The gaps in Medicare coverage

Medicare covers a lot, but it has significant gaps. You will pay out of pocket for dental care, vision care, hearing aids, most prescription drugs without a Part D plan, long-term care in a nursing home or at home, and many preventive services that fall outside the program's rules. Some of these gaps are partial — Medicare covers part of the cost and you cover the rest. Others are complete — Medicare covers nothing at all.

Understanding what Medicare does not cover matters because the costs can be large. A single hearing aid can cost $2,000 to $6,000. A year of dental work can run into thousands. Long-term care in a nursing home or assisted living can cost $50,000 to $100,000 per year or more, depending on where you live and what level of care you need. Knowing these gaps ahead of time lets you plan and budget.

Key Takeaways

  • Medicare Part A and Part B do not cover dental, vision, or hearing services, and you will pay the full cost unless you buy a separate plan.
  • Prescription drugs are not covered by Original Medicare unless you enroll in Part D, and even with Part D you will hit a coverage gap called the "donut hole" where you pay more.
  • Long-term care — whether in a nursing home, assisted living, or at home — is not covered by Medicare and can cost tens of thousands of dollars per year.
  • Some preventive services, physical therapy, and mental health care have limits or require you to meet a deductible first.
  • Medigap or Medicare Advantage plans can cover some of these gaps, but they cost extra and have their own rules about which providers you can see.

Dental, vision, and hearing — not covered at all

Original Medicare (Part A and Part B) does not cover routine dental care, dental exams, cleanings, fillings, crowns, or dentures. It does not cover eye exams for glasses or contacts, or the glasses and contacts themselves. It does not cover hearing tests or hearing aids. If you need any of these services, you pay the full cost out of pocket unless you have a separate plan.

Some Medicare Advantage plans (Part C) include dental, vision, or hearing coverage, but the coverage is usually limited — for example, one dental cleaning per year instead of two, or a $200 allowance toward hearing aids instead of full coverage. Read the plan's details before you enroll to see what is actually covered and what you will still pay.

You can also buy standalone dental, vision, and hearing plans from private insurers. These are separate from Medicare and have their own costs, deductibles, and coverage limits. Discount plans that offer reduced rates at participating providers are another option, though they are not insurance and do not cover emergencies.

Prescription drugs without Part D

Original Medicare does not cover prescription drugs. If you do not enroll in Part D (prescription drug coverage) when you first become may be able to access, you will pay the full price at the pharmacy. Once you do enroll, you will still pay a monthly premium, an annual deductible, and a copay or coinsurance for each drug.

Part D also has a coverage gap, often called the "donut hole." Once you and your plan have paid a certain amount toward your drugs in a year, you enter the gap and pay a larger share of the cost until you reach a yearly out-of-pocket limit. The amounts change each year. In 2024, the gap begins after combined spending of $5,850 and ends when you have paid $8,550 out of pocket. During the gap, you typically pay 25 percent of the cost of brand-name drugs and generic drugs.

If you cannot afford your medications, talk to your doctor about lower-cost alternatives, or ask the pharmacy if the drug maker offers a patient information program. Some nonprofits also help seniors pay for prescriptions.

Long-term care and home care services

Medicare does not cover long-term care — the ongoing help you need if you cannot care for yourself because of age, illness, or injury. This includes nursing homes, assisted living facilities, adult day care, and home health aides who help with bathing, dressing, and other daily tasks. Medicare will pay for skilled nursing care in a facility for a short time after a hospital stay, but only under strict conditions, and only for up to 100 days per benefit period.

Long-term care is one of the largest uncovered costs seniors face. A semi-private room in a nursing home costs an average of $100,000 to $110,000 per year, though prices vary widely by region. In-home care can cost $50,000 to $70,000 per year for part-time help, or much more for full-time care. Medicaid will pay for long-term care if you have very limited income and assets, but you must spend down your savings first.

Some people buy long-term care insurance to cover these costs, though premiums can be expensive and increase over time. Others plan to pay out of pocket, rely on family members, or use Medicaid once they have spent down their assets. There is no one right answer — it depends on your savings, your family situation, and your preferences about where you want to receive care.

Limits on therapy, mental health, and preventive care

Medicare covers physical therapy, occupational therapy, and speech therapy, but only if a doctor orders it for a medical reason and you receive it in a covered setting. There are also annual limits on how much Medicare will pay. In 2024, the limit is $2,430 per benefit period for physical therapy and speech therapy combined, and $2,430 for occupational therapy. Once you hit the limit, you pay the full cost unless your doctor gets an exception approved.

