- Original Medicare does not cover some fundamental health care costs. Out-of-pocket expenses are expected to increase in 2022 and beyond.
- Medigap and Medicare Part D prescription plans help fill coverage gaps. Medicare Advantage plans replace Original Medicare altogether.
- Original Medicare does not cover treatment outside of the U.S., except under very limited circumstances.
Understanding Coverage Gaps in Original Medicare
Many retirees think Medicare covers most health care expenses.
- Prescription drugs
- Long-term care (such as extended nursing home stays or custodial care)
- Hearing aids
- Most vision care, notably eyeglasses and contacts
- Most dental care, notably dentures
- Most cosmetic surgery
- Massage therapy
- Sterilization, including a hysterectomy (unless it's deemed medically necessary)
- Medical marijuana
- Medical expenses outside the United States
There are some exceptions, but beneficiaries should be aware of what is not covered by Medicare and plan accordingly.
A Medicare Advantage plan, also known as Part C, acts as an all-in-one alternative to Original Medicare and is offered by government-approved private insurance companies.
Medicare Advantage plans must provide the same base level of care as Medicare Part A and Part B but may also bundle other benefits, such as prescription drugs, dental, vision and hearing, into a single plan.
However, coverage for these additional services may be limited.
In 2016, the average person with Medicare coverage spent $5,460 out of pocket for health care, according to a November 2019 analysis by the Kaiser Family Foundation — a leading nonprofit focused on national health policy issues.
Long-term care, certain medical supplies, prescription drugs and dental services accounted for the biggest out-of-pocket costs, the study found.
It’s important to note that Medicare Part B includes a standard monthly premium of $170.10 in 2022. There are also deductibles, coinsurance and copayments, which can further drive up out-of-pocket expenses for beneficiaries.
Prescription Drug Coverage
Original Medicare does not cover most prescription drugs.
- With a standalone Medicare Part D prescription drug plan
- With a Medicare Advantage plan that includes prescription drug coverage
You can use the Medicare Plan Finder to compare Part D or Medicare Advantage plans in your area.
Medicare Part B may cover some outpatient drugs under limited circumstances.
For example, certain injectable osteoporosis drugs and oral drugs for end-stage renal disease are covered.
In general, drugs covered under Medicare Part B are usually received at a doctor’s office or hospital outpatient setting.
In these situations, you’ll owe 20 percent of the Medicare-approved amount for covered Part B drugs administered in a doctor’s office or pharmacy, and the Part B deductible applies.
Long-Term Care Coverage
Original Medicare does not cover the cost of long-term care, including extended stays at nursing homes and assisted living facilities.
Custodial care — or help with performing activities of daily living, such as dressing, eating or bathing — isn’t covered, either.
Medicare Advantage plans also lack long-term care coverage.
Medicare will cover some costs at a skilled nursing facility for up to 100 days. A short-term stay at these facilities must take place within 30 days of leaving the hospital and for the same illness or injury.
Long-term care is often considered one of the most expensive health care costs in retirement.
Private long-term care insurance can help, although policy premiums are often high.
Medicaid, a joint federal and state government program, is another way to pay for long-term care, but it’s available only to seniors with limited income and few resources.
Dental, Vision and Hearing Coverage
Generally, Original Medicare does not cover dental work and routine vision or hearing care.
Original Medicare won’t pay for routine dental care, visits, cleanings, fillings dentures or most tooth extractions.
The same holds true for routine vision checks. Eyeglasses and contact lenses aren’t generally covered.
However, Medicare Part B may cover tests and treatments for certain serious eye conditions, although you will still owe a copayment, and your Part B deductible applies.
- Yearly eye exam for people with diabetes
- Glaucoma tests for people at high risk
- Macular degeneration tests and treatment
- Cataract removal surgery
- One pair of eyeglasses or one set of contact lenses after cataract surgery
Finally, Original Medicare won’t pay for hearing aids or the exam required to select and fit these devices.
Medicare Part B may pay a portion of diagnostic hearing and balance exams but only if a doctor orders them in an emergency or to determine whether you need medical treatment.
For example, a doctor may order these tests to diagnose the cause of dizziness or vertigo.
If you decide to go with a Medicare Advantage plan, there’s a good chance dental and vision will be included. However, coverage may be limited.
Cosmetic Surgery Coverage
Like many health insurance plans, Medicare does not typically cover cosmetic surgery.
However, there are a few exceptions.
If you had a mastectomy because of breast cancer, Medicare covers breast prostheses for breast reconstruction.
Also, if cosmetic surgery is deemed necessary as a result of an accidental injury, or to improve the function of a malformed body part, Medicare covers 80 percent of approved costs.
For example, rhinoplasty is a procedure that changes the shape and contour of the nose.
