Medicare covers hospital and doctor visits, but leaves gaps that catch many people off guard

Medicare is insurance, but not the kind that covers everything. It pays for hospital stays, doctor visits, lab work, and some preventive care. It does not cover dental work, hearing aids, vision exams, or most long-term care. Whether it is "good" depends on what you need and what you can afford to pay out of pocket for the things it does not cover.

The real question is not whether Medicare is good in general, but whether it is enough for your situation. Some people do fine with Original Medicare plus a supplemental policy. Others find that Medicare Advantage plans work better because they bundle coverage differently. And some discover too late that they need coverage Medicare does not offer at all.

Key Takeaways

  • Medicare Part A covers hospital stays and some skilled nursing care, while Part B covers doctor visits and outpatient services, but neither covers dental, hearing, or vision care.
  • You will pay deductibles, copayments, and coinsurance amounts that vary by service, and these costs can add up quickly if you need frequent care.
  • Supplemental insurance (Medigap) or Medicare Advantage plans can reduce your out-of-pocket costs, but each has different coverage rules and networks.
  • Medicare does not cover long-term care in nursing homes or assisted living, which is one of the largest expenses seniors face.
  • Your coverage needs change as you age and your health changes, so reviewing your plan annually during open enrollment helps you avoid surprises.

What Medicare Part A and Part B actually pay for

Part A covers inpatient hospital care, skilled nursing facility stays (up to 100 days per benefit period), hospice care, and some home health services. You pay a deductible for each hospital stay, and after 60 days in the hospital, you start paying coinsurance. Part A is usually free if you or your spouse paid Medicare taxes for at least 10 years.

Part B covers doctor visits, outpatient surgery, lab work, imaging, and some preventive screenings. You pay a monthly premium (the amount changes each year based on your income), a yearly deductible, and then 20 percent coinsurance for most services. Part B does not cover routine dental cleanings, eyeglasses, hearing aids, or most physical therapy beyond what a doctor orders for a specific condition.

Many people assume Medicare covers more than it does because they have not needed to use it yet. The gaps become real when you get a dental bill for $3,000, a hearing aid bill for $5,000, or a nursing home bill for $100,000 a year.

The costs you will pay even with Medicare

Medicare is not free. You pay premiums, deductibles, and coinsurance. Part B premiums in 2024 start at $174.70 per month for most people, though higher earners pay more. The Part B deductible is $240 per year. After you meet that, you pay 20 percent of the cost for most services — so if a specialist visit costs $200, you pay $40.

Part A has a deductible of $1,632 per benefit period (a benefit period starts when you enter the hospital and ends 60 days after you leave). If you stay longer than 60 days, you pay $408 per day in coinsurance. If you stay longer than 90 days, the cost goes up to $816 per day. These numbers change each year.

If you take prescription drugs, Part D (prescription drug coverage) requires a separate premium, a deductible, and copayments or coinsurance. The amounts vary by plan and by drug. Many people are surprised to learn that Medicare does not cover all drugs — your doctor's preferred medication might not be on your plan's formulary, or it might be in a higher cost tier.

Supplemental insurance and Medicare Advantage as ways to reduce costs

Medigap (supplemental insurance) is sold by private insurance companies and covers some of the costs Medicare does not — deductibles, coinsurance, and copayments. There are ten standardized Medigap plans (labeled A through N), and each covers a different set of gaps. Plan G, for example, covers the Part B deductible and 20 percent coinsurance, so you pay less out of pocket. Medigap premiums vary by age, location, and plan, and can range from $100 to $300 or more per month.

Medicare Advantage (Part C) is an alternative to Original Medicare. Instead of Part A and Part B, you get coverage through a private insurance company that contracts with Medicare. Most Medicare Advantage plans include Part D drug coverage and cover some services Medicare does not, like dental or vision care. The trade-off is that you usually have a network — you must use doctors and hospitals in the plan's network, or pay more. Premiums are often lower than Original Medicare plus Medigap, but your out-of-pocket costs can be higher if you need a lot of care.

Choosing between Original Medicare with Medigap and Medicare Advantage depends on your health, your doctors, and how much you are willing to pay upfront versus when you use care. If you have a chronic condition and see the same specialists regularly, you need to know whether they are in your Medicare Advantage plan's network.

