What's Not Covered By Medicare?

Medicare is a federal health insurance program that helps eligible Americans pay for necessary healthcare services. The program primarily serves people over 65 but covers patients of all ages with certain medical conditions or disabilities. Medicare is often confused with Medicaid —  the two programs are quite different, with unique eligibility criteria and varying costs and benefits. 

While Medicare coverage has expanded to include more healthcare services, it still doesn't cover everything. There are many gaps in Medicare coverage, and seniors who do not know what services are not covered by Medicare may need to pay if they cannot find another source of assistance. This guide clarifies what Medicare does and doesn't cover and suggests other ways to pay for excluded services.

 

There are four main parts to Medicare: Medicare Part A, Medicare Part B, Medicare Part C, and Medicare Part D. Explore each part in detail below.

Medicare Part A provides hospital insurance, while Medicare Part B delivers medical insurance. When an individual first signs up for Medicare Part A and B through the Social Security Administration (or if they received Social Security benefits long enough to become automatically enrolled in Part A and B), their Part A and B coverage is managed by the federal government and is referred to as Original Medicare. 

People with Original Medicare can opt to change to Medicare Advantage. These plans offer at least the same level of coverage through a private company that has agreed to follow guidelines mandated by Medicare. Medicare Advantage Plans are, somewhat confusingly, also called "MA Plans" or "Medicare Part C." 

While the companies that offer these plans must offer equivalent benefits to Original Medicare, they can also include additional benefits, such as vision or dental. Medicare Advantage plans also frequently include Medicare Part D coverage, which is Medicare's prescription drug insurance.   

Individuals with Medicare Advantage Plans that don't include Part D coverage and people who keep their Original Medicare plans will have to enroll separately in Medicare Part D to receive prescription drug coverage. Similarly to Medicare Advantage plans, Part D plans are provided by Medicare-approved private insurance companies.    

Seniors need to know the benefits each part of Medicare provides to ensure they have comprehensive coverage that meets their needs. 

Medicare Part A

Commonly referred to as "hospital insurance," Medicare Part A covers the following services:

• Inpatient hospital care
• Home health care
• Short-term skilled nursing care
• Hospice care
• Mental health screenings, services, and programs

Medicare Part B

Also called "medical insurance," Medicare Part B covers these items and services:

• Ambulance services
• Durable medical equipment
• Emergency department services
• Diagnostic hearing and balance exams
• Outpatient physical therapy
• Preventative screenings and immunizations
• Some vaccines

Medicare Part C

Medicare Advantage plans, also referred to as "Medicare Part C," offer the following benefits:

• Medicare Part A and Medicare Part B services
• Possibly some additional benefits, such as dental, vision, and/or hearing services
• Most also offer Part D coverage

Medicare Part D

Seniors wondering, "What vaccines does Medicare not cover?" will be relieved to know that Part D covers all adult vaccines recommended by the CDC at no cost to patients. Medicare prescription drug plans also provide the following benefits:

• Coverage for many brand name and generic options and two or more drugs in the most common categories and classes
• Coverage for drugs in protected classes, such as those used to treat cancer or depression
• All adult vaccines recommended by the CDC, including shingles, Tdap, RSV, and whooping cough.

Unfortunately, Medicare does not cover certain items. Seniors living on a limited budget may worry that their Social Security benefits will not be enough to pay the resulting medical bills. Fortunately, there are other funding options available, and several government resources can help reduce overall living costs. 

Explore services excluded by Medicare and alternative ways to pay for these services below.

Covering the costs of independent living or residing in a retirement home can be challenging for seniors. Similarly, long-term residential care for those needing assisted living services, skilled nursing, and/or memory care is unaffordable for many seniors without financial assistance. 

Independent living costs an average of $3,000 per month, based on Caring.com's proprietary senior living cost data. Assisted living and memory care are even more expensive, with average costs of $4,200 per month and $5,100 per month, respectively.   

Unfortunately, none of the above are covered by Medicare, as independent living is considered a choice, not a medical necessity. Surprisingly, medical and non-medical long-term care for individuals with chronic conditions or disabilities is also not covered by Medicare. 

This includes help with the activities of daily living often provided in assisted living facilities and nursing homes, such as assistance dressing and toileting. It also includes adult day health care and home and community-based services. 

