Key Takeaways
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Even with Original Medicare, significant out-of-pocket expenses remain if you don’t address key coverage gaps in 2025.
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Understanding what isn’t covered by Medicare helps you make informed decisions about additional coverage options and avoid costly surprises.
Why Medicare Might Not Be As Complete As It First Seems
If you’re approaching Medicare eligibility or already enrolled, it can feel like you’ve finally secured solid health coverage. But in 2025, many people are still caught off guard by how much they pay out of pocket—even with Medicare. That’s because Medicare, especially Original Medicare (Part A and Part B), doesn’t cover everything. Some of the most expensive aspects of care aren’t included, and this can lead to unexpected costs.
Understanding the limitations of Medicare is essential to managing your health care finances. Let’s look at the gaps that can catch you by surprise—and how you can plan for them.
Hospital Costs That Can Quickly Add Up
Medicare Part A covers hospital stays, but not without limits or costs. In 2025, you’re responsible for:
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A deductible of $1,676 for each benefit period
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Daily coinsurance charges if your hospital stay extends beyond 60 days ($419/day for days 61–90, and $838/day for lifetime reserve days)
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Full cost of hospitalization once your lifetime reserve days (a total of 60 over your lifetime) are used
Skilled nursing facility care is also partially covered. After the first 20 days, a daily coinsurance of $209.50 applies from days 21–100. If you require longer-term care, Medicare stops paying after 100 days.
No Coverage for Long-Term Custodial Care
Perhaps the most significant—and misunderstood—gap in Medicare is its exclusion of custodial long-term care. This includes assistance with daily living activities like bathing, dressing, eating, or using the bathroom.
If you need care in a nursing home or assisted living facility due to chronic illness, dementia, or mobility limitations, Medicare will not pay for it unless there is a short-term medical need covered under skilled care. This means individuals often turn to Medicaid (if eligible) or private savings to fund long-term care—both of which require advance planning.
Prescription Drug Costs Without Limits
Medicare Part B may cover certain medications administered in clinical settings, but for routine prescriptions, you need Part D coverage. Even with Part D, in 2025 you’ll face:
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A maximum deductible of $590
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Copayments or coinsurance on most medications
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An annual $2,000 out-of-pocket spending cap (new as of 2025)
While this new cap helps limit total drug costs, you can still spend hundreds—or even thousands—before hitting that threshold, especially for brand-name or specialty medications.
Dental, Vision, and Hearing Are Not Included in Original Medicare
In 2025, Original Medicare still does not include coverage for:
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Routine dental care (cleanings, fillings, extractions, dentures)
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Eye exams for glasses or contact lenses
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Hearing exams and hearing aids
You must pay out of pocket for these services or seek separate coverage. These services are essential to maintaining overall health and quality of life, particularly for older adults. Neglecting them due to cost can lead to broader health problems.
Foreign Travel Emergencies Are Not Covered
Planning international travel? Medicare doesn’t pay for healthcare services outside the United States, except in very limited circumstances (such as onboard a ship within U.S. territorial waters). If you have an emergency while abroad, you’re responsible for the full cost of care unless you’ve purchased additional insurance that includes global coverage.
Excess Charges Under Medicare Part B
Doctors who do not accept Medicare assignment can charge up to 15% more than the Medicare-approved amount. These are known as Part B excess charges. While not very common, they can add up if you see such providers frequently. Medicare does not cover this extra cost.
In 2025, Part B also carries a standard monthly premium of $185 and an annual deductible of $257, which are your responsibility before coverage kicks in.
Out-of-Pocket Spending Without a Limit
Unlike most private insurance plans, Original Medicare has no annual out-of-pocket spending cap for medical services. This means your costs for copayments, coinsurance, and deductibles can continue to grow throughout the year without a ceiling—posing financial risk during years of major illness.
Adding supplemental coverage is one way many individuals limit this risk, but even that depends on plan selection, availability in your area, and timing of enrollment.
Timing Matters: Late Enrollment Penalties
If you delay enrolling in Medicare Part B or Part D when you’re first eligible and don’t have other credible coverage, you may face permanent penalties:
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A 10% increase in your Part B premium for each 12-month period you were eligible but didn’t enroll
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A 1% increase in your Part D premium for every month you delayed, unless you had other drug coverage
These penalties are applied monthly and continue for life. Many people don’t anticipate them, especially if they were still working past age 65.
Gaps in Mental Health Services
Medicare covers some mental health care, but there are still gaps. For instance:
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Limited coverage for long-term outpatient therapy
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Restrictions on the number of psychiatric hospital days (190-day lifetime limit in a freestanding psychiatric hospital)
In 2025, access to behavioral health support is a critical issue, and inadequate coverage can hinder treatment for conditions like anxiety, depression, and dementia.
Medical Devices and Equipment May Not Be Fully Covered
Medicare Part B covers durable medical equipment (DME), but not all items qualify. For example, stair lifts, grab bars, and most home modifications are not covered. Even for approved items, you typically pay 20% of the Medicare-approved amount, and the item must be prescribed by a Medicare-participating provider.
If you need a wheelchair, oxygen equipment, or diabetic supplies, these are partially covered, but associated maintenance and accessories may not be.
Emergency Transport Can Trigger High Bills
Ambulance services are covered under Part B but come with costs. You are generally responsible for:
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20% of the Medicare-approved amount
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A deductible of $257 (same as other Part B services)
Air ambulance services can be especially expensive, and Medicare only covers them if deemed medically necessary and if ground transport is not sufficient.
Gaps in Home Health Services
While Medicare covers some home health care, including part-time skilled nursing and physical therapy, it does not include:
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24-hour care at home
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Meal delivery
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Personal care (help with bathing, dressing, or using the bathroom) if it’s the only care you need
This creates a gap for individuals who need assistance but not medical-level services.
What You Can Do to Prepare
Understanding these gaps allows you to take steps to reduce financial risk. Here are some tips:
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Consider supplemental coverage: Explore Medigap or other private coverage options during your open enrollment period.
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Enroll on time: Avoid late enrollment penalties by signing up for Medicare as soon as you’re eligible or when your employer coverage ends.
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Budget for out-of-pocket costs: Especially for dental, vision, hearing, and long-term care expenses.
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Ask providers if they accept Medicare assignment: This avoids excess charges.
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Review your Part D plan each year: Drug coverage can change annually, including formularies and pharmacy networks.
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Consult a licensed agent listed on this website: They can help you understand your options and ensure your plan fits your health needs.
Protecting Yourself from Unexpected Medicare Costs
While Medicare provides valuable and often vital coverage, it’s not without its limitations. In 2025, gaps in coverage continue to impact millions of Americans—often when they least expect it. By understanding what isn’t included and exploring your options to fill those gaps, you can better protect your finances and your health.
For personalized help with finding the right Medicare strategy, reach out to a licensed agent listed on this website. They can walk you through your choices, explain costs, and help you avoid costly missteps.
