December 10

Medicare: What’s Covered, What’s Not

Medicare is a federally run insurance program that primarily serves people age 65 and over and younger people with disabilities or dialysis needs. 

Medicare is run by the Centers for Medicare & Medicaid Services (CMS), and because it is a federal program, it is essentially the same across the United States. 

Medicare participants are given three different subsets of Medicare that they can benefit from: 

  • Medicare Part A covers inpatient services and supplies in hospitals
  • Medicare Part B covers outpatient services and supplies
  • Medicare Part D covers prescription drugs through federally approved private health care insurers. 

Medicare coverage is based on 3 main factors

  • Federal and state laws.
  • National coverage decisions made by Medicare about whether something is covered.
  • Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

Medicare doesn’t cover everything

Some of the items and services Medicare doesn’t cover include:

  • Long-Term Care (also called custodial care)
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery  
  • Acupuncture  
  • Hearing aids and exams for fitting them
  • Routine foot care

If you need services Medicare doesn’t cover, you’ll have to pay for them yourself or with another insurance plan.

Medicare Supplemental Insurance policies are available to help cover that gap.  

Medicare Supplemental Insurance policies are sold by private insurance companies to Medicare beneficiaries and overseen by state insurance departments. 

These plans are specifically designed to pay costs related to Original Medicare, so depending on the plan, they can pay

  • the deductible for Medicare Part A or Part B
  • the 20% coinsurance leftover after Medicare coverage
  • other out-of-pocket expenses

They do not cover prescription medications or costs leftover from Medicare Part D. 

Will Medicare Cover It?

There are two ways to find out if Medicare covers what you need:

  1. Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something that’s usually covered but your provider thinks that Medicare won’t cover it in your situation. If so, you’ll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
  2. Visit the Medicare website and conduct a search.

Visit medicare.gov for the most up-to-date information on all things Medicare, and please reach out to New York Financial Organizers for a free consultation at info@nyfo.nyc.


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