What does Medicare not cover? Original Medicare generally does not cover six major categories: routine dental care, routine vision care, hearing aids, long-term custodial care, cosmetic surgery, and most care outside the United States. If you rely only on Original Medicare, you may have to pay the full cost of these services yourself.
I’m Michele Sanchez, owner of Michele Sanchez Insurance Agency. I help people in Marco Island and Naples compare Medicare Advantage and Medigap plans that may help address some of these gaps. In this guide, I go through each major exclusion and the options people often use to fill it.
Key Takeaways
- Original Medicare generally does not cover routine dental care, routine vision care, hearing aids, long-term custodial care, cosmetic surgery, or most care outside the United States.
- Original Medicare also doesn’t cover most outpatient prescription drugs. That’s what Medicare Part D is for.
- Many Medicare Advantage plans include dental, vision, and hearing benefits.
- Costs for these services vary widely, so it’s worth comparing your options before you need care.
What Does Original Medicare Not Cover?
Medicare Part A helps pay for hospital stays, and Part B helps pay for doctor visits and medically necessary care. Neither part generally pays for a routine dental cleaning, an eye exam for glasses, or a hearing aid.
There are a few limited exceptions. Original Medicare may cover some eye care, such as cataract surgery and glaucoma screenings for people at higher risk, and it may cover a diagnostic hearing exam when your doctor orders it. It generally does not cover routine exams, most glasses, or hearing aids.
Long-term custodial care is another gap. Custodial care means help with daily activities like bathing, dressing, and eating—the kind of support many nursing homes and home aides provide. Medicare may pay for a limited stay in a skilled nursing facility after a qualifying hospital stay, but it generally stops paying when your needs shift from medical care to daily personal care. People who need long-term support often pay out of pocket, qualify for Medicaid, or have long-term care insurance.
Cosmetic surgery is generally not covered either, unless it’s needed to repair an injury or restore function, such as breast reconstruction after a mastectomy.
What Can Medicare Advantage Include That Original Medicare Doesn’t?
Many Medicare Advantage plans include dental, vision, and hearing benefits as additional coverage. These plans must cover the services Original Medicare covers (except hospice care, which Original Medicare continues to cover), and many add extra benefits. Plan details can vary by county and plan, so the benefits available to you depend on where you live.
According to KFF’s analysis of March 2026 data, 35.2 million people, or 55 percent of eligible Medicare beneficiaries, are enrolled in Medicare Advantage plans. I review local plan options with my clients in Marco Island and Naples each fall during the Annual Enrollment Period.
What Does Medicare Part D Cover?
Medicare Part D helps pay for most outpatient prescription drugs, which Original Medicare generally doesn’t cover. Original Medicare covers a narrower list of drugs, mainly those given in a hospital or doctor’s office, or used with certain medical equipment. Part D plans are offered by private insurance companies approved by Medicare.
In 2026, Part D caps annual out-of-pocket costs for covered drugs at $2,100, up from $2,000 in 2025. Adult vaccines recommended by the CDC’s advisory committee, including the shingles and Tdap vaccines, have no cost-sharing under Part D. If you take several prescriptions, you may benefit from reviewing your Part D coverage each year. I go over this with my clients during every plan comparison.
Medicare Coverage Gaps at a Glance
Here’s a quick look at the most common gaps and how people often fill them.
| Service | Original Medicare | Medicare Advantage | Common ways to fill the gap |
| Routine dental care | Generally not covered | Often included | Medicare Advantage or standalone dental insurance |
| Routine vision care | Generally not covered | Often included | Medicare Advantage or standalone vision insurance |
| Hearing aids | Generally not covered | Often included | Medicare Advantage or paying out of pocket |
| Long-term custodial care | Generally not covered | Generally not covered | Long-term care insurance, personal savings, or Medicaid if eligible |
| Outpatient prescriptions | Generally not covered | Varies by plan | Part D or a Medicare Advantage plan with drug coverage |
| Care outside the U.S. | Very limited | Varies by plan | Some Medigap plans or travel insurance |
If you’d like to look at this table in relation to your own health needs, I’m happy to go through it with you.
How Does Medicare Coverage Work in Marco Island and Naples?
The choice between Original Medicare with a Medigap plan and a Medicare Advantage plan often depends on which gaps matter most to you and how you travel. In Collier County, many Medicare Advantage plans include dental, vision, and hearing benefits that Original Medicare generally doesn’t cover.
Many of my clients in Marco Island and Naples split the year between Florida and a northern state. Original Medicare works with any provider in the country that accepts Medicare, but many Medicare Advantage plans limit routine care to a local network. If you spend summers in Michigan or New York, for example, you may want a plan that works well in both places, or a Medigap policy paired with Original Medicare. I walk my clients through this tradeoff before they enroll.
What Should I Do If Medicare Denies My Claim?
Start by reading the reason for the denial on your Medicare Summary Notice or your Medicare Advantage plan’s Explanation of Benefits. Then:
1. Check whether the denial is for a service Medicare doesn’t cover, or for a question about medical necessity. Medical necessity decisions are often worth appealing.
2. File a written appeal as soon as possible or within 120 days of the notice for Original Medicare, or within 65 days for a Medicare Advantage plan. Check the Advantage plan materials sent from your plan as there may be restrictions or other deadlines for an appeal.
3. If your first appeal isn’t successful, you can move to the next level. Your decision letter explains how.
4. Reach out to a SHINE counselor, for help preparing your appeal.
How Can I Fill Medicare’s Coverage Gaps?
People in Marco Island and Naples often fill Medicare’s gaps in four ways: choosing a Medicare Advantage plan with added benefits, adding a Medigap policy to Original Medicare, buying standalone dental or vision insurance, or checking Medicaid eligibility for long-term care support. My Medicare guide covers the enrollment deadlines for each option, and my Medicare Basics post explains how Parts A, B, C, and D work together. You can find more guides like this one in my education center.
Frequently Asked Questions
Does Medicare cover dental implants?
Original Medicare generally does not cover dental implants. Some Medicare Advantage plans in Collier County include dental benefits that may help with part of the cost.
Does Medicare cover hearing aids in 2026?
Original Medicare generally does not cover hearing aids or hearing aid fittings. Many Medicare Advantage plans include a hearing aid benefit.
What happens if Medicare denies a claim?
You’ll receive a notice explaining the reason. You can file a written appeal within 120 days for Original Medicare, or within 65 days for a Medicare Advantage plan.
Does Medicare cover long-term care in a nursing home?
Medicare may cover a limited skilled nursing facility stay after a qualifying hospital stay. It generally does not cover long-term custodial care, such as help with bathing and dressing.
Does Medicare cover care I receive outside Florida?
Original Medicare covers care anywhere in the United States from providers who accept Medicare. Many Medicare Advantage plans limit routine care to a local network, which matters if you travel part of the year.
Get Local Help With Your Medicare Coverage Gaps
Original Medicare generally does not cover routine dental care, routine vision care, hearing aids, long-term custodial care, cosmetic surgery, most outpatient prescription drugs, or most care outside the United States. If you’re in Marco Island or looking for a Medicare broker in Naples, FL, I’d be glad to help you compare plans based on your health needs and budget. Please call me at (239) 682-8567. There’s no cost to you for my assistance.
Warmly,
Michele Sanchez
