Original Medicare, through its Part A (hospital insurance) and Part B (medical insurance), covers the central part of your health care needs after age 65. However, there are several areas that Original Medicare does not cover – and which you should know about so you can be prepared to handle them, one way or another. Here are some of those areas and possible solutions.
1. Most prescription drugs
Original Medicare does not cover prescription drugs it considers "self-administered." If you need prescription drugs during an inpatient hospital stay, they will be covered by Medicare Part A. And if your health care provider administers prescription drugs in a medical facility or office, they will be covered by Medicare Part B. Otherwise, you will have to pay for drugs out of pocket.
Takeaway action step: If you want prescription drug coverage, consider buying an optional, standalone Medicare Part D prescription drug policy to complement your Original Medicare coverage. You can also weigh the pluses and minuses of switching your Original Medicare coverage for an all-encompassing Part C (Medicare Advantage) plan. Do this when you first enroll in Medicare or when you lose other drug coverage you may have. A long-term penalty could be added to your premium if you go without creditable coverage and enroll later in Medicare Part D. You might also look into prescription drug discount cards.
If you do sign up for a Medicare Advantage or Part D prescription drug plan, compare available plans at Medicare's Medicare Plan Finder and change your policy each fall during the Open Enrollment Period if your health care or drug needs change.
2. Routine eye exams, prescription eyeglasses or contacts
Suppose you have a medical condition such as glaucoma, cataracts, macular degeneration, dry eye or vision issues related to diabetes. In that case, Original Medicare will likely cover the expense as outpatient care under Medicare Part B. It may even pay for a pair of eyeglasses after cataract surgery. But Original Medicare doesn't cover routine eye exams, prescription glasses or contact lenses: in that case, you're on your own.
Takeaway action step: For some people, buying a standalone vision insurance policy for a few hundred dollars a year may make sense to defray the cost of glasses or contact lenses. The alternative is to switch from Original Medicare to a Medicare Advantage plan bundled with good vision benefits. Check the fine print to be sure you're not giving up some of the substantial benefits of Original Medicare for a vision plan that covers very little when you try to use it.
3. Hearing exams, aids or related services
Medicare covers medical conditions related to the ears, plus diagnostic hearing exams needed to determine the cause of another condition, but not routine hearing tests or hearing aids.
Takeaway action step: If you have Original Medicare, you might consider buying a standalone hearing insurance plan or a membership in a discount plan that lowers your out-of-pocket costs for such tests and devices. Suppose your hearing loss is mild to moderate. In that case, you may benefit from the over-the-counter hearing aids that have become available recently in retail locations without a prescription. The alternative is to consider switching to a Medicare Advantage plan with good hearing benefits. Check the fine print of your plan to be sure it actually pays for what you need.
4. Dental exams, most dental care or dentures
Original Medicare does not cover routine dental visits, teeth cleanings, fillings, dentures, orthodontic devices, root canals, implants or most tooth extractions. However, Medicare Part A will cover the cost of specific emergency or complex dental procedures performed while you are in the hospital as an inpatient.
Takeaway action step: If you have Original Medicare, you can consider buying a standalone dental insurance plan or a dental discount plan to help cover the costs of dentistry. If you are willing to switch to a Medicare Advantage plan, you could find one with good dental benefits. However, such plans could have limitations on what they cover and when – or they could require an add-on to your monthly premium.
5. Medical coverage when you are traveling outside the U.S.
Original Medicare covers you wherever you travel in the U.S. However, it covers virtually no medical costs incurred outside of the U.S. Exceptions include having a medical emergency within six hours of a U.S. port on a cruise ship or when traveling between Alaska and another state – through Canada – where a Canadian hospital is closer.
