a Medicare Advantage plan that includes prescription drug coverage
You can use the Medicare Plan Finder to compare Part D or Medicare Advantage plans in your area.
Medicare Part B may cover some outpatient drugs under limited circumstances.
For example, certain injectable osteoporosis drugs and oral drugs for end-stage renal disease are covered.
In general, drugs covered under Medicare Part B are usually received at a doctor’s office or hospital outpatient setting.
In these situations, you’ll owe 20 percent of the Medicare-approved amount for covered Part B drugs administered in a doctor’s office or pharmacy, and the Part B deductible applies.
Long-Term Care Coverage
Original Medicare does not cover the cost of long-term care, including extended stays at nursing homes and assisted living facilities.
Custodial care — or help with performing activities of daily living, such as dressing, eating or bathing — isn’t covered, either.
Medicare Advantage plans also lack long-term care coverage.
Medicare will cover some costs at a skilled nursing facility for up to 100 days. A short-term stay at these facilities must take place within 30 days of leaving the hospital and for the same illness or injury.
Did You Know?
In 2021, the median cost of a private room in a nursing home was $9,034 a month.
Long-term care is often considered one of the most expensive health care costs in retirement.
Private long-term care insurance can help, although policy premiums are often high.
Medicaid, a joint federal and state government program, is another way to pay for long-term care, but it’s available only to seniors with limited income and few resources.
3 Minute Quiz: Can You Retire Comfortably?
Take our free quiz & match with a financial advisor in 3 easy steps. Tailored to your goals. Near you or online.
TAKE THE QUIZ NOW
Dental, Vision and Hearing Coverage
Generally, Original Medicare does not cover dental work and routine vision or hearing care.
Original Medicare won’t pay for routine dental care, visits, cleanings, fillings dentures or most tooth extractions.
The same holds true for routine vision checks. Eyeglasses and contact lenses aren’t generally covered.
However, Medicare Part B may cover tests and treatments for certain serious eye conditions, although you will still owe a copayment, and your Part B deductible applies.
Vision Care Covered by Medicare Part B
- Yearly eye exam for people with diabetes
- Glaucoma tests for people at high risk
- Macular degeneration tests and treatment
- Cataract removal surgery
- One pair of eyeglasses or one set of contact lenses after cataract surgery
Finally, Original Medicare won’t pay for hearing aids or the exam required to select and fit these devices.
Did You Know?
In 2022, the average cost of one hearing aid was about $2,000.
Medicare Part B may pay a portion of diagnostic hearing and balance exams but only if a doctor orders them in an emergency or to determine whether you need medical treatment.
For example, a doctor may order these tests to diagnose the cause of dizziness or vertigo.
If you decide to go with a Medicare Advantage plan, there’s a good chance dental and vision will be included. However, coverage may be limited.
Cosmetic Surgery Coverage
Like many health insurance plans, Medicare does not typically cover cosmetic surgery.
However, there are a few exceptions.
If you had a mastectomy because of breast cancer, Medicare covers breast prostheses for breast reconstruction.
Also, if cosmetic surgery is deemed necessary as a result of an accidental injury, or to improve the function of a malformed body part, Medicare covers 80 percent of approved costs.
For example, rhinoplasty is a procedure that changes the shape and contour of the nose.
If a doctor believes a rhinoplasty is medically necessary to correct a congenital defect or traumatic injury that causes a functional impairment, Medicare will likely cover this procedure.
It may also be covered to fix a chronic nasal obstruction that cannot be effectively treated in a less invasive way.
However, Medicare will never cover a procedure for cosmetic reasons.
Medicare may require prior authorization for some procedures. In these cases, the hospital or physician must provide medical records to Medicare for review.
Original Medicare will not cover some forms of alternative medicine, including experimental procedures, medical marijuana and massage therapy — even if these treatments are prescribed by your doctor.
Medicare pays for chiropractic manipulation only if one or more bones in your spine have slipped out of position.
This chiropractic service must be deemed medically necessary by your doctor, and you will owe 20 percent of the approved cost.
Medicare began covering acupuncture in January 2020, but only for chronic lower back pain, and restrictions may apply.
Medical Coverage Outside the United States
Original Medicare generally does not cover treatment outside the United States, except under very limited circumstances, such as on a cruise ship within six hours of a U.S. port.
However, some Medicare supplement insurance policies — also known as Medigap — cover overseas health care costs.
Medigap plans C, D, F, G, M, and N provide foreign travel emergency health care coverage outside the United States.
These Medigap Plans Will Cover
- Foreign travel emergency care if it begins during the first 60 days of your trip
- Eighty percent of billed charges for certain medically necessary emergency care after a $250 yearly deductible is met
A lifetime coverage limit of $50,000 applies.
In 2020, the average premium for a Medigap policy was roughly $150 per month, or $1,800 per year, according to full-service insurance organization Senior Market Sales.
Coverage Gaps of Medicare Part A & Part B FAQs
What is not covered by Medicare Part A?
Medicare Part A hospital insurance provides inpatient hospital coverage. But it does not cover a private room — unless it’s medically necessary — the first three pints of blood, a private nurse, television, telephone or personal items needed for your hospital stay.