If a doctor believes a rhinoplasty is medically necessary to correct a congenital defect or traumatic injury that causes a functional impairment, Medicare will likely cover this procedure.
It may also be covered to fix a chronic nasal obstruction that cannot be effectively treated in a less invasive way.
However, Medicare will never cover a procedure for cosmetic reasons.
Medicare may require prior authorization for some procedures. In these cases, the hospital or physician must provide medical records to Medicare for review.
Original Medicare will not cover some forms of alternative medicine, including experimental procedures, medical marijuana and massage therapy — even if these treatments are prescribed by your doctor.
Medicare pays for chiropractic manipulation only if one or more bones in your spine have slipped out of position.
This chiropractic service must be deemed medically necessary by your doctor, and you will owe 20 percent of the approved cost.
Medicare began covering acupuncture in January 2020, but only for chronic lower back pain, and restrictions may apply.
Medical Coverage Outside the United States
Original Medicare generally does not cover treatment outside the United States, except under very limited circumstances, such as on a cruise ship within six hours of a U.S. port.
However, some Medicare supplement insurance policies — also known as Medigap — cover overseas health care costs.
Medigap plans C, D, F, G, M, and N provide foreign travel emergency health care coverage outside the United States.
- Foreign travel emergency care if it begins during the first 60 days of your trip
- Eighty percent of billed charges for certain medically necessary emergency care after a $250 yearly deductible is met
A lifetime coverage limit of $50,000 applies.
In 2020, the average premium for a Medigap policy was roughly $150 per month, or $1,800 per year, according to full-service insurance organization Senior Market Sales.
18 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2020, January 21). CMS Finalizes Decision to Cover Acupuncture for Chronic Low Back Pain for Medicare Beneficiaries. Retrieved from https://www.cms.gov/newsroom/press-releases/cms-finalizes-decision-cover-acupuncture-chronic-low-back-pain-medicare-beneficiaries
- Cubanski, J. et al. (2019, November 4). How Much Do Medicare Beneficiaries Spend Out of Pocket on Health Care? Retrieved from https://www.kff.org/medicare/issue-brief/how-much-do-medicare-beneficiaries-spend-out-of-pocket-on-health-care/
- Levine, H. (2019, May 2). 4 Ways to Spend Less on a Hearing Aid. Retrieved from https://www.consumerreports.org/hearing-aids/ways-to-spend-less-on-a-hearing-aid/
- Genworth Financial. (2019). Cost of Care Survey. Retrieved from https://www.genworth.com/aging-and-you/finances/cost-of-care.html
- O’Brien, S. (2018, May 10). Medicare doesn’t cover everything. Here’s how to avoid surprises. Retrieved from https://www.cnbc.com/2018/05/03/medicare-doesnt-cover-everything-heres-how-to-avoid-surprises.html
- AARP. (n.d.). Does Medicare Cover Cataract Surgery? Retrieved from https://www.aarp.org/health/medicare-qa-tool/does-medicare-cover-cataract-surgery/
- AARP. (n.d.). Does Medicare Pay for Nursing Homes? Retrieved from https://www.aarp.org/health/medicare-qa-tool/current-long-term-nursing-home-coverage/
- Medicare.gov. (n.d.). Acupuncture. Retrieved from https://www.medicare.gov/coverage/acupuncture
- Medicare.gov. (n.d.). Chiropractic Services. Retrieved from https://www.medicare.gov/coverage/chiropractic-services
- Medicare.gov. (n.d.). Cosmetic surgery. Retrieved from https://www.medicare.gov/coverage/cosmetic-surgery
- Medicare.gov. (n.d.). Dental services. Retrieved from https://www.medicare.gov/coverage/dental-services
- Medicare.gov. (n.d.). Eye exams (routine). Retrieved from https://www.medicare.gov/coverage/eye-exams-routine
- Medicare.gov. (n.d.). Eyeglasses & contact lenses. Retrieved from https://www.medicare.gov/coverage/eyeglasses-contact-lenses
- Medicare.gov. (n.d.). Hearing & balance exams. Retrieved from https://www.medicare.gov/coverage/hearing-balance-exams
- Medicare.gov. (n.d.). Medigap & travel. Retrieved from https://www.medicare.gov/supplements-other-insurance/medigap-travel
- Medicare.gov. (n.d.). Prescription drugs (outpatient). Retrieved from https://www.medicare.gov/coverage/prescription-drugs-outpatient
- Medicare.gov. (n.d.). What’s not covered by Part A & B? Retrieved from https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b
- National Council on Aging. (n.d.). Medicare and Hearing. Retrieved from https://www.ncoa.org/economic-security/benefits/other-benefits/medicare-and-hearing/