What Does Medicare Actually Cover?

What does Medicare actually cover? It’s one of the most common questions I hear, and the answer isn’t as simple as most people think.

Medicare covers a lot. Hospital stays. Doctor visits. Lab work. Preventive care. But it doesn’t cover everything. And the gaps can be expensive if you’re not prepared.

Most people assume Medicare works like employer insurance — sign up, get your card, and you’re covered for everything. But that’s not how Medicare works.

There are coverage gaps. Services Medicare doesn’t pay for. Out-of-pocket costs that can add up fast. And if you don’t know what’s covered and what’s not, you could be in for some expensive surprises.

I treat every client like I would my own parents. And if my parents were asking what Medicare actually covers, here’s exactly what I’d walk them through — what’s included, what’s not, and how to fill the gaps.

Understanding Your Medicare Options

Before we talk about what Medicare covers, you need to understand your options. Because what you choose determines what’s covered and what you’ll pay.

You’ve got three main paths:

Option 1: Original Medicare (Parts A and B) only. This is the simplest option, but it’s also the riskiest. You’ll have the lowest premiums, but you’ll face high, uncapped out-of-pocket costs. Most people don’t choose this because the financial exposure is too great.

Option 2: Original Medicare plus a Medigap supplement. You keep Parts A and B, and you add a Medigap plan (like Plan G or Plan N) to cover your out-of-pocket costs. Your costs become predictable, and you can see any doctor nationwide who accepts Medicare. No networks. No referrals. No prior authorizations.

Option 3: Medicare Advantage. You replace Original Medicare with a private insurance plan that bundles everything together. Medicare Advantage plans often have lower premiums and include extras like dental and vision. But you’re limited to a network of doctors, and you may need prior authorizations for certain services.

Each option covers different things and works differently. Let’s break down what Original Medicare actually covers, and then we’ll talk about how to fill the gaps.

What Original Medicare Does and Doesn’t Cover

Original Medicare has two parts: Part A and Part B.

Part A covers hospital care:

Inpatient hospital stays
Skilled nursing facility care (limited to 100 days per benefit period)
Hospice care
Some home health care

If you’ve worked and paid Medicare taxes for at least 10 years (40 quarters), Part A is usually free. If you haven’t, you’ll pay a premium.

Part B covers outpatient care:

Doctor visits
Preventive services (annual wellness visits, screenings, vaccines)
Lab work and diagnostic tests
Imaging (X-rays, MRIs, CT scans)
Durable medical equipment (wheelchairs, walkers, oxygen)
Outpatient surgeries and therapies

Part B costs $185 per month in 2026 for most people. If you earn more, you’ll pay higher premiums based on your income (that’s called IRMAA).

What Medicare Doesn’t Cover

Here’s where it gets tricky. Medicare covers medically necessary services, but it doesn’t cover everything.

What’s not covered by Original Medicare:

Routine dental care — cleanings, fillings, extractions, dentures
Routine vision care — eye exams for glasses, eyeglasses, contact lenses
Routine hearing care — hearing exams for hearing aids, hearing aids
Long-term custodial care — nursing home care, help with daily activities like bathing and dressing
Cosmetic procedures — unless medically necessary
Most care outside the United States

And here’s the big one: Original Medicare has no out-of-pocket maximum. That means if you need major surgery or ongoing specialist care, your costs can climb into the tens of thousands without a cap.

That’s why most people add either a Medigap plan or choose Medicare Advantage — to protect themselves from those unlimited costs.

For more details, read Understanding Medicare Coverage Basics.

Dental, Vision, and Hearing: Filling the Gaps

One of the biggest surprises for new Medicare beneficiaries is that routine dental, vision, and hearing care aren’t covered.

Not a dime.

If you need a cleaning, a filling, or an extraction, you’re paying out of pocket. If you need glasses or contacts, you’re paying out of pocket. If you need hearing aids, you’re paying out of pocket.

Those costs add up fast. A cleaning might be $100. A filling could be $200 to $400. Hearing aids can run $3,000 to $6,000. Eyeglasses can cost $300 to $500 or more.

So how do you fill these gaps?

