Medicare Promises a Lot—Here’s What It Really Covers (and Quietly Leaves Out)

Key Takeaways

• Medicare in 2025 provides extensive coverage, but there are still key services it doesn’t fully include or may only partially cover.

• Knowing what’s omitted from Original Medicare can help you make smarter decisions about supplemental coverage and out-of-pocket budgeting.

What Medicare Promises on Paper

When you first become eligible for Medicare, it may seem like you’re entering a worry-free zone of healthcare coverage. After all, it’s a government-run program designed specifically for people aged 65 and older, and for certain younger individuals with disabilities. But as reassuring as that sounds, Medicare’s promises need context. The benefits are real—but not always complete.

Here’s what’s officially covered under Original Medicare in 2025:

Medicare Part A: Hospital Insurance

• Inpatient hospital care after you meet a deductible of $1,676 per benefit period

• Skilled nursing facility care after a qualifying hospital stay, with daily coinsurance starting after 20 days

• Hospice care for those with terminal illnesses

• Limited home health care (medically necessary)

Medicare Part B: Medical Insurance

• Doctor visits and outpatient services

• Preventive screenings like mammograms, colonoscopies, and flu shots

• Durable medical equipment (DME), such as walkers or oxygen tanks

• Medically necessary mental health services

• Annual deductible of $257, with beneficiaries paying 20% coinsurance for most services

Optional Parts

• Part D (Prescription Drug Coverage): Helps cover prescription drugs, but has a deductible of up to $590 in 2025 and cost-sharing until your out-of-pocket expenses reach the $2,000 cap

• Medicare Advantage (Part C): Offered by private insurers to bundle Parts A, B, and often D, sometimes with additional benefits

At first glance, that might seem thorough. But the fine print tells a more nuanced story.

What Medicare Doesn’t Cover That You Might Expect

Medicare’s list of exclusions isn’t hidden, but it also isn’t widely understood. Here are some of the most critical gaps:

Long-Term Custodial Care

Medicare covers skilled nursing under specific conditions, but it does not cover long-term custodial care in nursing homes or assisted living facilities. If you need help with daily activities like bathing, eating, or dressing—and it’s not tied to a medical recovery plan—you’ll need to pay out-of-pocket or rely on other resources.

Routine Dental, Vision, and Hearing Care

Despite how common dental cleanings, eyeglasses, and hearing aids are for older adults, Medicare doesn’t cover them:

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

• Vision care: Eye exams and corrective lenses not covered unless tied to a medical condition

• Hearing: No routine hearing exams or coverage for hearing aids

Prescription Drugs Without Part D

Original Medicare doesn’t include prescription drugs unless you’re hospitalized. To have medication coverage, you need to enroll in a Part D plan. And while Part D has improved with a $2,000 out-of-pocket cap starting in 2025, you still face cost-sharing up to that amount.

Health Care While Traveling Abroad

Medicare generally does not cover care received outside the U.S. There are a few limited exceptions (such as on a cruise ship within territorial waters), but you won’t have international health protection unless you add specific supplemental coverage.

Cosmetic Procedures and Routine Foot Care

Unless a service is medically necessary, like reconstruction after surgery, cosmetic procedures are excluded. The same goes for routine foot care, including nail trimming or callus removal, unless you have specific medical needs such as diabetes complications.

Cost-Sharing Adds to the Confusion

Even the services Medicare does cover often come with cost-sharing:

• Part A hospital stays require a deductible and coinsurance for longer stays.

• Part B charges a monthly premium (standard is $185/month in 2025), plus 20% coinsurance after meeting your deductible.

• Part D plans have varying costs, including premiums, deductibles, and copayments.

If you’re not prepared for these expenses, they can pile up quickly.

Supplemental Coverage Isn’t Just an Add-On—It’s a Shield

Because of the gaps mentioned above, many people look into extra coverage. These include:

• Medigap (Medicare Supplement Insurance): Helps cover some out-of-pocket costs like coinsurance and deductibles from Original Medicare

• Medicare Advantage Plans: May offer added benefits such as dental, vision, hearing, fitness programs, or even transportation to medical appointments

However, every type of supplemental coverage comes with trade-offs. Some have limited provider networks or require referrals. Others may cost more monthly but reduce out-of-pocket surprises.

Preventive Care: What You Get, What You Don’t

Medicare emphasizes prevention, which is a positive step. Here’s what you do get under Part B at no extra cost (assuming providers accept assignment):

• Annual wellness visits

• Screenings for diabetes, cancer, cardiovascular conditions, and more

• Vaccinations like flu, pneumonia, COVID-19, and hepatitis B (for high-risk individuals)

But not all preventive services are free. For example:

• Diagnostic tests that follow a screening may incur charges

• Follow-up appointments or treatments based on results often come with 20% coinsurance

Timing Matters: When You Enroll Impacts What You Pay

Medicare has specific enrollment periods, and missing them can cost you. These timelines are important:

• Initial Enrollment Period (IEP): A 7-month window around your 65th birthday (3 months before, the month of, and 3 months after)

• General Enrollment Period (GEP): January 1 to March 31 annually if you missed IEP

• Annual Open Enrollment: October 15 to December 7 for changes to coverage starting the next year

• Special Enrollment Periods (SEPs): Triggered by life events like losing employer coverage

Missing these deadlines can lead to late enrollment penalties for Part B and Part D, which may last for as long as you have Medicare.

Mental Health: Covered but Often Misunderstood

Medicare covers mental health services, but access can still be a barrier:

• Outpatient care: Visits to psychiatrists, psychologists, and therapists are covered under Part B with 20% coinsurance

• Inpatient psychiatric care: Part A covers up to 190 days over your lifetime in a psychiatric facility

But getting an appointment with a provider who accepts Medicare can be challenging, particularly in underserved areas. And ongoing care might involve repeated cost-sharing.

Chronic Care Management Is Limited

Medicare supports treatment for chronic illnesses like diabetes or heart disease. You might get help with:

• Medication adjustments

• Coordinated care plans

• Education and counseling

But chronic care management (CCM) services require extra documentation, provider coordination, and patient participation. Not all providers offer them, and some services aren’t fully covered.

Home Health: A Conditional Benefit

Medicare does offer home health services, but only under very specific conditions:

• You must be homebound and under a doctor’s care

• Services must be deemed medically necessary

Routine personal care, like meal prep or housekeeping, isn’t covered even if it’s essential to your daily life.

Why This Matters for You

Knowing what Medicare covers—and what it doesn’t—is the first step to protecting your health and finances in retirement. Don’t assume that just having Medicare means all your needs are taken care of. The core program is strong, but it has clear boundaries.

By evaluating your medical needs and financial situation, you can decide whether you need to explore supplemental coverage. And by understanding costs, exclusions, and timelines, you can avoid penalties and surprises.

Make Sure Your Coverage Matches Your Care Needs

Medicare offers a strong base of protection, but it isn’t comprehensive. Gaps in dental, vision, hearing, long-term care, and prescription drugs could leave you with high bills. Cost-sharing for covered services adds another layer of complexity.

Take the time to review your Medicare plan carefully each year, especially during Open Enrollment. Consider your health changes, medication list, and any expected surgeries or treatments.

If you’re unsure where to start, speak with a licensed insurance agent listed on this website who can help you make sense of your options.