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5 Things Original Medicare Won’t Cover

Posted on November 19, 2021 by Kyle Walton

Original Medicare: The Ins and Outs

Don’t get us wrong, Medicare Parts A and B, known collectively as Original Medicare, is a beloved health insurance program designed specifically to help seniors and certain qualifying disabled individuals with getting the healthcare coverage they need. Unfortunately, however, Original Medicare is not always as comprehensive as you may need it to be.

In fact, if you’ve been accustomed to receiving private, employer-sponsored health insurance plans that have provided you with virtually all of your healthcare needs throughout your entire working life, you may be surprised to learn that many of those same benefits do not transfer over to Original Medicare coverage once you become eligible.

But why doesn’t Medicare cover these common healthcare needs? Well, in actuality, Original Medicare Part B does sometimes cover at least a portion of these common benefits to some degree, usually in emergency, hospital, or medically necessary settings. 

Courtesy of MedicareInsurance.com, let’s take a look at what Original Medicare won’t cover.

Why doesn’t Medicare cover…

Dental?

It’s practically common knowledge that age increases your risk of developing many dental conditions, including tooth loss, gum disease, dry mouth, root decay, and other oral infections. For this reason, it is often necessary to continue your dental care coverage well into retirement.

Unfortunately, Original Medicare won’t cover routine dental visits, cavity treatments, treatments or repair for broken teeth, dentures, dental implants, or other serious dental issues. That said, Original Medicare will sometimes step up to the plate if treatment for dental issues is considered medically necessary. 

For example, if you have oral cancer and need dental surgery in order for your treatment to remain effective, Original Medicare will likely cover it. Original Medicare will also cover dental treatments that are considered necessary for the clearance of other medically necessary surgeries, such as dental exams prior to heart surgery.

Vision?

Did you know that approximately 80 percent of adults aged 55 and over wear prescription eyewear to help with daily vision difficulties?  By the age of 65, 90 percent suffer from cataracts, with about half losing some vision because of it. These numbers serve as a stark indication that most older adults will require some form of regular vision care in order to maintain their eyesight.

Currently, Original Medicare won’t cover vision care such as eye exams, glasses, or contact lenses. In the event that you are diagnosed with cataracts and require surgery to correct them, Original Medicare will usually cover this surgery and inpatient contact lenses if needed. That said, any outpatient vision treatment will not be covered.

Hearing?

Around one-third of seniors between the ages of 65 and 74 suffer from hearing loss to some degree. In addition, about half of the senior population aged 75 and over are considered hard of hearing.

Original Medicare won’t cover any routine hearing care, including hearing aids, hearing aid fittings, or the cost of your hearing exam. Unfortunately, this is not exclusive to Original Medicare, as many Medigap plans and other forms of health insurance do not cover hearing aids, which can cost a person about $2,700 out-of-pocket on average.

Prescription Drugs?

Despite over 90 percent of seniors relying on at least one prescription medication and 54 percent requiring four or more daily medications just to stay alive and healthy, Original Medicare does not cover most prescription drugs.

There are some circumstances where the administration of medically necessary medications may be covered by Original Medicare when given by a medical professional (via injection or infusion at a doctor’s office, for example).

Even if you supplement your Original Medicare coverage with a Medigap plan, chances are you will still be on your own for prescription medications. Out-of-pocket costs for prescription medications are usually not covered unless specifically covered by Original Medicare Parts A and B as a part of ongoing hospice or home-health treatment.

Long-term Care?

If you are a long-time Original Medicare recipient or you have recently researched Medicare, then you are likely aware that Original Medicare does cover treatments and services received in a skilled nursing facility — but only under specific circumstances. Keep in mind however, that long-term care is not the same as skilled nursing care, and therefore you will need to be separately prepared.

Under Original Medicare Parts A and B, long-term custodial care (such as assistance with daily hygiene, going to the bathroom, eating, etc.) is not covered either in a skilled nursing facility, nursing home, assisted living facility, or retirement community.

When it comes to skilled nursing care, Original Medicare will usually cover up to 100 days in a skilled nursing facility per benefit period. In order to stay covered, this stay must follow a qualifying inpatient hospital stay and it must be determined that you require assistance beyond just the custodial care activities associated with daily living.

Image of young, female doctor smiling while conversing senior patient.

What is Medicare Advantage and how can it help me get the coverage I need?

Although Original Medicare is not as comprehensive as you may have hoped for, you will likely be pleased to learn that there are Medicare options beyond just Parts A and B that can be specifically designed to help provide you with coverage where you need it. One such option is Medicare Advantage, also known as Medicare Part C.

Medicare Advantage plans are insurance plans offered by private insurance providers that can be carefully tailored to give you more comprehensive healthcare coverage when you need it. These plans are required by law to provide you with the same level of coverage as Original Medicare, but they may offer additional benefits such as treatments and services associated with the needs listed above. 

Keep in mind, however, that because Medicare Advantage plans are offered by private insurance companies, their exact benefits, pricing, and availability may vary.

Medicare Part D: Prescription Drug Coverage is also an additional Medicare option that is designed to help you pay for the costs associated with your prescription medications. In many cases, Medicare Part D coverage can help you pay for both name-brand and generic prescription drugs, and it is even possible to bundle a Medicare Part D plan into your Medicare Advantage coverage.

If you are interested in getting some professional assistance with researching and comparing your Medicare options, give the licensed insurance agents at MedicareInsurance.com a call today. We’ll be happy to help you learn more about your options.

About the Author

Kyle Walton

Kyle is a professional writer with several years of experience helping to inform the public on many diverse topics and industries, including healthcare. He is a Kutztown University graduate, Class of 2017.

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