Key Takeaways
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Many Medicare plans may advertise broad coverage, but you can still face gaps in key areas like out-of-network care, long-term support, and routine services.
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Understanding where your current plan stops—and where your own costs begin—can help you avoid surprise bills and unnecessary restrictions.
What “Covers Everything” Really Means
It’s easy to assume your Medicare plan takes care of all your healthcare needs, especially when the marketing highlights extra benefits and broad coverage. But when you look closer, “covers everything” often comes with conditions, restrictions, and exclusions. In 2025, Medicare continues to offer valuable support, yet it’s far from comprehensive without careful selection and planning.
Original Medicare (Part A and Part B) offers significant coverage for hospital and medical services. However, it leaves out essential components like prescription drugs (unless you add Part D), routine vision and dental care, and long-term custodial care. Many people choose to enroll in additional coverage such as a Medicare Advantage plan or a Medicare Supplement to address these gaps. But even these add-ons can fall short in important ways.
The Out-of-Network Reality
If you’re enrolled in a Medicare Advantage plan, you’re likely subject to provider networks. That means you’re encouraged—sometimes required—to get care within a specific group of hospitals, doctors, and clinics. Going outside that network can result in:
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Significantly higher costs
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Complete lack of coverage for certain services
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Complicated prior authorization processes
This restriction can be particularly limiting if you travel often, move between regions during the year, or want access to a specialist who isn’t in your plan’s network.
In contrast, Original Medicare lets you see any provider who accepts Medicare nationwide. That’s a broader reach, though still not truly “everything”—especially when you factor in coinsurance and deductibles.
Prescription Drug Gaps Still Exist
Prescription drug coverage is not included in Original Medicare. You need to enroll in a separate Part D plan or choose a Medicare Advantage plan that bundles drug coverage. But even then, coverage is not all-inclusive. In 2025, the Medicare Part D program has introduced a $2,000 out-of-pocket cap, which is a major improvement—but this cap only applies to covered drugs.
Here’s where the gap appears:
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Some medications may not be on your plan’s formulary (the list of approved drugs).
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Certain high-cost medications may require step therapy or prior approval.
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Drugs administered in an outpatient setting may be billed under Part B instead of Part D.
If your needed medication isn’t covered, or is placed in a high-cost tier, you’ll face large out-of-pocket expenses despite having a “comprehensive” drug plan.
Long-Term Care Isn’t Covered
Medicare does not cover custodial care—that is, non-medical help with daily living activities such as bathing, dressing, or eating. This type of care is typically required in assisted living facilities or nursing homes. Even short-term skilled nursing care is limited:
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Medicare pays only if you’ve had a qualifying 3-day inpatient hospital stay
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Coverage is limited to 100 days per benefit period
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After day 20, daily copayments apply and can become expensive
For many people, long-term care becomes one of the most significant expenses in retirement. Relying on Medicare alone won’t prepare you for that possibility.
Dental, Vision, and Hearing—Frequently Excluded
Another area where plans fall short is routine care:
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Dental care like cleanings, fillings, and dentures is not covered by Original Medicare.
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Vision services such as routine eye exams and glasses are also excluded.
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Hearing aids and related exams are left out too.
Some Medicare Advantage plans offer limited coverage for these services, but:
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Coverage is often capped at a low annual dollar amount
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You may be limited to a specific network of providers
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The benefit may be bundled with restrictions or usage limits
Even when included, these extras are more of a supplement than full coverage.
Prior Authorization Creates Delays
In Medicare Advantage plans, prior authorization requirements are common. This means you must get plan approval before certain services will be covered. In 2025, this remains one of the biggest sources of frustration for enrollees:
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Delays in getting care while waiting for approval
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Risk of denial, even for medically necessary services
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Additional paperwork and administrative burden for both you and your doctor
Original Medicare does not generally require prior authorization for most services. So while Medicare Advantage may appear more coordinated, that coordination can lead to red tape when you need timely care.
Emergencies Can Still Cost You
Even emergency care isn’t always covered the way you might expect. While Medicare and Medicare Advantage plans do cover emergency room visits and ambulance services, problems arise in situations like:
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Air ambulance transport, which can result in unexpected and high out-of-network bills
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Follow-up care after an emergency, which may fall outside of a covered network
If you’re hospitalized during travel or in another state, Medicare Advantage may not pay the same way it does at home, depending on your plan’s policies. That means high bills can show up when you least expect them.
Supplemental Coverage Doesn’t Eliminate All Costs
Many people use Medicare Supplement (Medigap) plans to reduce their out-of-pocket costs under Original Medicare. These plans help cover coinsurance, copayments, and deductibles. But they don’t extend the scope of Medicare’s coverage. That means:
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No additional coverage for dental, vision, hearing, or long-term care
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You still need a standalone Part D plan for prescription drugs
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Premiums may increase over time
While Medigap offers nationwide provider access and predictable costs, it still doesn’t make Medicare complete.
Travel Coverage Isn’t Guaranteed
Medicare generally doesn’t cover healthcare outside the U.S. Some Medigap plans provide limited foreign travel emergency coverage, but restrictions apply:
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Usually only emergency care is covered
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Coverage is time-limited and capped (often $50,000 lifetime maximum)
Medicare Advantage plans rarely offer any international coverage. If you’re planning international travel, you’ll likely need to purchase separate travel health insurance.
Extra Benefits Sound Good—Until You Read the Fine Print
Many Medicare Advantage plans in 2025 offer supplemental perks such as:
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Fitness memberships
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Transportation assistance
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Over-the-counter product allowances
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Meal delivery after a hospital stay
While these extras can be useful, they often come with limitations:
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Monthly caps or usage limits
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Geographic restrictions
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Must use specific vendors or services
These benefits are not guaranteed from year to year and can be changed or dropped entirely. It’s easy to overestimate their value when choosing a plan, only to realize later that they don’t match your actual needs.
Annual Changes Can Affect Your Coverage
Every year, Medicare Advantage and Part D plans can change their:
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Covered medications
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Provider networks
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Copayments and coinsurance rates
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Extra benefits
Even if your plan seemed to “cover everything” last year, the new year may bring new restrictions. That’s why it’s critical to review your Annual Notice of Change (ANOC) each fall during the Open Enrollment Period (October 15 through December 7).
Medicare Still Has a Strong Foundation—But You Need to Fill the Gaps
Medicare remains a valuable healthcare foundation for millions of Americans. However, in 2025, no single plan truly covers everything. Whether you’re enrolled in Original Medicare, a Medicare Advantage plan, or a combination that includes Medigap and Part D, there are still areas where coverage may fall short.
Being proactive—reading your plan’s documentation, understanding its limits, and knowing where you might need additional support—is your best defense against surprise bills and care delays. That starts with knowing the facts, not the headlines.
Make Sure You’re Actually Covered Where It Counts
Before you assume your Medicare plan has all your needs covered, take the time to ask the right questions:
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Are your medications fully covered and reasonably priced?
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What happens if you get sick while traveling?
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Will you have access to the specialists or hospitals you want to use?
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What’s excluded from dental, vision, or hearing benefits?
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How much are you likely to spend on care that isn’t covered?
If you’re unsure about any of these, or if your situation has changed since you first enrolled, it’s a good time to speak with a licensed agent listed on this website. They can help you compare plans and understand the fine print before your next Open Enrollment window.
