What Medicare Covers—and What It Doesn’t
As you approach retirement or begin navigating life after 65, understanding your healthcare options becomes more important than ever. One of the most critical components of senior healthcare in the United States is Medicare, a federal program that provides health insurance to millions of Americans. While Medicare offers essential coverage for hospital stays, doctor visits, and preventive care, it doesn’t cover everything—and many enrollees are surprised by the gaps.
From hospital insurance to outpatient services and prescription drug plans, Medicare is made up of several parts that can be confusing without proper guidance. And while it provides a strong foundation, there are important services—like dental, vision, and long-term care—that aren’t included. Knowing exactly what Medicare pays for and what it doesn’t can help you avoid unexpected expenses and make smarter decisions about supplemental insurance or retirement budgeting.
Understanding Medicare: An Overview
Medicare is a federal health insurance program primarily for people aged 65 and older. It is divided into four parts—A, B, C, and D—each addressing specific healthcare needs.
Original Medicare refers to Part A and Part B.
Medicare Advantage (Part C) plans are offered by private insurers.
Part D covers prescription drugs.
From hospital insurance to outpatient services and prescription drug plans, Medicare is made up of several parts that can be confusing without proper guidance. And while it provides a strong foundation, there are important services—like dental, vision, and long-term care—that aren’t included. Knowing exactly what Medicare pays for and what it doesn’t can help you avoid unexpected expenses and make smarter decisions about supplemental insurance or retirement budgeting.
Understanding Medicare: An Overview
Medicare is a federal health insurance program primarily for people aged 65 and older. It is divided into four parts—A, B, C, and D—each addressing specific healthcare needs.
Enrollment typically begins three months before your 65th birthday and lasts for seven months, including the month you turn 65 and the three months following.
What Medicare Covers
Part A: Hospital Insurance
Medicare Part A covers inpatient hospital stays, hospice care, and some home health care. It includes:
- Semi-private hospital rooms
- Meals
- General nursing
- Inpatient care in critical access hospitals and rehabilitation facilities
- Hospice and palliative care
- Limited skilled nursing facility care
Part B: Medical Insurance
Medicare Part B covers outpatient care and medically necessary services like:
Part B usually comes with a monthly premium. In 2025, the standard premium is approximately $174.70, though this can vary based on income.
Medicare Part B covers outpatient care and medically necessary services like:
- Doctor visits
- Preventive screenings (mammograms, colonoscopies, etc.)
- Diagnostic tests (X-rays, MRIs)
- Outpatient surgeries
- Durable medical equipment (DME) such as wheelchairs and oxygen
- Mental health services
- Ambulance services
Part C: Medicare Advantage
Medicare Advantage (Part C) is an alternative to Original Medicare and is offered by private companies approved by Medicare. These plans typically include all benefits under Parts A and B and often Part D.
Many Advantage plans also offer extras such as:
However, provider networks are usually more restricted, and out-of-pocket costs may differ.
Covered drug categories typically include:
Medigap (Medicare Supplement Insurance)
Medigap plans are sold by private insurers and help cover out-of-pocket costs like:
These plans only work with Original Medicare (Parts A and B) and do not offer drug coverage (you’ll need a separate Part D plan for that).
Medicaid
Low-income individuals may qualify for Medicare and Medicaid. Medicaid may help pay premiums, deductibles, and services not covered by Medicare.
Medicare Advantage (Part C) is an alternative to Original Medicare and is offered by private companies approved by Medicare. These plans typically include all benefits under Parts A and B and often Part D.
Many Advantage plans also offer extras such as:
- Vision, hearing, and dental coverage
- Fitness memberships
- Transportation to medical appointments
Part D: Prescription Drug Coverage
Part D provides prescription drug coverage and is offered through private insurance companies. Each plan has its own formulary (list of covered drugs), and costs vary depending on the medications and pharmacy used.
Covered drug categories typically include:
- Antidepressants
- Antipsychotics
- Immunosuppressants
- Cancer drugs
What Medicare Doesn’t Cover
Despite its wide coverage, Medicare has significant gaps. Here are common services not covered:
- Long-Term Custodial Care: Medicare does not cover help with activities of daily living like bathing, dressing, or eating in a long-term care facility.
- Dental Services: Routine dental exams, cleanings, fillings, dentures, and extractions are not covered.
- Vision Care: Routine eye exams, eyeglasses, and contact lenses are excluded (unless related to specific conditions).
- Hearing Aids: Hearing exams and hearing aids are not covered under Original Medicare.
- Overseas Care: Medicare generally does not pay for healthcare received outside the U.S.
- Cosmetic Surgery: Procedures for aesthetic reasons are not covered.
- Routine Foot Care: Nail trimming or removal of corns and calluses are excluded unless medically necessary.
Supplemental Coverage Options
To help pay for the services Medicare doesn’t cover, many beneficiaries purchase supplemental insurance plans:
Medigap (Medicare Supplement Insurance)
Medigap plans are sold by private insurers and help cover out-of-pocket costs like:
- Deductibles.
- Copayments
- Coinsurance
Medicaid
Low-income individuals may qualify for Medicare and Medicaid. Medicaid may help pay premiums, deductibles, and services not covered by Medicare.
Tips for Choosing the Right Medicare Plan
- Assess Your Needs: Consider your current health conditions, medications, and whether you want dental or vision coverage.
- Compare Costs: Don’t just look at premiums—consider deductibles, copays, and out-of-pocket maximums.
- Check Provider Networks: Make sure your doctors and hospitals are in-network for any Medicare Advantage plan.
- Review Drug Coverage: Check if your prescriptions are on the formulary of any Part D or Advantage plan.
- Use Medicare Tools: Visit Medicare.gov for plan comparisons, enrollment timelines, and more.
Conclusion
Medicare is an essential part of healthcare for seniors and certain individuals with disabilities, offering a wide range of coverage for hospital stays, outpatient care, preventive services, and prescription drugs. However, it’s equally important to recognize its limitations—especially when it comes to long-term care, dental, vision, hearing, and other everyday health needs that can result in significant out-of-pocket costs if not properly planned for.
Understanding exactly what Medicare includes—and what it doesn’t—empowers you to make informed decisions about your health coverage. Whether you choose to stick with Original Medicare and add a Medigap policy, or opt for a Medicare Advantage plan with broader benefits, taking the time to compare plans and consider supplemental options can save you both stress and money in the long run.
Ultimately, Medicare isn’t one-size-fits-all. By staying informed, evaluating your personal health needs, and planning ahead, you can ensure your Medicare coverage supports both your well-being and your financial security throughout retirement.
Medicare is an essential part of healthcare for seniors and certain individuals with disabilities, offering a wide range of coverage for hospital stays, outpatient care, preventive services, and prescription drugs. However, it’s equally important to recognize its limitations—especially when it comes to long-term care, dental, vision, hearing, and other everyday health needs that can result in significant out-of-pocket costs if not properly planned for.
Understanding exactly what Medicare includes—and what it doesn’t—empowers you to make informed decisions about your health coverage. Whether you choose to stick with Original Medicare and add a Medigap policy, or opt for a Medicare Advantage plan with broader benefits, taking the time to compare plans and consider supplemental options can save you both stress and money in the long run.
Ultimately, Medicare isn’t one-size-fits-all. By staying informed, evaluating your personal health needs, and planning ahead, you can ensure your Medicare coverage supports both your well-being and your financial security throughout retirement.
