The gaps in Original Medicare coverage

Medicare Part A covers hospital stays, skilled nursing care, and hospice. Medicare Part B covers doctor visits, outpatient care, and some medical equipment. But neither part pays for many things seniors need. Understanding what falls outside these two parts helps you plan for costs that will come out of your own pocket or require additional coverage.

The gaps are substantial. A single hospital stay can leave you responsible for a deductible. A prescription drug can cost hundreds of dollars monthly. Dental work, hearing aids, and vision care are almost entirely your responsibility. Long-term care in a nursing home or at home is not covered at all. Knowing which services have no Medicare payment means you can budget, buy supplemental insurance, or find community programs before you face a bill.

Key Takeaways

  • Medicare Part A and Part B do not cover prescription drugs, dental care, hearing aids, eyeglasses, or routine vision and hearing exams.
  • Long-term care — whether in a nursing home or at home — is not covered by Original Medicare, and you pay the full cost yourself.
  • You are responsible for deductibles and coinsurance on services that Medicare does cover, which can total thousands of dollars per year.
  • Many seniors buy a Medigap policy or join a Medicare Advantage plan to cover some of these gaps, though costs and coverage vary widely.

Prescription drugs and medications

Part A and Part B do not pay for prescription medications at all. If you take blood pressure medicine, diabetes medication, or any other drug by mouth or injection at home, you pay the full pharmacy price unless you have separate coverage.

Medicare Part D is the prescription drug plan, but it is separate from Part A and Part B. You must sign up for Part D during your initial enrollment window or when you first become may be able to access for Medicare, or you may face a penalty if you join later. Part D plans are sold by private insurance companies and vary in which drugs they cover and how much you pay. Some drugs are covered fully; others require you to pay a percentage of the cost or a flat amount per prescription.

If you cannot afford medications, ask your doctor about generic versions, patient information programs run by drug manufacturers, or community health center pharmacies that offer discounts. The Medicare website has a tool to compare Part D plans and see estimated costs for your specific medications.

Dental, vision, and hearing care

Original Medicare does not cover routine dental care, tooth extractions, dentures, or dental implants. You also do not get coverage for routine eye exams, eyeglasses, contact lenses, or hearing aids. These are among the most expensive gaps for seniors on a fixed income.

Some Medicare Advantage plans (Part C) include dental or vision benefits, though coverage is usually limited and may require you to use dentists or eye doctors in their network. If you stay with Original Medicare, you can buy a standalone dental or vision plan from a private insurer, but these are not part of Medicare and have their own costs and limits.

Community health centers, dental schools, and senior centers sometimes offer low-cost or sliding-scale dental and vision services. Your local Area Agency on Aging can tell you what programs exist in your county. Some states also run programs that help seniors pay for hearing aids.

Long-term care and custodial services

Medicare does not pay for long-term care — whether you need help in a nursing home, assisted living facility, or your own home. This is one of the largest uncovered expenses seniors face. If you need someone to help you bathe, dress, take medication, or manage daily tasks, you pay for that care yourself.

Medicare Part A does cover a limited stay in a skilled nursing facility after a hospital stay of at least three days, but only if you need skilled nursing or rehabilitation — not custodial care. Once that skilled care ends, you pay the full cost of the facility. Medicaid may cover long-term care if your income and assets fall below your state's limits, but Medicare does not.

Some seniors buy long-term care insurance years before they need it, though premiums can be expensive and increase over time. Others set aside savings or rely on family to provide unpaid care. Talking with a financial advisor or elder law attorney about your state's Medicaid rules can help you understand your options.

Deductibles and coinsurance you owe

Even for services that Medicare does cover, you are responsible for paying part of the cost. Part A has a deductible for hospital stays — the amount you pay before Medicare begins to pay. Part B has a yearly deductible and then you pay 20 percent coinsurance for most services after that.

These costs add up. If you have multiple doctor visits, lab work, imaging, or a hospital stay in one year, your out-of-pocket costs can reach thousands of dollars. Many seniors buy a Medigap policy (also called supplemental insurance) to cover these deductibles and coinsurance, though Medigap premiums are an additional monthly cost.

Keep track of what you have paid toward your deductible each year. Your Medicare statements show what you owe. If you are having trouble affording care because of these costs, talk to your doctor's office about payment plans or ask about community health centers that charge based on income.

