What is not included in Medicare?
Original Medicare (Parts A and B) does not cover routine dental care, eye exams for glasses, hearing aids, or long-term custodial care.
You can check the official Medicare Not Covered Guide for a complete breakdown of excluded services.
Major Excluded Services
- Dental Care: Routine cleanings, fillings, tooth extractions, root canals, and dentures are generally not paid for, with rare exceptions for specific medical treatments like organ transplants or head and neck cancer.
- Vision Care: Routine eye exams, eyeglasses, and contact lenses are excluded, though diagnostic exams for conditions like cataracts or glaucoma are covered.
- Hearing Services: Routine hearing tests, hearing aid fittings, and hearing aids themselves are not covered.
- Long-Term Care: Custodial care (help with everyday personal needs like bathing, dressing, or eating) in a nursing home or at home is not covered when it is the only care you need.
- Routine Physical Exams: Standard annual wellness checkups that go beyond the initial preventive physical exam are out-of-pocket.
- Cosmetic Surgery: Elective plastic surgery or procedures done purely to change appearance are excluded.
- Overseas Care: Medical treatment received outside of the United States is generally not covered.
What are the five things that Medicare will not cover?
Original Medicare does not cover long-term care, routine dental care, routine vision care and eyeglasses, hearing aids and exams, and routine physical exams.
Common Exclusions in Original Medicare
- Long-Term Care: Custodial care (help with daily activities like dressing, bathing, or eating) in a nursing home or at home is not covered unless you need skilled nursing care.
- Routine Dental Care: Standard cleanings, fillings, tooth extractions, root canals, and dentures are generally excluded.
- Routine Vision Care: Eye exams for prescription glasses, contact lenses, and routine eyeglasses are not covered (though certain surgeries like for cataracts or glaucoma are).
- Hearing Aids: Standard hearing exams, fittings, and hearing aids are not paid for by Original Medicare.
- Routine Physical Exams: Traditional full annual physical checkups with routine blood panels are not covered, though Medicare does cover an initial preventive physical and yearly wellness visits.
You can review specific guidelines on the Official Medicare Coverage Page.
What is the big mistake people make with Medicare?
The single biggest and most costly mistake people make with Medicare is missing enrollment deadlines, leading to permanent late-enrollment penalties and gaps in coverage.
Missing Enrollment Deadlines
- Initial Enrollment Period (IEP): This window lasts for seven months. It starts three months before the month you turn 65, includes your birthday month, and ends three months after.
- Late Penalties: Failing to sign up for Part B or Part D on time can trigger permanent monthly or yearly financial penalties added to your premiums.
- Delayed Enrollment Confusion: Many people wrongly assume they can delay Medicare past age 65 just because they have health coverage like COBRA, a marketplace plan, or small-employer insurance.
Other Costly Medicare Mistakes
- Ignoring Annual Changes: Sticking with automatic renewal without reading the Annual Notice of Change (ANOC) can result in unexpected costs, as drug lists and doctor networks shift every year.
- Choosing Solely by Low Premiums: Picking a plan based only on a low monthly cost while ignoring total out-of-pocket expenses like deductibles, copays, and coinsurance.
- Missing the Medigap Window: Forgetting to apply for a Medigap (Medicare Supplement) policy during your open enrollment window. After this six-month period, insurers can use medical underwriting to charge more or deny coverage.
- Skipping Financial Assistance: Overlooking programs like Medicare Savings Programs or Part D Extra Help that assist with out-of-pocket medical and prescription expenses.
Why are routine physicals not covered by Medicare?
Original Medicare does not cover routine annual physical exams because federal law and the original Social Security Act exclude routine physicals and restrict coverage to medically necessary care and specific preventive services.
Why Medicare Excludes Routine Physicals
- Statutory Limits: Federal law dictates that Medicare pay for diagnosis and treatment of illness or injury, or specific authorized preventive services, rather than routine checkups.
- Focus on Problem-Based Care: Historically, Medicare was built to cover problem-based medical visits and treatments rather than general physical maintenance.
- Shift to Wellness Visits: Instead of a traditional hands-on physical, Medicare offers alternative preventive options.
