Understanding Medicare: What’s covered and what’s not

Medicare is a federal health insurance program primarily for people age 65 and older, although it also covers some younger individuals with disabilities and those with end-stage renal disease. Medicare is divided into four parts:

• Part A (hospital insurance). Covers inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
• Part B (medical insurance). Covers certain doctors' services, outpatient care, medical supplies and preventive services.
• Part C (Medicare Advantage plans). An alternative to Original Medicare that offers additional benefits through private insurance companies approved by Medicare.
• Part D (prescription drug coverage). Helps cover the cost of prescription drugs.

Despite its comprehensive nature, Medicare has significant gaps in coverage that can lead to unexpected out-of-pocket expenses.

1. Does Medicare cover dental care?

No, Medicare does not cover routine dental care, including cleanings, fillings, tooth extractions and dentures. This lack of coverage can be particularly challenging for seniors, as dental health is closely linked to overall health. For instance, untreated dental issues can lead to infections and other serious health problems. However, there are some exceptions under Medicare Part A. If you are hospitalized and require dental services as part of your inpatient care, such as a dental exam before a heart valve replacement surgery, Medicare may cover these services. It's important to note that these exceptions are rare and typically only occur when the dental care is integral to a covered medical procedure.

2. Are vision services covered by Medicare?

Medicare does not cover routine eye exams, glasses or contact lenses. This can lead to significant out-of-pocket expenses for those who need regular vision correction. However, Medicare Part B does provide coverage for some preventive and diagnostic eye exams. For example, individuals with diabetes are eligible for an annual eye exam for diabetic retinopathy. Additionally, Medicare covers glaucoma tests for those at high risk, such as individuals with a family history of glaucoma, African-Americans age 50 and older and Hispanic-Americans age 65 and older. Cataract surgery is another exception where Medicare Part B covers the cost of the surgery and one pair of corrective lenses or contact lenses following the procedure.

3. Will Medicare pay for hearing aids?

No, Medicare does not cover hearing aids or exams for fitting them. This can be a significant financial burden, as hearing aids can be quite expensive, often costing thousands of dollars. However, Medicare Part B does cover diagnostic hearing and balance exams if your doctor orders them to determine if you need medical treatment. These exams are crucial for diagnosing conditions like vertigo or other balance disorders. Despite the lack of coverage for hearing aids, some Medicare Advantage Plans (Part C) offer additional benefits, including hearing aid coverage. It's essential to review the specifics of any Medicare Advantage Plan to understand the extent of coverage provided for hearing aids.

4. Does Medicare cover long-term care?

Medicare does not cover long-term care if that is the only care you need. Long-term care, also known as custodial care, includes non-medical services such as assistance with daily activities like bathing, dressing and eating. This type of care is essential for many seniors, especially those with chronic illnesses or disabilities. Medicare Part A may cover short-term stays in a skilled nursing facility for rehabilitation after a hospital stay, but this is limited to situations where skilled care is needed, such as physical therapy or intravenous injections. The coverage is also time-limited, typically up to 100 days, with the first 20 days fully covered and a copayment required for days 21-100. For those needing long-term care, other options like Medicaid, long-term care insurance, or personal savings must be considered.

5. Are alternative therapies covered by Medicare?

Medicare generally does not cover alternative therapies such as acupuncture, chiropractic care (except for certain conditions like spinal subluxation) and naturopathy. These treatments are often sought for pain management, stress relief and other health benefits. However, Medicare Part B does cover chiropractic care but only for manual manipulation of the spine to correct a subluxation (when one or more of the bones of your spine move out of position). Acupuncture is not covered by Medicare, except for chronic low back pain under specific conditions as part of a pilot program. Naturopathy and other holistic treatments are also excluded from Medicare coverage. Patients interested in these therapies will need to pay out-of-pocket or seek supplemental insurance that may offer some coverage.

• Medigap. Medigap policies, also known as Medicare Supplement Insurance, can help cover some of the costs not covered by Original Medicare, such as copayments, coinsurance and deductibles. These policies are sold by private companies and can provide additional financial protection. Medigap plans are standardized and labeled A through N, each offering different levels of coverage. It's important to compare the plans available in your state and choose one that best meets your needs.
• Dental, vision and hearing insurance. Separate insurance policies are available to cover dental, vision, and hearing services. These policies can help manage the costs of routine care and necessary treatments. For example, some plans cover preventive dental care, such as cleanings and exams, as well as major services like crowns and dentures. Vision insurance may cover annual eye exams and a portion of the cost for glasses or contact lenses. Hearing insurance can help cover the cost of hearing aids and related services.
• Medicare Advantage Plans. Medicare Advantage Plans (Part C) are an alternative to Original Medicare and are offered by private insurance companies approved by Medicare. These plans often include additional benefits, such as dental, vision and hearing coverage. However, it is important to compare plans carefully to ensure they meet your specific needs. Medicare Advantage Plans may have different networks of doctors and hospitals, and the costs for services can vary. Some plans may offer additional benefits like gym memberships or transportation to medical appointments. It's crucial to review the plan details, including premiums, copayments and coverage limits, before enrolling.
• Health Savings Accounts (HSAs). If you are still working and have a high-deductible health plan, you can contribute to a Health Savings Account (HSA). HSAs offer tax advantages and can be used to pay for qualified medical expenses, including some services not covered by Medicare. Contributions to an HSA are tax-deductible, and the funds grow tax-free. Withdrawals for qualified medical expenses are also tax-free. After age 65, HSA funds can be used for any purpose without penalty, although non-medical withdrawals will be subject to income tax. HSAs can be a valuable tool for saving for future health care expenses, including those not covered by Medicare.

Setting aside funds specifically for health care expenses not covered by Medicare can provide a financial cushion. This can be particularly important for services like long-term care, dental procedures and hearing aids. Creating a dedicated savings account for health care expenses can help ensure you have the funds available when needed. It's also helpful to budget for these expenses and regularly review your financial plan to make adjustments as needed. Consulting with a financial professional can provide additional guidance on how to best save and plan for health care costs in retirement.

Understanding what Medicare does and does not cover is crucial for effective health care planning in retirement. While Medicare provides comprehensive coverage for many services, significant gaps exist, particularly in areas like dental, vision, hearing and long-term care. By being aware of these limitations and exploring supplemental insurance options, Medicare Advantage Plans, HSAs and personal savings, you can better manage your health care expenses and ensure you receive the care you need.

For more information on Medicare coverage and planning for health care expenses in retirement, consider visiting the following resources:

• Medicare.gov: The official U.S. government site for Medicare.
• State Health Insurance Assistance Program (SHIP): Offers free, unbiased counseling and assistance to Medicare beneficiaries.
• National Council on Aging (NCOA): Provides resources and tools for aging well, including information on Medicare and health care planning.