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What Medicare Doesn’t Cover: Avoid Costly Surprises

When you think about Medicare, it’s easy to assume it covers everything you might need as you age, but that’s far not quite the truth. While Medicare provides important and often lifesaving benefits, there are several healthcare services and items that Original Medicare (Parts A and B) simply doesn’t pay for. If you’re not aware of these gaps, you could face unexpected bills. Let’s take a closer look at what Medicare doesn’t cover and how you can protect yourself from high out-of-pocket costs.

Long-Term Care (Custodial Care)

One of the biggest misconceptions about Medicare is that it covers long-term care. In reality, Medicare does not cover custodial care, which includes help with daily activities like bathing, dressing, or eating; if it’s the only care you need.
Medicare may cover short stays in a skilled nursing facility after a hospital stay, but not ongoing assistance in a nursing home or at home.

How to plan: Look into long-term care insurance or other alternatives, such as life insurance with long-term care riders or setting aside personal savings.

Most Dental Care

Original Medicare doesn’t cover routine dental cleanings, fillings, extractions, root canals, dentures, or implants.
It will only cover dental procedures if they’re medically necessary as part of another covered procedure; like jaw surgery in a hospital.

Your options: Some Medicare Advantage (Part C) plans include limited dental coverage. Standalone dental plans are also available.

Vision Care

Medicare doesn’t cover routine eye exams for glasses or contact lenses. It also won’t pay for eyeglasses or lenses unless you’ve had cataract surgery.

Exceptions: Medicare does cover exams for certain conditions like glaucoma, diabetic retinopathy, or macular degeneration.

Your options: Many Medicare Advantage plans offer some vision benefits and like dental plans there are stand alone options as well as dental & vision packages.

Hearing Aids and Exams for Fitting Them

Hearing loss is common with age, but Medicare won’t cover hearing aids or the exams needed to fit them.
This can be a big financial hit, with hearing aids often costing thousands of dollars per pair.

Your options: Check Medicare Advantage plans or look for a stand alone plan, discount programs and clinics offering more affordable devices.

Routine Foot Care

Unless you have a qualifying condition like diabetes, Original Medicare doesn’t cover routine foot care like callus removal, nail trimming, or orthotics.

Your options: Some Medicare Advantage plans may cover podiatry services.

Over-the-Counter Medications and Most Prescription Drugs

Medicare Parts A and B don’t cover most prescription drugs or any over-the-counter medications. For that, you’ll need to enroll in a Medicare Part D plan (Prescription Drug Plan) or choose a Medicare Advantage plan that includes drug coverage.

Important: Even with drug coverage, some expensive medications may not be on your plan’s formulary; always check!

Foreign Travel Emergency Care

Generally, Medicare doesn’t cover healthcare you receive outside the U.S., except in very limited circumstances.

Your options: Some Medigap plans (like Plan G or Plan N) include limited foreign travel emergency benefits. You can also buy standalone travel insurance.

Cosmetic Surgery

Medicare doesn’t cover cosmetic procedures unless they’re needed due to accidental injury or to improve function from a deformity or illness (e.g., breast reconstruction after a mastectomy).

Acupuncture (Beyond Limited Use)

Medicare only covers acupuncture for chronic lower back pain, and only under specific guidelines. Other types of acupuncture, or treatment for other conditions, aren’t covered.

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How to Fill the Gaps

To protect yourself from unexpected expenses, consider:

• Medigap (Medicare Supplement Insurance): Helps pay for deductibles, copays, and coinsurance.
• Medicare Advantage (Part C): May include extra benefits like dental, vision, hearing, and wellness.
• Prescription Drug Plan (Part D): Adds drug coverage to Original Medicare.
• Dental, Vision, and Hearing Insurance: Available as standalone policies.

Agents: Watch a quick YouTube video on why and how to sell ancillary with Medicare

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Medicare is an important program, but it’s not all-inclusive. Being proactive and understanding what it doesn’t cover can help you make smarter choices and avoid surprise bills. Talk to a licensed Medicare agent to help assess your needs and explore coverage options that close the gaps.

Understanding Medicare Coverage of Physical Therapy

Physical therapy can play a vital role in recovery from injury or illness, helping individuals regain strength, mobility, and independence. However, it can also be a time-consuming and costly process. If you’re a Medicare beneficiary, it’s important to understand Medicare coverage of physical therapy.

