Medicare is pretty black and white about what they do and do not cover. Many will find it surprising that services like long-term care and prescription drugs are not covered. These can often be the biggest expenses that one may face when on Medicare, and that’s largely the reason you won’t find them covered on Original Medicare. The good news is that they can often be covered either through a separate insurance policy or through Medi-Cal. Below we list what’s not covered under Original Medicare and where/how to find coverage for it.
Non-medical Home Health
Original Medicare will not cover any home health services that are not medically necessary. This includes having someone help you with bathing, going to the bathroom, cleaning the house, shopping, or any other service that can fall under assisted living with home health. This would also include any nursing homes or assisted living facilities. To get coverage for these services you have to pay out of pocket, have a long-term health policy, or have Medi-Cal.
If you have Medi-Cal, then you will likely get coverage through In-Home Supportive Services (IHHS). You will need to apply for this. Often your doctor will help you, but if not, you can go to the local office in your city.
There are many services that are considered “extra” that aren’t covered under original Medicare. These include:
Most dental care – including dentures, dental procedures/cleanings, fillings, dental plates, tooth extractions, and checkups – is not covered by Medicare. Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you’re in a hospital. Part A can pay for inpatient hospital care if you need to have emergency or complicated dental procedures, although the dental care isn’t covered. You can often get dental coverage through a Medicare Advantage plan, as an add-on to a Medicare Supplement (Medi-gap) plan, or by itself as a standalone dental plan.
Pretty much no one in the Medicare space will cover this for you. If it is considered cosmetic in any way, you can often expect to pay the full cost of the service.
Medicare won’t cover hearing aids. You can get coverage form the following sources:
A Medicare Advantage plan:
Many Medicare Advantage plans will offer either an allowance (flat amount) or charge a flat deductible for hearing aids.
Certain Medicare Supplement F Plans:
There are certain Plan F’s that will include hearing aid coverage. They will often have the words “extra” or “innovative” in the title.
Medi-Cal provides a very basic level of hearing aid coverage. Each year they will cover up to $1,510 for hearing aids. This will not cover anything fancy or even mid-level. To receive coverage for higher quality items, you may want to explore the other options on this list.
Most local Lion’s Clubs have a hearing aid program where individuals who are low income can apply for support. Often those who just missed the income limits for Medi-Cal may qualify. Once accepted you will pay a small fee and receive a quality pair of hearing aids. Contact your local Lion’s Club for more information.
Eye exams for prescription glasses and lenses:
Medicare doesn’t cover routine vision exams to check for vision correction or glasses. These services can be covered through a Medicare Advantage plan and certain Medicare Supplement F Plans. Medi-Cal will pay for the exam but not the glasses.
Routine foot care
Routine foot care includes, but is not limited to, the treatment of bunions (except capsular or bone surgery thereof), calluses, clavus, corns, hyperkeratosis and keratotic lesions, keratoderma, nails (except surgery for ingrown nails), plantar keratosis, tyloma or tylomata, and tylosis. The reduction of nails, including the trimming of nails, is also considered routine foot care. Often diabetics will benefit from these types of services.
Original Medicare won’t cover this service, so any Medicare Supplement won’t cover it as well. To get coverage for this you will need to enroll into a Medicare Advantage plan or have Medi-Cal.
The only way to get coverage for acupuncture is through a Medicare Advantage plan. No other Medicare Supplement or even Medi-Cal will cover this service.
Original Medicare does not include prescription drug coverage. Some medications may be covered when administered within a doctor’s office. Outside of the doctor’s office, any pharmacy filled medications will require a prescription drug plan (PDP) to be purchased from a private company. Medicare requires you to purchase a PDP or pay a penalty for the time you didn’t have coverage when you do enroll into a PDP later.
Any Medicare Beneficiary who does not enroll into a PDP and does not have creditable Coverage will incur a 1% penalty of the National Drug Premium average for every month without creditable Drug Coverage. If you meet any of the following criteria below, then you are not required to buy a PDP. If you are uncertain if your coverage is “creditable”, then you may want to contact your coverage provider and ask. They are required to let you know.
Examples of Creditable Coverage:
✓ Group/Employer Coverage
If you are interested in getting coverage for anything listed above please contact us below. We can support you in exploring your options and finding the plan that fits your needs.