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What Doesn’t Medicare Cover?

Medicare covers a lot. In fact, the vast majority of services offered by the various medical professions are covered. But it’s important to remember that there are new treatments, new medical devices, new drugs, and new remedies (we all know that apple cider vinegar and baking soda cure everything, right?) coming on the market all the time. Medicare does not cover these automatically.

In addition, Medicare does not pay every hospital for every service. For complex procedures like most heart surgeries and transplants, Medicare requires that hospitals be designated as “centers of excellence” based on their results in terms of survival, infections, complications, and so on.

Medicare regularly issues “coverage decisions” that specify what its management has decided to cover, or not. It also regularly enrolls and disenrolls providers for specific services. Recently, it disenrolled one of the nation’s major heart transplant centers because of poor results.

So, What Can I Expect to Be Covered?

Medicare will cover any of the “ordinary and medically necessary” treatments, with some exceptions, unless they are required to be performed only in a “center of excellence.” If the services are not covered if performed in your hospital, you will be told and will usually be transferred. A list of centers of excellence for transplants can be found at Medicare-approved Transplant Programs.

If the services your doctor wants for you are not covered by Medicare, you will usually be informed. If you have a Medigap supplemental policy or a Medicare Advantage plan, it may cover the services Medicare does not.  For detailed information on what each Medigap policy or Medicare Advantage policy covers, consult Medicare2019.com.

So, What Definitely Isn’t Covered Right Now?

The list is long, because the number of new treatments, drugs, etc., coming on the market is long. In general, the list includes:

  • Prescription drugs, unless you have Part D, or the drug is administered in a doctor’s office or hospital;
  • Long-term care beyond very limited recovery from a hospital stay;
  • Deductibles and co-payments (your Medicare supplement or Medicare Advantage Plan or Medicaid may cover these);
  • Most dental care;
  • Routine vision care and eyeglasses, except for those needed following eye surgery;
  • Hearing aids;
  • Care outside the United States (some Medicare supplement and Medicare Advantage plans cover it);
  • Any surgery considered cosmetic (as opposed to restoring normal appearance following injury or disease);
  • Homeopathic care;
  • Dietary supplements, unless prescribed;
  • Exercise equipment, even if prescribed;
  • Some medical equipment;
  • Medical equipment and supplies from providers not approved by Medicare;
  • Any custodial care that does not need to be provided by a medical professional;
  • Insulin and associated supplies unless you have an implanted insulin pump;
  • Humidifiers and similar equipment, unless prescribed as medically necessary; and,
  • Transportation costs other than for ambulances.

In addition, some services, such as physical therapy, speech and language pathology, and rehabilitation have limits, and you must show satisfactory progress. The limits were increased for 2019, but still exist.

Medicare Advantage plans may cover some services and equipment that Original Medicare does not cover. For a list of what Original Medicare does cover, see Medicare Benefits 2019.

How Can I Know If My Needs Will be Covered?

By the time you are eligible for Medicare, you may have a pretty good idea of the services you need. If, on the other hand, you have been blessed with excellent health, you may not have a clue. Your best bet is to contact one of the professional agents at Medicare2019.com at 1-844-374-1950 to assess your needs and see which plan – supplement, Part D, or Medicare Advantage – is right for you.