When Physical Therapy May Be Necessary

Physical therapy (PT) is designed to evaluate and treat conditions that limit the ability to function in daily life. The goals of PT may include:

• Restoring lost mobility or strength
• Slowing physical decline
• Managing chronic conditions
• Preventing further injury

Medicare Coverage of Physical Therapy

Most outpatient physical therapy services are covered under Medicare Part B, which includes:

• Medically necessary physical therapy
• Occupational therapy (OT)
• Speech-language pathology (SLP)

If you receive physical therapy during an inpatient stay (such as in a hospital or skilled nursing facility), Medicare Part A may cover those services as part of your inpatient benefits.

Medicare Advantage (Part C) members should refer to their plan’s Evidence of Coverage or contact the plan’s member services for specific benefits, as coverage may vary by plan.

Eligibility & Medical Necessity

For Medicare to cover physical therapy:

• The services must be medically necessary
• A doctor or healthcare provider must prescribe and supervise the treatment
• The patient must receive care at a facility that accepts Medicare assignment

Services must target a diagnosed condition and be part of a treatment plan with documented goals and progress reviews.

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Therapy Thresholds and the KX Modifier Rule (2025 Limits)

In 2018, Medicare eliminated the hard cap on therapy services, replacing it with a “soft cap” or threshold. This allows continued access to necessary care while tracking usage and ensuring services are medically necessary.

In 2025, the therapy thresholds are:

• $2,330 for combined Physical Therapy (PT) and Speech-Language Pathology (SLP) services
• $2,330 for Occupational Therapy (OT) services

Once a patient exceeds these thresholds, the provider must apply a KX modifier on Medicare claims to confirm that services continue to be medically necessary.

Important: These thresholds are not a hard limit. As long as therapy is medically necessary and properly documented, Medicare will continue to cover services beyond the threshold.

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What Will You Pay?

Under Medicare Part B:

• You pay the annual Part B deductible (which is $240 in 2025)

• After meeting the deductible, you’re responsible for 20% coinsurance of the Medicare-approved amount

If you have a Medicare Supplement (Medigap) plan, it may cover the 20% coinsurance. Be sure to confirm your provider accepts Medicare assignment, which ensures you’re not billed more than Medicare’s approved rates.

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Who Can Provide Covered Therapy Services?

To be covered by Medicare, therapy must be delivered by:

• A licensed Physical Therapist (PT)

• A licensed Occupational Therapist (OT)

• A licensed Speech-Language Pathologist (SLP)

These professionals must meet Medicare’s credentialing and billing requirements.

Documentation and Progress Tracking

For continued Medicare coverage, your therapy provider must:

• Track and document your progress

• Demonstrate ongoing medical necessity

• Review and update your care plan as needed

Active participation in your therapy plan and attending all scheduled sessions are key to both recovery and continued coverage.

With understanding and guidance, accessing the necessary physical therapy services is easy and comes without added financial stress. 

Beneficiaries enrolled in a Medicare Advantage plan should review plan-specific benefits or contact their Medicare agent or your plan’s customer service for details. 

Assisted Living FAQs

Because many people have questions about assisted living, we are providing answers to the most asked Assisted living FAQs in the post below.

What is an assisted living facility:

Assisted living facilities provide individuals assistance with the ADLs (activities of daily living).  These activities include; meal preparation, bathing, dressing as well as medication management to name a few.  All these activities are categorized as custodial care.

Click here to learn more about the activities of daily living

What is the difference between Medicaid and Medicare in assisted living coverage:

There are definitely difference in how Medicare and Medicaid provide coverage for assisted living.

1.  Medicare does not provide any coverage for assisted living facilities. Although it does short-term stays in a skilled nursing facility for rehabilitation purposes as long as specific requirements are met.  This criterion includes the exclusion of the need for long-term care.
2. In some states, qualified Medicaid enrollees may receive help from a waiver program they provide with the costs for personal care as well as some other support services beneficiaries receive in an assisted living setting.  This assistance can reduce the total cost of assisted living quite a bit.  However, Medicaid does not offer help with the costs of room and board in an assisted living facility.

