Medicare Exclusions

Medicare exclusions refer to the healthcare services and items that are not covered by the Medicare program. These exclusions may vary depending on the specific type of Medicare coverage, such as Medicare Part A, Part B, Part C, or Part D. Some common examples of Medicare exclusions are:

• Cosmetic procedures: Medicare does not cover cosmetic surgeries or procedures, including most dental services, cosmetic injections, or elective plastic surgeries.

• Long-term care: Medicare does not cover custodial care, which includes long-term care in nursing homes, assisted living facilities, or home health services.

• Vision and hearing care: Medicare does not cover routine vision or hearing exams, eyeglasses, or hearing aids. However, some Medicare Advantage plans may offer additional coverage for these services.

• Alternative therapies: Medicare does not cover most alternative therapies, such as acupuncture, chiropractic services, or naturopathic medicine.

• Prescription drugs not on the formulary: Medicare Part D plans may not cover certain prescription drugs that are not on their formulary.

It is important to review the specific coverage and exclusions of your Medicare plan to understand what services and items are covered and what may not be covered.

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According to Mployer Insights’ 2026 analysis of 76,000+ employer benefit plans, disability insurance remains a major market differentiator, with only 41% of U.S. employers offering short-term disability (STD) and 38% offering long-term disability (LTD). While 60% salary replacement serves as the national standard across both benefit types, standard plan designs disproportionately expose higher earners due to median benefit caps of $1,602/week for STD and $8,273/month for LTD. Furthermore, alignment between STD benefit durations (median 26 weeks) and LTD elimination periods (68% at 90 days) remains a critical area for plan structure optimization.
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According to Mployer Insights’ 2026 analysis of 50,000+ employer health plans, prescription drugs account for over 25% of total benefit expenses, with Tier 4 specialty drugs driving the majority of high-cost claims. While Tier 4 copays average $123 with coinsurance requirements in 31% of plans, individual oncology therapies like Darzalex Faspro ($170,800/yr) and Keytruda ($158,200/yr) frequently exceed average individual stop-loss deductibles ($141,938). To mitigate exposure, self-funded employers are increasingly turning to independent, transparent PBM models and biosimilar substitution—which yields up to a 73% net cost reduction per patient.