What Doesn’t Medicare Cover

What Doesn’t Medicare Cover?

Both Original Medicare and Medicare Advantage plans cover a lot of treatments and services. But there is also a lot that they don’t cover. For example, neither covers extended stays in a nursing home (that is covered either by Medicaid or a purchased long-term care policy.) And new treatments, drugs, and the like are coming on the market all the time.

Private insurers generally deem these “experimental” and do not cover them until they have become so broadly accepted and used by the medical profession that they become part of the “standard of care”—what the medical professions are normally expected to do when confronted with a specific illness or situation.
In addition, some treatments, like liver and heart transplants, are so complex and require such a large team of top-notch experts that Medicare will pay for them only in “centers of excellence” that meet rigid standards. If one of these centers does not perform up to par, Medicare will stop paying for that treatment at that hospital. This can and does happen, particularly if mortality or the infection rate gets too high.
In addition, there are a lot of “treatments” that simply have no scientific basis (we all know that kratom, kombucha, baking soda, and apple cider vinegar cure everything, right?). Medicare will not pay for these.

You can check if a particular treatment you want is covered by going to What Medicare Covers. Enter the name of the treatment at the lower right, and you will be told whether or not it is covered. The Centers for Medicare and Medicaid Services (CMS) which runs Medicare, regularly issues “coverage decisions” which indicate which new treatments are covered, and if they are not covered everywhere, where they are covered, (Remember, “centers of excellence.”) Medicare may cover services only at hospitals it deems to have adequate staff and equipment. (IF you are in a hospital and need to be transferred for this reason, you will be fully informed.)

Long Term Care

From its beginnings in 1965, Medicare has excluded nursing home coverage except for very limited stays for recovery from hospitalization. Long term care is covered either by Medicaid, for those who qualify, or by private long-term care insurance.

Right of Appeal

If you are denied coverage to which you think you are entitled and it is a service for which Medicare normally pays, you have the right to appeal the decision. (See How to File an Appeal.) This is not applicable for services that Medicare does not normally cover – that is, you cannot use the appeal process to force Medicare to make a positive coverage decision for an uncovered service that you want.
The Other Things Original Medicare Doesn’t Cover (The list is long) :

• Surgery and treatments that are considered cosmetic and are intended to approve appearance rather than restore appearance found before an injury or illness;

• Nursing home care other than very short stays following hospitalization;

• Insulin and blood glucose testing supplies unless one has an implanted insulin pump;

• Most prescription drugs (if one does not have a Part D or Medicare Advantage Plan);

• Medical equipment not provided by a Medicare-approved supplier;

• Hearing aids;

• Most dental care;

• Eyeglasses except those needed following eye surgeries;

• Homeopathic medicines;

• Care outside the United States;

• Dietary supplements, unless prescribed to treat a diagnosed deficiency;

• Custodial care that does not need to be provided by a medical professional;

• Transportation costs other than ambulances; and,

• Care outside the United States.

Medigap and Medicare Advantage

Unlike Original Medicare (Parts A and B) and Part D (prescription drugs), both Medigap policies and Medicare Advantage plans may cover some services that Original Medicare does not cover. What is covered depends totally on the specific plan you have picked, but usually includes things like eyeglasses and hearing aids.
Beginning in 2019, Medicare Advantage plans may choose to cover services that are aimed at the “social determinants” of health. This term embodies the recognition on the part of public health experts that a good deal of one’s health status depends on factors beyond medical care. For example, the new services that may be covered include meals delivered to the home, non-custodial care that does not require a medical professional, such as assistance with bathing, dressing, and cooking, modifications to the home to improve mobility, and modifications to the home to improve safety. These are not mandatory services; they are services that the Medicare Advantage plan may choose to offer. It is best to check with an insurance broker who represents multiple companies to see if a particular plan is offering services you need.

Summing Up

If you have an ordinary illness for which established treatments are available, it is almost certain that Medicare will cover it, except for the items listed above. Medicare Advantage plans and some Medigap plans offer more, such as coverage of care outside the United States. Remember that the services you receive are in part up to you. So, pick your coverage carefully

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