What does Medicare NOT pay for?

What Does Medicare NOT Pay For

Once you are Medicare-eligible, you will be part of a great program that protects 61 Million people from financial hardship that can come from medical expenses. BUT it can also create financial hardship by itself if you don’t have it set up correctly. I will go over a little of what Medicare covers but the important part of this article will be ” What does Medicare NOT pay for“.

Original Medicare

Original Medicare is made of Part A, which is known as Hospital Insurance & Part B is know as your Medical Insurance. In 2006 the government added Part D to help beneficiaries with the cost of Prescription Drugs.

Let's look at Part A

If you have worked for at least 10 years and you paid Medicare taxes you will NOT have to pay a premium for part A. This is determined by social security work credits, you need 40 credits to qualify for $0 monthly premium. You get 4 credits for every year that you worked and paid Medicare taxes. If you worked at least 10 years you have 40 credits. You can check your current credits by visiting SSA.GOV.

Part A helps you pay for the costs associated with being a inpatient in a hospital. If you are ever admitted into a hospital as an inpatient, Part A will help you pay for those expenses. You will only be responsible for a $1484 (2021) deductible. This deductible will protect you for a period of 60 days, so even if you return to the hospital in the next 60 daysyou will NOT have to pay the deductible again. If you go back to the hospital after the 60 days, you WILL have to pay that deductible again. Worst case scenario, you can pay this deductible up to 6 times per year.

Let's look at Part B

Part B is known as your medical insurance or doctor’s insurance. It covers all qualifying medical expenses outside the hospital. Everyone has to pay a monthly premium for Part B. In 2021 that amount is $148.50. Some people pay a little less if this amount is taken out of your social security check. If you are considered a high-income earner you might pay more but this affects less than 7% of all Medicare enrollees.

To use Part B benefits you will be responsible for a $203 yearly deductible. This is only once per year, so once you paid it you don’t have to pay it again until the next year. After you have paid your deductible, Part B will usually pay 80% of all your approved medical expenses. You are responsible for the other 20%.

Example; You go to the doctor and he does a bunch of tests and scans. Let’s say the bill is $1,000, Part B will pay $800 and you will have to pay $200.

Original Medicare does NOT have a maximum out of pocket. That means you will be responsible for 20% of everything, no matter how large the bill. If the bill is $100,000, you will be responsible for $20,000.

What does Medicare NOT pay for?

Medicare covers most medically necessary services, but Medicare doesn’t cover everything. Some of the items and services Medicare doesn’t cover include:

Long-Term Care (Custodial Care)

Longterm care is a range of services and support for your personal care needs. Most longterm care isn’t medical care. Instead, most longterm care is help with basic personal tasks of everyday life, sometimes called activities of daily living ( like bathing, dressing, using the bathroom, and eating). It is also known as Custodial care which means all personal needs that could be done safely and reasonably without professional skills or training.

Medicare Part A (Hospital Insurance) may cover some care in a certified skilled nursing facility (SNF), but not at home. If you don’t have private insurance to cover the cost of Long-Term care you will have to pay 100% for those services out of pocket.

Dental Care

Medicare doesn’t cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. 

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 an emergency or complicated dental procedures, even though dental care isn’t covered. Think of it this way, if it’s part of a medical emergency and you can’t live without it, they will most likely pay. Anything that you can get done at a regular dentist they will not pay.

Eye Exams

Medicare only covers routine eye care in the following circumstances; If you have diabetes, Medicare covers an annual eye exam by a state-authorized eye doctor to check for diabetes-related vision problems.

Medicare will pay for emergency services in Canada if you are traveling a direct route, without unreasonable delay, between Alaska and another state, and the closest hospital that can treat you is in Canada.

Cosmetic Surgery

Medicare usually doesn’t cover cosmetic surgery unless it’s needed because of accidental injury or to improve the function of a malformed body part.


Original Medicare doesn’t cover acupuncture. You pay 100% for those services.

Hearing aids and exams for fitting them

Original Medicare doesn’t cover hearing aids or exams for fitting hearing aids. 

Routine foot care

Routine foot care is not a covered Medicare benefit. Medicare assumes that the patient or caregiver will perform these services by themselves, and therefore, these services are excluded from coverage.

Travel outside the U.S.

Medicare usually does not cover the medical care you receive when traveling outside the U.S. and its territories. However, Original Medicare and Medicare Advantage Plans must cover care you receive outside the U.S. in certain circumstances:

Medicare will pay for emergency services in Canada if you are traveling a direct route, without unreasonable delay, between Alaska and another state, and the closest hospital that can treat you is in Canada.

Medicare will pay for the medical care you get on a cruise ship if you get the care while the ship is in U.S. territorial waters. This means the ship is in a U.S. port or within six hours of arrival at or departure from a U.S. port.

In limited situations, Medicare may pay for non-emergency inpatient services in a foreign hospital (and any connected provider and ambulance costs). Your care is covered if the hospital is closer to your residence than the nearest available U.S. hospital. This may happen if, for example, you live near the border of Mexico or Canada.

If you want to read about what options you have to cover the gaps in your Medicare coverage, read my article “Should you choose a Medigap plan or MA plan?

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If you life in Pasco, Hernando, Citrus, Pinellas, Hillsborough, Polk or Sumter counties, you can schedule an in-person appointment with me to discuss your Medicare options. Give me a call 813-842-1421 or Click Here to schedule an appointment on our website. Thank you 

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