Drugs, Supplies, and Services that Medicare Doesn’t Cover
This article was updated on: 11/20/2017
In general, Medicare doesn’t cover supplies, services, and drugs that are not “medically necessary and reasonable.” Medicare considers services needed for the diagnosis, care, and treatment of a patient’s condition to be medically necessary. These supplies and services cannot be primarily for the convenience of the provider or beneficiary.
Always ask your doctor to clarify if you’re not sure whether a specific service or item is covered by Medicare.
What Medicare doesn’t cover
Original Medicare, Part A and Part B, doesn’t generally cover the following services and supplies. This may not be a complete list.
Alternative medicine: In general, Medicare doesn’t cover most alternative or holistic treatments, including acupuncture and chiropractor services (except when medically necessary to correct a misalignment of the spine).
Cosmetic surgery: Medicare won’t cover cosmetic surgery, unless it is medically required because of an injury or to improve functionality of a deformed body part. If you are a breast cancer patient who had a mastectomy, Medicare will cover breast prostheses.
Routine dental care: Original Medicare doesn’t cover most routine dental services and supplies. This includes dentures, oral exams, cleanings, extractions, fillings, and root canals. Medicare Part A (hospital Insurance) might pay for certain dental services that you get while you’re in a hospital.
Foot care: Medicare does not cover routine foot care (such as removal of calluses or nail-cutting), but Part B covers medically necessary podiatrist services to treat foot injuries or diseases.
Hearing care: Medicare won’t cover routine hearing exams, hearing aids, and exams to get fitted for hearing aids. However, you may be covered if your doctor orders a diagnostic hearing exam to see if you need further treatment.
Health care outside of the United States: In general, Medicare doesn’t cover health care if you are traveling outside of the 50 states, the District of Columbia, Puerto Rico, Guam, the United States Virgin Islands, American Samoa, and the Northern Mariana Islands. There are exceptions if you are in a medical emergency and the foreign hospital is closer than the closest United States hospital, or if you live in the U.S., but your home is closer to a foreign hospital than the nearest U.S. hospital. You may also be covered if you have a medical emergency while traveling through Canada between Alaska and another state, and the nearest Canadian hospital is closer than the nearest U.S. hospital. You must be taking the most direct route and traveling “without unreasonable delay.”
Homemaker services: Medicare won’t cover homemaker services, such as cooking and cleaning. An exception is if the beneficiary is in hospice care, and the homemaker services are included in the care plan.
Long-term care: Medicare doesn’t cover long-term or nursing home care. However, Medicare does cover short-term skilled nursing care when it follows a qualifying inpatient hospital stay. Medicare Part A may cover nursing care in a skilled nursing facility (SNF) for a limited time if it’s medically necessary for you to receive skilled care. However, Medicare won’t cover nursing home stays if personal care is the only care you need.
Personal care: Medicare doesn’t cover non-skilled personal care (also known as custodial care) if it’s unrelated to your treatment and the only care you need. Personal care is non-skilled care and includes help with most daily living activities, like getting dressed, bathing, and using the restroom.
Personal comfort items: Medicare does not cover personal comfort items used during an inpatient hospital stay, such as shampoo, toothbrushes, or razors. It doesn’t cover the cost of a radio, television, or phone in your hospital room if there’s an extra charge for those items.
Prescription drugs: Original Medicare, Part A and Part B, doesn’t cover most prescription drugs you’d take at home. You’ll have to sign up separately under Medicare Part D Prescription Drug Plan if you need this type of coverage. However, Medicare Part A will cover drugs administered during a covered inpatient stay in a hospital or skilled nursing facility. Medicare Part B may cover drugs that are given in a doctor’s office and aren’t typically self-administered. Examples include vaccines and chemotherapy.
Routine vision care: Original Medicare won’t cover most routine vision services and supplies, including eye exams, eyeglasses, contacts, and exams to get fitted for contacts and glasses. Medicare Part A may cover certain vision benefits if they’re related to treatment for a covered service, such as corrective lenses or glasses following a covered cataract surgery. Medicare Part B will cover preventive or diagnostic eye exams, such as glaucoma screenings if you’re at high risk.
Can I get benefits that pay for services Medicare does not cover?
Medicare Advantage plans may be an option to consider since they are required to have at least the same level of coverage as Original Medicare, but may have other benefits, such as routine vision, dental, and prescription drug coverage. Hospice services are covered directly under Medicare Part A instead of through a Medicare Advantage plan. You need to keep paying your Part B premium (as well as any premium the plan charges, if any).
What Medicare Part D doesn’t cover
Medicare Part D is optional prescription drug coverage. You can enroll in this coverage through a stand-alone Medicare Part D Prescription Drug Plan, or through a Medicare Advantage Prescription Drug plan.
Each Medicare Prescription Drug Plan has a formulary. The formulary may change at any time. You will receive notice from your plan when necessary.
Generally, Medicare Part D will cover certain prescription drugs that meet all of the following conditions:
- Only available by prescription
- Approved by the Food and Drug Administration (FDA)
- Sold and used in the United States
- Used for a medically accepted purpose
- Not already covered under Medicare Part A or Part B
Based on these criteria, there are certain drugs that Medicare Part D does not generally cover:
- Weight loss or weight gain drugs
- Erectile or sexual dysfunction drugs (unless used to treat a condition other than erectile or sexual dysfunction)
- Over-the-counter, non-prescription drugs
- Hair growth drugs, or drugs used for cosmetic reasons
- Fertility drugs
- Drugs used for symptomatic relief of coughs or colds
- Prescription vitamins and minerals (exception: prenatal vitamins and fluoride preparation products)
If you are taking a medication that is not covered by Medicare Part D, you may try asking your plan for an exception. As a beneficiary, you have a guaranteed right to appeal a Medicare coverage or payment decision.
Since Original Medicare doesn’t always cover the services, supplies, and treatments you may need, you may want to consider a Medicare Advantage Prescription Drug plan or a stand-alone Medicare Part D Prescription Drug Plan. Your particular health and financial needs may determine which plan could work for you. For help figuring this out, feel free to contact me.
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