Robert is new to Medicare and begins the conversation with common assumptions. David has already researched his options and explained what he learned.
Robert and David had been friends for years. They were talking casually when the subject of turning 65 came up.
Robert leaned back comfortably. “You know what I’m looking forward to? Medicare. After working all these years and paying into it, at least I won’t have to worry about healthcare bills anymore.”
David looked at him. “You think Medicare covers everything?”
Robert said, “Sure. That’s what Medicare is for, isn’t it? I paid into it my whole working life.”
David smiled slightly. “Medicare is very important, Robert, but it doesn’t cover everything. And even when it covers a service, that doesn’t always mean you pay nothing.”
Robert’s smile faded a little. “Wait. What do you mean?”
David explained, “For example, Original Medicare generally doesn’t cover routine dental care, dentures, hearing aids, or routine eye exams for prescription glasses.”
Robert shifted forward. “Hold on. No hearing aids?”
David replied, “Not under Original Medicare.”
Robert asked, “And dental?”
David clarified, “Most routine dental care isn’t covered either.”
Robert sat back, his arms opening slightly as if trying to make sense of what he had just heard. “I really thought all of that was part of Medicare.”
David smiled and replied, “A lot of people do.”
Robert suddenly became more serious. “Well, if something serious happens and I need a nursing home, Medicare pays for that, right?”
David shook his head. “That depends on what kind of care you need. Medicare can cover qualifying skilled nursing facility care when it meets Medicare’s requirements. But ongoing long-term custodial care, like needing help with bathing, dressing, eating, or using the bathroom, is different. Medicare generally doesn’t pay for that.”
Robert paused. “Now you’ve really surprised me. So, what exactly does Medicare cover?”
David replied, “A lot. Hospital care, doctors’ services, outpatient services, preventive services, and many medically necessary services. But Medicare has rules, costs, and gaps. That’s why you need to understand how it works before you choose your coverage”
Robert said, “I thought I just signed up for Medicare and that was it.”
“That’s another common misunderstanding,” David explained. “Once you have Part A and Part B, you still need to understand your choices. You might stay with Original Medicare and consider Part D and a Medicare Supplement policy. Or you might choose a Medicare Advantage plan. What makes sense depends on your doctors, prescriptions, budget, travel, other coverage, and what matters to you.”
Robert looked at David for a moment. “How did you figure all of that out?”
“I sat down with a licensed insurance broker,” David said. “He explained the options he represented and helped me compare them based on my situation. You can also get information directly from Medicare or free counseling through SHIP. The important thing is not to choose based on assumptions.”
Robert nodded. “So having Medicare and understanding my Medicare are two different things.”
David smiled. “Exactly. Learn first. Then decide.”
Medicare Is an Important Foundation, But It Doesn’t Cover Everything
Robert’s assumption is understandable. After working for decades and paying Medicare taxes, many people reach Medicare eligibility believing that Medicare will now take care of all their healthcare expenses.
The reality is more nuanced. Medicare provides important health coverage, but it is not one program that simply pays 100% of every healthcare bill. Depending on how you receive your Medicare coverage, you may have premiums, deductibles, copayments or coinsurance. There are also services that Original Medicare does not cover.
That does not make Medicare less valuable. It means understanding your Medicare is just as important as having Medicare.
“I Paid Into Medicare My Whole Life. Isn’t It Free?”
Medicare taxes paid during your working years generally help you qualify for premium-free Part A if you or your spouse paid Medicare taxes long enough. Most people do not pay a monthly premium for Part A.
Part B is different. Most beneficiaries pay a monthly Part B premium. Part A and Part B also include cost sharing for covered services. If you add prescription drug coverage, Medigap, or choose a Medicare Advantage plan, additional premiums or other costs may apply depending on the coverage.
So, “Medicare covers it” does not necessarily mean “Medicare pays the entire bill.”
