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What’s Not Covered by Original Medicare

Medicare Parts A and B provide basic healthcare coverage—but there’s a lot that Original Medicare leaves out.

By Clover Health

Original Medicare offers basic healthcare coverage to older adults and people with qualifying disabilities across the country. Medicare Part A provides basic hospital coverage for inpatient hospital stays and surgeries. Medicare Part B gives you basic medical insurance. This pays a portion of doctors’ visits, preventive services, screenings, and durable medical equipment.

But Original Medicare certainly doesn’t cover everything. There are some big gaps in coverage you might not know about. Let’s take a look at what’s not covered by Original Medicare.

Prescription Medication Is Not Covered by Original Medicare

The cost of medications can add up quickly. Almost 90% of adults aged 65 and older take prescription medications. And more than half of older adults take four or more medications.

Unfortunately, Original Medicare only covers a limited number of outpatient prescription drugs under limited conditions. Usually, Part B covers drugs you wouldn't usually give to yourself, like those you get at a doctor's office or hospital outpatient setting. Even then, Original Medicare doesn’t cover the whole cost. In most cases, you’ll pay 20% of the Medicare-approved amount, and Medicare Part B covers the remaining 80%. Your Medicare Part B deductible also applies.

Medicare Advantage Plans with Prescription Coverage

Most Medicare Advantage plans offer prescription coverage. Clover Health plans include comprehensive prescription drug coverage that covers hundreds of medications. To find out what’s covered, check your plan’s formulary. This list will tell you exactly what medications are covered and what copay or coinsurance you’ll pay for each medication.

Routine Dental Care Is Not Covered by Original Medicare

Is it time for a dental checkup and cleaning? You might be surprised to learn that Original Medicare doesn’t cover routine dental services. Original Medicare Part A will only pay for dental services you receive while you’re in the hospital. This could include emergency dental procedures or oral surgery. All other dental care, including routine exams and cleaning, is not covered by Original Medicare.

Medicare Advantage Plans With Routine Dental Coverage

Original Medicare doesn’t cover routine dental services, but Clover Health’s Medicare Advantage plans do include routine dental care. This benefit includes:

  • Two oral exams per year, with a $0 copay
  • Two cleanings per year, with a $0 copay
  • One set of dental X-rays per year, with a $0 copay

Many Clover Health plans offer additional dental benefits like fillings, crowns, and dentures.

Routine Vision Services Are Not Covered by Original Medicare

Medicare doesn’t cover routine eye exams, prescription eyeglasses, or contact lenses. If you have Original Medicare, you’ll pay 100% for eye exams and eyeglasses. There are only a few exceptions. Medicare Part A will help you pay for cataract surgery, and Medicare Part B will help pay for Medicare covered eyeglasses following surgery. Medicare Part B will also cover a portion of eye exams for diabetic retinopathy.

Medicare Advantage Plans With Routine Vision Care

Are you looking for more coverage? Medicare Advantage plans from Clover Health offer routine vision care. This includes:

  • One routine eye exam per year, with a $0 copay
  • A yearly allowance for one pair of eyeglasses or contact lenses

Hearing Aids Are Not Covered by Original Medicare

One in three adults aged 65 or older have hearing loss—but Original Medicare doesn’t cover any hearing services. Original Medicare beneficiaries pay 100% for hearing exams, hearing aids, and hearing aid fittings. There is only one exception: If your doctor orders a hearing and balance exam, Medicare Part B will cover 80% of the exam. Doctors only order this exam if they think you may need medical treatment for a hearing or balance issue.

Medicare Advantage Plans With Routine Hearing Care

Clover Health Medicare Advantage plans offer routine hearing services. Treating hearing loss can help you stay physically active, social, and maintain your overall health. That’s why Clover Health Medicare Advantage hearing benefits include:

  • One routine hearing exam per year, with a $0 copay
  • One pair of TruHearing hearing aids per year, with a copay of $699 to $999
  • Three hearing aid provider visits during the first 12 months after your hearing aid purchase
  • A 45-day trial for your new hearing aids
  • A three-year warranty on your hearing devices
  • 48 free batteries per aid if you choose non-rechargeable hearing aids

Deductibles and Copays Are Not Covered by Original Medicare

Monthly premiums, yearly deductibles, and copays can add up quickly. Original Medicare doesn’t cover copays or deductibles.

Monthly premiums: Most older adults qualify for premium-free Part A. But you will need to pay a monthly premium for Medicare Part B. 

Yearly deductible: The Original Medicare Part A deductible for 2022 is $1,556 for each benefit period. If you have an inpatient hospital stay, you’ll need to reach this deductible before Medicare Part A coverage kicks in. The annual Part B deductible for 2022 is $233. You’ll need to reach this deductible before Part B coverage kicks in.

Copays and Coinsurance: With Original Medicare, you’ll also need to pay a copay or coinsurance whenever you access healthcare. For most services, Original Medicare only covers 80%. You’ll need to pay the remaining 20% of the bill every time you visit your doctor or get care.

Affordable Clover Health Medicare Advantage Plans

Medicare Advantage plans offer a cost-effective alternative to Original Medicare (with those added supplemental benefits). Clover Health plans have low/$0 monthly premiums so you won’t break the bank on healthcare spending. 

Clover Health Medicare Advantage plans also include a Maximum Out of Pocket limit (known as MOOP), which is the most that you pay out-of-pocket during the calendar year for in-network covered Part A and Part B services. Even if you have a serious illness, you’ll have the peace of mind that you won’t pay more than your Maximum Out of Pocket limit. 

Deductibles, copays, and coinsurance vary by plan, so take a closer look at each plan to calculate your costs. Medicare Advantage plans make it easy to access the healthcare you need and stay within budget.

If you have questions or want to learn more about Clover Health Medicare Advantage plans, give us a call at 1-800-836-6890. We're available from 8am to 8pm local time, 7 days a week.*


Published on 5/10/22

Photo Credit: Adobe Stock