Medicare Doesn't Cover Everything — Learn What It Doesn't

Medicare provides valuable healthcare coverage for millions of Americans, but one of the biggest misconceptions about Medicare is that it pays for everything once you turn 65.

It doesn't.

Even with Medicare, you may still be responsible for deductibles, coinsurance, prescription costs, and services that aren't covered by Original Medicare at all. Understanding these gaps before you need care can help you avoid unexpected expenses and make better decisions about your retirement healthcare coverage.

Here are some of the most important things Medicare may not fully cover.

1. Routine Dental Care

One of the most common surprises for people entering Medicare is the lack of comprehensive routine dental coverage under Original Medicare.

Original Medicare generally doesn't cover routine services such as:

• Dental cleanings

• Routine dental exams

• Fillings

• Dentures

• Most tooth extractions

• Other routine dental procedures

Medicare may cover certain dental services when they're directly connected to specific covered medical treatments, but routine dental care generally isn't included.

Some Medicare Advantage plans offer dental benefits, although coverage, provider networks, annual limits, and out-of-pocket costs vary by plan.

2. Routine Vision Care and Eyeglasses

Original Medicare generally doesn't cover routine eye examinations for eyeglasses or contact lenses.

There are exceptions. For example, Medicare may cover certain eye examinations and treatments related to medical conditions such as diabetes, glaucoma, or macular degeneration when eligibility requirements are met.

Medicare may also cover one pair of corrective eyeglasses or contact lenses following certain cataract surgeries.

However, routine vision care is generally an expense you'll need to plan for separately.

3. Hearing Aids

Hearing loss becomes increasingly common as people age, and hearing aids can be expensive.

Original Medicare generally doesn't cover hearing aids or examinations performed solely for fitting hearing aids.

Certain diagnostic hearing and balance examinations may be covered when medically necessary and ordered by a healthcare provider.

Some Medicare Advantage plans provide additional hearing benefits, but coverage varies considerably between plans.

4. Most Long-Term Care

This can be one of the most financially significant Medicare coverage gaps.

Many people assume Medicare will pay for an extended stay in a nursing home or assisted living facility. Medicare generally doesn't cover long-term custodial care when that's the only care you need.

Custodial care can include assistance with everyday activities such as:

• Bathing

• Dressing

• Eating

• Using the bathroom

• Moving around safely

Medicare may cover qualifying short-term skilled nursing facility care under certain circumstances, but that's very different from paying for years of long-term care.

Because long-term care can become a major retirement expense, it's important to plan for this possibility separately.

5. Routine Foot Care

Original Medicare generally doesn't cover routine foot care, such as cutting or removing corns and calluses or routine nail maintenance.

However, certain foot care may be covered when it's medically necessary because of an underlying condition, such as diabetes-related complications.

Knowing the difference between routine and medically necessary care can help you understand when Medicare may pay.

6. Cosmetic Surgery

Medicare generally doesn't cover cosmetic surgery when it's performed solely to improve appearance.

However, reconstructive surgery may be covered when medically necessary—for example, following an accident or to repair certain physical abnormalities.

Before undergoing a procedure, it's a good idea to confirm whether Medicare considers it medically necessary and covered.

7. Healthcare Outside the United States

Planning to travel internationally during retirement?

Original Medicare generally provides very limited coverage for healthcare received outside the United States and its territories.

There are specific exceptions, but you shouldn't assume you'll be covered simply because you have Medicare.

Certain Medicare Supplement plans may provide limited foreign travel emergency benefits. Travelers may also want to investigate separate travel medical insurance depending on their destination and needs.

8. Prescription Drugs Aren't Automatically Included With Original Medicare

Original Medicare Parts A and B don't provide comprehensive coverage for most outpatient prescription medications.

That's where Medicare Part D comes in.

You can purchase a standalone Medicare Part D prescription drug plan if you have Original Medicare. Many Medicare Advantage plans also include prescription drug coverage.

Even with Part D coverage, you'll want to consider:

• Monthly premiums

• Deductibles

• Copayments or coinsurance

• The plan's formulary

• Pharmacy networks

• Whether your specific medications are covered

Prescription needs can change, so reviewing your drug coverage each year can be worthwhile.

9. Medicare Doesn't Pay 100% of Covered Medical Expenses

This is another important distinction.

Something can be covered by Medicare without Medicare paying the entire bill.

With Original Medicare, beneficiaries may still be responsible for costs such as:

• Premiums

• Deductibles

• Copayments

• Coinsurance

For Medicare Part B services, beneficiaries commonly pay coinsurance after satisfying the applicable deductible, although the amount depends on the service and circumstances.

Unlike many private health insurance plans, Original Medicare also doesn't have a general annual out-of-pocket maximum for Part A and Part B expenses.

That potential exposure is one reason some beneficiaries consider Medicare Supplement coverage.

10. Medicare Supplement Insurance Can Help With Some Gaps — But Not All

Medicare Supplement insurance, also known as Medigap, works alongside Original Medicare and can help pay certain out-of-pocket expenses.

Depending on the Medigap plan, coverage may help with expenses such as Medicare coinsurance, copayments, and certain other Medicare cost-sharing.

However, Medigap shouldn't be confused with insurance that covers everything Medicare doesn't.

Medicare Supplement plans generally don't provide benefits for routine dental care, routine vision care, hearing aids, or long-term custodial care.

Understanding this distinction can prevent costly assumptions.

What About Medicare Advantage?

Medicare Advantage plans are another way to receive Medicare benefits.

These plans are offered by private insurance companies approved by Medicare and must provide covered Part A and Part B benefits. Many plans also include Part D prescription drug coverage and may offer additional benefits for services such as dental, vision, hearing, or fitness programs.

However, Medicare Advantage plans can have different:

• Provider networks

• Copayments and coinsurance

• Deductibles

• Prescription formularies

• Prior authorization requirements

• Out-of-pocket maximums

• Additional benefits

Benefits can also change from year to year.

That's why it's important to evaluate the entire plan rather than choosing one based solely on an advertised premium or extra benefit.

How Can You Protect Yourself From Medicare Coverage Gaps?

The first step is understanding your coverage before you need to use it.

Take time to review:

• What Original Medicare covers

• Your potential out-of-pocket expenses

• Your prescription drug coverage

• Whether Medicare Supplement insurance makes sense

• Medicare Advantage options available in your area

• Dental, vision, and hearing needs

• Potential long-term care expenses

• Travel plans during retirement

Your healthcare needs and budget are unique, so the right Medicare strategy for someone else may not necessarily be the right strategy for you.

Review Your Medicare Coverage Regularly

Medicare shouldn't necessarily be a decision you make once and then forget about.

Plans, premiums, prescription formularies, provider networks, and healthcare needs can change.

Reviewing your coverage regularly can help you identify potential gaps before they turn into expensive surprises.

Final Thoughts

Medicare provides essential healthcare protection during retirement, but Medicare doesn't cover everything.

Routine dental care, hearing aids, most long-term care, routine vision services, healthcare outside the United States, and certain other expenses may not be covered by Original Medicare. Even when Medicare does cover a service, you may still have out-of-pocket costs.

Knowing these limitations allows you to plan ahead rather than discovering a coverage gap when you receive a medical bill.

At Sentinel Retirement Services, we help individuals understand Medicare, compare their available options, and identify potential gaps in their healthcare coverage.

Have questions about what Medicare will—and won't—cover? Contact Sentinel Retirement Services today for help reviewing your Medicare options. https://sentinelretirementservices.com