\n<\/p>\n
Turns out, there are a number of big health expenses that Original Medicare, the federal health insurance program for Americans over 65, doesn\u2019t cover. But\u2014and it\u2019s a big but\u2014for most of those there\u2019s often an exception to the rule.\u00a0<\/p>\n
It\u2019s also worth noting that Medicare Advantage plans\u2014the private-insurance alternative to Original Medicare\u2014sometimes offer coverage that Original Medicare doesn\u2019t. But, as you\u2019ll see below, that coverage may be skimpier than you think because Medicare Advantage benefits aren\u2019t standardized.<\/p>\n
\u201cMedicare Advantage plans are required to cover everything Original Medicare covers and nothing more. A supplemental benefit could be robust, or it could be not,\u201d says Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center. \u201cWe hear from a lot of people who are surprised by what their Medicare Advantage plan doesn\u2019t cover.\u201d\u00a0<\/p>\n
The government\u2019s free annual handbook, Medicare & You<\/a>,<\/em> and the Medicare website<\/a>, provide specifics about what Original Medicare does and doesn\u2019t cover. The Medicare.gov site has a handy tool called \u201cIs my test, item, or service covered?\u201d<\/a> where you type in a word or phrase to get the answer. State Health Insurance Assistance Programs, or SHIPs, also provide free information about Medicare rules\u2014you can find the program in your state with a quick Google search.<\/p>\n Here are big coverage gaps to look out for, what to know about them, and how to appeal a Medicare claim denial if you believe your care is covered:<\/p>\n Original Medicare doesn\u2019t cover routine medical expenses for your eyes, your mouth, or your ears. You generally can\u2019t get reimbursed for annual visits to the dentist or optometrist. And forget about coverage for new\u00a0eyeglasses or hearing aids. But some types of vision, dental, and hearing expenses are<\/em> covered.\u00a0<\/p>\n For vision care, \u201cit\u2019s really pretty pathetic what Medicare covers,\u201d says Diane Omdahl, founder and president of 65 Incorporated<\/a>, a Medicare advisory group.<\/p>\n But Original Medicare will<\/em> cover what are considered \u201cmedically necessary services\u201d such as treating an eye injury; cataract surgery; corrective lenses for eyeglasses or contacts after cataract surgery; and annual glaucoma tests if you\u2019re at high risk for the eye disease.<\/p>\n Medicare Advantage plans may say they cover routine eye exams and eyeglasses. \u201cBut their allowance for glasses might be $150 to $300,\u201d says Omdahl. \u201cDo you want the right side or the left side of your glasses?\u201d she jokes.<\/p>\n Original Medicare won\u2019t pay for teeth cleanings, dentures, root canals, or annual X-rays. But it does cover X-rays and dental surgery after an accident, treatment for mouth cancers, and dental exams needed before kidney or heart surgery.<\/p>\n \u201cIf you are in a car accident and have to have your teeth taken out, Original Medicare will cover that,\u201d says Omdahl, because it\u2019s medically necessary. \u201cBut they won\u2019t cover putting them back in,\u201d since that isn\u2019t, she adds.<\/p>\n Medicare Advantage plans sometimes provide dental insurance, but Schwarz says often their dental benefit \u201cis actually very limited or amounts to a discount on dental service but not robust coverage.\u201d<\/p>\n Some Medicare Advantage plans cover just two exams a year and maybe one cleaning, notes Omdahl. \u201cSome plans will cover comprehensive dental care, but no implants. And they set an annual dollar limit of $2,000 or so out-of-pocket.\u201d<\/p>\n Not all dentists are enrolled in Medicare, though, so Schwarz advises seeing whether your dentist is and can then submit claims for you.\u00a0<\/p>\n Although Original Medicare usually won\u2019t cover hearing exams, it might provide reimbursement if your hearing is creating a medical problem. \u201cIf you have a balance problem, they\u2019ll cover hearing, but they won\u2019t cover hearing if you just can\u2019t hear,\u201d says Omdahl.<\/p>\n Here, you need to tread carefully. Original Medicare won\u2019t cover routine foot exams, corns, calluses, or flat feet.\u00a0<\/p>\n But it does cover therapeutic shoes for diabetes treatment and medically necessary treatment for foot injuries or diseases, such as hammer toe, heel spurs, and foot warts. It also covers yearly exams or treatment if you have diabetes-related lower leg nerve damage.