5 Things Original Medicare Won’t Cover(and a Key Distinction You Need to Know)

QUICK LINKS:

• Routine Dental Care
• Routine Eye Exams Eyeglasses and Contact Lenses 
• Hearing Aids and Routine Hearing Exams 
• Long Term Custodial Care
• Most Care While Traveling Outside the U.S.
• What Are Your Options To Fill These Gaps 

At Apollo Health Insurance, we talk to people every day who are excited about Medicare, and rightly so! It’s a fantastic health insurance option for millions of Americans, providing essential coverage as we age or face certain disabilities. However, there’s a common misconception that Medicare covers everything. We’ve found that a lot of people confuse the broader benefits often found in Medicare Advantage plans with what Original Medicare (Parts A and B) actually provides, which can leave them with some significant gaps and unexpected out-of-pocket costs.

Understanding these limitations before you need the services is key. It helps you plan for your healthcare needs and explore supplemental coverage options that truly fit your situation. Here are 5 common things that Original Medicare typically does not cover, along with a crucial clarification about “annual wellness exams” that often trips people up..

1. Routine Dental Care (and Most Dentures)

Your yearly cleaning, fillings, extractions, and most dentures are generally not covered by Original Medicare. While there are a few very specific, medically necessary dental procedures that Medicare might cover (like an exam before an organ transplant or certain cancer treatments), the vast majority of routine dental work falls outside this scope. This can quickly become a significant expense as we get older and dental needs tend to increase., most dentures are not covered by Original Medicare, so you will have to pay out of pocket for this type of dental care.

2. Routine Eye Exams, Eyeglasses, and Contact Lenses

If you’re looking to get your eyes checked for new glasses or contacts prescription, Original Medicare won’t pick up the tab. While it does cover medically necessary eye care, such as for cataracts or glaucoma, routine vision services are excluded. That means the cost of new frames and lenses will likely be your responsibility.

3. Hearing Aids and Routine Hearing Exams

The cost of hearing aids can be substantial, and unfortunately, Original Medicare does not cover routine hearing exams, fittings, or the hearing aids themselves. This lack of coverage often presents a significant financial burden for many seniors who experience hearing loss, a common age-related condition.

While Medicare Part B may cover diagnostic hearing and balance exams if your doctor orders them to determine the need for medical treatment, it does not extend to the purchase or maintenance of hearing aids. As a result, beneficiaries frequently face considerable out-of-pocket expenses to obtain these essential devices.

To mitigate these costs, some individuals explore alternative coverage options such as Medicare Advantage plans, which often include hearing benefits, or separate supplemental insurance policies specifically designed to cover hearing-related services and devices. Understanding these limitations and planning accordingly is crucial for maintaining quality of life and effective communication as hearing health declines with age.

4. Long-Term Custodial Care

This is perhaps one of the biggest misunderstandings about Medicare, and it’s an important one. While Medicare Part A does cover short-term skilled nursing facility care (like rehabilitation after a hospital stay, up to 100 days under specific conditions), it generally does not cover long-term custodial care. This includes day-to-day assistance with activities like bathing, dressing, eating, or using the restroom, whether that care is provided in a nursing home, an assisted living facility, or even in your own home. Long-term care costs can be astronomical, and without proper planning, they can quickly deplete your savings and financial legacy.

5. Most Care While Traveling Outside the U.S.

Dreaming of international travel in retirement? Just be aware that Original Medicare typically doesn’t cover healthcare services you receive while traveling outside the United States. There are a few very limited exceptions for emergencies in Canada or Mexico, or on a ship in U.S. territorial waters. But for most international adventures, you’ll definitely want to look into travel insurance or a Medicare Advantage plan that offers out-of-country coverage.

6. Routine Annual Physical Exams (and why they’re different from a “Wellness Visit”)

This is a point that causes a lot of confusion! While Medicare does cover an “Annual Wellness Visit” (AWV) once every 12 months (after your first 12 months with Part B), this is not the same as a comprehensive annual physical exam that many people are used to getting.

Here’s the key distinction, and why it matters for your wallet:

• Medicare Annual Wellness Visit (AWV): This visit is all about prevention and planning for your health. Your doctor will primarily review your medical and family history, discuss your health risks, help you create or update a personalized prevention plan, and perform basic measurements like height, weight, and blood pressure. They might also screen for cognitive impairment and discuss advance care planning. The important part? An AWV typically does not include a hands-on physical exam, blood work, or other diagnostic tests unless there’s a specific medical necessity, which would then be billed separately.

• Routine Annual Physical Exam: This is the more traditional, hands-on head-to-toe examination by your doctor. It usually involves a physical assessment (listening to your heart and lungs, palpating your abdomen, checking reflexes, etc.), and often includes blood work or other lab tests. Original Medicare generally does NOT cover a routine annual physical exam. If you receive one, you’ll likely be responsible for the full cost.

It’s absolutely vital to understand this difference to avoid unexpected bills. If your doctor performs additional services during your Annual Wellness Visit that go beyond the scope of preventive planning (for example, addressing a new health concern or ordering specific tests), those services will likely be billed separately, and you may owe a deductible or coinsurance. Always ask your doctor’s office how services will be billed!

What are your options to fill these gaps?

While Original Medicare is a cornerstone of retirement healthcare, understanding its limitations is crucial for smart planning. To help cover these uncovered services and reduce your out-of-pocket costs, many people consider:

• Medicare Advantage Plans (Part C): These plans are offered by private insurance companies approved by Medicare and often include valuable extra benefits like dental, vision, and hearing coverage, as well as prescription drug coverage (Part D). Some Medicare Advantage plans may even cover a traditional annual physical exam. Plus, they come with an annual out-of-pocket limit, giving you peace of mind.
• Medicare Supplement Insurance (Medigap): These plans work with Original Medicare and help pay for some of the costs that Original Medicare doesn’t cover, such as deductibles, copayments, and coinsurance. However, it’s important to remember that Medigap plans generally don’t cover the routine services we listed above (like routine dental, vision, hearing aids, or long-term care).
• Stand-alone Dental, Vision, or Hearing Plans: You can purchase separate insurance policies specifically for these services. This can be a great way to get targeted coverage for your specific needs.
• Long-Term Care Insurance: For the potentially substantial costs of long-term custodial care, a separate long-term care insurance policy is often the primary way to gain coverage and protect your savings.

By being informed about what Medicare does and doesn’t cover, and clearly understanding the distinction of the Annual Wellness Visit, you can make smarter decisions about your healthcare coverage. At Apollo Health Insurance, we’re here to help you navigate these choices and ensure a more secure financial future.

FAQ About What Original Medicare Won’t Cover