5 Things That Medicare Doesn't Cover, but Some Medicare Advantage Plans Do
Updated: Jun 26, 2022
Choosing between Original Medicare and Medicare Advantage is complicated because there are so many factors to compare.
But what about comparing something as basic as what each program covers? Let's see:
By law, Medicare Advantage (Medicare Part C) has to cover everything Original Medicare does. But it can also cover other services.
However, Original Medicare, with its Part A (hospital insurance) and Part B (medical insurance), can only cover services and treatments that your health care provider can certify to be medically necessary.
So, it could be helpful to see what Medicare Advantage sometimes covers that Original Medicare never does.
Here are the top five things:
Medicare Part A will pay for certain dental services, such as emergency or complex procedures, if provided in a hospital setting. But neither Part A nor Part B will cover routine dental care and dentures, including check-ups, cleanings, fillings, extractions, dentures, dental plates or other orthodontic or dental devices.
Yet these services are needed by seniors not only for comfort but also because poor oral health is associated with diabetes, heart disease, strokes and other issues.
Some Medicare Advantage plans do offer dental care, usually through networks of qualified dentists. However, it's essential to understand exactly what's covered, as it could be limited to fillings, cleanings and specific X-rays. You will also want to check the maximum your insurance plan will pay.
Original Medicare does not cover routine vision care, such as eye exams, eyeglasses or contact lenses. However, the exceptions are:
Annual eye exams for people with diabetes,
Eyeglasses after specific cataract surgery, and
Care related to glaucoma and macular degeneration.
Many Medicare Advantage plans offer some routine vision care, but you will want to check each plan's description of what is covered. There will be limitations on what is included, plus a dollar limit, perhaps described as an allowance that can be used with plan-assigned optical retailers.
Original Medicare will not cover routine hearing exams or hearing aids under ordinary circumstances. But Part B will cover diagnostic hearing exams if needed to determine the cause of another condition.
Once again, hearing is a sense that becomes a challenge to seniors, and hearing aids are notoriously costly. So when checking on the hearing care covered by a Medicare Advantage plan, be sure to check on the spending cap on hearing aids.
Original Medicare doesn’t cover prescription drugs, with the following exceptions: Part A pays for the prescription drugs you need while you're a hospital inpatient. And Part B pays for prescription drugs that your health care provider administers in a doctor's office or medical facility.
Yet about 90% of seniors take prescription drugs – and more than half of them take four or more – so controlling those costs is vital. Two solutions exist:
Seniors can buy an optional Medicare Part D prescription drug insurance plan from a private insurer.
They can sign up for Medicare Advantage, where most plans bundle Part D into their coverage.
When you look at the prescription drug coverage related to a Medicare Advantage plan, check to ensure that its "formulary" or list of covered drugs includes what you take. Also, check the price of each.
Original Medicare doesn’t cover fitness programs or gym memberships, although Part B does cover medically necessary outpatient physical therapy.
But some Medicare Advantage plans do cover gym memberships such as SilverSneakers. This nationwide fitness program helps seniors get and stay active through a network of participating gyms and fitness centers.
Other gym memberships may also be available. And some plans offer healthy living benefits that might include nutritional home meal delivery.
Other extra benefits
To help market their plans, some Medicare Advantage insurers offer services as varied as chiropractic care, acupuncture, counseling, enhanced disease management, bathroom safety devices, home safety assessments, personal emergency response systems and non-emergency transportation.
Action step: Medicare Advantage plans must be renewed each year during the Fall Annual Enrollment Period. Before renewing, check the medicare.gov website, as well as the Summary of Benefits your insurer sends you, to be sure your plan still provides the best benefits for you.