<\/p>\n Coverage for the cost of canes and walkers? That depends.\u00a0<\/p>\n \u201cIf you have a diagnosis and a prescription and can get the equipment from a Medicare-approved supplier, Medicare will cover canes and walkers,\u201d says Schwarz. \u201cBut you have to have an ambulatory need within your home.\u201d<\/p>\n Forget trying to get Original Medicare to pay for a tummy tuck, breast enhancement, or a nose job. Those types of cosmetic procedures aren\u2019t covered.\u00a0<\/p>\n But, if you need plastic surgery because you were burned or in an accident or had complications from surgery, Original Medicare covers that. \u201cIf you can\u2019t breathe and need rhinoplasty on your nose, it\u2019s covered. But if it\u2019s just to make you prettier, then it\u2019s not,\u201d says Omdahl.<\/p>\n Not to put too fine a point on it, but whether Original Medicare will cover your acupuncture depends on why you\u2019re getting it.<\/p>\n Normally, acupuncture isn\u2019t covered, but there\u2019s one exception: if your doctor prescribes it for your chronic low back pain. But then, you\u2019ll only be reimbursed for up to 12 sessions over 90 days (eight more if you\u2019re showing improvement), with a maximum of 20 treatments over a 12-month period.<\/p>\n In most cases, Original Medicare won\u2019t cover going to the chiropractor. But there\u2019s an exception, of course: treatment for some spinal diagnoses.<\/p>\n Generally, Original Medicare won\u2019t kick in if you have health expenses while traveling outside the United States, though some Medigap and Medicare Advantage policies might.\u00a0<\/p>\n But Original Medicare may pay for services on a cruise ship if you\u2019re in a U.S. port or within six hours of one when the ship arrives or departs.\u00a0<\/p>\n By and large, Original Medicare doesn\u2019t cover most long-term care costs and only covers some home care expenses when they are for medical reasons. In other words, it won\u2019t pay for what are called \u201cactivities of daily living,\u201d such as help with dressing, bathing, or meals.<\/p>\n \u201cI think that can be surprising, especially to family members taking on the management of a loved one\u2019s care for the first time, such as for dementia,\u201d says Schwarz.<\/p>\n Medicare considers an assisted living community the patient\u2019s residence. \u201cThe criteria for getting Original Medicare coverage in an assisted living facility is the same as if you are in your home,\u201d says Omdahl.<\/p>\n When Omdahl\u2019s father was in a skilled nursing facility and had kidney cancer, Medicare paid for the care for drainage of nephrectomy tubes going into his kidney. \u201cBut as soon as the tubes were implanted and there was no longer a need for a nurse to take care of him, it all went into private pay,\u201d she notes.<\/p>\n Original Medicare will, however, pay for a home health aide if you\u2019re homebound and, say, recovering from a stroke and getting physical therapy or need some other type of skilled medical care.<\/p>\n Although Medicare Part A covers hospital costs, there are serious limits.\u00a0<\/p>\n For instance, Original Medicare typically won\u2019t pay for a private room in a hospital, only a semiprivate room (unless there are no semiprivate rooms or a private room is deemed medically necessary).<\/p>\n It also won\u2019t pay for private-duty nursing if you feel you need extra nursing coverage or for a TV or phone in your hospital room if there\u2019s a separate charge for those.<\/p>\n If Original Medicare denies a claim that you believe is legitimate, you can appeal by submitting a Redetermination Request Form<\/a>. And Omdahl and Schwarz think you should, if you have a good case.<\/p>\n \u201cIf Medicare says, \u2018This was not medically necessary for you; we don\u2019t think you had the diagnosis that requires this treatment\u2019 and you can show you did, your chance of a successful appeal is high,\u201d says Schwarz.\u00a0<\/p>\nThe big 3: Vision, dental, and hearing<\/strong><\/h2>\n
Foot care<\/strong><\/h2>\n
Plastic surgery<\/strong><\/h2>\n
Acupuncture<\/strong><\/h2>\n
Chiropractic care<\/strong><\/h2>\n
Medical care overseas<\/strong><\/h2>\n
Long-term care and home care<\/strong><\/h2>\n
Some hospital costs<\/strong><\/h2>\n
Appealing a Medicare claim denial<\/strong><\/h2>\n