Key Takeaways

• Many popular Medicare benefits come with limitations that can surprise you if you only consider the headlines.

• Understanding what Medicare doesn’t cover is just as important as knowing what it does, especially when planning your healthcare budget in retirement.

What You Think You’re Getting vs. What You Actually Get

At first glance, Medicare sounds like a fully protective shield for your health in retirement. While it certainly provides a strong foundation, it’s important to look closer. The truth is, the most talked-about Medicare benefits often leave out significant details. This can lead to unexpected costs or gaps in your care.

Let’s break down some of the most popular features people assume are fully covered and what they really mean in 2025.

1. Preventive Services: Not Always Cost-Free

Medicare Part B is well known for covering many preventive services. These include screenings for cancer, diabetes, and heart disease, along with flu shots and annual wellness visits. However, the term “preventive services” doesn’t mean everything is free.

Here’s what you need to know:

• The “Welcome to Medicare” visit is only available within the first 12 months of enrolling in Part B.

• The Annual Wellness Visit is not a full physical exam. It’s more of a planning session.

• If your doctor finds something during a screening that requires further testing or treatment, those follow-ups are not preventive and may come with costs.

So while preventive care is promoted as free, any resulting procedures from what they find likely aren’t.

2. Prescription Drug Coverage: The $2,000 Cap Still Has Limits

In 2025, Medicare Part D features a major change: the introduction of a $2,000 annual out-of-pocket cap on prescription drugs. This is a huge win for many, but it doesn’t mean you won’t pay anything beyond your monthly premiums and copays.

Key facts:

• You still pay up to $590 in deductible costs in 2025 before your plan starts covering your medications.

• While the cap helps in catastrophic phases, drugs not listed on your plan’s formulary (approved list) may not be covered at all.

• Drugs obtained from out-of-network pharmacies may not count toward your cap.

That $2,000 limit only applies to covered drugs within your plan’s network. Exclusions still exist.

3. Dental, Vision, and Hearing: Not Core Benefits

One of the most common misconceptions about Medicare is that it covers routine dental, vision, and hearing care. While some plans may include these as extras, Original Medicare does not.

Here’s what you typically won’t get:

• No coverage for routine dental cleanings, fillings, or dentures

• No routine eye exams or eyeglasses

• No coverage for hearing aids or exams to fit them

Some private Medicare plans offer these, but coverage varies and may come with high cost-sharing or narrow provider networks. In other words, the benefits may sound great, but they may not work the way you expect.

4. Long-Term Care: Largely Not Covered

Another area that surprises many retirees is long-term care. Medicare is designed to treat medical conditions, not support daily living assistance long-term.

Important limitations:

• Medicare covers short-term skilled nursing care only after a qualifying hospital stay and for a limited time (up to 100 days)

• Custodial care, such as help with bathing, eating, or dressing, is not covered

If you need long-term care at home or in a facility, you will likely have to pay out of pocket or explore other options like Medicaid or long-term care insurance.

5. Emergency Coverage While Traveling

Travel is a major retirement goal for many, but Medicare’s protections don’t always follow you.

What to keep in mind:

• Original Medicare typically does not cover care received outside the U.S., with very limited exceptions.

• Some Medigap plans include limited foreign travel emergency coverage, but they usually come with lifetime limits and require you to pay a portion upfront.

• Emergency services within the U.S. are generally covered, but follow-up care may depend on your plan network (especially with Medicare Advantage).

If travel is on your retirement checklist, you’ll want to look carefully at what protections your Medicare plan does and doesn’t offer.

6. Telehealth: Expanded Access, But Not for Everything

Since 2020, Medicare has expanded telehealth access. In 2025, many of these temporary changes have become permanent. But while the program now offers broader options, it still comes with boundaries.

Know the following:

• Telehealth isn’t available for all services. Some procedures still require in-person visits.

• Your provider must be Medicare-approved to bill for telehealth.

• Audio-only visits may not be reimbursed for all specialties or conditions.

Telehealth is a convenient tool, but it doesn’t fully replace in-person care—and it may not save you money compared to regular visits.

7. Out-of-Pocket Costs Add Up

Even with Medicare, you still face significant costs unless you have additional coverage or support. In 2025:

• The Part A hospital deductible is $1,676 per benefit period.

• The Part B deductible is $257, with a standard monthly premium of $185.

• Coinsurance under Part B is typically 20% of Medicare-approved charges.

These can add up fast, especially if you require multiple services or hospitalizations. Many people consider additional policies or savings to handle these costs, but it requires planning ahead.

8. Coverage Varies by Plan and Provider

If you’re enrolled in a Medicare Advantage plan, what’s covered depends heavily on your specific plan. Each plan can:

• Set its own rules and networks

• Charge different copayments or coinsurance

• Offer extra benefits that Original Medicare doesn’t

What this means is that two people with Medicare Advantage plans in the same ZIP code might have entirely different benefits, coverage levels, and restrictions. It’s not enough to know what’s theoretically covered—you need to know your plan.

9. Annual Plan Changes Can Affect Benefits

Each year, Medicare Advantage and Part D plans adjust their premiums, benefits, drug formularies, and provider networks. These changes are outlined in your Annual Notice of Change (ANOC), typically sent every September.

But many people don’t read the ANOC carefully or don’t compare plans during the fall Open Enrollment period.

Consequences:

• You could lose access to a preferred doctor or medication

• Copays or coinsurance may rise unexpectedly

• New restrictions or prior authorization requirements might be introduced

Understanding your ANOC and reviewing options each fall is essential to avoid these surprise changes.

10. Mental Health and Substance Use Services Have Limits

While Medicare has expanded access to mental health services, some limitations still exist in 2025.

Key things to note:

• There may be limits on the number of therapy sessions covered annually

• Outpatient mental health services are generally covered under Part B, but you pay 20% after meeting the deductible

• Substance use disorder treatment coverage varies widely between plans

More behavioral health professionals are now included under Medicare, but coverage is still not on par with physical health services in some cases.

Don’t Let the Headlines Fool You: Medicare Needs Closer Inspection

Medicare can be an essential part of your retirement health strategy, but it’s not without blind spots. Understanding what’s excluded or restricted allows you to take better control of your planning, savings, and supplemental coverage.

If you’re unsure how your plan handles these limitations or what options are best for your situation, it may be time to speak with a licensed agent listed on this website.