Mental health services are covered, but you will pay a 20 percent coinsurance after you meet your Part B deductible. Outpatient mental health visits are covered at the same rate as other doctor visits. Inpatient psychiatric hospital care is covered under Part A, but only for up to 190 days in your lifetime.

Some preventive services — like cancer screenings, blood pressure checks, and vaccines — are covered with no cost to you. But others have limits. For example, Medicare covers one routine eye exam every two years to check for glaucoma, but not for glasses or contacts. It covers one bone density test, but not repeat tests unless medically necessary. Always ask your doctor whether a preventive service is covered before you have it done.

Other services and supplies not covered

Medicare does not cover cosmetic surgery, even if it is medically necessary to you. It does not cover most over-the-counter medications, vitamins, or supplements. It does not cover routine foot care unless you have diabetes, and even then only if a doctor provides it. It does not cover weight loss programs or bariatric surgery, except in rare cases where a doctor documents medical necessity.

Acupuncture is covered only for chronic lower back pain, and only under specific conditions. Chiropractic care is not covered. Massage therapy is not covered. Most alternative or complementary therapies are not covered unless they are part of a clinical trial that Medicare has approved.

If you travel outside the United States, Medicare does not cover care you receive abroad, with very limited exceptions for emergency care in Canada or Mexico if you are traveling directly to or from Alaska. Travel insurance or a Medigap plan that covers foreign travel can help, but you need to buy it before you leave the country.

How Medigap and Medicare Advantage plans fill the gaps

A Medigap plan (also called Medigap insurance) is private insurance that works alongside Original Medicare. It pays some or all of the costs that Medicare does not cover — like copays, coinsurance, and deductibles. Different Medigap plans cover different gaps. Plan G, for example, covers your Part B deductible and most coinsurance. Plan N covers coinsurance but not the Part B deductible. Medigap plans do not cover dental, vision, hearing, or long-term care, but they do reduce what you pay for the services Medicare does cover.

A Medicare Advantage plan (Part C) is an alternative to Original Medicare. It is run by a private insurance company and usually includes prescription drug coverage, and sometimes dental, vision, or hearing coverage. But Medicare Advantage plans have networks — you must see doctors and hospitals in the plan's network, or pay more. They also have annual out-of-pocket limits, which means your costs are capped, but they may have higher copays and coinsurance than Original Medicare.

Both Medigap and Medicare Advantage plans cost extra money each month. The choice between them depends on your health, your doctors, your budget, and what gaps matter most to you. There is no single best choice for everyone.

Frequently Asked Questions

Does Medicare cover glasses or contact lenses?

No. Original Medicare does not cover eye exams for refraction, glasses, or contact lenses. Some Medicare Advantage plans include vision coverage, but it is usually limited — for example, one eye exam per year and a small allowance toward frames or lenses. You can also buy a standalone vision plan or use a discount vision program.

Will Medicare pay for a hearing aid?

No. Original Medicare does not cover hearing aids or hearing tests. Some Medicare Advantage plans offer hearing coverage, but it is often limited to one hearing aid per ear per year or a fixed dollar amount. Hearing aids are expensive, so ask your doctor about programs that help seniors pay for them, or look into nonprofit organizations that donate hearing aids.

What happens if I need a nursing home after I leave the hospital?

Medicare will pay for skilled nursing care in a facility for up to 100 days per benefit period, but only if you were hospitalized for at least three days first, and only if the care is for a condition related to your hospital stay. You pay nothing for days 1–20, and a copay for days 21–100. After 100 days, you pay the full cost. Medicaid may help if you run out of money.

Can I get help paying for prescriptions if I cannot afford them?

Yes. Talk to your doctor about generic or lower-cost alternatives. Ask the pharmacy if the drug maker has a patient information program. Some nonprofits, like NeedyMeds and RxAssist, help seniors find programs that pay for medications. Your state may also have a pharmaceutical information program for low-income seniors.

What if I travel outside the United States?

Medicare does not cover care outside the U.S., except for emergency care in Canada or Mexico if you are traveling directly to or from Alaska. If you travel internationally, buy travel insurance or a Medigap plan that covers foreign care before you leave. Some credit cards also offer travel medical coverage.