Posted on June 14, 2022 by Austin Lang
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Posted on June 14, 2022 by Austin Lang
If you’ve just switched from private health insurance to Original Medicare, you might be in for a shock. Medicare is a wide-reaching program that covers a variety of medical services, but it doesn’t cover all of them. This is intuitive in some cases: elective cosmetic procedures aren’t usually covered under insurance, after all. Sometimes, however, you’ll run into a service that isn’t covered. Here are 10 surprising things Original Medicare won’t cover.
Before we begin, it’s important to establish the difference between Original Medicare and the various supplemental programs (Medicare Advantage, Medicare Part D, and Medigap) offered by private insurers. Original Medicare specifically refers to the government-sponsored insurance program offered to American citizens 65 and older, as well as to those with a qualifying condition.
Original Medicare is divided into two parts: Medicare Part A, which covers hospital stays and inpatient services, and Medicare Part B, which covers doctor’s visits, outpatient services, and certain medical supplies. If you’ve paid your taxes and worked in the United States for most of your adult life, you’re probably eligible for Original Medicare.
The other programs, including Medicare Part C: Medicare Advantage, Medicare Part D: Prescription Drug Coverage, and Medicare Supplemental Insurance (Medigap) are privately offered plans that either supplement or replace your Original Medicare coverage, and often come with additional benefits. When one of the items on this list is covered by something that is not part of Original Medicare, we’ll mention how you can use one of these supplemental plans to cover it.
Some people are wary of Medicare Advantage plans. After all, why pay for Medicare when you’ve paid into it your entire adult life? You can just sit back, relax, and reap the benefits of your labor at no cost to y– wait, why did you get a bill?
Unfortunately, Original Medicare isn’t free, even if you’ve already paid into it with taxes. There’s a monthly premium, usually deducted from your Social Security payment, that goes to your Part B coverage. This premium is dependent on your income but sits at a minimum amount that rises each year, which you can check here. Thankfully, Medicare Part A usually doesn’t have a premium, but can under certain circumstances.
Original Medicare also comes with a deductible, like traditional health insurance. You’ll need to meet this deductible before Medicare will pay out for most services. However, unlike private insurance, Medicare has no out-of-pocket maximum.
You see, all insurers rely on something called cost-sharing to manage their expenses. In addition to your premium and deductible, you may be asked to pay a portion of the cost for any services received. This is called a copayment when visiting a doctor or purchasing medication and called coinsurance when applied to other medical procedures. After you pay a certain amount of money out-of-pocket, referring to your deductible and any costs you share with the insurer, they’re legally obligated to cover any further medical expenses you may incur, provided they fall under the purview of the Affordable Care Act.
Original Medicare, as a government-run program, is exempt from these regulations. Instead, you’ll continue paying 20 percent coinsurance for most approved services in perpetuity, until your benefits period (and deductible) resets. This can add up quickly.
Certain supplemental plans can reduce these extra costs. Medigap, for instance, can cover your deductible and coinsurance payments under certain plans. Medicare Advantage plans can offer similar benefits, and can also cover some of your Part B premiums. Many Medicare Advantage plans have no premium beyond what you pay for Part B, so this benefit can actually end up saving you a considerable amount of money. This does come at the expense of being limited to a specific network of providers, so it isn’t suitable for everyone. Be sure to weigh everything a plan has to offer before enrolling.
This one is probably the most shocking: prescription medications are an element of the medical world that many of us encounter every day. Some medications are even vital to our survival! Yet, surprisingly, Medicare doesn’t cover them.
There are some exceptions to this rule, like medicine administered by a doctor, or as part of a device like an insulin pump, but you’ll need to pay out-of-pocket for most medications. If you’ve been getting your medication through insurance at no-cost, switching to Medicare can lead to some sticker shock. Even generic medications can be $20 or more, in some cases.
If you want prescription drug coverage, you’ll need to enroll in Medicare Part D. This is a privately offered plan that specifically covers medications, including insulin, antidepressants, and heart medication. Each plan has a unique formulary, or list of covered medications, so be sure to check that your medications are covered before enrolling.
Medicare Advantage plans often also include prescription drug coverage, and may even help cover over-the-counter medications like pain relievers and allergy medications. If you’re reliant on such medications, consider a plan with an OTC benefit.
Traveling this summer? If you need medical care for any reason, you should be wary about leaving the states. Original Medicare, as an American program, only offers coverage in US territories except in special circumstances: namely, if you live near the Mexican or Canadian borders and a foreign hospital is the closest option in an emergency. This is pretty typical for insurance in general.
Certain Medigap plans can cover medical care while traveling, which is essential for people vacationing overseas. Medicare Advantage plans may also cover international healthcare, but be aware that leaving your coverage area for an extended period can result in the cancellation of your plan.
We’re not entirely sure why insurance providers consider 20/20 vision a luxury, but vision insurance isn’t a common insurance benefit. This is also true for Original Medicare: aside from certain catastrophic injuries or life-threatening eye conditions, eye exams, glasses, and contacts aren’t covered. Fortunately, vision care is one of the most common benefits of a Medicare Advantage plan, so you won’t have to depend on drug-store reading glasses to keep your vision sharp.
If you need long-term care in a nursing home or assisted living facility, your options under Medicare are limited. Original Medicare is not obliged to cover a stay in a nursing home, though it will cover short-term stays in skilled nursing facilities. Medicare Advantage plans won’t be much help either. While they may cover medication and medical services you receive while in a nursing home, they won’t cover room and board. Consider looking into alternative options to find long-term care coverage.
‘Teeth are luxury bones’ has become somewhat of a meme among bitter internet users frustrated that most insurers don’t cover basic dental services. The truth is, oral health is anything but a luxury. Your mouth can be an early warning sign for many diseases, and untreated tooth decay can lead to serious complications. Medicare Advantage plans often cover dental care, including regular cleanings, dentures and implants, and more complex procedures.
Are you suffering from agony of the feet? While Original Medicare covers podiatry for people with diabetes, it does not cover routine foot care like corn removal or treating ingrown toenails. These services can be found in certain Medicare Advantage plans, so consider checking your option if your toes need some treatment.
While Original Medicare will cover many medical services delivered at home, it only covers medical services like exams, dialysis, and physical therapy. If you need help cleaning, bathing, dressing, or performing other tasks related to daily living, Original Medicare will only cover a part-time aide as part of a larger medical plan. For instance, if you’re receiving hospice care at home. Otherwise, these services fall under the purview of Medicare Advantage.
Hearing care is another common need that is unfortunately not covered by Original Medicare parts A and B. Although you can get cheap hearing aids at a drugstore, you shouldn’t need to rely on expensive over-the-counter solutions to be able to hear. Luckily, Medicare Advantage can cover hearing tests and hearing aids, even when Original Medicare does not.
Medicare Part A is designed to cover all of the basic things you’ll need during your hospital stay, but certain aspects of your stay may not be included. Do you want a private room? TV or internet service? More luxurious food than the carefully balanced meals provided? Original Medicare won’t cover that, but Medicare Advantage can. Check with your provider to see what options are available and how to file a claim.
Original Medicare does a lot, but it’s far from all-encompassing. Thankfully, it’s easy to fill the gaps. Call one of our licensed insurance agents at (800) 950-0608 or enter your zip code to begin comparing your options and see what extra coverage you may be eligible for.
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Austin is dedicated to breaking down complex topics, like Medicare, in a way that's easy to understand. He graduated with an M.A. from Florida Atlantic University in 2018.