Click here for more details on Assisted living coverage

Is there a way to get financial assistance for assisted living:

As stated above, several states provide help with assisted living costs for anyone who has limited financial resources and qualifies for help such as Medicaid.

Veterans may qualify for help through programs offered through their local VA.  These programs and VA benefits may offer help with the costs of assisted living.

Although Medicare does not cover assisted living facilities, it will cover cost for medical treatment provided by doctors or hospitals as well as some approved skilled nursing facility care. If prescription drugs are needed, they are covered by Medicare Part D.

Medicare rules for physical therapy

If you are like many people, you may need physical therapy at one time or another.  Physical therapy (P.T.) can be a lengthy and expensive process.  If you are a Medicare beneficiary, you might ask about the Medicare rules for physical therapy coverage.

Why do you need physical Therapy:

Physical Therapy is provided to evaluate and treat injuries or diseases that impede your ability to function.  The goal of P.T. is to either improve or maintain current function as well as to slow the decline.

When it comes to physical therapy and Medicare coverage, in most cases, it is covered by Medicare Part B.  Medicare Part B covers outpatient services, including medically necessary physical therapy, occupational therapy, and speech-language pathology services.

In some cases, Medicare Part A covers Physical therapy if it is received as inpatient rehabilitation.  This is usually connected to an inpatient hospital stay.

Please note: members of Medicare Advantage plans need to check their evidence of coverage for benefit and coverage information.  If you do not have a copy, call the member services number located on the back of your ID card to get coverage details.

Physical therapy eligibility and medical necessity:

Although Medicare Part B covers physical therapy, it is important to understand that not all therapy sessions are eligible for reimbursement. Medicare requires that the therapy services are medically necessary to address a specific condition or injury.  Additionally, your doctor or healthcare provider must prescribe and oversee the therapy sessions.

Caps and Exceptions:

In the past, Medicare put annual therapy caps in place to limit the benefit amount members could use. However, as of 2018, Medicare has removed these caps.  This is because of MACRA (Medicare Access and CHIP Reauthorization Act). This change gives beneficiaries access to necessary therapy services without the stress of being cut off due to an arbitrary cap.

Although these days there is an annual “soft cap” in place, all this means is, providers must track their patients’ progress and state that the Pt is medically necessary, and coverage will be provided.  Once a patient gets close to the threshold, providers must use a KX modifier when submitting claims to prove services are medically necessary.

In 2023, the threshold is $2,230 for PT and SLP services combined.  For OT services it is $2,230.  This is a total annual coverage amount even if a patient seeks therapy for several different conditions during the course of the benefit period.  All services count toward that patient’s threshold. This threshold (soft cap) is not intended to prevent Medicare patients from obtaining medically necessary care.  It is just in place to avoid abuse of the system and track a patient’s progress to ensure the medical necessity.

Please note; as long as your physical therapy is medically necessary there is not limit on outpatient therapy services in one year.

What is the cost for physical therapy:

Under Medicare Part B, most beneficiaries pay an annual deductible. Once you meet your deductible, you must pay the 20% of the Medicare-approved amount for covered therapy services. If you have a Medicare Supplement plan, that plan pays the 20% left after your deductible is met and Medicare pays its part.  It’s important to verify that your therapy provider accepts Medicare assignment, which means they agree to accept the amount that Medicare deems reasonable for their services as payment in full.

Requirements for therapy providers:

To make sure Medicare covers the services you receive, your physical therapy must be provided by a qualified healthcare professional who meets Medicare’s standards. This rule applies to licensed physical therapists (PTs), licensed occupational therapists (OTs), as well as licensed speech-language pathologists (SLPs).

Documentation and Progress Reporting:

In order to receive continued coverage of physical therapy sessions, your provider must document your progress regularly.  Documenting helps justify the medical necessity of ongoing therapy as well as provides insight into your functional improvements. It is also important to attend all recommended therapy sessions and actively participate in your treatment plan.

Once you know the rules and requirements for Medicare coverage for physical therapy, you can move forward with your recovery without having to worry about any possible financial strain your treatment may cause. It is imperative that you communicate with your healthcare provider and therapy team to maximize the benefits of Medicare’s coverage and work towards achieving your health and wellness goals.

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