What Isn’t Covered by Medicare? 

According to the Centers for Medicare & Medicaid Services (CMS), Medicare insurance is relied upon by over 65 million people in the United States. The program provides benefits for all kinds of medically necessary services, including doctor visits, surgery, inpatient care and even prescription drugs.

Unfortunately, despite the wide range of covered items available under Medicare, the program does have limitations. Understanding the limits of Medicare is important for seniors to find the right coverage options and plan for the future.

What isn’t covered by Medicare?

Medicare coverage is limited in several ways. It’s important to note that Medicare benefits can change from year to year, so you’ll want to check with CMS to receive the latest information on coverage limitations.

Coverage restrictions on Medicare Part A

Medicare Part A provides inpatient coverage for healthcare services. Medicare recipients typically do not need to pay a premium for Medicare Part A as this has been paid through FICA taxes. If you don’t qualify for premium-free Part A, you may be able to purchase it.

Medicare Part A does not cover medical treatment or healthcare services outside of those provided in an inpatient setting. This means that you must be formally admitted to a Medicare-participating facility in order to utilize Medicare benefits under Part A.

If you have not been formally admitted to a hospital or skilled nursing facility, Medicare Part A does not apply to your treatment. For example, if you visit a hospital emergency room and receive treatment for an illness or injury but are not admitted, Medicare Part A does not pay for your visit despite medical services being rendered in a hospital.

Coverage restrictions on Medicare Part B

Medicare Part B is outpatient coverage, and it helps pay for doctor visits and clinical treatment as well as surgery. In order to receive Medicare coverage for outpatient services under Part B, you will need to pay a monthly premium.

Although Medicare Part B covers a wide range of outpatient services, it is limited when it comes to certain durable medical equipment (DME). Medicare Part B pays for 80% of the cost of DME, but your items must come from an approved supplier, and DME must be prescribed by a Medicare-participating physician.

Additionally, Medicare Part B does not cover certain elective procedures. For example, Medicare benefits do not apply toward things like cosmetic surgery or weight loss treatment; however, Medicare coverage is available for medically necessary bariatric surgery or reconstructive surgery following an illness, injury or cancer treatment.

Coverage restrictions on Medicare Part D

Medicare Part D is the prescription drug portion of the program. This is optional coverage that Medicare recipients must elect to receive. Medicare Part D requires a monthly premium, and you may need to pay a copay for each prescription.

The limitations of each Part D plan are outlined in a document known as a formulary. This list includes all covered drugs in your plan, and any outside of this list will generally need to be paid for out of your own pocket unless you get an exception from CMS.

Original Medicare benefits do not cover over-the-counter medications under Part D. Items like bandages, supplements, ointments and other OTC healthcare products are restricted from coverage.

Additional restrictions on Medicare benefits

Outside of the restrictions listed above, a good rule of thumb to go by is medical necessity. In general, Medicare benefits will cover any medically necessary healthcare service or treatment. In some cases, you may need to work with your doctor to document medical necessity if CMS rejects an initial claim.

If you seek out healthcare services on your own outside of those prescribed by a Medicare-participating physician or that are provided at a medical facility that is not approved by Medicare, the service will likely not be eligible for Medicare coverage. To learn more about your Medicare benefits, you’re encouraged to review your plan materials, speak with your plan manager or work with an independent Medicare plan broker to discuss your options.