Medicare covers many doctor visits and hospital stays, but it has real limits
Medicare pays for a lot, but not everything. The program does not cover dental work, vision care, hearing aids, or most long-term care. It also does not pay for prescription drugs unless you have Part D, does not cover routine foot care, and does not pay for most cosmetic procedures. Understanding what falls outside Medicare's reach helps you plan for costs and know when to look for other coverage.
The gaps vary depending on which Medicare parts you have. Original Medicare (Parts A and B) leaves out entire categories of care. Medicare Advantage plans (Part C) may cover some of these gaps, but each plan is different. Part D covers some drugs but not all. Knowing what is not covered lets you make decisions about supplemental insurance, savings accounts, or out-of-pocket spending before you need the care.
Key Takeaways
- Medicare does not cover dental care, vision exams, eyeglasses, hearing aids, or routine foot care, even though seniors use these services regularly.
- Long-term care in a nursing home or assisted living facility is not covered by Medicare, though it may cover a short hospital-related stay in a skilled nursing facility.
- Prescription drugs are not covered unless you have Part D, and even Part D has a coverage gap called the "donut hole" where you pay more out of pocket.
- Medicare Advantage plans may cover some gaps that Original Medicare does not, but coverage varies by plan and by year.
- Medigap supplemental insurance can cover some costs that Original Medicare leaves behind, such as copayments and coinsurance.
Dental, vision, and hearing care are not covered
Medicare does not pay for routine dental care, tooth cleaning, fillings, crowns, or dentures. It does not cover vision exams, eyeglasses, contact lenses, or most eye surgery. Hearing aids and hearing exams are also not covered, though Medicare does cover some hearing tests ordered by a doctor for other reasons.
These are among the most common gaps seniors face. A single dental crown can cost $800 to $1,500 out of pocket. Hearing aids range from $1,000 to $6,000 per ear. If you know you will need these services, look into a dental discount plan, a vision plan through your employer or a union, or a standalone hearing aid plan. Some Medicare Advantage plans include dental or vision benefits, though the coverage is usually limited.
Long-term care and nursing home stays
Medicare does not pay for long-term care in a nursing home or assisted living facility. This is one of the largest gaps for seniors. Medicare will pay for a short stay in a skilled nursing facility (SNF) only if you were hospitalized first for at least three days and the stay is medically necessary and related to that hospital stay. Even then, Medicare covers only the first 20 days fully and days 21 through 100 with a daily copayment.
If you need care for more than 100 days, or if you need help with daily activities like bathing or dressing without a recent hospital stay, Medicare does not pay. Long-term care insurance, Medicaid (if you meet income limits), or personal savings are the main ways seniors cover these costs. Some people use a combination: they spend down their savings until they may have access to for Medicaid, which does cover long-term care.
Prescription drugs without Part D coverage
Original Medicare (Parts A and B) does not cover prescription drugs at all. If you do not have Part D or a Medicare Advantage plan that includes drug coverage, you pay the full price at the pharmacy. Part D plans do cover many drugs, but not all. Each plan has a formulary — a list of covered drugs — and drugs not on that list are not covered.
Part D also has a coverage gap, sometimes called the "donut hole." Once you and your plan have spent a certain amount on drugs in a year, you enter the gap and pay a larger share of the cost until you reach a catastrophic coverage level. The exact amounts change each year. If you take multiple medications, the gap can mean hundreds of dollars in extra costs. You can see which drugs a plan covers and what the gap will cost you before you sign up.
Routine foot care and self-care supplies
Medicare does not cover routine foot care like trimming toenails, removing corns, or treating calluses, even if you have diabetes. A podiatrist visit for these routine services is not covered. Medicare covers foot care only when it is related to treatment of a disease, such as diabetic neuropathy, and only if a doctor orders it.
Medicare also does not cover most self-care supplies. This includes items like compression stockings, orthopedic shoes, most bandages, and over-the-counter medications. Some durable medical equipment is covered if a doctor orders it and it meets Medicare's definition of medically necessary, but the bar is high and the item must be prescribed, not bought on your own.
Cosmetic procedures and elective surgery
Medicare does not pay for cosmetic procedures or elective surgery done purely for appearance. This includes facelifts, hair transplants, and most weight-loss surgery. If surgery is medically necessary — for example, a knee replacement for severe arthritis — Medicare covers it. But if the same surgery is done for cosmetic reasons, it is not covered.
The line between cosmetic and medically necessary can be unclear. For example, Medicare may cover eyelid surgery if drooping eyelids block your vision, but not if it is done only to reduce wrinkles. If you are unsure whether a procedure will be covered, ask your doctor to submit a request to Medicare for a coverage information before you have the procedure done.
Travel, experimental treatments, and care outside the United States
Medicare does not cover medical care outside the United States, except in very limited cases. If you are traveling in Canada or Mexico and need emergency care, Medicare may cover it, but only if the emergency occurred while you were traveling to or from Alaska and Canada, or if you live near the Mexican border. Routine care abroad is not covered.
Medicare also does not cover experimental treatments or clinical trials, though it may cover some routine care you receive while in a trial. If you are considering a treatment that is not yet standard, ask your doctor whether it is considered experimental and whether Medicare will cover any part of it. Some clinical trials cover all costs for trial participants, so it is worth asking.
How Medicare Advantage and Medigap handle these gaps
Medicare Advantage plans (Part C) are required to cover everything Original Medicare covers, but they can add benefits that Original Medicare does not. Some Advantage plans include dental, vision, or hearing coverage, though usually with limits. For example, a plan might cover one dental cleaning per year or one hearing aid every three years. Coverage varies widely by plan and by year, so you need to check the specific plan's details.
Medigap supplemental insurance works differently. It does not add new benefits; instead, it pays some of the costs that Original Medicare leaves behind, such as copayments, coinsurance, and deductibles. Medigap does not cover the gaps that Medicare itself does not cover — so a Medigap plan will not pay for dental or vision care. If you want coverage for those services, you need to buy a separate dental or vision plan.
Frequently Asked Questions
Does Medicare cover any dental work at all?
No. Medicare does not cover any routine dental care, including cleanings, fillings, or extractions. It also does not cover dentures or dental implants. Some Medicare Advantage plans include limited dental benefits, but Original Medicare does not cover dental work under any circumstance.
Will Medicare pay if I need to stay in a nursing home for a year?
No, not for a full year. Medicare covers up to 100 days in a skilled nursing facility only if you were hospitalized first for at least three days and the stay is related to that hospital stay. After 100 days, you pay all costs yourself. Long-term care insurance or Medicaid are the main ways to cover extended nursing home stays.
What happens if my doctor prescribes a drug that is not on my Part D plan's list?
You can pay out of pocket for the drug, or you can ask your doctor to prescribe a different drug that is on the plan's formulary. You can also ask the plan to make an exception and cover the drug anyway, though they may deny the request. Some plans cover similar drugs in the same class if your doctor requests it.
Does Medicare cover hearing aids?
No. Medicare does not cover hearing aids or hearing exams done to fit hearing aids. It does cover some hearing tests ordered by a doctor for other medical reasons. Some Medicare Advantage plans include hearing aid coverage, usually limited to one or two aids every few years.
Can I use Medicare if I travel outside the United States?
Medicare does not cover care outside the U.S. except in rare cases — mainly emergency care while traveling to or from Alaska through Canada. If you travel internationally regularly, you may want to buy a travel health insurance plan that covers care abroad.