Key Takeaways
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Medicare covers a broad range of healthcare services, including hospital stays, doctor visits, and prescription drugs, but there are coverage limits and out-of-pocket costs.
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Certain services, such as long-term care, dental, vision, and hearing, are generally not covered by Original Medicare, making it essential to understand potential gaps and alternative options.
Understanding What Medicare Covers in 2025
Medicare provides millions of Americans with healthcare coverage, but knowing exactly what it covers—and what it doesn’t—can help you plan for potential out-of-pocket costs. While Medicare includes benefits for hospital stays, medical services, and prescription drugs, there are significant gaps that could leave you responsible for additional expenses. Let’s break down what Medicare pays for and where you might need extra coverage.
Hospital Stays and Skilled Nursing Facility Care
What’s Covered
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Inpatient hospital stays under Medicare Part A are covered after you pay the annual deductible of $1,676 per benefit period.
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Coverage includes semi-private rooms, meals, and necessary medical care while admitted.
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Skilled nursing facility (SNF) care is covered for up to 100 days per benefit period, with coinsurance costs starting after day 20 ($209.50 per day from days 21-100).
What’s Not Covered
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Long-term custodial care, such as assisted living or nursing home stays that don’t require medical treatment.
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Private rooms (unless medically necessary) and non-medical amenities.
Doctor Visits, Outpatient Care, and Preventive Services
What’s Covered
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Medicare Part B covers doctor visits, outpatient procedures, and preventive services after you meet the annual deductible of $257.
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Includes flu shots, cancer screenings, and cardiovascular screenings at no additional cost.
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Medically necessary services like diagnostic tests, lab work, and mental health care.
What’s Not Covered
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Routine physical exams (Medicare covers an annual wellness visit but not a full physical exam).
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Elective cosmetic procedures.
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Most chiropractic care, except for specific spine adjustments for subluxation.
Prescription Drug Coverage: What You Need to Know
What’s Covered
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Medicare Part D helps cover prescription drug costs.
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In 2025, out-of-pocket prescription drug spending is capped at $2,000.
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Coverage includes both generic and brand-name medications but varies by plan.
What’s Not Covered
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Over-the-counter medications unless explicitly prescribed and covered by a plan.
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Some specialty drugs may require prior authorization or higher cost-sharing.
What About Dental, Vision, and Hearing Care?
What’s Covered
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Medicare covers medically necessary dental procedures related to other covered medical treatments (e.g., jaw surgery).
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Some vision services, such as cataract surgery and medically necessary eye exams for diabetes.
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Limited hearing coverage includes diagnostic hearing exams when medically necessary.
What’s Not Covered
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Routine dental cleanings, fillings, and dentures.
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Routine eye exams and prescription glasses (except after cataract surgery).
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Hearing aids and hearing exams for fitting them.
Home Health Care and Durable Medical Equipment
What’s Covered
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Home health services are covered if prescribed by a doctor, including intermittent skilled nursing care and physical therapy.
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Durable medical equipment (DME), such as wheelchairs, walkers, and oxygen equipment, is covered with a 20% coinsurance.
What’s Not Covered
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Full-time home health aides for personal care assistance.
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Household modifications, such as wheelchair ramps or stairlifts.
Emergency and Urgent Care: What to Expect
What’s Covered
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Emergency room visits and urgent care visits are covered under Part B after the deductible is met.
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Ambulance services are covered if deemed medically necessary.
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Emergency care abroad may be covered in specific, limited situations.
What’s Not Covered
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Non-emergency transportation to medical appointments.
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Routine care received outside the U.S. (except in rare cases where Medicare allows it).
Mental Health and Substance Abuse Treatment
What’s Covered
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Inpatient mental health care is covered under Part A, with a daily coinsurance amount after 60 days.
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Outpatient mental health services, including therapy and counseling, are covered under Part B.
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Substance use disorder treatment, including medically necessary inpatient and outpatient services.
What’s Not Covered
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Alternative therapies like acupuncture (except for chronic lower back pain).
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Long-term inpatient stays beyond the allowed benefit period.
The Hidden Costs: Medicare Out-of-Pocket Expenses
While Medicare covers many essential services, you’ll still face out-of-pocket costs like:
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Deductibles ($1,676 for Part A and $257 for Part B in 2025).
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Coinsurance and copayments for hospital stays, skilled nursing facilities, and outpatient care.
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Medications beyond the $2,000 out-of-pocket cap if not covered by a plan.
Alternative Coverage Options for Services Medicare Doesn’t Cover
If you need coverage beyond what Medicare offers, consider:
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Employer-sponsored retiree health plans, if available.
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Medicaid, for those with low income and limited assets.
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Stand-alone dental, vision, and hearing plans.
Making the Most of Your Medicare Coverage
To avoid unexpected costs, take these steps:
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Review your Annual Notice of Change (ANOC) to stay updated on any Medicare plan changes.
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Use preventive services covered by Medicare to stay ahead of health issues.
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Consult a professional to discuss your specific healthcare needs and coverage options.
How to Prepare for Medicare Gaps in Coverage
Understanding what Medicare does and doesn’t cover can help you plan for additional costs and explore supplemental coverage options. Take time to review your plan, consider alternative insurance, and ensure you have the right coverage for your healthcare needs in 2025.
Need help navigating your Medicare options? Get in touch with a professional listed on this website to discuss coverage gaps, costs, and the best plan for your needs.
