What Does Medicare Not Cover? Coverage Gaps Explained

Original Medicare covers hospital care, doctor visits, and many preventive services, but it leaves real gaps in routine dental, vision, hearing aids, long-term care, and most pharmacy prescriptions.

Knowing those gaps before you need care is the easiest way to avoid a surprise bill.

What Services Does Original Medicare Not Cover?

Part A and Part B pay for a wide range of medical care.

Some services are excluded, though, even when your doctor recommends them.

Dental, vision, hearing, and prescriptions tend to be recurring costs you'll see year after year.

Long-term care can be one of the largest expenses Medicare doesn't cover, particularly when someone needs years of ongoing assistance.

Does Medicare Cover Dental, Vision, or Hearing Care?

Routine care in all three areas is generally your responsibility. Medicare steps in only when the care is tied to a medical condition.

Dental

Cleanings, fillings, extractions, dentures, and implants aren't covered.

Medicare may pay for dental care tied to certain covered treatments, such as before an organ transplant or heart valve procedure, during certain cancer treatments, or before or during dialysis for kidney failure. Medicare.gov explains the rules.

For routine care, see our guide to the best dental insurance for seniors on Medicare.

Vision

Routine eye exams, glasses, and contacts aren't covered.

Part B does cover medically necessary eye care, like treatment for eye diseases, glaucoma screenings for people at high risk, diabetic eye exams, and one pair of glasses or contacts after cataract surgery with an implanted lens.

Hearing

Hearing aids and fitting exams aren't covered.

Part B may cover diagnostic hearing and balance exams, usually with a doctor's order. Once every 12 months, you can see an audiologist without an order for certain non-acute hearing assessments.

Does Medicare Pay for Nursing Homes or Long-Term Care?

Medicare doesn't cover most long-term custodial care, and it's one of the most important gaps to plan for.

Custodial care means ongoing help with everyday activities like bathing, dressing, eating, or using the bathroom, whether at home, in assisted living, or in a nursing home.

Under Original Medicare, skilled nursing facility coverage usually requires a hospital stay of at least three consecutive inpatient days. Time under observation generally doesn't count.

Some arrangements can waive the three-day rule, including certain Medicare Advantage plans and some providers in Medicare's Accountable Care Organization programs.

Part A may cover up to 100 days per benefit period, but coverage can end sooner once you no longer need daily skilled care, and you'll owe a daily coinsurance after day 20. Medicare.gov lists the requirements.

People who need long-term care typically rely on savings, private long-term care insurance, or Medicaid if they qualify.

Does Medicare Cover Prescription Drugs?

Original Medicare doesn't cover most prescriptions you pick up at a pharmacy.

That coverage comes through Medicare Part D, either as a standalone drug plan or built into a Medicare Advantage plan.

Part B does cover some drugs, mostly ones a provider gives you:

• Given during a medical visit: Certain injections and infusions may be covered under Part B when Medicare's requirements are met.
• Picked up at a pharmacy: A prescription you take at home is generally covered through Part D, not Original Medicare.

Even with Part D, not every drug is covered. Each plan has a formulary, or list of covered drugs, and may require prior authorization or set quantity limits.

Before you choose a plan, confirm your medications are on its formulary and check what you'll pay at your preferred pharmacy.

What Other Services Does Medicare Not Cover?

• Cosmetic surgery: Procedures done only to improve appearance aren't covered. Reconstructive surgery may be covered when medically necessary, such as after an injury.
• Routine physicals: Medicare covers a one-time Welcome to Medicare visit and yearly Wellness Visits, which focus on prevention, not a traditional head-to-toe physical. Extra tests or services during those visits may cost you.
• Massage and alternative treatments: Standalone massage therapy isn't covered, though Medicare does cover acupuncture for qualifying chronic low back pain.
• Care outside the U.S.: Original Medicare generally doesn't pay for care abroad, except in limited cases. See our guide to the best Medicare plans for travelers.

For services that aren't covered, you may owe the entire bill, not just a deductible or coinsurance.

What Healthcare Costs Does Medicare Leave You Responsible For?

Even when Medicare covers a service, it isn't free.

After you meet the Part B deductible, you generally pay 20% of the Medicare-approved amount for many Part B-covered services. Some benefits, like many preventive services, have different cost-sharing.

Doctors who don't accept assignment may also add Part B excess charges on top of that.

Example assumes a covered service from a provider who accepts assignment, after your Part B deductible is met.

Unlike Medicare Advantage, Original Medicare has no annual out-of-pocket limit, so that 20% keeps adding up in a heavy medical year.

That leaves two different kinds of costs to plan for:

• Services Medicare doesn't cover: You may pay the entire cost.
• Services Medicare does cover: You may still owe deductibles, copays, or coinsurance.

The difference matters, because most extra coverage is built to handle one of these, not both.

Can Medicare Advantage or Medigap Cover What Medicare Doesn't?

Several types of coverage can help, but they fill different gaps.

The pattern is simple: Medicare Advantage tends to add benefits for excluded services, while Medigap reduces your share of costs for covered services.

Neither Medicare Advantage nor Medigap generally pays for ongoing custodial care in a nursing home or assisted living facility.

Medicare Advantage extra benefits vary by plan and can change every year. Many plans cap what they pay for dental work annually and require network providers. Our comparison of Original Medicare vs. Medicare Advantage covers the other tradeoffs.

Medigap plans like Plan G cover most remaining Medicare-approved costs after the Part B deductible. Several plans also include limited foreign travel emergency coverage; the Medigap comparison chart shows which.

Whether you need either one depends on your situation; our guide to whether you need supplemental insurance and our Medicare Advantage vs. Medigap guide walk through the choice.

How Can You Check Whether Medicare Covers a Service Before You Get It?

You don't have to wait for a bill to find out. Before you schedule a service:

1. Check Medicare's coverage information.

   Look up the service, treatment, or equipment with Medicare.gov's coverage search to see whether it's generally covered and what requirements apply.

2. Ask your provider about coverage.

   Ask whether Medicare covers it for your condition, whether the office accepts assignment, and what you'll owe if Medicare denies it.

3. Get an estimate and read any notices.

   If your provider thinks Medicare may not pay, you may get an Advance Beneficiary Notice of Non-coverage (ABN) explaining why and estimating the cost. An ABN doesn't mean Medicare has already denied the claim.

If you have Medicare Advantage, call your plan to confirm coverage, network rules, and whether you need prior authorization.

What if Medicare denies a claim?

With Original Medicare, denied services show up on your Medicare Summary Notice, which arrives every few months and is also available in your Medicare.gov account.

If you disagree with a denial, you can file an appeal. The first step is a re-determination request, which generally must be filed within 120 days of receiving the notice.

Ask your doctor for supporting records; a letter explaining medical necessity often carries the most weight. Medicare.gov explains the appeals process.