Medicare plans aren’t all-inclusive for every individual healthcare need. Because Medicare receives funding from the federal government, there are restrictions in place to intercept medical overspending. This means preventing healthcare given at a higher price, quantity, or level of care than what is medically necessary.
Medicare Advantage plans (Part C) will cover many of the gaps of traditional Medicare, including vision, hearing, and dental benefits.
Some procedures that may be medically necessary for you will be considered cosmetic by Medicare without proper documentation.
Open enrollment for 2023 Medicare plans ends December 7th, 2022.
Medicare benefits are structured in 4 parts: Part A, Part B, Part C, and Part D. Each part covers different healthcare needs. When Medicare enrollees pay their monthly premiums, deductibles, and co-insurance, they are entitled to the services under Parts A - D that are covered in their plan. If services were rendered that weren’t part of plan coverage, the individual will responsible for part or all of the cost.
Services Medicare doesn’t cover
You might be surprised to hear that Medicare doesn’t cover the following eight services.
Vision care, including glasses, contact lenses, and eye exams, is not covered by traditional Medicare. According to a 2018 study, over 40 million Medicare beneficiaries were found to need eyeglasses. Cataract surgery is one of the few exceptions in which Medicare will cover eyeglasses and vision services.
Hearing exams, hearing aids, and hearing aid fittings are also not a benefit of traditional Medicare. About 1 in 3 Americans over the age of 65 have age-related hearing loss. Much of this hearing loss is noise-induced and irreversible. Unfortunately, hearing supplies are considered to be elective and not medically necessary by Medicare.
Although dental health is considered a “window to an individual’s overall health”, dental care is not covered by Medicare. Even regular dental cleanings, fillings, and denture care are not reimbursable. In the case of dental emergencies, Part A will cover an associated hospital stay and its dental procedures, like emergency oral surgery due to an accident.
4. Massage therapy
Massage therapy is a necessity rather than a luxury for many individuals with chronic diseases. Despite a national push to reduce pain medication use, massage therapy is still not part of Medicare coverage. It may take additional research for some massage techniques to be considered medically necessary by Medicare.
5. Cosmetic procedures
It might not be shocking to hear that cosmetic procedures aren’t covered by Medicare, as they also aren’t covered by many traditional insurance plans. However, many procedures that end up being considered “cosmetic” by insurance companies are recommended by a provider for medical reasons.
Eyelid and eyebrow surgery
During the aging process, the eyelids and eyebrows begin to droop and sag. When this happens, it may cause restricted vision and decreased ability to do daily activities, especially driving. When medical providers recommend corrective procedures, called “blepharoplasty” and “brow ptosis repair”, insurance companies may be skeptical that these are for cosmetic reasons.
Lid and brow procedures are common to enhance the physical appearance of younger and elderly populations. Medicare will require documentation of an exam that proves visual impairment, as well as photographs of the eyelids and brows.
Botox and injectables
Botox isn’t only used as a wrinkle remedy. Individuals with muscle spasms, chronic migraines, overactive bladder, or excessive sweating may experience relief through Botox injections. Medicare Part B or Part D may cover Botox (depending on the healthcare setting) if it’s medically necessary. They may also require that you have tried and failed other medications before moving to Botox injections.
Many seniors experience leg pain, swelling, and fatigue. After spending decades in an occupation that requires you to be on your feet, you may develop varicose veins. These veins may be enlarged and have difficulty functioning.
Because these veins have an enlarged appearance, vein treatments may be considered to be cosmetic. A provider must show that an ultrasound exam demonstrated significant vein reflux, and increased vein diameter and that the vein is causing limitations to daily activities due to pain and swelling.
6. Custodial Care
Nursing home care (custodial care) isn’t covered by Medicare when that is the only care an individual needs. Medicare beneficiaries must require skilled nursing care after a qualifying hospital stay to receive any type of long-term care coverage from Medicare Part A.
7. Health tech
Medicare Part B and C may cover certain types of medical devices, but health tech devices are not generally covered. This includes fitness watches and phone applications. Other health technology, like cardiac patches or continuous glucose monitors, may only be covered in special circumstances with a documented need.
8. Medical Alarms
Medical alarms, or personal emergency response systems (PERS), are not covered by Medicare. Although Medicare enrollees experience a staggering number of falls every year costing over 29 billion dollars, these items are still not a covered benefit. If you are taking blood thinners, have an osteoporosis diagnosis, or are concerned about falls, speak with your medical provider on fall prevention and rescue strategies.
Don’t miss open enrollment for 2023
Separate Medicare Advantage plans (Medicare Part C) are sometimes able to fill in the gaps of what Medicare itself doesn’t cover. Medicare Advantage plans often cover vision, hearing, and dental. If you are planning on getting a procedure that may be misunderstood to be cosmetic, double-check that your medical documentation demonstrates the need for the procedure. This will mitigate some of the issues with reimbursement or prior authorization.
Speak with your medical provider about what healthcare needs are necessary for you next year. Open enrollment for 2023 ends on December 7th, 2022. Don’t miss the opportunity to re-evaluate your healthcare plan during the open enrollment period this year.