Routine care and preventive services with limits

Medicare covers some preventive services at no cost to you — like annual wellness visits, cancer screenings, and vaccinations. But it does not cover all routine care, and some preventive services have limits.

For example, Medicare covers one routine eye exam every two years to check for glaucoma, but does not cover the cost of glasses or contacts. It covers one routine hearing test, but not hearing aids. It covers colorectal cancer screening but not all types of screening tests. Routine foot care is not covered unless you have diabetes, and even then only in limited situations.

Ask your doctor which preventive services Medicare covers and which ones you will need to pay for yourself. The Medicare website lists all covered preventive services, though the list changes and varies based on your age and health history.

Other services not covered

Medicare Part A and Part B also do not cover acupuncture, massage therapy, or most chiropractic care. They do not pay for cosmetic surgery, weight loss programs, or fertility treatment. Routine physical exams for work or travel are not covered. Neither are most over-the-counter medications, vitamins, or supplements.

If you travel outside the United States, Medicare generally does not pay for care you receive abroad, with rare exceptions. Travel insurance or a Medigap plan with international coverage can help if you spend time outside the country.

Some of these services may be covered by a Medicare Advantage plan or a Medigap policy, so check your specific plan documents. If you are unsure whether a service is covered, call Medicare at 1-800-MEDICARE before you have the service done.

How to cover the gaps: Medigap and Medicare Advantage

Two main ways to cover gaps in Original Medicare are Medigap policies and Medicare Advantage plans. They work very differently.

A Medigap policy is supplemental insurance sold by private companies. It pays some or all of your deductibles, coinsurance, and copayments for services that Original Medicare covers. It does not cover prescription drugs, dental, hearing, or vision care — those gaps remain. Medigap premiums vary by plan type and your age, and you keep your Original Medicare coverage.

A Medicare Advantage plan (Part C) is an alternative to Original Medicare, sold by private insurance companies. It covers everything Part A and Part B cover, usually with lower premiums, but often includes dental or vision benefits and always includes prescription drug coverage. The trade-off is that you must use doctors and hospitals in the plan's network, and you may face higher costs for out-of-network care. Medicare Advantage plans have their own deductibles and coinsurance.

Neither Medigap nor Medicare Advantage covers long-term care. You need to decide which approach fits your health needs and budget. The choice is personal and depends on which doctors you see, how much health care you use, and what services matter most to you.

Frequently Asked Questions

Does Medicare cover physical therapy or occupational therapy?

Medicare Part B covers physical therapy and occupational therapy if a doctor orders it for a medical reason — like recovery after a stroke or hip replacement. You pay the Part B deductible and then 20 percent coinsurance. Therapy for general wellness or fitness is not covered. There are also limits on the number of visits Medicare will pay for in a year.

What if I need mental health or substance abuse treatment?

Medicare Part B covers mental health visits with a psychiatrist, psychologist, or licensed counselor at the same rate as other doctor visits — you pay the deductible and 20 percent coinsurance. Inpatient psychiatric hospital care is covered under Part A. However, coverage for residential treatment programs or long-term rehabilitation varies, and some facilities are not in-network.

Does Medicare pay for medical equipment like wheelchairs or oxygen?

Medicare Part B covers durable medical equipment — wheelchairs, walkers, oxygen, CPAP machines — if a doctor prescribes it as medically necessary. You pay 20 percent of the approved amount after your deductible. The equipment must come from a Medicare-approved supplier. You do not own the equipment; you rent it, and Medicare pays the rental company directly.

Are there any programs that help pay for services Medicare doesn't cover?

Some states have programs that help seniors pay for prescription drugs, hearing aids, or other uncovered services based on income. Your local Area Agency on Aging can tell you what programs exist where you live. Nonprofit organizations also offer information for specific needs — dental care, vision care, or medications — though may be able to access varies.

What happens if I cannot afford my out-of-pocket costs?

If your income is low, you may be may be able to access for Extra Help with prescription drug costs or Medicaid, which can cover some of your Medicare costs. Community health centers charge based on income and can provide primary care at reduced cost. Ask your doctor's office about payment plans or financial hardship programs. Medicare also has a website tool to find low-cost clinics and pharmacies in your area.