Eligible seniors and disabled or ill individuals have the opportunity sign up for Original Medicare coverage, which is composed of two parts, Part A and Part B. As covered in a previous post, this traditional coverage offered by the government allows beneficiaries to have access many different medically-necessary hospital and medical benefits. However, Medicare does not cover all health care costs even if Part A and Part B do cover a service or supply. This means that beneficiaries may still have to pay for some of the cost themselves. This post will explore the benefits and costs that Original Medicare does not cover.
Prescription drug costs
Original Medicare, Part A and Part B, do not cover most prescription drug costs. Medicare Part A may cover drugs as part of an inpatient treatment during an inpatient stay in a hospital or a Skilled Nursing Facility (SNF). Medicare Part B or medical insurance may cover a certain prescription drugs in limited outpatient settings. These are typically drugs that you do not administer yourself and are given at doctor’s offices or in a hospital outpatient setting. Examples of drugs covered by Part B include vaccinations and drugs used with durable medical equipment to name a few. However, Part A and Part B do not cover most regular medications needed by beneficiaries.
Long-term care services
Medicare does not pay for long-term care services, also known as custodial care. This includes medical and non-medical care provided to those who are unable to perform everyday activities, such as dressing, bathing, or feeding themselves. Medicare will not pay for these long-term care support and services, especially if it is the only kind of care that is needed. SNF care can be covered by Medicare, but only in specific circumstances.
All health care costs
While Original Medicare covers many services, it does not mean that it covers all costs associated with these benefits, including deductibles, copayments, coinsurance, and other out-of-pocket costs. For example, all Part B covered services, with the exception of preventive care, requires a 20% coinsurance. This means that for every Part B covered service, beneficiaries are required to pay for 20% of the covered services themselves, while Medicare pays for the other 80%. Additionally, a doctor is allowed to charge an excess charge if they do not accept Medicare assignment or full payment by the government. This charge could be as much as 15% higher than the Medicare-approved amount and would be paid by the beneficiaries themselves.
Additional benefits not covered by Medicare
In additional to benefits that are not medically necessary or reasonable, here are some more services and supplies to add to the list of what is not covered by Medicare:
- Routine vision, dental, hearing, and foot care
- Dentures or hearing aids
- Cosmetic surgery
- Alternative medicine
- Housekeeping services
- First three pints of blood used each year
- Non-emergency transportation, such as traveling to and from doctors’ visits
- Coverage while traveling abroad outside of the U.S. (in most cases)
Please note that this is not a complete list. To find out if Medicare covers a specific test, item, or service you need, please visit this tool.
How to get coverage for what Original Medicare does not cover
Without additional coverage, you would have to pay for the full cost of what Medicare does not cover in addition to cost sharing for benefits that are covered. These costs can add up. That’s why some beneficiaries opt to enroll in a Medicare private insurance plan to cover the health care costs that Original Medicare does not cover. These plan options include:
- Medicare Advantage (Part C or MA) plans provide beneficiaries with all their Part A and Part B benefits, with the exception of hospice care, but can also provide additional benefits like vision, dental, and hearing benefits. Many of these plans also come with prescription drug coverage.
- Medicare drug plans stand-alone drug coverage that can be added to Medicare Part A and/or Part B.
- Medicare Supplement (Medigap) plans are a type of plan that beneficiaries can sign up for in addition to their Part A and Part B coverage. In most states, these plans come in 10 standardized plan types which vary in benefits and supplement their Original Medicare benefits.
It is important to figure out which plan type is right for your needs if you need coverage beyond what Original Medicare covers. During the Annual Election Period this year, which starts on October 15, beneficiaries should reevaluate their coverage for 2014 and determine what coverage is right for their needs and budget. This may be the only time during the year, outside of extenuating circumstances, that they can make changes to their health and/or prescription drug coverage.
Medicare hasn’t approved or endorsed this information.