What Medicare does and does not cover

Medicare covers hospital stays, doctor visits, and many medical services, but it has gaps. You pay out-of-pocket for dental work, vision care, hearing aids, and most prescription drugs unless you add separate coverage. Long-term care — nursing homes, assisted living, home health aides — is not covered by Medicare at all, even though many seniors need it. Understanding what falls outside Medicare's main coverage helps you plan for costs that can add up quickly.

Original Medicare (Parts A and B) also does not cover routine physical exams, preventive screenings beyond what Medicare lists, or certain treatments your doctor recommends. If you choose a Medicare Advantage plan (Part C) instead, the coverage rules change — some plans cover dental or vision, but you may pay more for doctor visits or have a smaller network of providers. The plan you pick shapes what you pay for the same service.

Key Takeaways

  • Medicare Part A covers hospital care; Part B covers doctor visits and outpatient services, but you pay a monthly premium for Part B and a deductible for each hospital stay.
  • Dental, vision, hearing, and long-term care are not covered by Original Medicare, and you must buy separate insurance or pay out of pocket.
  • Prescription drug coverage (Part D) is separate and optional, but you pay a penalty if you wait to sign up when you become may be able to access.
  • Medicare Advantage plans (Part C) bundle hospital and doctor coverage but often have higher copays and smaller provider networks than Original Medicare.
  • Medigap (supplemental insurance) works only with Original Medicare and helps cover costs Medicare does not, such as copays and coinsurance.

Costs you pay under Original Medicare

Original Medicare has three main out-of-pocket costs: the Part B monthly premium (currently $164.90 for most people in 2024, though it changes yearly), the Part A deductible for hospital stays, and copays or coinsurance for services. The Part A deductible covers your first 60 days in the hospital per benefit period; after that, you pay a daily coinsurance amount. For doctor visits and outpatient care, you typically pay 20 percent of the cost after you meet your Part B deductible.

These costs can be unpredictable. A single hospital stay can trigger the Part A deductible. Multiple doctor visits add up through the 20 percent coinsurance. If you need physical therapy, imaging, or lab work, each service counts toward your out-of-pocket maximum — but Original Medicare does not have an annual out-of-pocket maximum the way commercial insurance does. You can keep paying coinsurance indefinitely. This is why many people buy Medigap coverage to cap their costs.

Prescription drug coverage and how to avoid penalties

Part D (prescription drug coverage) is optional but important. If you do not sign up when you first become may be able to access — usually when you turn 65 — you pay a late enrollment penalty for as long as you have Medicare. The penalty is roughly 1 percent of the national average drug plan premium for each month you were not covered. If you wait two years, the penalty compounds. The only way to avoid the penalty is to sign up during your initial enrollment period (the three months before, the month of, and the three months after your 65th birthday) or within 63 days of losing other drug coverage.

Part D plans vary widely in which drugs they cover and how much you pay. Some drugs are on the formulary (the plan's list of covered medications) and some are not. You may need prior authorization from the plan before your doctor can prescribe a drug. Costs change every year, and plans change which drugs they cover. You can switch Part D plans once a year during the annual enrollment period (October 15 to December 7), so it is worth reviewing your plan each fall to see if a different one would cost less for your specific medications.

Medigap versus Medicare Advantage: which covers more

Medigap (supplemental insurance) and Medicare Advantage (Part C) are two different ways to handle costs under Medicare. Medigap works alongside Original Medicare — you keep your Medicare coverage and buy a private policy to cover some of the costs Medicare does not. Medigap plans are labeled A through N, and each covers a different set of costs. Plan G, for example, covers the Part B deductible, copays, and coinsurance. Plan N covers most copays and coinsurance but not the Part B deductible. Medigap premiums vary by age, location, and the plan you choose, and they can be high — sometimes $150 to $300 per month or more.

Medicare Advantage (Part C) is an alternative to Original Medicare. You enroll in a private plan (usually an HMO or PPO) that covers hospital, doctor, and outpatient care. Many Advantage plans include Part D (drug coverage) and may cover dental or vision. The trade-off is that you usually pay a copay for each doctor visit (sometimes $0, sometimes $50 or more), and you must use doctors and hospitals in the plan's network. If you go out of network, you pay more or the plan does not cover it at all. Advantage plans have an annual out-of-pocket maximum, so your costs are capped — but that maximum can be $6,700 or higher depending on the plan.

What happens if you cannot afford Medicare costs

If your income is low, you may be able to reduce your Medicare premiums and out-of-pocket costs through programs run by your state. The Medicare Savings Program (MSP) helps pay your Part B and Part D premiums and some copays if your income is below a certain level (the threshold varies by state). The Extra Help program reduces what you pay for prescription drugs under Part D. Both are run by your state's Medicaid office, not Medicare itself, so you explore through your state.

