One of the most common misconceptions people bring to their first Medicare conversation is
this:”I’m turning 65, so I’ll be covered.”
Covered — yes. Covered for everything — definitely not
Medicare is genuinely excellent coverage for a wide range of healthcare services. But it has
real, significant gaps that catch people off guard every single day. And some of those gaps
involve the exact services that people over 65 need most — dental care, vision, hearing, and<
long-term care.
AARP reports that 1 in 5 adults of Medicare age faced over $2,000 in out-of-pocket costs annually from services Original Medicare simply will not pay for. That’s not a rounding error. That’s a meaningful financial exposure that requires planning before you turn 65 — not after.
gaps actually cost in real dollars, and what your options are to fill them.
Key Takeaways
- Original Medicare (Parts A and B) covers hospital care, doctor visits, outpatient services, and preventive care — but pays only 80% of most costs, leaving a 20% gap with no annual limit.
- Medicare does not cover routine dental, vision, or hearing care — three of the most common healthcare needs for people over 65.
- Long-term custodial care — help with bathing, dressing, and daily living — is not covered by Medicare. This is the gap that drains retirement savings.
- Part D covers prescription drugs but requires a separate plan enrollment and has its own costs.
- Most preventive services are covered at 100% — including annual wellness visits,
cancer screenings, and vaccines. Many people don’t use all the free benefits available to
them. - The 20% gap under Original Medicare has no annual ceiling. A $100,000 procedure
leaves you owing $20,000. - Medigap covers the financial gaps Medicare leaves. It does not cover the benefit gaps —
dental, vision, and hearing still require separate planning.
Table of Contents
- How Medicare Decides What It Covers
- What Medicare Part A Covers (and What It Doesn’t)
- What Medicare Part B Covers (and What It Doesn’t)
- The Free Preventive Benefits Most People Don’t Use
- What Medicare Does NOT Cover — The Big Six
- What Those Gaps Actually Cost in 2026
- Part D — Prescription Drug Coverage
- How to Fill the Gaps: Your Options
- Frequently Asked Questions
How Medicare Decides What It Covers
Medicare covers services that are deemed “medically reasonable and necessary” for
diagnosing or treating a condition. That standard is set by the Centers for Medicare & Medicaid
Services (CMS) and determines what gets covered — and what doesn’
The important nuance: “medically necessary” is not the same as “beneficial” or “recommended.
” Medicare can exclude entire categories of care — like routine dental or hearing aids —
regardless of how medically important they are to your quality of life. The exclusions aren’t
judgment calls made case by case. They’re structural — written into how the program was
originally designed in 1965 and largely unchanged since.
This is why understanding the gaps matters so much. They’re not exceptions or billing errors. They’re features of the system as designed.
What Medicare Part A Covers (and What It Doesn't)
skilled nursing facility, or hospice.
What Part A Covers
meals, nursing care, and most services provided during your stay. After your deductible ($1,736
per benefit period in 2026), Part A covers the first 60 days in full.
Skilled Nursing Facility (SNF) care After a qualifying hospital stay of at least 3 days, Part A
covers up to 100 days of skilled nursing or rehabilitation care. Days 1–20 are covered in full.
Days 21–100 require a daily coinsurance of $217 in 2026. Day 101 and beyond: you pay 100%.
This is a critical distinction many people miss: Medicare covers skilled nursing care — physical
therapy, occupational therapy, wound care, IV medications — administered by licensed
professionals. It does not cover custodial care — help with daily activities like bathing, dressing,
and eating. More on that in the gaps section.
Hospice care For patients with a terminal illness and a life expectancy of six months or less,
Medicare covers hospice care including pain management, symptom control, and support
services for the patient and family.
Home health care Medicare covers medically necessary home health services — skilled
nursing visits, physical therapy, speech therapy — if you’re homebound and your doctor orders
the care. It does not cover full-time home health aides or personal care services.
What Part A Does NOT Cover
- Custodial or long-term care (the gap most people don’t see coming)
- Private duty nursing
- A private hospital room (unless medically necessary)
- Personal items during a hospital stay (toiletries, phone charges, TV)
- Care that isn’t medically necessary
What Medicare Part B Covers (and What It Doesn't)
Part B is your medical insurance — everything outpatient. It’s where most of your day-to-day
healthcare runs through.
What Part B Covers
after your Part B deductible ($283 in 2026).
Outpatient procedures and surgery Lab work, X-rays, MRIs, CT scans, outpatient surgeries,
and diagnostic tests — all covered at 80% after the deductible.
Mental health services Outpatient mental health care, including therapy visits with licensed
clinical social workers, psychologists, and psychiatrists — covered at 80%.
