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Medicare Coverage Limitations – It Won’t Pay for These 5 Things

As a Medicare beneficiary, understanding what is not covered is as important as knowing what is covered. While Medicare provides crucial coverage for a wide range of healthcare services, some services and items are not covered under the program. These include long-term care, dental care, hearing aids, cosmetic surgery, and certain prescription drugs outside Part D coverage. 

We will outline what is covered and not covered and what options are available instead for each of these items. 

1. Long-Term Care

You may have heard that Medicare benefits will cover your long-term care. This is a common misconception, as over 50% of baby boomers mistakenly believe that to be true. However, Medicare does not (and has never) paid for long-term care.

What does Medicare cover? 

Long-term care is one of the significant gaps in Medicare coverage. It refers to a range of services and supports you may need when you have difficulty performing daily activities independently. Long-term care is required over an extended period, often involving assistance with bathing, dressing, eating, using the toilet, and moving around.

Medicare typically covers short-term skilled nursing facility (SNF) care under Medicare Part A (Hospital), such as rehabilitation after a hospital stay. However, it does not cover long-term custodial care, whether at a nursing home, an assisted living facility, or a home.

Since most long-term care services focus on custodial care, it does not fall within Medicare’s purpose to provide coverage for medically necessary services. Medicare focuses on acute care and short-term rehabilitation services, such as those required after a hospital stay, rather than ongoing assistance with daily activities.

What are my options? 

If you qualify under Medicaid’s requirements, you may receive some assistance. You can also purchase a long-term care insurance policy to help cover the costs of long-term care. When considering long-term care insurance, review your policy carefully to understand what services and expenses are covered and any limitations or exclusions. 

2. Dental Care

Medicare Coverage Limitations - Woman sitting in dental chair and listening to dentist

What does Medicare cover? 

Another area where Medicare coverage falls short is dental care. Routine dental services are not covered, such as cleanings, fillings, extractions, or dentures.

However, Medicare will cover minimal dental examinations and procedures if they relate to other diseases and treatments. For example, Medicare will cover oral examinations before a kidney transplant or heart valve replacement.

The primary reason behind the lack of dental coverage is that the Medicare program was established primarily to cover medical services, not routine dental care. 

What are my options? 

Some Medicare Advantage plans (Part C) may offer dental coverage as an added benefit. Alternatively, individuals can explore standalone dental insurance plans, discount dental plans, or seek low-cost dental clinics. If you have Medicaid, you will likely receive some dental coverage. That coverage will vary by state. 

3. Hearing Aids

What does Medicare cover? 

Medicare does not cover hearing aids. While hearing aids can significantly improve quality of life, they are considered an “elective” or cosmetic device rather than a medical necessity under Medicare guidelines.

However, as we have previously noted, changes to this policy may be on the horizon. 

What are my options? 

To address this gap, some Medicare Advantage plans may offer limited coverage for hearing aids or provide discounts on their purchase. Additionally, veterans may be eligible for hearing aids through the Department of Veterans Affairs (VA). Again, the Hearing Industries Association also has a helpful guide of programs that can help. 

4. Cosmetic Surgery

a plastic surgeon measures old senior man's eyelid with a ruler

What does Medicare cover? 

Cosmetic surgery, which includes procedures performed solely for aesthetic purposes, is generally not covered by Medicare. Exceptions may be made if the surgery is deemed medically necessary, such as in reconstructive surgery following an accident or illness.

Individuals interested in cosmetic surgery may need to explore private insurance options or consider paying out-of-pocket for these procedures. Consult with a healthcare professional and thoroughly understand the associated costs, risks, and potential outcomes before proceeding.

The program focuses on medically necessary procedures to improve health or treat a specific medical condition. However, cosmetic procedures like facelifts, breast augmentation, or liposuction are typically not covered.

What are my options? 

Most insurance plans do not cover cosmetic procedures. Besides paying out of pocket, you can explore your plastic surgeon’s financing plans. Alternatively, you can research lower-cost alternatives such as non-surgical treatments. 

5. Prescription Drugs (outside of Part D)

What does Medicare cover? 

While Medicare Part D provides prescription drug coverage, not all medications are covered. Each Part D plan has a formulary or a list of what the prescription drug plan covers.

Medicare does not cover certain medications, including non-prescription, not approved by the FDA, or not used for a medically accepted purpose. Examples of medications that Medicare does not cover include weight loss or gain drugs, cold or cough remedies, fertility medications, vitamins (except prenatal or fluoride preparations), hair growth or cosmetic drugs, and medications for sexual dysfunction (unless used to treat another condition). 

What are my options? 

Medications not included in the formulary may require individuals to pay out-of-pocket or seek alternative coverage options.

In such cases, individuals can discuss with their healthcare provider the possibility of switching to generic or otherwise covered medications. You can also explore patient assistance programs offered by pharmaceutical companies. Medicaid can assist with prescription drug costs for individuals with limited income and resources.

Additionally, if you and your doctor believe that a specific medication is necessary to treat your condition, you can apply for a formulary exception to have the drug covered. 

Understanding your Medicare coverage with The Medicare Family

Understanding the limitations of Medicare coverage is vital to plan your healthcare needs. Knowing what will and will not be covered can help you make informed decisions. 

Working with the team at The Medicare Family can help you make smart Medicare choices. For over 40 years, The Medicare Family has provided valuable assistance and support to individuals navigating the complexities of Medicare. 

Whether it’s understanding the coverage gaps, exploring additional coverage options, or finding assistance for medications not covered by Medicare, we support you every step of the way. With our guidance, you can confidently and confidently navigate the Medicare landscape.

Reach out today and let us help you understand your Medicare coverage limitations and explore the best options for your specific needs.

Sylvia Gordon, aka Medicare Mama®, is an expert on all things Medicare and Social Security. She is the 2nd Generation here at The Medicare Family and has served on the advisory boards of major insurance companies like UnitedHealthcare®, Cigna, and Anthem. In her free time, she can be found taking care of her animals (dogs, goats, peacocks, chickens), and reading a good book. Learn More.
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