Your local Area Agency on Aging can tell you whether you meet the income limits and help you explore. You can also call 1-800-MEDICARE to ask about these programs. If you are already on Medicaid, you may be automatically enrolled in Extra Help, but it is worth confirming. These programs do not cover all costs, but they can reduce your monthly bills significantly if you may have access to.

Costs that surprise people: what to budget for

Many seniors are caught off guard by costs that are not part of the standard Medicare conversation. Routine eye exams and glasses are not covered, and a pair of prescription glasses can cost $200 to $500. Hearing aids are not covered, and a single hearing aid can cost $1,000 to $6,000. Dental cleanings, fillings, and extractions are not covered — a root canal can run $1,000 or more. If you need a wheelchair, walker, or oxygen equipment, Medicare covers some durable medical equipment but not all, and you may pay 20 percent coinsurance.

Long-term care is the biggest surprise. If you need a nursing home, assisted living, or a home health aide for more than a few weeks, Medicare does not pay for it. Nursing home care can cost $6,000 to $10,000 per month or more, depending on where you live. Some people buy long-term care insurance before they turn 65, but if you did not, you will pay out of pocket or rely on Medicaid (which requires spending down your savings first). Planning for these costs early — or at least understanding them — prevents financial crisis later.

How to review your coverage each year

Medicare coverage and costs change every year. Your Part B premium may go up. Part D plans change which drugs they cover and how much they cost. If you have a Medicare Advantage plan, the copays and network may change. The annual enrollment period runs from October 15 to December 7 each year, and this is when you can switch plans without penalty.

Before the enrollment period, review your current coverage. If you take prescription drugs, check whether your medications are still on your plan's formulary and at what cost. If you see specific doctors, confirm they are still in your plan's network. Compare the premiums, deductibles, and copays of other plans available to you. Medicare.gov has a plan comparison tool, or you can call 1-800-MEDICARE and ask a counselor to walk you through your options. Making changes during the enrollment period takes effect January 1.

Questions to ask your doctor or Medicare counselor

Before you choose a plan or make changes, ask your doctor which Medicare plans they accept and whether they are in-network for the plans you are considering. Ask whether any treatments or medications you need require prior authorization from your plan. If you are thinking about switching from Original Medicare to Medicare Advantage, ask your doctor how the change might affect your care — some doctors do not participate in Advantage networks, and switching plans could mean finding a new provider.

Ask your state's Medicare Savings Program or your Area Agency on Aging whether you may have access to for help with premiums and copays. Ask whether you are enrolled in Extra Help for prescription drugs, or whether you should explore. If you are confused about what you owe after a doctor visit or hospital stay, ask the provider's billing office to explain the charges and confirm what your insurance should cover. Do not assume a bill is correct — errors happen, and asking questions can save you money.

Frequently Asked Questions

Do I have to buy Part D coverage when I turn 65?

Part D is optional, but if you do not sign up when you first become may be able to access, you pay a late enrollment penalty for as long as you have Medicare. The penalty is roughly 1 percent of the national average drug plan premium per month you were not covered. If you already have drug coverage through an employer or union, you may not need Part D, but you should confirm this with your plan before your initial enrollment period ends.

What is the difference between a copay and coinsurance?

A copay is a fixed amount you pay for a service — for example, $20 for a doctor visit. Coinsurance is a percentage of the cost — for example, 20 percent of what Medicare approves. Under Original Medicare, you typically pay 20 percent coinsurance for doctor visits and outpatient services after you meet your Part B deductible. Medicare Advantage plans use copays instead, so you know exactly what you will pay.

Can I switch from Original Medicare to Medicare Advantage if I change my mind?

Yes, but only during the annual enrollment period (October 15 to December 7) or within 63 days of losing other coverage. If you switch to Medicare Advantage and then want to go back to Original Medicare, you can do so during the enrollment period, but you may not be able to buy Medigap coverage when ready — some states have rules about when you can enroll in Medigap after leaving an Advantage plan.

What if I cannot afford my Medicare premiums?

Contact your state's Medicaid office or your Area Agency on Aging to ask about the Medicare Savings Program, which helps pay Part B and Part D premiums if your income is below a certain level. You can also call 1-800-MEDICARE. If you are struggling with costs, do not skip coverage — these programs exist to help, and you may may have access to without realizing it.

Does Medicare cover hearing aids or glasses?

Original Medicare does not cover hearing aids, routine eye exams, or glasses. Some Medicare Advantage plans include vision or hearing coverage, but the benefits are usually limited — for example, a small allowance toward glasses or one hearing aid every few years. If you need these services, check your specific plan's coverage or budget for out-of-pocket costs.