When Medicare benefits were created in 1965, they reflected the restrictions and limitations of most health insurance at that time. The federal law that created Medicare has specific provisions that exclude coverage for certain things, like dental care and routine vision services. Long-term care services are additionally excluded because they do not meet the definition of health care services in the law. Just because something is not covered by Medicare, though, does not mean that it isn’t needed. As we discuss some types of care that Medicare doesn’t cover, we will include information about other ways of accessing or paying for these services.
First, it is important to understand that most dental and vision care is excluded from Medicare coverage.
Medicare does not cover dental services that you need primarily for the health of your teeth, such as routine checkups, cleanings, fillings, most tooth extractions, and dentures. Medicare does, however, offer very limited coverage for some dental care needed to protect particular aspects of your general health, or for dental care needed for another Medicare-covered health service to be successful. For example, Medicare may cover an oral examination in the hospital before a kidney transplant, surgery to treat fractures of the jaw or face, or dental splints and wiring needed after jaw surgery.
Routine eye care services, such as regular eye exams, are also excluded from Medicare coverage. However, Medicare will cover an annual eye exam if you have diabetes or are at high risk for glaucoma. Medicare also covers certain eye care services if you have a chronic eye condition, such as cataracts or glaucoma. For example, Medicare covers cataract surgery, as well as eyeglasses or contacts after cataract surgery.
You may, however, have other options to receive dental or vision care.
First, learn what dental and vision services your state’s Medicaid program covers. If you have limited income, you may be eligible for Medicaid coverage, which can cover services that Medicare does not. Contact your local Medicaid office to learn more.
Second, you can compare Medicare Advantage Plans. Some offer routine dental or vision care as a supplemental benefit. There are also private stand-alone dental or vision plans you can purchase.
If Medicaid or a private plan is not an option, you can also use a low-cost dental resource, such as free dental clinics, dental schools, Community Health Centers, or Federally Qualified Health Centers.
While long-term care is also excluded from Medicare coverage, there are other types of insurance and resources to assist with long-term care needs.
Long-term care (LTC) refers to a range of services and support that help you perform everyday activities. LTC can be provided in a nursing home, assisted living facility, or other setting. LTC may include medical care, therapy, 24-hour care, personal care, and custodial care, also called homemaker services. Medicare usually does not cover non-medical LTC services. However, if you need care, there are other organizations and forms of insurance you can try.
First, if you have limited income, you can apply to Medicaid. Medicaid is the country’s largest payer of long-term services and supports and will pay for nursing home care. Medicaid benefits also coordinate with Medicare. Contact your local Medicaid office to learn more.
Second, you might look into long-term care insurance, which generally covers nursing care and custodial care. Note that these plans can be very expensive, and you can only purchase certain LTC policies if you are in good health.
In addition to Medicaid and LTC policies, you might find local resources that can help with your long-term care needs. For example, your local Area Agency on Aging (AAA) may have programs that deliver meals or provide transportation. Contact your local AAA to be connected with services in your area.
Finally, as you seek access to these other types of care, protect yourself from potential marketing violations and enrollment fraud.
As we reviewed, some Medicare Advantage Plans may offer dental coverage, vision coverage, and other supplemental benefits beyond traditional Medicare. Be aware, though, that there are often rules and restrictions around these supplemental benefits. Sometimes, plan marketing materials can even make it seem that the plan offers additional services, when those services are actually covered by Medicare. If you are comparing Medicare Advantage Plans, practice being an informed consumer to avoid being enrolled in a plan that does not meet your needs or expectations. For example, ask plan representatives questions like:
Is this benefit offered to everyone enrolled in the plan, or is it an optional benefit I sign up for?
Is there an additional premium I must pay for this benefit?
Are there limits to how much I can use this service?
Are there restrictions on where and how I can access these services?
Are there copays or coinsurance charges for these services?
Specifically, when asking about supplemental dental and vision coverage, make sure you know exactly which dental and vision services are covered, at what cost, and how often. You can also request that a representative send this information to you in writing. If you would like assistance comparing Medicare Advantage Plans and their supplemental benefits, you can call your local State Health Insurance Assistance Program (SHIP). Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
If you sign up for a plan after being told that certain services were covered, but later receive a denial because those services are not covered, you may have experienced potential enrollment fraud. If you believe you are experiencing potential Medicare fraud, abuse, or errors, you should call your local Senior Medicare Patrol (SMP).
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any other Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
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