What Medicare Covers Instead
- Welcome to Medicare Visit: An Initial Preventive Physical Examination (IPPE) covered once during your first 12 months on Part B, which records your medical history and establishes vital baselines.
- Annual Wellness Visits (AWV): Covered yearly after your first year on Part B, focusing on a health risk assessment, medical history review, and a personalized prevention plan.
- Important Distinction: Neither the Welcome to Medicare visit nor the Annual Wellness Visit includes a traditional hands-on, head-to-toe physical exam or routine lab tests like blood work, unless they are ordered separately as medically necessary.
Does Medicare pay 100% of anything?
Original Medicare (Parts A and B) does not pay 100% of any single medical bill or service, as it always requires out-of-pocket costs like deductibles, copayments, or coinsurance.
Preventive Services Exception
- Zero Cost-Sharing: Medicare pays 100% of the Medicare-approved amount for certain preventive services (such as specific annual wellness visits, flu shots, and cancer screenings).
- The Catch: You still owe nothing only if your doctor accepts assignment (agrees to accept Medicare's approved amount as full payment). If the doctor performs extra non-preventive tests during that same visit, you may be billed for those parts.
How Original Medicare Splits Costs
- Part A (Hospital): For an inpatient hospital stay, you pay a deductible ($1,736 in 2026) plus daily coinsurance if your stay exceeds 60 days.
- Part B (Medical): After you meet your annual deductible ($283 in 2026), Medicare generally pays 80%, leaving you responsible for a 20% coinsurance with no yearly out-of-pocket maximum.
When 100% Coverage Happens
- Medicare Advantage (Part C): These private plans have a yearly out-of-pocket maximum. Once you reach that limit, the plan pays 100% for covered services for the rest of the year.
- Medigap (Supplement): Certain standardized Medigap policies pay 100% of the remaining coinsurance and deductibles left over by Original Medicare.
11 Things NOT Covered by Medicare?
9 related questions found
What is no longer covered by Medicare?
Original Medicare Original Medicare Not Covered and Medicare Advantage plans have strict rules regarding items and services that are excluded from coverage.
Expiring & Restrictive Coverage Changes
- Broad Telehealth Flexibilities: Pandemic-era telehealth waivers expired on January 31, 2026 Medicare telehealth flexibilities expire. Beneficiaries generally must be located in a medical facility and in a rural area to receive covered telehealth services, except for behavioral health care Medicare Will No Longer Cover This Popular Service Starting Jan. 31.
- Medicare Advantage Non-Qualifying Supplemental Items: CMS rules restrict Medicare Advantage plans from covering non-health items previously allowed for chronically ill enrollees, including alcohol, cannabis, tobacco, unhealthy foods, cosmetic procedures (facelifts), funeral costs, and life or hospital indemnity insurance Medicare Advantage Can No Longer Cover These Items in 2026.
Standard Exclusions in Original Medicare
- Routine Dental Care: Cleanings, fillings, tooth extractions, and dentures What Medicare will not cover in 2026 | The American Legion.
- Routine Vision Care: Eye exams for prescription glasses, contact lenses, or eyeglasses (except following cataract surgery) What Medicare will not cover in 2026 | The American Legion.
- Hearing Care: Routine hearing exams and hearing aids What Medicare will not cover in 2026 | The American Legion.
- Long-Term Custodial Care: Extended nursing home care or assisted living that only involves personal help with daily living activities What Does Medicare Not Cover? Eight Things You Should Know.
- Routine Foot Care: Cutting corns or calluses and basic toenail clipping What Medicare will not cover in 2026 | The American Legion.
- Overseas Care: Medical treatment received outside the United States What Medicare will not cover in 2026 | The American Legion, with rare exceptions.
Can I deduct Medicare premiums taken out of my social security check?
Yes, you can deduct Medicare premiums withheld from your Social Security check on your federal income taxes, provided you itemize your deductions and your total medical expenses exceed 7.5% of your adjusted gross income (AGI).
How the Deduction Works
- Itemizing required: To claim the deduction, you must file Form 1040 and itemize your deductions on Schedule A.
- The 7.5% threshold: You can only deduct the portion of your total qualified medical expenses (including Medicare Parts A, B, C, D, and Medigap premiums, plus out-of-pocket costs like copays and prescription drugs) that goes over 7.5% of your AGI.
