What Original Medicare Does and Doesn’t Cover

Original Medicare gives millions of Americans access to healthcare through Medicare Part A and Part B. But one of the biggest mistakes people make is assuming that Medicare covers almost everything they may need as they get older.

It does not.

Understanding what Original Medicare covers and does not cover can help you plan for healthcare expenses, avoid unexpected bills, and determine whether additional Medicare coverage may make sense for you.

If you are turning 65 in California or already enrolled in Medicare, here is what you should know.

What Is Original Medicare?

Original Medicare is the traditional federal Medicare program made up of:

Part A: Hospital Insurance
Part B: Medical Insurance

Part A generally helps cover medically necessary inpatient hospital care, skilled nursing facility care under certain conditions, hospice care, and some home health care.

Part B generally covers medically necessary doctor services, outpatient care, preventive services, durable medical equipment, and certain other medical services.

You can generally visit any doctor or healthcare provider in the United States that accepts Medicare and is accepting new Medicare patients. You do not need a referral to see a specialist in most cases.

However, Original Medicare does not pay 100% of every covered service.

What Does Original Medicare Cover?

1. Hospital Care

Medicare Part A helps cover eligible inpatient hospital services, including:

• Inpatient hospital stays
• Medications and supplies received during an inpatient stay
• Skilled nursing care following a qualifying hospital stay
• Hospice care
• Certain home health services

However, deductibles and other cost sharing may apply.

2. Doctor and Outpatient Services

Part B covers many medically necessary services you receive outside of an inpatient hospital, including:

• Primary care visits
• Specialist visits
• Outpatient procedures
• Diagnostic tests
• Some mental health services
• Preventive screenings
• Certain medical supplies and equipment

Preventive care can be particularly valuable because Medicare covers many preventive services when specific requirements are met.

3. Preventive Services

Original Medicare covers a wide range of preventive services designed to identify health problems early.

Depending on eligibility, these can include certain:

• Cancer screenings
• Cardiovascular screenings
• Diabetes screenings
• Vaccinations
• Wellness visits
• Counseling services

The exact coverage requirements can vary, so it is important to check whether a service is covered before receiving it.

4. Durable Medical Equipment

Part B may help pay for medically necessary durable medical equipment such as:

• Wheelchairs
• Walkers
• Oxygen equipment
• Hospital beds
• Certain diabetic equipment

Medicare generally has specific requirements for both the medical necessity and the supplier.

What Doesn’t Original Medicare Cover?

This is where many beneficiaries are surprised.

Dental Care

Routine dental care is generally not covered by Original Medicare.

That means services such as routine cleanings, dental exams, fillings, dentures and most tooth extractions are generally not covered.

There are limited circumstances where Medicare may cover certain dental services when they are directly connected to another covered medical treatment.

Routine Vision Care

Original Medicare generally does not cover routine eye examinations for glasses or contact lenses.

There are exceptions for certain medical conditions and situations, such as specific treatment related to eye disease or certain circumstances involving cataract surgery.

Hearing Aids

Original Medicare generally does not cover hearing aids or routine exams for fitting hearing aids.

This can become a significant expense for beneficiaries who need hearing assistance.

Long Term Custodial Care

One of the most important exclusions to understand is long term custodial care.

Original Medicare generally does not pay for ongoing custodial care when that is the only care you need. This can include assistance with everyday activities such as:

• Bathing
• Dressing
• Eating
• Using the bathroom
• Getting in and out of bed

Medicare may cover skilled nursing care in specific circumstances, but that is different from long term custodial care.

Routine Foot Care

Original Medicare generally does not cover routine foot care, such as cutting toenails or removing corns and calluses.

There are exceptions for certain beneficiaries with specific medical conditions when the service meets Medicare’s coverage requirements.

Cosmetic Procedures

Cosmetic surgery is generally not covered when it is performed solely to improve appearance.

However, Medicare may cover certain procedures when they are medically necessary.

Original Medicare Also Has Out of Pocket Costs

Another important point is that having Medicare does not mean having no medical bills.

With Original Medicare, you may have:

• Part A deductibles
• Part B premiums
• Part B deductible
• Coinsurance
• Copayments for certain services
• Costs for services Medicare does not cover

Unlike Medicare Advantage plans, Original Medicare does not have a yearly out of pocket maximum for covered Part A and Part B services.

That distinction is important when planning your healthcare budget.

Can You Get Additional Coverage With Original Medicare?

Yes.

Some people with Original Medicare purchase a Medicare Supplement Insurance plan, also called Medigap, to help pay certain costs that Original Medicare does not fully cover.

You can also generally add a separate Medicare Part D prescription drug plan if you need prescription drug coverage.

Medigap and Part D serve different purposes. Medigap helps with certain Medicare approved cost sharing, while Part D helps cover prescription medications.

It is also important to understand that Medigap generally does not cover everything Original Medicare excludes. For example, routine dental, vision and hearing benefits are generally not included simply because you have a Medigap policy.

Original Medicare vs. Medicare Advantage

If you are comparing Medicare options, one of the biggest decisions is whether to stay with Original Medicare or enroll in a Medicare Advantage plan.

Medicare Advantage plans are offered by private insurance companies approved by Medicare. Many plans include Part A and Part B coverage along with prescription drug coverage and may offer additional benefits such as dental, vision or hearing benefits.

But Medicare Advantage plans can have provider networks, different cost sharing and plan specific rules.

There is no universally “best” Medicare option. The better choice depends on your doctors, medications, healthcare needs, budget and preferred way of receiving care.

A Simple Way to Think About Original Medicare

Before choosing your coverage, ask yourself three questions:

What healthcare services do I expect to use?

What services might Medicare not cover?

How much could I afford to pay out of pocket?

These questions can reveal coverage gaps that are easy to overlook when you only compare monthly premiums.

The Bottom Line

Original Medicare provides valuable coverage for hospital care, doctor visits, outpatient services, preventive care and many medically necessary treatments. But it does not cover everything.

Routine dental care, most routine vision care, hearing aids and long term custodial care are among the important exclusions beneficiaries should understand.

For California residents approaching Medicare eligibility, understanding these gaps before choosing coverage can make it easier to plan for healthcare costs and evaluate whether additional coverage may be appropriate.

Cal-Society Insurance Services helps California residents understand Medicare coverage options and make informed decisions based on their healthcare needs and circumstances.