Coverage You Thought Was Guaranteed by Medicare Might Be Missing When You Need It Most

Key Takeaways

• Medicare offers broad coverage for hospital stays, doctor visits, and preventive care, but some essential health needs fall outside its scope—especially long-term care, dental, and vision services.

• Understanding the limits of what Medicare pays for in 2025 can help you plan better, avoid surprise bills, and consider supplemental options if needed.

What Medicare Covers in 2025

Medicare remains the cornerstone of health coverage for millions of older adults and people with disabilities in the U.S. In 2025, its structure still includes four parts:

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility care (under strict conditions), hospice, and some home health care.

• Part B (Medical Insurance): Pays for outpatient care, doctor visits, durable medical equipment, lab tests, and preventive services.

• Part C (Medicare Advantage): An alternative to Original Medicare, these plans are offered by private companies and include Part A and Part B services, often bundling extras.

• Part D (Prescription Drug Coverage): Provides coverage for prescription medications through standalone plans or as part of Medicare Advantage.

While these parts address a wide range of healthcare needs, significant gaps persist—and some of them may surprise you.

The Big Gap: Long-Term Custodial Care

Many people assume Medicare will cover the cost of nursing home care or assistance with daily living if their health declines. It doesn’t. Here’s what Medicare does and doesn’t pay for:

• Medicare does cover short-term skilled nursing facility care after a qualifying hospital stay, but only up to 100 days per benefit period, and only if you need skilled services like physical therapy.

• Medicare does not cover long-term custodial care, which includes help with dressing, bathing, or eating if you’re not improving medically.

In other words, if you need extended care in a nursing home or help at home over the long run, you may have to pay out of pocket or explore other options like Medicaid, long-term care insurance, or personal savings.

Dental, Vision, and Hearing: Often Overlooked but Vital

You may be surprised to learn that Original Medicare doesn’t cover routine dental, vision, or hearing services. This includes:

• Dental: No coverage for cleanings, fillings, extractions, dentures, or implants.

• Vision: No coverage for eye exams, glasses, or contact lenses unless related to a medical condition (like diabetes).

• Hearing: No coverage for hearing aids or routine hearing tests.

In 2025, some Medicare Advantage plans may include limited coverage for these services, but benefits vary significantly and may not fully meet your needs.

Emergency Coverage Outside the U.S.

Traveling abroad? Medicare won’t go with you—at least not entirely. In general:

• Original Medicare offers no coverage for medical services outside the U.S. and its territories.

• Some Medigap policies (Plans C, D, F, G, M, and N) may offer limited foreign travel emergency coverage, typically with a $50,000 lifetime maximum.

If you’re planning international travel, you may want to look into standalone travel insurance that covers medical emergencies.

Prescription Drugs and Out-of-Pocket Costs

Medicare Part D has seen a major update in 2025 with the introduction of a $2,000 out-of-pocket maximum for prescription drugs. This cap eliminates the old coverage gap (formerly known as the “donut hole”).

Still, you could be on the hook for:

• Up to $590 in deductibles before coverage begins.

• Copayments or coinsurance throughout the year depending on your medication tier.

Even with improvements, the cost of specialty drugs or multiple prescriptions can still feel overwhelming. Carefully reviewing formularies and cost-sharing structures during enrollment is essential.

Home Health Care: Limited and Conditional

While Medicare covers some home health services, it is conditional and often misunderstood.

• You must be homebound and under a physician’s care.

• Coverage includes intermittent skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy.

• Custodial care at home is not covered.

So if you need daily help with routine activities at home but don’t meet the “skilled” criteria, Medicare won’t pay.

Ambulance and Emergency Services: Not Always Fully Covered

If you’re transported by ambulance, you might assume Medicare covers all the cost. Not quite.

• Medicare Part B generally covers 80% of the Medicare-approved amount for emergency ground ambulance transport after you meet your $257 annual deductible.

• Air ambulance services may be covered but only if certain conditions are met.

• Non-emergency ambulance services are rarely covered unless deemed medically necessary and pre-authorized.

You could be left with a significant bill depending on the circumstances and provider.

Mental Health and Substance Use Treatment: Gaps Remain

Medicare includes important mental health benefits, but gaps still affect access:

• Inpatient psychiatric care in a general hospital is covered under Part A, but there’s a lifetime limit of 190 days in a psychiatric hospital.

• Outpatient therapy and counseling are covered under Part B, but may require coinsurance.

• Coverage for substance use disorder treatment is available, but program availability and participation vary.

The structure may discourage long-term or intensive treatment in some cases, leaving you without the support you expect.

Medical Equipment: Not All Is Approved

Durable Medical Equipment (DME) includes items like walkers, hospital beds, and oxygen tanks. Medicare Part B covers many of these, but not all:

• Items must be prescribed by a doctor and obtained through Medicare-approved suppliers.

• Medicare does not cover most items for convenience or comfort (e.g., stair lifts, air purifiers, grab bars).

• Coverage may require rental instead of purchase.

Reviewing what qualifies as DME and checking approved suppliers ahead of time can help reduce unexpected costs.

Preventive Services: Not Always Without Cost

Medicare offers a wide range of preventive services, but not all are free or fully covered.

• Many screenings (like mammograms, colonoscopies, and flu shots) are fully covered.

• Others (such as glaucoma tests or cardiovascular screenings) may involve copayments or coinsurance.

• Annual wellness visits are covered, but don’t include full physical exams.

It’s important to ask your provider whether a preventive service is fully covered or could lead to an additional charge.

When Timing Affects Coverage

You might be entitled to a service but miss out simply because of timing issues. Here are some examples:

• Skilled nursing facility coverage only applies after a 3-day inpatient hospital stay, not an observation stay.

• Enrollment timing affects your ability to get Part D without penalties. Miss your Initial Enrollment Period (IEP), and you might face higher costs later.

• Annual Enrollment Period (AEP) runs from October 15 to December 7 each year. Missing it could leave you stuck with an ill-fitting plan for another year.

Understanding these timelines is critical to avoiding penalties and coverage gaps.

What You Can Do About These Gaps

Knowing what Medicare doesn’t cover allows you to plan accordingly:

• Consider a Medigap policy to cover out-of-pocket costs under Original Medicare.

• Look at standalone dental, vision, and hearing plans if those services matter to you.

• Explore long-term care insurance if you’re concerned about needing ongoing custodial care.

• Use a licensed agent listed on the website to review your coverage annually and explore all your options.

Medicare Is Strong but Not All-Inclusive

Medicare continues to serve as a dependable foundation for healthcare in retirement, but gaps still exist—especially in areas that matter most as you age. Dental work, vision correction, and long-term support aren’t fringe issues. They’re real needs.

Reviewing your options now can make the difference between having coverage when you need it and being left with unexpected bills. For personalized support, speak with a licensed agent listed on the website who can guide you through available plans and help fill the gaps that matter most to you.