Medicare Covers More Than You Think—And It Still Leaves Plenty Out

Key Takeaways

• Medicare does offer a wide range of health benefits in 2025—but there are critical gaps that can leave you with unexpected out-of-pocket costs.

• Understanding what Medicare covers and what it does not is essential for planning and protecting your health and finances.

The Broad Scope of Medicare Coverage

Medicare remains the primary health insurance program for Americans age 65 and older, as well as certain younger individuals with disabilities. It offers four distinct parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage). Each serves a unique purpose, collectively creating a fairly comprehensive framework—but not a complete one.

Inpatient and Hospital Care (Medicare Part A)

Part A covers:

• Inpatient hospital stays

• Skilled nursing facility care (under certain conditions)

• Hospice care

• Some limited home health services

This coverage is foundational, and most people receive it without a premium if they or their spouse paid Medicare taxes for at least 40 quarters.

Still, Part A has:

• A hospital deductible ($1,676 per benefit period in 2025)

• Daily coinsurance for extended hospital stays

• Time limits on skilled nursing facility coverage (100 days per benefit period)

Outpatient and Preventive Services (Medicare Part B)

Part B includes:

• Doctor visits

• Outpatient surgeries

• Durable medical equipment (DME)

• Lab tests and diagnostic imaging

• Preventive screenings (like mammograms and colonoscopies)

In 2025, the standard Part B premium is $185 monthly, with an annual deductible of $257. After meeting the deductible, Medicare typically covers 80% of approved services, and you’re responsible for the remaining 20% unless you have supplemental coverage.

Prescription Drugs (Medicare Part D)

As of 2025, Part D offers significant changes:

• An annual out-of-pocket cap of $2,000

• Elimination of the coverage gap (formerly known as the “donut hole”)

• $35 insulin cost cap

• No-cost vaccines

These updates make prescription drug coverage more affordable—but not all medications are included, and plan formularies can vary. Prior authorizations, step therapy, and tiered pricing can still create access barriers.

Medicare Advantage (Part C)

While offered through private insurers, Medicare Advantage plans are approved by Medicare and must cover everything Original Medicare (Parts A and B) does. Many plans also offer:

• Vision, hearing, and dental services

• Transportation to medical appointments

• Fitness benefits

However, these plans often operate within network structures and may require prior authorizations for services. Your access to care depends on the plan’s rules and provider network. Plan availability and benefits vary widely by ZIP code.

What Medicare Doesn’t Cover in 2025

While Medicare covers a lot, there are still major services it either limits or doesn’t cover at all. Here’s a breakdown of what you can’t count on Medicare to pay for.

1. Long-Term Custodial Care

Medicare does not pay for long-term care in a nursing home or assisted living facility if the primary need is help with daily activities (like bathing or dressing) rather than skilled medical care. This remains one of the most significant gaps in coverage. Families typically rely on long-term care insurance, Medicaid, or private savings.

2. Most Dental Services

Routine dental care—such as cleanings, fillings, dentures, and root canals—is not covered by Original Medicare. Some Medicare Advantage plans offer limited dental benefits, but coverage is often capped annually and excludes more expensive procedures.

3. Routine Vision and Hearing Services

While Medicare Part B may cover eye exams for certain conditions (like glaucoma or macular degeneration) and hearing exams ordered by a physician, it doesn’t cover:

• Routine eye exams

• Eyeglasses or contact lenses (unless following cataract surgery)

• Hearing aids or exams for fitting them

Vision and hearing coverage, if available, typically comes through Medicare Advantage, with restrictions and annual limits.

4. Overseas Emergency Care

If you travel outside the United States, Medicare will generally not cover medical services you receive abroad, with very limited exceptions. Some Medigap policies include limited foreign travel emergency coverage, but it is not standard.

5. Cosmetic Procedures

Any surgery or procedure performed primarily for aesthetic purposes, such as Botox for wrinkles or plastic surgery not medically necessary, is not covered by Medicare.

6. Alternative and Complementary Therapies

Medicare does not cover services such as:

• Acupuncture (except for chronic low back pain)

• Massage therapy

• Naturopathy

• Homeopathy

These are considered outside the scope of conventional treatment and remain uncovered.

7. Personal Comfort Items

Items like hospital phones, TVs, or personal care supplies provided during a hospital stay are not covered. You’ll have to pay for these out-of-pocket.

Gaps That Can Lead to High Out-of-Pocket Costs

Even when Medicare covers a service, your share of the cost can still be significant if you don’t have supplemental coverage. Key areas include:

Deductibles and Coinsurance

In 2025:

• Part A has a $1,676 deductible per benefit period

• Part B has a $257 deductible and 20% coinsurance

These expenses can add up quickly if you have multiple hospitalizations or need ongoing outpatient care.

No Cap on Out-of-Pocket Costs in Original Medicare

Unlike many Medicare Advantage plans, Original Medicare does not have an annual limit on what you may spend out-of-pocket. That means there’s no financial ceiling if you experience a serious illness or require high-cost care. A Medigap plan can help, but it’s not automatic—you need to apply and be approved.

Part D Limitations

While the new $2,000 annual cap on drug spending is a positive change, it does not eliminate all costs. You’ll still be responsible for:

• Monthly plan premiums

• Annual deductible (up to $590)

• Cost-sharing (copayments or coinsurance) until reaching the cap

Additionally, the $2,000 cap applies only to covered drugs. If a medication is not included in your plan’s formulary, you’ll need to pay for it entirely out of pocket.

Planning Around the Coverage Gaps

Understanding what Medicare doesn’t cover helps you plan better and avoid surprise expenses. Here are a few practical steps:

Compare All Available Options

• Evaluate whether Original Medicare or Medicare Advantage better fits your needs.

• Review your coverage during the Annual Enrollment Period from October 15 to December 7.

• If you have Original Medicare, consider adding a Medigap policy for supplemental protection.

Consider Additional Insurance When Appropriate

Long-term care insurance, dental discount plans, and travel medical insurance are all examples of coverage you might explore based on your lifestyle and needs.

Use Preventive Services Fully

Many preventive services are covered without cost-sharing. Taking advantage of screenings, vaccines, and wellness visits may help you avoid costlier treatments down the line.

Stay Within Networks When Applicable

If you’re in a Medicare Advantage plan, staying in-network and following your plan’s rules can reduce your overall costs and prevent denial of services.

What All This Means for You in 2025

Medicare offers solid protection against many healthcare costs, but it is not complete coverage. Being aware of its limitations—especially for dental, vision, long-term care, and out-of-pocket caps—can help you make smarter, more informed decisions.

You don’t need to navigate all this alone. For guidance that reflects your specific situation, talk to a licensed agent listed on this website.