Key Takeaways

• Medicare in 2025 offers robust benefits, but you must still plan around its exclusions, such as long-term care, dental, vision, and hearing services.

• Without proper supplemental coverage, you could be left with high out-of-pocket costs for routine needs and serious health events.

Medicare Covers a Lot—But Not Everything

Medicare is often seen as a complete solution once you turn 65. While it does provide broad coverage for hospital stays, doctor visits, and preventive services, there are significant gaps you may not be aware of until you’re already facing large bills. Understanding what Medicare does not cover is just as important as knowing what it does.

In 2025, Original Medicare still consists of Part A (hospital insurance) and Part B (medical insurance). These two parts provide coverage for inpatient and outpatient care. However, they do not cover everything you may need as you age. If you assume you’re fully protected, you could be blindsided by thousands of dollars in costs.

1. Long-Term Care Isn’t Part of the Package

This is one of the most commonly misunderstood aspects of Medicare. Original Medicare does not cover custodial long-term care. This includes assistance with activities of daily living like bathing, dressing, eating, and toileting—services most often needed in nursing homes or assisted living facilities.

Medicare will cover up to 100 days in a skilled nursing facility—but only after a qualifying 3-day inpatient hospital stay, and only if you’re receiving skilled care such as physical therapy. After the first 20 days, you pay a daily coinsurance of $209.50 in 2025. On day 101, all costs are your responsibility.

Unless you have long-term care insurance or Medicaid, you’re on your own.

2. Dental, Vision, and Hearing Get Left Out

Routine dental care, eyeglasses, and hearing aids are essential to overall health as you age, but they’re missing from Original Medicare’s coverage list.

In 2025:

• Cleanings, fillings, dentures, and extractions are not covered.

• Eye exams for glasses or contact lenses are excluded.

• Hearing aids and fitting exams are not covered.

You can add coverage for these services through other options, but they are not part of your basic Medicare plan. Ignoring this can lead to high costs for procedures that many people assume are included.

3. Prescription Drug Coverage Isn’t Built Into Parts A or B

You don’t get prescription drug coverage with Original Medicare by default. You need to enroll in a separate Medicare Part D plan if you want coverage for medications. In 2025, the Part D program introduces some changes:

• A $2,000 annual cap on out-of-pocket drug costs.

• A redesigned payment structure with three phases: deductible, initial coverage, and catastrophic (now at $2,000 cap).

• Many drugs still fall into tiered pricing systems, meaning brand-name or specialty drugs could still cost hundreds per month before reaching the cap.

Skipping Part D, or waiting too long to enroll, can result in late penalties and significant expenses.

4. Overseas Travel? Don’t Count on Medicare

If you travel abroad, you should know that Medicare does not cover medical care outside the U.S., except in very limited circumstances (e.g., if you’re near a U.S. border and a foreign hospital is closer).

Emergency care, hospital stays, ambulance services—none of this is covered while traveling internationally. Some Medicare Supplement (Medigap) plans include limited foreign travel emergency benefits, but Original Medicare does not.

If you’re a frequent traveler, it’s critical to plan for this gap.

5. Excess Charges and Balance Billing Are Possible

Not every doctor who accepts Medicare patients agrees to Medicare’s approved payment rates. Physicians who don’t accept Medicare assignment may charge you up to 15% more than the Medicare-approved amount.

This means you could face surprise bills if you receive care from one of these providers. Some states restrict or ban balance billing altogether, but many do not. Medicare Supplement Plans can help with these costs—but if you don’t have one, you pay the difference out-of-pocket.

6. Home Health Care Is Limited

Medicare does provide coverage for intermittent skilled home health care, such as wound care or physical therapy, but it doesn’t cover 24-hour care or custodial help.

If you require help several hours a day or ongoing in-home support, Medicare does not pay for it. This often comes as a surprise to people recovering from surgery or managing chronic illness at home.

Eligibility is tightly restricted:

• You must be under the care of a doctor.

• You must be homebound.

• The services must be medically necessary.

If any of these conditions aren’t met, you’re not covered.

7. Out-of-Pocket Costs Still Add Up

Even for services that are covered, Medicare doesn’t mean free. In 2025, here’s what you’re responsible for under Original Medicare:

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

• Part B premium: $185 monthly (standard premium).

• Part B deductible: $257 annually.

• Coinsurance: 20% of the Medicare-approved amount for most outpatient services.

With no out-of-pocket maximum, costs can climb quickly if you experience serious illness or need repeated treatments. This is a major gap in Medicare’s financial protection.

8. Mental Health Coverage Isn’t Comprehensive

While Medicare covers inpatient and outpatient mental health services, there are limits. Hospital stays for psychiatric care are capped at 190 days in a lifetime for treatment in a freestanding psychiatric hospital.

Outpatient therapy is covered, but you’re still responsible for 20% coinsurance, and finding Medicare-participating therapists can be a challenge in some areas. Many beneficiaries end up paying out-of-pocket or delaying care.

9. Medical Equipment Has Its Own Rules

Durable medical equipment (DME)—like walkers, wheelchairs, and oxygen—is covered by Medicare, but only if prescribed by a doctor and obtained through a Medicare-approved supplier.

You still pay 20% of the cost, and you must meet all Medicare guidelines. If the equipment is not deemed medically necessary, or you buy it from a non-approved vendor, you’re on the hook for the full price.

10. Preventive Services Are Covered, But With Limits

Medicare has expanded its list of preventive services in recent years, covering:

• Annual wellness visits

• Mammograms

• Colonoscopies

• Flu shots

• Diabetes screenings

However, not all screenings are free of cost. If your provider orders more frequent tests than Medicare allows, you may have to pay. Similarly, follow-up procedures or treatments resulting from these screenings may not be fully covered.

Understanding what’s preventive and what’s diagnostic is essential to avoid billing surprises.

11. No Cap on Annual Spending with Original Medicare

Unlike many private health plans, Original Medicare does not have an annual out-of-pocket maximum. This means your costs can theoretically go as high as your healthcare needs.

Without a Medicare Supplement plan or switching to an all-in-one plan with a limit, you’re financially exposed every year. Many people mistakenly assume Medicare has a built-in safety net. It doesn’t—not without extra coverage.

How to Protect Yourself from Medicare’s Gaps

Planning ahead is your strongest defense against Medicare’s coverage shortfalls. While the program does a great job handling the basics, it was never intended to cover everything. The following strategies can help fill the voids:

• Consider a Medicare Supplement (Medigap) plan to reduce out-of-pocket costs.

• Enroll in a Medicare Part D plan as soon as you’re eligible to avoid penalties.

• Explore stand-alone dental, vision, and hearing plans to avoid surprise expenses.

• Look into long-term care insurance or Medicaid eligibility for future needs.

• Travel often? Consider coverage that includes foreign medical benefits.

When You Think You’re Covered—But You’re Not

Misunderstanding Medicare’s limits can lead to financial strain at the worst possible time. These hidden gaps leave many retirees underprepared for costs that aren’t just possible—they’re common. Before you assume you’re protected, take a closer look at your situation.

If you have questions or want to explore your supplemental options, get in touch with a licensed insurance agent listed on this website. They can help you evaluate your needs and find coverage that works with your current Medicare benefits.