The Surprises: What Original Medicare Generally Doesn’t Cover
Routine dental care and dentures: Original Medicare generally does not cover routine cleanings, fillings, tooth extractions, or dentures. Medicare can cover certain dental services when they are closely connected to specific covered medical treatment.
Routine vision care for glasses: Routine eye exams for prescription eyeglasses or contact lenses generally are not covered, although Medicare covers certain medically necessary eye services and limited eyeglass benefits in specific circumstances.
Hearing aids: Original Medicare does not cover hearing aids or exams for fitting hearing aids. Diagnostic hearing and balance exams can be covered in qualifying circumstances.
Long-term custodial care: Medicare does not pay for long-term custodial care when that is the care you need. This can include ongoing help with activities such as bathing, dressing, eating, or using the bathroom.
Routine physical examinations: Medicare covers many preventive services and an Annual Wellness Visit, but that is not the same as a traditional routine physical examination.
Most healthcare outside the United States: Original Medicare generally does not cover healthcare outside the United States, although limited exceptions apply.
Other commonly misunderstood services: Original Medicare also lists services such as massage therapy, most cosmetic surgery, concierge care, and many common medical supplies used at home among items that may not be covered.
| A service can be covered by Medicare and still leave you with part of the cost. If a service is not covered by Original Medicare, Medigap does not automatically make it a covered Medicare service. |
Skilled Nursing Care Is Not the Same as Long-Term Care
One of the most important Medicare misunderstandings involves nursing home and long-term care.
Medicare Part A may cover qualifying skilled nursing facility care when Medicare’s requirements are met. Long-term custodial care is different. It often involves ongoing assistance with everyday activities and may be provided at home, in assisted living, or in a nursing facility.
Because this subject deserves more than a paragraph, we explore it separately in our Long-Term Care Planning resource at JanixLife.com.
If Medicare Covers a Service, Does That Mean I Pay Nothing?
No. Original Medicare generally requires beneficiaries to share some of the cost of covered services through deductibles and coinsurance.
Another important consideration is that Original Medicare itself does not have a yearly out-of-pocket limit. Supplemental coverage, such as Medigap, Medicaid, employer or retiree coverage, can change a person’s financial exposure.
Medicare Advantage plans work differently. They have a yearly limit on what you pay out of pocket for covered Part A and Part B services. Costs and limits vary by plan.
If Medicare Doesn’t Cover Everything, What Choices Do I Have?
For most people, the starting point is understanding the two main ways to receive Medicare coverage.
| ORIGINAL MEDICARE PATH | MEDICARE ADVANTAGE PATH |
| Part A + Part B Add a stand-alone Part D plan for prescription drug coverage May add a Medicare Supplement (Medigap) policy to help with certain Original Medicare cost sharing May consider separate coverage for needs such as routine dental, vision, or hearing | Receive Part A + Part B benefits through a Medicare Advantage plan Most plans include Part D prescription drug coverage, often called MAPD when drug coverage is included Plans may offer additional benefits, such as certain dental, vision, or hearing services Networks, costs, prior authorization requirements, benefits, and plan rules vary |
What Does Medigap Do?
Medicare Supplement Insurance, commonly called Medigap, works with Original Medicare. Depending on the standardized plan, it can help pay some of your share of costs for services covered by Original Medicare, such as copayments, coinsurance, and certain deductibles.
Medigap generally does not cover long-term care, routine vision or dental care, hearing aids, eyeglasses, or private-duty nursing. Medigap policies sold after 2005 do not include prescription drug coverage, so someone who wants drug coverage generally considers a separate Part D plan.
Some Medigap policies include limited foreign travel emergency benefits, subject to the policy’s terms and limits.
What About Medicare Advantage and MAPD?
Medicare Advantage, also called Part C, is another way to receive Medicare Part A and Part B benefits through a Medicare-approved private insurance company. You must continue to have Part A and Part B and keep paying your Part B premium.
Most Medicare Advantage plans include Part D prescription drug coverage. When a Medicare Advantage plan includes drug coverage, it is commonly referred to as an MAPD plan.
