Key Takeaways
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While Medicare covers a wide range of services in 2025, some essential needs still fall outside the program, potentially leading to significant out-of-pocket expenses.
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Understanding what Medicare doesn’t cover is just as important as knowing what it does, especially when planning for long-term health and financial security.
Understanding Medicare’s Core Benefits in 2025
In 2025, Medicare continues to serve as the primary source of health coverage for millions of Americans aged 65 and older, as well as for certain individuals with disabilities. The program is divided into four parts, each addressing different types of care:
Medicare Part A: Hospital Insurance
This part covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. In 2025:
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The hospital deductible is $1,676 per benefit period.
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Coinsurance applies after 60 days of hospitalization, reaching up to $838 per day by day 91.
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Skilled nursing care has no coinsurance for the first 20 days, but days 21 to 100 require a daily coinsurance of $209.50.
Medicare Part B: Medical Insurance
Part B includes outpatient care, doctor visits, preventive services, and durable medical equipment. In 2025:
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The monthly premium is $185.
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The annual deductible is $257.
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After the deductible, you typically pay 20% of the Medicare-approved amount for most services.
Medicare Part C: Medicare Advantage Plans
These are all-in-one alternatives to Original Medicare. They are offered by private companies approved by Medicare. While they may include additional benefits, such as dental or vision care, costs and coverage vary widely. It’s important to compare plans during the Open Enrollment Period from October 15 to December 7.
Medicare Part D: Prescription Drug Coverage
Part D helps cover the cost of prescription drugs. Notably in 2025:
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There is now a $2,000 annual cap on out-of-pocket costs for covered drugs.
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The deductible can be as high as $590.
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Once you reach the out-of-pocket threshold, you enter the catastrophic coverage phase, during which the plan pays 100% of covered drugs.
Common Services That Are Not Covered by Medicare
Despite covering a broad range of healthcare services, Medicare still excludes many routine and long-term needs. These gaps can catch you off guard if you’re not prepared.
1. Long-Term Custodial Care
Medicare does not cover non-medical assistance with daily activities such as bathing, dressing, or using the bathroom. This includes care in nursing homes or assisted living facilities unless it is short-term and medically necessary following a hospital stay.
2. Routine Dental, Vision, and Hearing Services
Original Medicare does not cover:
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Dental exams, cleanings, fillings, or dentures.
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Routine eye exams or eyeglasses.
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Hearing exams or hearing aids.
While some Medicare Advantage plans may include these benefits, they are not guaranteed.
3. Foreign Travel Emergency Care
Standard Medicare generally does not provide coverage for medical care outside the United States, except in very limited circumstances. Travel insurance or a Medicare Supplement plan with travel benefits is often needed for international coverage.
4. Prescription Drugs Without Part D
If you are enrolled in Original Medicare without a Part D plan or other creditable drug coverage, you will have to pay out-of-pocket for medications. Waiting to enroll in Part D may result in late penalties.
5. Routine Foot Care
Unless medically necessary due to conditions like diabetes, routine foot care, including nail trimming and removal of corns or calluses, is not covered.
6. Cosmetic Procedures
Medicare does not cover elective cosmetic surgeries or procedures that are not deemed medically necessary.
7. Acupuncture and Alternative Therapies
With limited exceptions, such as certain cases of chronic low back pain, most alternative treatments like acupuncture, chiropractic beyond spinal subluxation, and naturopathy are not covered.
Hidden Costs That Could Surprise You
Even for services Medicare does cover, there can be additional costs you should prepare for.
Deductibles and Coinsurance
You must meet annual deductibles for Parts A and B. After that, coinsurance or copayments typically apply. For example, under Part B, you pay 20% of the cost of doctor visits and outpatient procedures.
Excess Charges
Doctors who do not accept Medicare assignment may charge up to 15% more than the Medicare-approved amount. These “excess charges” are your responsibility unless you have supplemental coverage.
Late Enrollment Penalties
If you delay enrolling in Part B or Part D when first eligible, you could face lifetime penalties added to your monthly premiums. This applies unless you have qualifying coverage elsewhere.
Prescription Drug Tiers
Even with Part D coverage, drugs are often divided into tiers. Medications in higher tiers may come with higher copays or coinsurance, and some may require prior authorization.
Options to Manage or Fill the Gaps
There are several ways to handle these gaps and avoid unexpected expenses.
Medicare Supplement Insurance (Medigap)
Medigap policies can help pay some of the costs not covered by Original Medicare, such as deductibles, coinsurance, and excess charges. However, these policies do not include prescription drug coverage, dental, vision, or hearing benefits.
Medicare Advantage Plans
Some Advantage plans include additional benefits not offered under Original Medicare, like routine dental, vision, or hearing services. However, benefits and costs vary, and you may face network restrictions.
Employer or Union Plans
If you or your spouse are still working, you might be eligible for health coverage through an employer. This can serve as primary or secondary coverage alongside Medicare.
Medicaid and Extra Help Programs
If you have limited income and resources, you may qualify for Medicaid or Medicare Savings Programs that can help cover premiums, deductibles, and other out-of-pocket expenses. The Extra Help program also assists with Part D costs.
Health Savings Accounts (HSAs)
Although you can no longer contribute to an HSA once enrolled in Medicare, you can use existing funds to pay for qualified medical expenses, including dental and vision care not covered by Medicare.
Timelines You Should Know in 2025
Being aware of Medicare enrollment and change windows is critical to avoiding penalties and ensuring appropriate coverage.
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Initial Enrollment Period (IEP): Lasts 7 months (3 months before, the month of, and 3 months after your 65th birthday).
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General Enrollment Period (GEP): January 1 to March 31, for those who missed their IEP. Coverage starts July 1.
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Open Enrollment Period: October 15 to December 7. You can switch, drop, or enroll in a Medicare Advantage or Part D plan.
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Medicare Advantage Open Enrollment: January 1 to March 31. You can switch to another Advantage plan or return to Original Medicare.
Missing these periods can result in delayed coverage or financial penalties.
Reviewing Your Coverage Every Year Matters
Your health needs can change from year to year, and so can Medicare plans. Reviewing your coverage annually during the fall Open Enrollment Period is essential. Look out for the Annual Notice of Change (ANOC) sent by your plan provider to see how your plan may be changing in 2025.
Staying Ahead of Medicare’s Coverage Landscape
In 2025, Medicare provides a strong foundation for your healthcare needs, but it’s not all-inclusive. By knowing where the gaps are and preparing for them, you can avoid costly surprises down the line. Whether it’s considering supplemental insurance, reviewing plan options during enrollment periods, or understanding service exclusions, taking a proactive approach gives you greater peace of mind.
To get personalized support, reach out to a licensed agent listed on this website for expert guidance tailored to your situation.
