Key Takeaways

• Medicare in 2025 covers a wide range of health services, but you may still face major out-of-pocket costs for specific categories like dental, vision, hearing, and long-term care.

• Understanding what’s excluded or only partially covered under Medicare can help you avoid unexpected bills and plan for supplemental options if needed.

The Coverage Myth: What Medicare Promises vs. What It Delivers

Medicare provides essential health insurance for millions of Americans, primarily those aged 65 and older. However, many people mistakenly believe that Medicare covers everything they might need. The reality is more complex. While Medicare Parts A and B form the foundation of coverage, there are clear gaps that leave you responsible for significant costs if you’re unprepared.

Gaps in Routine and Preventive Care

Medicare does well with covering preventive screenings like mammograms, colonoscopies, and annual wellness visits. But not all routine care is fully paid for.

What’s Usually Missing:

• Annual physical exams: Medicare offers a “Wellness Visit” once a year, but this is not the same as a full physical. If your doctor performs extra tests or procedures during that visit, you may receive a bill.

• Foot care: Routine podiatric care, like nail trimming or callus removal, isn’t covered unless it’s for a medically necessary reason related to a condition like diabetes.

• Chiropractic care: Coverage is limited to spinal manipulation for subluxation. Broader chiropractic services aren’t included.

Hearing, Vision, and Dental: Largely Excluded

You might assume that services essential to maintaining your quality of life—like hearing aids or dentures—are part of Medicare’s benefits. In most cases, they’re not.

Hearing

• What’s not covered: Hearing exams for fitting hearing aids, the hearing aids themselves, and follow-ups.

• Exceptions: Diagnostic hearing exams may be covered if ordered by a physician to diagnose a hearing problem.

Vision

• What’s not covered: Routine eye exams, glasses, or contact lenses, unless related to specific conditions such as cataract surgery.

• Exceptions: Medicare will cover glaucoma tests, diabetic retinopathy screening, and macular degeneration treatment if medically necessary.

Dental

• What’s not covered: Cleanings, fillings, tooth extractions, dentures, and implants.

• Exceptions: Some dental services may be covered if they are part of a Medicare-covered procedure (e.g., jaw reconstruction after an accident).

Long-Term Custodial Care: A Common Misunderstanding

This is one of the most significant areas where Medicare coverage is limited. Many people wrongly believe Medicare pays for long-term care in a nursing home or assisted living facility. That’s not the case.

What Medicare Covers:

• Short-term skilled nursing care: After a qualifying three-day inpatient hospital stay, Medicare Part A covers up to 100 days in a skilled nursing facility.

  • Days 1–20: Fully covered

  • Days 21–100: You pay a daily coinsurance (over $200 per day in 2025)

  • Beyond 100 days: No coverage

What Medicare Doesn’t Cover:

• Custodial care: Help with bathing, dressing, eating, and other daily activities isn’t covered if it’s the only type of care you need.

• Assisted living facilities: Generally excluded, even if you’re there due to health needs.

Emergency and Foreign Travel Care: Limited at Best

Medicare doesn’t travel well. If you’re planning to go outside the U.S., you need to understand the boundaries of your coverage.

What’s Covered:

• Emergency care in the U.S. is covered by Part A (hospital) and Part B (outpatient), subject to deductibles and coinsurance.

What’s Not Covered:

• Routine or emergency care outside the U.S.: Original Medicare typically does not cover foreign travel emergencies.

• Exceptions: In rare cases, such as when you’re traveling through Canada on a direct route between Alaska and another U.S. state, coverage may apply.

Mental Health and Addiction Services: Coverage Has Limits

Medicare covers mental health services, but limitations exist, especially for long-term care and support.

Inpatient Coverage:

• Psychiatric hospital stays are covered for up to 190 lifetime days in a freestanding psychiatric facility.

• Standard inpatient care for mental health in a general hospital is subject to Part A rules and does not count against the 190-day cap.

Outpatient Coverage:

• Therapy visits and medication management are covered under Part B, but you’re responsible for 20% coinsurance after meeting your deductible.

What’s Missing:

• Long-term therapy or ongoing counseling may be limited by provider availability and session caps.

• Residential treatment programs for addiction recovery are rarely covered unless they qualify as inpatient hospital stays.

Prescription Drugs: Coverage Depends on Enrollment

Medicare does not automatically include drug coverage. You must enroll in Part D or a plan that includes prescription benefits.

What to Know in 2025:

• Deductible: The standard Part D deductible is $590.

• Out-of-pocket cap: Drug spending is now capped at $2,000 annually, a major improvement over past years.

What May Still Slip Through:

• Some high-cost or specialty drugs may not be on your plan’s formulary.

• Tiered pricing structures can result in higher coinsurance for brand-name or non-preferred drugs.

Home Health Services: Not All Are Included

Home health care is often misunderstood. While Medicare does offer coverage, it comes with conditions.

Covered Services:

• Intermittent skilled nursing care

• Physical therapy

• Speech-language pathology

• Occupational therapy

Not Covered:

• 24/7 home care or supervision

• Meal delivery or homemaker services (unless part of a broader, medically necessary plan)

Medical Equipment and Supplies: Some Gaps Remain

Durable medical equipment (DME) is partially covered, but not all supplies fall under Medicare’s rules.

What’s Covered:

• Wheelchairs, walkers, oxygen equipment, and hospital beds ordered by your doctor

What’s Not Covered:

• Bathroom safety items (e.g., grab bars)

• Convenience items (e.g., air purifiers, massage devices)

• Most over-the-counter medical supplies

Cosmetic and Elective Procedures: Not a Medicare Priority

Medicare is structured around medical necessity. Procedures done for aesthetic or non-critical purposes are excluded.

Not Covered:

• Cosmetic surgery (e.g., facelifts, liposuction)

• Most vision correction surgeries (like LASIK)

• Dental veneers or whitening

If a procedure has a medically necessary reason, you may receive partial coverage, but documentation must clearly show necessity.

Preventing Costly Surprises: What You Can Do

Being proactive is your best defense against surprise medical bills under Medicare.

Steps to Take:

• Review your Medicare Summary Notice (MSN): This outlines what was billed, paid, and what you owe.

• Understand your plan’s Explanation of Benefits (EOB): Especially important if you have supplemental coverage.

• Use Medicare’s Procedure Price Lookup tool: This helps estimate your costs for common services.

• Consult a licensed agent listed on this website: They can guide you through your options, including potential supplemental plans that help fill the coverage gaps.

Coverage Gaps Deserve Clarity, Not Assumptions

It’s easy to assume Medicare will cover everything you need in retirement, but the truth is that several vital services regularly fall outside its scope. From hearing aids to long-term custodial care, these exclusions can add up fast—both in financial cost and in your quality of life.

Planning ahead is not just wise—it’s essential. If you’re unsure about what’s covered or whether you need additional protection, it’s time to take the next step. Get in touch with a licensed agent listed on this website for help tailoring your health coverage to your needs.