Medicare Advantage plans must cover medically necessary services that Original Medicare covers and may offer additional benefits that Original Medicare does not cover, such as certain dental, vision, or hearing benefits. The details vary by plan.
Depending on the plan, you may need to use a provider network or obtain prior authorization for certain services. Costs, formularies, networks, benefits, and service areas can change, so the details matter.
Which Option Fits Your Situation?
There is no single Medicare coverage arrangement that fits everyone. Before making a decision, consider questions such as:
• Are my doctors, specialists, hospitals, and preferred healthcare systems accessible under the option I am considering?
• How are my prescription drugs covered, and which pharmacies are preferred or in network?
• What will I pay when I actually use healthcare, not just what is the monthly premium?
• Do I travel frequently or spend part of the year in another state?
• How important are dental, vision, and hearing benefits to me?
• What provider network or prior authorization rules apply?
• What other insurance or benefits do I already have, such as employer, retiree, Medicaid, VA, or military coverage?
• What financial exposure am I comfortable assuming if my health changes?
Back to Robert and David
Robert shook his head with a small smile. “I came into this conversation thinking Medicare covered everything. Now I know I have some homework to do.”
David nodded. “That’s the point. Don’t let anyone choose for you. Understand your choices first.”
“And I probably shouldn’t pick a plan just because my neighbor likes his,” Robert replied.
David answered: “Exactly. Your doctors, prescriptions, budget, travel, and health needs may be completely different from his.”
Robert nodded. “All right. I’m going to get some help and compare my options before I decide.”
Don’t Just Have Medicare. Understand Your Medicare.
Medicare is an important part of healthcare in retirement, but your Medicare card is only the beginning of the conversation.
Before choosing coverage, take time to understand what Medicare covers, what it does not cover, what you may have to pay, and how the different coverage options work with your doctors, prescriptions, finances, travel, and lifestyle.
A licensed insurance broker can help you understand and compare the Medicare plan options the broker represents. You can also obtain information directly from Medicare and receive free, unbiased counseling through your State Health Insurance Assistance Program (SHIP).
The goal is not simply to enroll. The goal is to make an informed decision that you understand.
EDUCATE • PROTECT • EMPOWER
About the Author
Janix Barbosa-LLanos, MBA, CEP®, RSSA®, FSN
Licensed Insurance & Retirement Professional Navigator
Janix Assurance LLC
Janix Barbosa-LLanos is a licensed insurance and retirement professional who provides education and guidance on Medicare, health insurance, retirement, life insurance, long-term care planning, and financial protection strategies. She is fully bilingual in English and Spanish and believes that better decisions begin with education.
Medicare Disclosure
We do not offer every plan available in your area. Currently we represent seven organizations which offer 43 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.
Not affiliated with or endorsed by the U.S. government or the federal Medicare program.
Educational Disclaimer
This article is provided for educational purposes only and is not intended as individualized insurance, financial, tax, legal, or medical advice. Medicare coverage, costs, benefits, eligibility requirements, provider networks, formularies, and plan availability may vary and may change. Review official Medicare information and the specific plan documents applicable to your situation before making coverage decisions.
Resources
Medicare.gov — What Original Medicare Covers
https://www.medicare.gov/providers-services/original-medicare
Medicare.gov — What’s Not Covered
https://www.medicare.gov/providers-services/original-medicare/not-covered
Medicare.gov — What Does Medicare Cost?
https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/what-does-medicare-cost
Medicare.gov — Compare Original Medicare & Medicare Advantage
https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage
Medicare.gov — Learn What Medigap Covers
https://www.medicare.gov/health-drug-plans/medigap/basics/coverage
Medicare.gov — Long-Term Care
https://www.medicare.gov/coverage/long-term-care
State Health Insurance Assistance Program (SHIP)
https://www.shiphelp.org/
JanixLife — Long-Term Care Planning
https://janixlife.com/long-term-care/
