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.
This guide gives you the complete picture. What Medicare covers, what it doesn’t, what those 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.
Key Takeaways
- 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’t.
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)
Part A is your hospital insurance. It kicks in when you’re admitted as an inpatient to a hospital, skilled nursing facility, or hospice.
What Part A Covers
Inpatient hospital stays When you’re formally admitted to a hospital, Part A covers your room, 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
Doctor and specialist visits Office visits, consultations, second opinions — covered at 80% 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
Here’s the part of Medicare that genuinely surprises people — in a good way. Medicare covers a 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
When you first enroll in Part B, you’re entitled to a one-time “Welcome to Medicare” preventive 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
Every year after your first 12 months of Part B coverage, you get a free 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
Up to two fasting blood glucose tests per year if you’re at risk for diabetes. Diabetes 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
Note: Other recommended vaccines like RSV, Tdap, and shingles (Shingrix) are covered under 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
Annual alcohol misuse screening and up to four brief counseling sessions if needed. Tobacco cessation counseling covered as well.
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
These are the coverage gaps that blindside people most often. Some are well known. Others aren’t — until the bill arrives.
Gap 1: Routine Dental Care
This is the one that shocks people most. Original Medicare does not cover 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.
Your options:
- 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
Medicare generally does not cover eye exams, glasses, or contact lenses unless tied to specific 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.
Your options:
- 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
Hearing loss is a major health risk, linked to dementia and falls, yet Medicare classifies hearing 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.
Your options:
- 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
This is the most financially devastating gap — and the one most people are least prepared for.
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
Original Medicare provides no coverage for healthcare received outside the United States with 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
This deserves its own entry because it’s technically covered care — just not fully covered. Under Original Medicare, after your Part B deductible, you pay 20% of every covered service 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 |
There is no ceiling on this exposure under Original Medicare alone. This is what Medicare Supplement plans are specifically designed to eliminate.
What Those Gaps Actually Cost in 2026
To make this concrete, here’s a realistic picture of what someone with only Original Medicare 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 |
You don’t need all of these to hit significant out-of-pocket exposure. A single hospitalization 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
Original Medicare Parts A and B cover very few outpatient prescription drugs. Most medications 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
The late enrollment penalty: If you don’t enroll in a Part D plan when first eligible and go 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
Understanding the gaps is only useful if you know what to do about them. Here’s a clear summary of your options:
Option 1: Medicare Supplement (Medigap)
Medigap covers the financial gaps — the 20% coinsurance, deductibles, and hospital 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)
Medicare Advantage plans bundle your hospital, medical, and usually drug coverage into one 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
Regardless of whether you choose Medigap or Medicare Advantage, dedicated standalone 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
Given that Medicare covers essentially none of the custodial care costs that are the biggest 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.
Medicare is genuinely good coverage. The preventive benefits alone — free 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