Dental Plans

You can buy a standalone dental plan to cover routine care. Most dental plans work like this:

Preventive care (cleanings, exams, X-rays): Covered at 100%
Basic care (fillings, extractions): Covered at 80%
Major care (crowns, bridges, dentures): Covered at 50%

Most plans have an annual maximum of $1,500 to $5,000. Once you hit that limit, you’re paying out of pocket for the rest of the year.

Premiums for dental plans typically run $30 to $80 per month. Plans with higher annual maximums and broader networks cost more.

Vision Plans

Vision plans usually cover:

Annual eye exams
Eyeglasses or contact lenses (usually a $300 allowance every year or two)

Vision coverage is modest, but it helps offset the cost of routine care.

Hearing Plans

Medicare doesn’t cover hearing aids at all. But some Medicare Advantage plans include hearing benefits, and you can buy standalone hearing coverage.

Coverage varies widely. Some plans cover exams and fittings. Some offer discounts on hearing aids. Others provide an annual allowance toward the cost of hearing aids.

If you’re considering dental, vision, or hearing coverage, check waiting periods. Many plans require you to wait 6 to 12 months before you can use benefits for basic or major services.

Learn more about Medicare dental, vision, and hearing options.

Comparing Supplemental vs. Advantage Plans

Now that you know what Medicare covers and what it doesn’t, let’s talk about how to fill the gaps.

You’ve got two main options: add a Medigap supplement to Original Medicare, or choose a Medicare Advantage plan.

Medigap Plans

Medigap plans work with Original Medicare to cover your out-of-pocket costs — deductibles, copays, coinsurance.

Advantages of Medigap:

Predictable costs. You pay a monthly premium, and most of your out-of-pocket costs are covered.
Nationwide access. You can see any doctor who accepts Medicare, anywhere in the country. No networks. No referrals.
No prior authorizations. You don’t need permission to see a specialist or get a test.

Disadvantages of Medigap:

Higher premiums. Plan G averages around $150 per month. Plan N averages around $120 per month.
No extras. Medigap doesn’t include dental, vision, or hearing benefits. You’ll need to buy those separately.
Separate Part D coverage. You’ll need to add a standalone Part D drug plan (average $25 per month).

For more details, read Medicare Advantage vs. Medigap: Which Saves You More?

Medicare Advantage Plans

Medicare Advantage plans replace Original Medicare. They’re offered by private insurance companies and bundle everything together — hospital care, outpatient care, and usually drug coverage.

Advantages of Medicare Advantage:

Lower premiums. Many plans have $0 premiums.
Out-of-pocket maximum. Most plans cap your annual costs at $3,000 to $10,000.
Extra benefits. Many plans include dental, vision, gym memberships, and over-the-counter allowances.
Bundled drug coverage. You don’t need a separate Part D plan.

Disadvantages of Medicare Advantage:

Networks. You’re limited to a network of doctors and hospitals. If you go out of network, you’ll pay more or you won’t be covered (except in emergencies).
Prior authorizations. Many services require approval before you can get them. If your plan denies authorization, you’re stuck appealing or paying out of pocket.
Plans change every year. Networks, drug formularies, and costs can change. You need to review your plan every year.

For more on how Medicare Advantage works, read Original Medicare vs. Medicare Advantage: What’s the Difference.

Networks, Premiums, and Annual Benefit Limits

If you’re considering dental, vision, or hearing coverage — whether through Medicare Advantage or standalone plans — you need to understand how networks, premiums, and benefit limits work.

Networks

Most dental and vision plans use networks. You’ll pay less if you use in-network providers. Go out of network, and you’ll pay more — sometimes a lot more.

Preventive care (cleanings, exams) often has zero copays if you stay in-network. But if you go out of network, you might pay full price and then file for reimbursement — if the plan covers out-of-network care at all.

Before you enroll, confirm your dentist and eye doctor are in-network. Otherwise, you’ll be paying more than you need to.

Premiums

Dental plan premiums typically run $30 to $80 per month. Plans with richer benefits and broader networks cost more.

Vision coverage is usually modest — often included as a rider on a dental plan or bundled into Medicare Advantage.

Hearing coverage varies widely. Some Medicare Advantage plans include hearing benefits. Others don’t. Standalone hearing plans are less common and can be expensive.

