These Common Medicare Misunderstandings Could Leave You With Gaps in Care

Key Takeaways

• Misunderstanding how Medicare enrollment works can lead to late penalties, coverage gaps, or higher out-of-pocket costs.

• Knowing what Medicare does not cover in 2025 is just as important as knowing what it does to avoid unpleasant financial surprises.

The Danger of Waiting Too Long to Enroll

One of the biggest misunderstandings about Medicare involves timing. Many people think they can enroll whenever they’re ready or delay enrollment until they need it. Unfortunately, this assumption can lead to costly penalties and coverage gaps.

Here’s how the timeline works in 2025:

• Initial Enrollment Period (IEP): This seven-month window begins three months before your 65th birthday, includes your birth month, and ends three months after.

• General Enrollment Period (GEP): From January 1 to March 31 each year. This is for those who missed their IEP. Coverage starts July 1.

• Special Enrollment Period (SEP): If you delay Medicare due to having credible employer coverage, you may qualify for a SEP. You typically have eight months after the employment or coverage ends to enroll without penalties.

Delaying enrollment outside of these windows can result in:

• A 10% Part B penalty for each 12-month period you delay.

• A Part D penalty calculated based on how long you went without credible prescription coverage.

Thinking Medicare Covers Everything

It’s common to assume that once you enroll in Medicare, all your health needs will be covered. But Medicare has its limits, and misunderstanding this can result in unexpected out-of-pocket costs.

What Medicare covers in 2025:

• Part A covers inpatient hospital care, skilled nursing facilities, hospice, and limited home health care.

• Part B includes outpatient care, doctor visits, preventive services, and durable medical equipment.

• Part D offers prescription drug coverage.

What Medicare does not cover:

• Most dental care, including cleanings, dentures, and root canals

• Vision care for routine eye exams and glasses

• Hearing aids and exams for fitting them

• Long-term care or custodial care in nursing homes

• Overseas medical care in most situations

Knowing these limitations helps you plan better and consider supplemental options if needed.

Overlooking the Importance of Medicare Part D

Many people make the mistake of skipping Medicare Part D if they aren’t currently taking prescription medications. It might seem like a good way to save money, but this can backfire.

Even if you don’t take medications today, here’s why enrolling in Part D is worth it:

• You avoid the lifetime late enrollment penalty which adds up the longer you wait.

• Medications can be expensive, and your health needs may change suddenly.

• You gain peace of mind knowing you’re covered when you need it.

In 2025, the maximum deductible for Part D is $590, and the out-of-pocket cap is $2,000. These limits help protect you from high drug costs, but only if you’re enrolled in a plan.

Confusing Medicare Advantage With Original Medicare

There’s often confusion between Original Medicare and Medicare Advantage plans. Each has different rules, coverage options, and cost structures.

Here’s a breakdown of key distinctions:

• Original Medicare includes Part A and Part B and allows you to see any provider who accepts Medicare.

• Medicare Advantage (Part C) combines A and B, and often includes Part D and extra benefits, but limits you to a network.

In 2025, many Advantage plans may offer dental, vision, and hearing coverage, but they usually require you to use specific providers. This network restriction is a key difference and can limit your access to care if misunderstood.

If you’re switching from one type to another, be careful about timing and ensuring uninterrupted coverage.

Believing You Don’t Need medigap

Some people think Medigap, also known as Medicare Supplement Insurance, isn’t necessary. But this decision should be made based on your medical and financial situation.

Medigap helps cover costs Original Medicare does not, such as:

• Part A and B deductibles and coinsurance

• Copayments for hospital and outpatient services

• Foreign travel emergencies (up to plan limits)

If you enroll during your Medigap Open Enrollment Period—a six-month window starting the month you turn 65 and enroll in Part B—you can get any plan offered in your area without medical underwriting. After this window, you might be denied coverage or pay more due to health conditions.

Assuming Employer Coverage Means You Can Skip Medicare

Another common misconception involves employer health plans. You might assume that if you’re still working and covered by employer insurance, you don’t need to sign up for Medicare. That depends on the size of the employer.

Here’s the 2025 rule:

• If your employer has 20 or more employees, your group plan pays first, and Medicare is secondary. You can delay Part B without penalty.

• If your employer has fewer than 20 employees, Medicare pays first. You should enroll in Part A and B to avoid gaps.

Not knowing this distinction can lead to denied claims or uncovered medical bills.

Underestimating Out-of-Pocket Costs

Even with Medicare, out-of-pocket expenses can add up. Medicare doesn’t offer a yearly out-of-pocket maximum for Original Medicare. This can surprise people who assume they’ll be fully covered.

Here’s what you’re responsible for under Original Medicare in 2025:

• Part A deductible: $1,676 per benefit period

• Part B premium: $185 per month (standard)

• Part B deductible: $257 annually

• Coinsurance: 20% of most outpatient services

Without extra coverage like Medigap or an Advantage plan, these costs can be substantial.

Missing the Annual Enrollment Period

Every year from October 15 to December 7, Medicare offers an Annual Enrollment Period (AEP). This is your chance to:

• Switch from Original Medicare to a Medicare Advantage plan

• Switch back from Advantage to Original Medicare

• Change or enroll in a Part D plan

Many people miss this window, thinking they can make changes at any time. If you miss AEP, you generally have to wait until the next AEP unless you qualify for a Special Enrollment Period.

This makes it essential to review your plan each year and confirm it still meets your needs.

Assuming Medicare Covers Long-Term Care

A major source of confusion involves long-term care. Medicare doesn’t cover custodial care—help with daily living activities like bathing, dressing, or eating—when that’s the only care needed.

Medicare covers short-term stays in skilled nursing facilities only after a qualifying hospital stay of at least three days, and only for rehabilitation, not ongoing care. In 2025, the daily coinsurance for days 21–100 in a skilled nursing facility is $209.50. After day 100, you pay all costs.

Planning ahead for long-term care is critical, whether through private savings or long-term care insurance.

Misjudging the Value of Preventive Services

Medicare offers a wide range of preventive services, many at no cost to you. However, people often skip them, thinking they’re not important or assuming they’ll cost extra.

Preventive care covered in 2025 includes:

• Annual wellness visits

• Screenings for cancer, diabetes, cardiovascular disease

• Flu and pneumonia shots

• Depression and alcohol misuse screenings

Taking advantage of these services can help catch health problems early and reduce your long-term costs.

Final Thoughts on Avoiding Gaps in Medicare Coverage

Understanding Medicare is more than just enrolling—it’s about knowing the details, timelines, and coverage limits. In 2025, the stakes are high if you misinterpret how and when to get coverage, what Medicare does and doesn’t cover, and which costs are yours to handle. Make informed choices now so you can avoid surprises later.

If you’re unsure about your Medicare decisions or coverage gaps, talk with a licensed agent listed on this website to receive professional guidance tailored to your situation.