Durable medical equipment (DME) Wheelchairs, walkers, hospital beds, oxygen equipment,
blood sugar monitors — covered at 80% when ordered by your doctor and obtained from a
Medicare-approved supplier.
Ambulance services Emergency and some non-emergency ambulance transportation when
other transport would endanger your health — covered at 80%.
Outpatient physical, occupational, and speech therapy Covered when medically necessary.
Note that there are coverage limits for therapy that isn’t making measurable progress.
What Part B Does NOT Cover
- Routine dental care (exams, cleanings, fillings, extractions, dentures)
- Routine vision care (eye exams for glasses, prescription glasses, contact lenses)
- Hearing aids or routine hearing exams
- Cosmetic surgery
- Acupuncture (with limited exceptions for chronic low back pain)
- Most chiropractic care beyond spinal manipulation
- Overseas medical care (with very limited exceptions)
- Long-term custodial care
The Free Preventive Benefits Most People Don't Use
wide range of preventive services at absolutely no cost to you when you see a participating
provider. No deductible. No 20% coinsurance. Zero. You can find the complete official list at
medicare.gov’s preventive services page.
Many beneficiaries don’t take full advantage of these benefits — which is a missed opportunity
for both their health and their wallet.
The "Welcome to Medicare" Visit
visit. Your provider will review your medical history, update your vaccinations, screen for risk
factors, and create a baseline health profile. This is separate from and in addition to your annual
wellness visits going forward.
Annual Wellness Visit
This is not a physical exam — it’s a comprehensive health review that includes:
- Review of your medical and family history
- Cognitive impairment screening
- Blood pressure, height, weight, and BMI measurements
- Personalized prevention plan
- Referrals for any needed screenings or follow-up care
Cancer Screenings — All Free
- Mammogram: One per year for women 40 and older
- Colorectal cancer screening: Colonoscopy every 10 years (or every 2 years for
high-risk individuals); fecal tests covered annually - Cervical and vaginal cancer screening: Pap test and pelvic exam every 24 months
(annually for high-risk) - Prostate cancer screening: PSA test and digital rectal exam annually for men 50+
- Lung cancer screening: Annual low-dose CT scan for adults 50–80 who currently
smoke or have quit within the past 15 years
Cardiovascular Screenings
Cholesterol, lipid, and triglyceride blood tests every five years — no cost.
Diabetes Screenings
self-management training if you’re diagnosed.
Mental Health Screenings
One depression screening per year in a primary care setting — no cost.
Vaccines — All Free Under Part B
- Annual flu shot
- Pneumococcal vaccine
- Hepatitis B vaccine (if at medium or high risk)
- COVID-19 vaccine
Part D, not Part B. Make sure your Part D plan covers them.
Bone Density Testing
Every 24 months for people at risk for osteoporosis — covered at no cost.
Alcohol and Tobacco Counseling
The bottom line on preventive care: if you’re not scheduling your annual wellness visit and
taking advantage of these screenings, you’re leaving real value on the table. These benefits
were specifically designed to catch health issues early — when they’re less expensive and more
treatable.
What Medicare Does NOT Cover — The Big Six
aren’t — until the bill arrives.
Gap #1: Routine Dental Care
including checkups, cleanings, X-rays, fillings, root canals, tooth extractions, and dentures.
Medicare will cover dental care only when it’s directly connected to a covered medical
procedure — for example, dental work required before heart valve surgery, or treatment for a
jaw fracture that requires hospitalization. Routine care, no matter how medically necessary it is
to your overall health, is excluded.
What it costs you in 2026:
- A single dental crown: $1,000–$1,700. A full set of dentures: $1,500–$3,500 per arch. A
dental implant: $3,000–$6,000. A routine annual cleaning and exam: $200–$350.
- Standalone dental insurance (watch for waiting periods and annual maximums)
- Dental discount plans
- Medicare Advantage plans that include dental benefits (coverage varies significantly —
read the details carefully) - Dental schools, which offer significantly reduced rates for routine procedures
Gap #2: Routine Vision Care
conditions like cataract surgery.
What Medicare does cover for vision: treatment for medical eye conditions — diabetic
retinopathy, macular degeneration, glaucoma screenings for high-risk individuals, and one pair
of glasses or contact lenses after cataract surgery. Routine annual eye exams and prescription
eyewear for everyday use are not covered.
What it costs you in 2026:
- A comprehensive eye exam: $100–$250. A pair of prescription progressive lenses with
frames: $300–$700.
- Standalone vision insurance
- Medicare Advantage plans with vision benefits
- Retail vision plans through chains like Costco, Walmart Vision, or America’s Best
Gap #3: Hearing Aids and Routine Hearing Exams
aids as “elective.” Routine hearing exams and hearing aids are not covered under Original
Medicare.