- Self-employed exception: If you are self-employed and show a net profit, you may qualify for an above-the-line deduction for health insurance premiums without needing to itemize.
Finding Your Total Premiums
- Form SSA-1099: The Social Security Administration sends you an annual Form SSA-1099. This document lists the exact total of your Medicare premiums that were withheld from your checks over the prior year.
What is the average Medicare payment for seniors?
Most seniors pay a standard Part B monthly premium of $202.90 and $0 for Part A in 2026.
Medicare Cost Breakdown
- Part A (Hospital Insurance): Costs $0 per month for roughly 99% of seniors who paid Medicare taxes for at least 10 years. The inpatient hospital deductible is $1,736 per benefit period.
- Part B (Medical Insurance): The standard monthly premium is $202.90, with an annual deductible of $283. Higher-income earners pay more through income-related adjustments (IRMAA).
- Part D (Prescription Drugs): Standalone prescription drug plans average about $34.50 per month, featuring a yearly out-of-pocket spending cap of $2,100.
- Supplemental Coverage: Adding a Medigap policy typically adds $150 to $220 per month, bringing total monthly out-of-pocket costs for Original Medicare plus drug and supplement coverage to roughly $388 to $458. Alternatively, many seniors choose Medicare Advantage (Part C) which often features a $0 additional premium.
Is it better to be on Medicare or private insurance?
Neither option is universally "better"; Medicare is generally more cost-effective and flexible for individuals aged 65 and older, whereas private insurance is necessary for younger individuals, families with dependents, or those wanting bundled extra perks like routine dental and vision.
To decide which fits your situation, consider the core differences across key areas:
Costs and Expenses
- Medicare: Part A is typically premium-free if you worked and paid taxes long enough, while Part B has a standard monthly premium. However, Original Medicare does not have a cap on out-of-pocket expenses unless you add a Medigap (Supplement) policy.
- Private Insurance: Monthly premiums and deductibles are often higher for older adults, but plans feature an annual out-of-pocket maximum that limits your catastrophic financial risk.
Coverage and Dependents
- Medicare: Covers only individuals; you cannot add a spouse (unless they also qualify) or children. Original Medicare also excludes routine dental, vision, hearing, and prescription drugs, requiring separate Part D or Medicare Advantage (Part C) plans to fill the gaps.
- Private Insurance: Allows you to extend coverage to family members and dependents (such as children up to age 26) and frequently bundles dental, vision, and comprehensive prescription drugs into standard packages.
Doctor Networks and Flexibility
- Medicare: Original Medicare has no network restrictions; about 98% of doctors and virtually all hospitals nationwide accept it, and you rarely need referrals or pre-authorizations.
- Private Insurance: Relies heavily on specific networks (like HMOs or PPOs) that require you to stay within a defined group of doctors or get referrals to see specialists.
You can read a detailed breakdown of these differences on Medical News Today or review structural advantages on The Medicare Family.
What will happen to Medicare in 2026 for seniors?
Standard Medicare Part B monthly premiums rise to $202.90 in 2026, alongside new prescription drug caps and negotiated price drops detailed by the AARP Medicare Guide.
Key Cost Changes
- Part B Premium & Deductible: The standard Part B monthly premium increases to $202.90, and the annual deductible rises to $283.
- Part A Deductible: The inpatient hospital deductible increases to $1,736 per benefit period.
- Part D Out-of-Pocket Cap: The maximum out-of-pocket spending limit for Part D prescription drugs rises to $2,100 (up from $2,000).
- Part D Deductible: The maximum standard Part D deductible increases to $615.
Prescription and Coverage Updates
- Negotiated Drug Prices: Medicare begins offering lower prices for the first 10 high-cost drugs selected under the drug price negotiation program.
- Payment Plans: Enrollees in the Medicare Prescription Payment Plan are automatically renewed unless they opt out.
- New Protections: Beneficiaries who join a Medicare Advantage plan based on inaccurate online provider directory info get a special 3-month window to switch plans.
- Prior Authorization Pilot: Traditional Original Medicare introduces a prior-authorization pilot program for select services in six states.