The big gaps: long-term care, dental, hearing, and vision

Medicare does not cover custodial care — help with bathing, dressing, eating, and toileting in a nursing home or assisted living facility. It covers skilled nursing care (like wound care or physical therapy after a hospital stay) for up to 100 days per benefit period, but only if you were hospitalized first and only if the care is medically necessary. After that, you pay out of pocket.

Long-term care insurance is a separate product that covers nursing home and assisted living costs, but it is expensive and must be purchased before you need it. Many people pay for long-term care by spending down their savings until they may have access to for Medicaid, which does cover nursing home care. This is not a plan — it is what happens when there is no other option.

Dental, hearing, and vision care are not covered by Original Medicare. Some Medicare Advantage plans include dental or vision benefits, but they are usually limited — a cleaning or two per year, a basic eye exam, or a hearing aid discount rather than full coverage. If you need significant dental work, hearing aids, or new glasses, you will pay most or all of the cost yourself.

How to know if your current coverage is enough

Start by listing the services you use regularly: doctor visits, prescriptions, specialists, lab work, dental care, vision care, hearing care. Then look at what your plan covers and what you pay. If you see a cardiologist four times a year and pay $40 per visit, that is $160 per year. If you need a hearing aid every five years at $5,000, that is $1,000 per year on average. Add up the real costs, not the ones you think you might have.

Next, think about what could change. If you develop diabetes or heart disease, your doctor visits and prescriptions will increase. If you have a fall and need rehabilitation, you might need skilled nursing care. If you live to 95, you might need long-term care. Your coverage should handle the things that are likely, not just the things that are happening now.

Review your coverage every year during Medicare open enrollment (October 15 to December 7). Plans change — premiums go up, networks change, covered drugs change. What worked last year might not work this year.

Questions to ask your doctor and your plan

Before you decide whether your coverage is enough, ask your doctor which specialists you might need, what prescriptions you take long-term, and whether you have any conditions that require ongoing care. Ask your plan whether your doctors are in-network, whether your prescriptions are covered, and what your out-of-pocket maximum is (the most you will pay in a year for covered services).

If you are considering a Medicare Advantage plan, call the plan and ask whether your current doctors participate. Do not assume they do. Ask whether you need a referral to see a specialist. Ask what happens if you need care outside the network while traveling.

If you are considering Medigap, ask an insurance agent which plan makes sense for your health and your budget. The agent can show you the difference in premium and out-of-pocket costs between plans.

When to talk to someone about your coverage

Talk to someone if you are turning 65 and have not signed up for Medicare yet — you can face penalties if you delay. Talk to someone if you are on Original Medicare and your prescriptions or doctors have changed. Talk to someone if you are paying more than a few hundred dollars per month out of pocket for care that feels routine.

Your State Health Insurance information Program (SHIP) offers free counseling about Medicare. You can find your local SHIP by calling 1-800-MEDICARE or visiting Medicare.gov. A counselor can walk through your specific situation and help you understand what your plan covers and what it does not.

Frequently Asked Questions

Does Medicare cover my doctor visits?

Part B covers doctor visits, but you pay a yearly deductible ($240 in 2024) and then 20 percent coinsurance. So if your doctor charges $100, you pay $20. If you see many specialists, those costs add up. Medigap or Medicare Advantage can reduce what you pay per visit.

What is the difference between Medicare Advantage and Original Medicare?

Original Medicare is fee-for-service — you can see any doctor who accepts Medicare, and Medicare pays the provider. Medicare Advantage is a managed care plan run by a private insurance company — you must use doctors in the plan's network, but premiums are often lower and some plans cover dental or vision. The trade-off is less flexibility and potentially higher costs if you need a lot of care.

Does Medicare cover hearing aids or glasses?

Original Medicare does not cover hearing aids, eyeglasses, or routine eye exams. Some Medicare Advantage plans include limited vision or hearing benefits, like one eye exam per year or a hearing aid discount. You will pay most of the cost yourself in either case.

What happens if I need nursing home care?

Medicare covers skilled nursing care (like physical therapy after surgery) for up to 100 days per benefit period, but only after a hospital stay. It does not cover custodial care — help with daily living in a nursing home. You pay out of pocket unless you have long-term care insurance or eventually may have access to for Medicaid.

Can I change my Medicare plan if I do not like it?

Yes, during open enrollment (October 15 to December 7 each year) you can switch from Original Medicare to Medicare Advantage, from Medicare Advantage to Original Medicare, or between Medicare Advantage plans. You can also switch Medigap plans, though some plans may not cover pre-existing conditions if you switch after your initial enrollment period.