Medicare will cover diagnostic hearing and balance exams if your doctor orders them to
diagnose a specific condition — but not routine exams to check your hearing or to fit aids.
What it costs you in 2026:
- Prescription-grade hearing aids for severe hearing loss cost $4,000–$6,000 a pair.
Over-the-counter hearing aids for mild to moderate loss are available for $200–$1,500.
- Medicare Advantage plans — many offer some hearing benefit, though coverage limits
vary - VA benefits if you’re a veteran
- Over-the-counter hearing aids (now FDA-approved for mild to moderate hearing loss)
- Costco Hearing Aid Center offers prescription-grade fittings at significantly lower prices
Gap #4: Long-Term Custodial Care
Long-term care costs can easily exceed $50,000 per year, depending on the level of care. In
2026, the average cost of a nursing home is over $100,000 a year. Medicare pays none of it.
What Medicare does cover is short-term skilled nursing care — physical therapy, wound care, IV
medications — for up to 100 days after a qualifying hospital stay. Once that skilled care need
ends, Medicare stops paying. The moment care shifts to helping someone bathe, dress, eat, or
manage daily activities — what’s called “custodial care” — Medicare is out of the picture
entirely.
This is the gap that quietly drains retirement savings and estates. Planning for it requires action
well before you need the care.
Your options:
- Long-term care insurance (most affordable when purchased in your 50s)
- Hybrid life insurance/LTC policies
- Self-funding through savings
- Medicaid (for those who qualify based on income and assets after spending down)
Gap #5: Overseas Medical Care
very limited exceptions near the Canadian and Mexican borders. If you travel internationally —
even occasionally — this is a real exposure.
Your options:
- Travel health insurance
- Medigap Plans C, D, F, G, M, and N include a foreign travel emergency benefit covering
80% of emergency care costs abroad after a $250 deductible, up to a $50,000 lifetime
maximum
Gap #6: The 20% Coinsurance — With No Annual Cap
with no annual limit.
For routine care, 20% is manageable. For a serious illness, surgery, or extended treatment, it
compounds fast:
| Medical Service | Approved Cost | Your 20% Share |
| Outpatient surgery | $15,000 | $3,000 |
| Cancer treatment (per year) | $100,000+ | $20,000+ |
| Cardiac procedure | $50,000 | $10,000 |
| Chemotherapy course | $75,000 | $15,000 |
Supplement plans are specifically designed to eliminate.
What Those Gaps Actually Cost in 2026
might face in a given year if they have significant healthcare needs:
| Gap | Potential Out-of-Pocket Cost |
| Annual dental cleaning and exam | $250–$400 |
| One crown or filling | $1,000–$1,700 |
| Annual vision exam + glasses | $400–$900 |
| Hearing aids (every 5 years) | $4,000–$6,000 |
| Hospital stay coinsurance (day 61+) | $434/day |
| SNF coinsurance (days 21–100) | $217/day |
| 20% coinsurance on major procedure | Unlimited |
| Nursing home custodial care | $100,000+/year |
beyond 60 days, or one major outpatient procedure, can generate thousands in out-of-pocket
costs under Original Medicare alone.
Part D — Prescription Drug Coverage
you take at home require a separate Part D plan. You can compare Part D plans available in
your area at medicare.gov.
In 2026, Part D has two major features to know:
The $2,100 out-of-pocket cap: Once you’ve spent $2,100 on covered prescriptions at the
pharmacy, your plan pays 100% for the rest of the year. This replaced the old “donut hole” and
is the most significant Part D improvement in decades.
The $35 insulin cap: Insulin costs are capped at $35/month per prescription for Medicare
beneficiaries.
What Part D still doesn’t cover:
- Drugs not on your plan’s formulary (covered drug list)
- Some over-the-counter medications, even if prescribed
- Cosmetic drugs or lifestyle medications not deemed medically necessary
without creditable drug coverage for 63 or more days, you’ll pay a permanent late enrollment
penalty of 1% of the national base premium per uncovered month — for life. Even if you don’t
take medications now, enrolling in a low-cost Part D plan protects you from future penalties.
How to Fill the Gaps: Your Options
summary of your options:
Option 1: Medicare Supplement (Medigap)
coinsurance — that Original Medicare leaves behind. With Plan G, for example, your
out-of-pocket exposure for covered services is essentially zero after the annual Part B
deductible ($283 in 2026). You can learn more about choosing the right Medigap company in
our guide to what makes a Medicare Supplement company reliable.
What Medigap does NOT cover: dental, vision, hearing, and long-term care. These benefit gaps
require separate planning regardless of which Medigap plan you choose.
You’ll also need a separate Part D plan for prescriptions.