Alternative ways to pay: Residential or home-based long-term care may be covered by Medicaid, long-term care insurance, veteran's benefits, or a reverse mortgage. Sources seniors can use to fund independent living are more limited and may include Social Security payments, pensions, retirement accounts, or savings. Seniors can also look into Health Savings Accounts (HSAs) to cover some senior care expenses.

While Original Medicare may cover certain medically required dental services on a case-by-case basis, many routine services are not covered. These include general cleanings, extractions, fillings, and dentures. Some Medicare Advantage Plans may offer these services as covered benefits. 

Alternative ways to pay: Medicaid (in some states), veteran's benefits, Dental Lifeline Network's volunteer dentist services, discounted services at U.S. dental schools, Social Security payments, pensions, retirement accounts, or savings.    

Eye exams are not covered by Original Medicare when they are used to prescribe eyeglasses or contact lenses. Eyeglasses and contact lenses are also normally not covered (except after a qualifying cataract surgery). Some Medicare Advantage Plans may cover vision services excluded by Original Medicare.

Alternative ways to pay: Medicaid (certain states only), veteran's benefits, American Academy of Ophthalmology's list of eyeglass resources, Social Security, pensions, retirement accounts, or savings.   

Medicare covers ear-related medical conditions, but Original Medicare plans don't pay for routine hearing tests or hearing aids. ​Similar to vision and dental, some hearing services not provided by Original Medicare plans may be included in Medicare Advantage plans (such as exams and hearing aids). 

If you are concerned about whether or not Medicare covers a test, item, or service not listed above, you can use the Medicare website's search function to determine coverage specifics. 

Additional ways to pay: Medicaid, veteran's benefits, Hearing Aid Project's national or state resources, Help America Hear program, Social Security payments, pensions, retirement accounts, or savings

Whether on their own or with the help of a long-term care specialist, seniors should know the basics of Medicare and compare plans to find the best option for their needs. They should also be aware of which services are not covered by Medicare to avoid having to pay unexpected bills. Fortunately, alternative sources of funding can help with long-term living costs and/or dental, vision, and hearing care excluded from some or all Medicare plans.

• Compare Original Medicare & Medicare Advantage (n.d.). Medicare.gov
• Costs. (n.d.) Medicare.gov
• Dental care. (n.d.) Medicaid.gov
• Dental services. (n.d.). Medicare.gov
• Does Medicare cover independent living? A comprehensive guide. (2023). National Council on Aging
• Drug coverage (Part D). (n.d.). Medicare.gov
• Eye exams (routine). (n.d.). Medicare.gov
• Eyeglasses & contact lenses. (n.d.). Medicare.gov
• Frequently asked questions. (2024). Help America Hear
• Hearing aid resources. (2024). Hearing Aid Project
• Holm, Chrissy. Does Medicare & insurance cover hearing aids in 2024? (2023). National Council on Aging
• I'm getting Social Security benefits before 65. (n.d.). Medicare.gov
• Long-term care. (n.d.). Medicare.gov
• Nursing homes, assisted living, and home health care. (2024). U.S. Department of Veterans Affairs
• Medicaid vision coverage for adults varies widely by state. (2024). National Institutes of Health
• Our donated dental services across the states. (n.d.). Dental Lifeline Network
• Parts of Medicare. (n.d.). Social Security Administration
• Prescription drug coverage (Part D). (2024). BlueCross BlueShield
• Rehabilitation and prosthetic services. (2024). U.S. Department of Veterans Affairs
• Resources for eye glasses. (2024). American Academy of Ophthalmology
• Shingles shots. (n.d.). Medicare.gov
• U.S. dental schools. (2024). American Student Dental Association
• VA dental care. (2024). U.S. Department of Veterans Affairs
• VA vision care. (2024). U.S. Department of Veterans Affairs
• What Part A covers. (n.d.). Medicare.gov
• What Part B covers. (n.d.). Medicare.gov
• What's the difference between Medicare and Medicaid? (2022). U.S. Department of Health and Human Services
• Your health plan options. (n.d.). Medicare.gov
• Your Medicare coverage. (n.d.). Medicare.gov