What does Medicare Part B not cover?
Medicare Part B covers costs associated with doctors’ care outside of a hospital. Part B does not cover hearing aids or hearing tests, cosmetic surgery, massage therapy, routine physical exams, concierge care and several other outpatient services.
What are three services not covered by Medicare?
There are several services Medicare does not cover including long-term care in a nursing home or similar facility, routine dental care including dentures and vision care including prescription eyeglasses.
There are some things Original Medicare won't cover. Generally, most vision, dental and hearing services are not covered by Medicare Parts A and B. Other services not covered by Medicare Parts A and B include: Routine foot care.What 6 things will Medicare not cover? ›
- Most dental care.
- Eye exams (for prescription glasses)
- Cosmetic surgery.
- Massage therapy.
- Routine physical exams.
- Hearing aids and exams for fitting them.
In 2023, Medicare Part A costs will be increasing in the following ways: Inpatient Hospital Deductible: $1600 per stay (an increase of $44 from 2022) Daily Coinsurance For 61 st-90 th Day Of The Benefit Period: $400. Daily Coinsurance For Lifetime Reserve Days: $800.Which of the following does Medicare not pay for? ›
Medicare will cover your medical needs, as it would no matter where you live. But it does not pay for room and board at these facilities or for help with everyday activities such as bathing, dressing, eating or using the bathroom (also called “custodial care”) if that is the only care that you need.How much will Social Security take out for Medicare in 2023? ›
For most people, $164.90 will be deducted each month from your Social Security to pay for Medicare Part B (medical insurance). This amount will be higher for those who have higher incomes.What 9 medical cost will Medicare not cover? ›
Original Medicare doesn't cover routine medical expenses for your eyes, your mouth, or your ears. You generally can't get reimbursed for annual visits to the dentist or optometrist. And forget about coverage for new eyeglasses or hearing aids. But some types of vision, dental, and hearing expenses are covered.What are the 10 things that Medicare does not cover? ›
- Opticians and eye exams. While original Medicare covers ophthalmologic expenses such as cataract surgery, it doesn't cover routine eye exams, glasses or contact lenses. ...
- Hearing aids. ...
- Dental work. ...
- Overseas care. ...
- Podiatry. ...
- Cosmetic surgery. ...
- Chiropractic care. ...
- Massage therapy.
The Centers for Medicare & Medicaid Services (CMS) has announced that the standard monthly Part B premium will be $164.90 in 2023, a decrease of $5.20 from $170.10 in 2022.How much will Medicare Part B premium be in 2023? ›
Most people pay the standard Part B monthly premium amount ($164.90 in 2023). Social Security will tell you the exact amount you'll pay for Part B in 2023. You pay the standard premium amount if you: Enroll in Part B for the first time in 2023.Does Medicare cover insulin in 2023? ›
As of January 1, 2023, your Medicare drug plan can't charge you more than $35 for a one-month supply of each Part-D covered insulin product, and you don't have to pay a deductible for your insulin.
Since the introduction of Medicare in 1965, Medicare Part B has never paid for annual physical exams. In fact, it wasn't until 2011 that Medicare expanded their preventive services to include the AWV for all beneficiaries.Does Medicare pay for cataract surgery? ›
The short answer is, yes. Original Medicare doesn't often cover routine vision services, but cataracts are covered if the procedure is considered medically necessary.Will Medicare pay for an ultrasound? ›
Medicare Part A covers ultrasound testing in inpatient settings, such as hospitals and medical centers and nursing care facilities. Medicare Part B covers ultrasound testing in outpatient settings such as doctor's offices, day surgeries, community health clinics and other specialized outpatient clinics.Are Medicare benefits being reduced in 2023? ›
What are the changes to Medicare benefits for 2023? Changes to 2023 Medicare coverage include a decrease in the standard Part B premium to $164.90 and a decrease in the Part B deductible to $226. Part A premiums, deductible and coinsurance are all increasing for 2023.How do I get the $16728 Social Security bonus? ›
Have you heard about the Social Security $16,728 yearly bonus? There's really no “bonus” that retirees can collect. The Social Security Administration (SSA) uses a specific formula based on your lifetime earnings to determine your benefit amount.How do I get my $144 back from Medicare? ›
- Be enrolled in Medicare Parts A and B.
- Pay your own premiums (if a state or local program is covering your premiums, you're not eligible).
- Live in a service area of a plan that offers a Part B giveback.
Medicare covers a baseline mammogram once in a woman's lifetime between ages 35-39. Screening mammograms are covered once every 12 months for women 40 and older. If you need a diagnostic mammogram, Medicare will cover as many as you need if they're deemed medically necessary.Does Medicare pay for colonoscopy? ›
Medicare covers screening colonoscopies once every 24 months if you're at high risk for colorectal cancer. If you aren't at high risk, Medicare covers the test once every 120 months, or 48 months after a previous flexible sigmoidoscopy. There's no minimum age requirement.What are exclusions in Medicare? ›
Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, ...What assets are considered for Medicare? ›
Assets are resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate. In all states, there are certain resources that will never be counted as assets. These include: Your primary house.