Option 2: Medicare Advantage (Part C)
plan — often with dental, vision, and hearing benefits included. For people who want a single
plan that addresses more of the gaps, Advantage plans can be appealing.
The tradeoffs: network restrictions, prior authorization requirements, and variable cost-sharing
when you use care. Annual out-of-pocket maximum in 2026 is up to $9,250 for in-network care.
Option 3: Standalone Dental, Vision, and Hearing Plans
insurance for dental, vision, and hearing is worth evaluating. These plans vary widely in cost
and coverage — watch for waiting periods, annual maximums, and what’s actually included.
Option 4: Long-Term Care Insurance
financial threat to most retirees, long-term care insurance deserves a serious look — ideally
purchased in your 50s or early 60s when premiums are more affordable and you’re more likely
to qualify medically.
Frequently Asked Questions
Not exactly. Medicare covers an Annual Wellness Visit, which is different from a traditional physical exam. The wellness visit is free and includes a health review, prevention planning, and screening referrals. However, if your doctor performs a full physical examination and addresses medical concerns during the same visit, you may owe coinsurance for those additional services. Knowing the distinction ahead of time can prevent an unexpected bill.
No. Original Medicare does not cover dental implants, extractions, cleanings, or any routine dental care. Some Medicare Advantage plans include limited dental benefits, but implants are often excluded or subject to annual maximums that don’t come close to covering the full cost.
Generally no. Original Medicare does not cover routine eye exams for glasses or the glasses themselves. The one exception: Medicare does cover one pair of standard glasses or contact lenses after cataract surgery with an intraocular lens implant.
No. Original Medicare does not cover hearing aids or the exams to fit them. Some Medicare Advantage plans offer hearing benefits, though coverage limits vary significantly. Over-the-counter hearing aids, now FDA-approved for mild to moderate hearing loss, are available without a prescription and represent a more affordable alternative.
Medicare covers medically necessary skilled home health care — nursing visits, physical therapy, occupational therapy — when you’re homebound and your doctor orders the care. Medicare does not cover personal or custodial home care — a home health aide helping you bathe, dress, cook, or manage daily activities. That distinction is critical and often misunderstood.
Yes — for emergency transport and some medically necessary non-emergency transport. Medicare covers 80% after the Part B deductible. You pay 20%. If the ambulance company doesn’t accept Medicare assignment, you may owe more.
Yes. Part B covers outpatient mental health services — therapy with psychologists, licensed clinical social workers, and psychiatrists — at 80% after the Part B deductible. Inpatient psychiatric care is covered under Part A. Medicare also covers annual depression screenings at no cost.
Yes. Part B covers outpatient physical, occupational, and speech therapy when medically necessary. You pay 20% after the deductible. Coverage continues as long as you’re making measurable progress.
Yes — both inpatient and outpatient surgery. Inpatient surgery (you’re formally admitted) falls under Part A. Outpatient surgery falls under Part B. In both cases, you’ll owe your applicable deductible and coinsurance. A Medigap plan covers most or all of this cost-sharing.
Yes. Chemotherapy, radiation, immunotherapy, and related treatments are covered under Part B (outpatient) or Part A (inpatient). After your deductible, you pay 20% of covered costs — with no annual limit. For someone undergoing extended cancer treatment, this 20% can become a very significant number. This is one of the primary reasons oncology patients and their families are strong candidates for a Medigap plan.
screenings, free vaccines, free annual wellness visits — have real value that many people don’t fully use. And for
hospital and medical care, Medicare provides a solid foundation.
But it’s not complete coverage. The 20% gap with no ceiling, the dental exclusion, the vision
exclusion, the hearing exclusion, and the long-term care gap are real — and they require real
planning.
The good news: there are clear, well-established ways to fill these gaps. If you’re just getting
started, our Medicare for Dummies 2026 guide is the best place to begin. If you’re focused on
choosing the right Medigap company to cover your financial gaps, our guide on which Medicare
Supplement companies to avoid is worth reading before you enroll.
The key is understanding your gaps before you turn 65 — not after a bill arrives.
If you’d like help understanding which gaps matter most for your specific situation — and which
options make the most sense given your health, your budget, and your state — I’m happy to
walk through it with you at no cost.
Call 631-358-5793 or visit paulbinsurance.com to schedule your free consultation.
Paul Barrett is the founder and Principal Agent of The Modern Medicare Agency,a
Medicare-only independent brokerage based in Melville, NY. With 18+ years of
Medicare-exclusive experience, licensure in 34 states, and relationships with 40+ carriers, Paul
has helped 5,000+ clients navigate Medicare with clarity and confidence. He is the author of
Medicare Mastery Unlocked.
paulbinsurance.com | 631-358-5793 | medicare@paulbinsurance.com