Takeaway action step: If you have a Medicare Supplement Insurance (Medigap) plan complementing your Original Medicare, your plan may offer up to 80% emergency care coverage for medically necessary care. Coverage begins after you meet a $250 deductible and has a $50,000 lifetime limit. Some Medicare Advantage plans may offer limited coverage abroad, but you must check your policy. You can also buy travel insurance that covers you abroad and will pay for emergency medical evacuation (medevac) to a nearby medical facility or back home. If you're considering moving abroad, think carefully about the penalties involved with your Plan B premiums if you later decide to return to the U.S. and reestablish your Medicare insurance.
6. Routine foot care
Original Medicare doesn't cover anything considered routine related to your feet – such as corn or callus removal – or anything that can be considered preventive or maintenance. You will have to cover 100% of the cost of such treatments. However, Medicare Part B does cover caring for foot injuries or ailments such as bunion deformities, heel spurs or hammer toe, plus the cost of foot exams or treatment for nerve damage related to diabetes or other medical issues.
Takeaway action step: Routine foot care is one area that will not be covered by insurance, so any cost will have to be figured into your budget.
7. Cosmetic surgery
Original Medicare does not cover elective cosmetic surgery such as facelifts, tummy tucks or breast augmentation. (Cosmetic surgery refers to procedures that alter the appearance of an otherwise healthy body part based on the guidelines of the American Medical Association.) However, it does cover surgeries that are medically necessary because of an accidental injury or to correct the function from a malformation. It will cover breast reconstruction surgery in mastectomy cases related to breast cancer. It may cover rhinoplasty if nose surgery is needed to repair breathing problems or an eyelid lift in cases of impaired vision.
Takeaway action step: Unless you and your doctors can show a medical reason for the procedure, you will likely have to find other ways to finance your surgery.
8. Most chiropractic services
Original Medicare doesn't cover most chiropractic services, including the tests a chiropractor orders, such as X-rays. Medicare Part B will, however, cover one spine manipulation by a chiropractor or other qualified provider to correct a vertebral subluxation – a partial dislocation where the spinal joints fail to move correctly, but the contact between the joints remains intact.
Takeaway action step: If chiropractic care is essential, you may consider a Medicare Advantage plan instead of Original Medicare, as some plans will cover a chiropractor's services. Read what limitations might apply to such services by examining the Medicare Advantage plan's Evidence of Coverage (EO) documentation.
9. Acupuncture or other alternative treatments
Alternative medicine is typically not covered by Original Medicare. That's the case with massage therapy, which can reduce chronic pain. However, Original Medicare does cover doctor-prescribed physical and occupational therapy. As for acupuncture, when related to chronic low-back pain experienced for 12 weeks or longer, it covers up to 20 treatments per year: 12 visits within 90 days and eight more if you show improvement. No other reason for acupuncture is covered.
Takeaway action step: With Original Medicare, check with your health care provider to find a pain management strategy that it covers. An alternative is to switch to Medicare Advantage, as some plans might even cover massage therapy.
10. Long-term care
Original Medicare will not cover long-term care, something the Department of Health and Human Services says a 65-year-old today has a 7-in-10 chance of needing at some point. It will provide some skilled nursing services after a qualifying 3-day inpatient hospital stay, including limited stays in rehab facilities related to inpatient physical therapy. However, it will not cover you if you become so sick or weak that you must move to a nursing home or assisted living facility. That is custodial care, and Medicare only covers skilled nursing care – for up to 100 days, with a daily coinsurance charge under Medicare Part A. You are responsible for all costs after that.
Takeaway action step: The cost of long-term care is the most significant potential expense in retirement, from $50,000 per year for home health aide assistance to over $100,000 per year for a private room in a nursing home. Because Original Medicare will not cover it, you should look into long-term care insurance, with or without a life insurance policy combined, if you can. Some Medicare Advantage plans may cover limited additional benefits in the form of in-home help but nothing long-term. If your income and savings are limited, look into the requirements to qualify for Medicaid to help cover your needs – and do so well in advance, as Medicaid may include a "5-year lookback" of your finances during qualification.