Annual Benefit Limits

Most dental plans have an annual maximum — usually $1,500 to $5,000. Once you hit that limit, you’re paying out of pocket for the rest of the year.

Preventive care (cleanings, exams, X-rays) draws from that limit, but it’s covered at 100%. Basic care (fillings, extractions) is covered at 80%. Major care (crowns, bridges, dentures) is covered at 50%.

If you need major work, track how much you’re using so you don’t exhaust your benefits midyear.

Vision plans often have annual or biennial allowances — usually around $300 for eyeglasses or contacts.

Enrollment Timing and Avoiding Gaps

Timing matters when you’re enrolling in Medicare and adding supplemental coverage.

Here’s what you need to know:

Enroll within 30 to 60 days of losing prior coverage. If you’re transitioning from employer insurance to Medicare, enroll as soon as your coverage ends. Many supplemental plans will waive waiting periods if you enroll within this window.

Watch out for waiting periods. Many dental plans require you to wait 6 to 12 months before you can use benefits for basic or major services. Preventive care usually starts immediately, but fillings, crowns, and extractions might have a waiting period.

Coordinate effective dates. Make sure your Medicare, Medigap, Part D, and any ancillary coverage all start on the same day. Gaps in coverage can leave you exposed to high costs or penalties.

Keep documentation handy. If you’re enrolling based on loss of prior coverage, you may need to provide proof. Keep letters from your former employer or insurance company showing when your coverage ended.

For more on enrollment timing, read How to Apply for Medicare: Step-by-Step Guide and Medicare Supplement Open Enrollment Explained.

Frequently Asked Questions

How do Medicare Savings Programs help with premiums and cost-sharing?
Medicare Savings Programs lower your costs by paying your Part A and/or Part B premiums and reducing some or all of your cost-sharing (deductibles, copays, coinsurance). You may also qualify for Part D Extra Help. You qualify based on income and assets, and you apply through your state Medicaid agency.

Can I change plans outside Annual Enrollment due to life events?
Yes. You can switch plans during Special Enrollment Periods triggered by life events like moving, losing employer coverage, plan termination, Medicaid changes, or entering a nursing facility. You’ll need to document the event and enroll within the SEP window.

How do prescription drug (Part D) formularies and tiers work?
Part D plans list covered drugs in formularies and place them in cost tiers. You’ll pay lower copays for generics (Tier 1) and higher copays for brand-name or specialty drugs (Tiers 3-5). Plans can require prior authorization, step therapy, or quantity limits. You can file for exceptions and appeals. Learn more about Part D enrollment.

What assistance is available for low-income beneficiaries (Extra Help)?
You can get Extra Help, which lowers Part D premiums, deductibles, and copays. You apply through Social Security. Many people qualify automatically if they receive Medicaid or SSI. You’ll also get the Low-Income Subsidy and access to a Special Enrollment Period.

How does travel or living in multiple states affect coverage?
With Original Medicare and Medigap, you can see any provider accepting Medicare anywhere in the U.S. Medicare Advantage plans are regional — traveling outside your service area may result in out-of-network costs. Emergency care is covered, but routine care may not be. Confirm your plan’s coverage area before enrolling.

The Bottom Line: Know What’s Covered Before You Need It

So, what does Medicare actually cover? A lot — but not everything.

Medicare covers hospital stays, doctor visits, lab work, preventive care, and much more. But it doesn’t cover routine dental, vision, or hearing care. It doesn’t cover long-term custodial care. And without supplemental coverage, it doesn’t cap your out-of-pocket costs.

That’s why most people add either a Medigap plan or choose Medicare Advantage — to protect themselves from gaps and unexpected costs.

The key is understanding your options, comparing costs, and choosing the coverage that fits your health, your budget, and your life.

Don’t wait until you need care to figure this out. Know what Medicare covers now, before you’re facing a surprise bill.

Need Help Understanding What Medicare Covers?

If you’re not sure what Medicare covers or what plan is right for you, let’s talk.

We’ll walk through your situation, answer your questions, and help you choose the coverage that protects you — without the confusion or pressure.

You can also scan the QR code to fill out your medications, doctors, and pharmacy information ahead of time. That way, we can waive the 48-hour rule and get you answers faster.

Next step is simple: Book your free consultation, or reach out with questions. We’re here to help.