You may be surprised to discover that budgeting for health care is still necessary once you’re on Medicare, especially for those on a limited income.
Educating yourself on what is paid for by Medicare is essential so that you’re not caught off guard by medical bills. Here are the things that Medicare doesn’t cover.
[Read: Medicare vs. Medicare Advantage: How to Choose.]
What Medicare Doesn’t Cover
— Medically unreasonable and unnecessary services and supplies
— Health care costs for spouses and dependents
— Deductibles and co-payments
— Long-term hospitalization
— Dental, non-medically necessary vision and hearing
— Non-medically necessary foot care
— Nursing home care
— International medical care
— Cosmetic surgery
[READ: Get These 9 Screenings to Keep Your Medicare Costs Down]
1. Medically unreasonable and unnecessary services and supplies
Examples of items and services that fall into this category include excessive therapies, diagnostic procedures, exams and treatments for which the patient has no symptoms or diagnoses. Alternative therapies, such as transcendental meditation, also fall under this category.
2. Health care costs for spouses and dependents
Casey Schwarz, senior counsel, education and federal policy, at MedicareRights.org, explains that people eligible for Medicare but currently covered by an employer health plan must think about their loved ones and themselves.
“Oftentimes employer coverage is family coverage, meaning it covers you, your spouse and dependents. Medicare is coverage just for you. So for some people, it makes sense to keep their employer plan even if Medicare is going to be the primary payer because they want to keep the coverage for their spouse and children.”
[Medicare Coverage: Can You Opt Out if You’re Still Employed?]
3. Deductibles and copayments
Many people fail to budget for deductibles and copayments. In 2025, original Medicare (Part A and Part B) beneficiaries must pay a $1,676 Part A deductible before their coverage kicks in. That is in addition to a $257 deductible for Part B. After the Part B deductible has been fulfilled, Medicare will cover 80% of doctor services, lab tests and X-rays.
“The sky is the limit as far as potential out-of-pocket costs unless someone goes for a Medicare supplement or Medigap plan. And Medigap plans essentially fill a lot of those gaps in original Medicare,” explains Joel Mekler, a health benefits professional, Medicare expert and writer of the “Medicare Moments” weekly column in the New Castle (Pennsylvania) News. “It would cover the Part A hospital deductible, the Part B deductible plus coinsurance and copayments.”
[READ: How to Pick a Medigap Plan]
4. Long-term hospitalization
Original Medicare covers 90 days of hospitalization with you paying deductibles and copays per benefit period, explains Jaime Fenimore, a Medicare specialist and broker based in Pittsburgh, Pennsylvania. For each benefit period, you will need to pay a $1,676 deductible in 2025. If your hospital stay is 60 days or less, you must only pay the deductible. If it is between 60 and 90 days, however, you will also be responsible for a $419 co-payment each day in 2025.
Over your lifetime, original Medicare will only cover some hospitalization costs once you exceed 90 days during a benefit period. After 90 days, you dip into your “lifetime reserve days,” with higher copays — $838 per day in 2025.
“To understand lifetime reserve days, one must first understand how Medicare defines a benefit period,” Fenimore points out. “A benefit period begins the day you are admitted as an inpatient to the hospital or a skilled nursing facility and ends when you have not gotten any inpatient care for 60 days in a row.”
In other words, if you’re hospitalized on May 1 and then again on June 15, you’re still in the same benefit period because both incidents are less than 60 days apart. And you’ll only have to pay your deductible once.
However, Medicare will add the length of stay of both hospitalizations during that benefit period, and if they equal more than 90 days, you’ll begin to use your lifetime reserve days. These 60 lifetime reserve days are for one-time use only. Once they’re used, they’re gone for good.
5. Dental, vision and hearing
Original Medicare does not cover routine dental exams, dental work or dentures. Unless you have diabetes or need eyeglasses following specific types of cataract surgery, original Medicare also does not cover routine vision care, including eye exams, eyeglasses or corrective contacts. The Centers for Medicare & Medicaid Services describes these items as “routine services and supplies.” Chiropractic services and certain immunizations also fall into this category.
Similarly, original Medicare will not assist with the cost of hearing exams or hearing aids, but Medicare Advantage plans may. Most Medicare Advantage plans also cover some vision services.
Although Medicare Advantage plans often cover things like some vision, dental and hearing care that original Medicare doesn’t, there might still be annual limits, such as the common dental limit of $1,500 per year, or the benefits might need to be received from a limited list of providers to be covered. Medicare members can opt to also purchase a separate dental or vision plan.
6. Non-medically necessary foot care
If podiatrist visits are a regular part of your care schedule, you’ll need to set aside money to cover the cost of these appointments out of pocket, unless they’re medically necessary. (Medicare doesn’t cover these services if they’re not medically necessary.) Regular foot care services that aren’t covered include flat foot treatment, corn and callus removal, nail care, creams to maintain skin tone and orthopedic shoes. However, therapeutic shoes for individuals with diabetes, treatment of ulcers or other wounds and foot care necessary due to a systemic disease would be covered.
7. Nursing home care
Medicare does not generally cover long-term nursing home care, though it may cover short-term support in a skilled nursing facility. However, while Medicare won’t always pay for the nursing home, you can’t drop your coverage once you’re admitted. You’ll still use your Medicare for many services, including hospital care and medical supplies while you’re in the nursing home, as well as physician visits.
Most nursing homes accept Medicaid, so if you’re dual eligible and receive both Medicaid and Medicare, you’ll likely be covered for admission. Some people on Medicare elect to purchase a separate long-term care insurance policy to cover this level of care.
8. International medical care
If you’re a frequent international flier, you might consider that, in most cases, original Medicare will not cover care outside the U.S. The following, other than the 50 states and the District of Columbia, are covered by original Medicare:
— Commonwealth of Puerto Rico
— U.S. Virgin Islands
— Guam
— Commonwealth of North Mariana Islands
— American Samoa
— When on a ship, territorial waters touching U.S. land
However, several Medigap plans will cover 80% of these international medical costs. Some, but not all, Medicare Advantage plans will also cover necessary emergency medical care outside the country.
9. Cosmetic surgery
Medicare will not cover cosmetic surgery costs or procedures, such as Botox, with a few exceptions. For instance, Medicare might elect to cover the prompt repair of severe burns, facial injuries after a serious car accident or other surgeries for therapeutic reasons that also happen to serve a cosmetic purpose.
Do You Need Prior Authorization for Procedures?
Generally, Medicare does not require prior authorization for many services, but Medicare Advantage plans do. For example, Medicare Advantage plans may require prior authorization before members can see specialists, seek out-of-network care or get many forms of nonemergency care. Even if a service may have been approved, it may be denied post-service if the proper steps are not taken prior to receipt.
Prescription medications also often require prior authorization under Medicare Part D prescription drug plans. What requires prior authorization can also differ from plan to plan, so it is generally a good idea to call your plan if you have any questions about whether something will be covered.
If you have any questions about what your Medicare plan covers, it is best to call the customer service phone number on the back of your insurance card. Another beneficial service is State Health Insurance Assistance Programs, which provide free and unbiased assistance and advice on a wide range of Medicare-related topics. With a bit of extra research, you can avoid costly and unnecessary medical bills.
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What Medicare Doesn’t Cover ? and How to Manage Your Out-of-Pocket Costs originally appeared on usnews.com
Update 11/19/24: This story was published at an earlier date and has been updated with new information.
