← Back to Blog

What Does Medicare NOT Cover? Filling the Gaps in Tucson

Many people are surprised — and unprepared — for what Original Medicare doesn't cover. Here's a clear, honest look at the gaps, and what Tucson seniors can do about them.

The 20% Gap — And No Out-of-Pocket Limit

Let's start with the most fundamental gap: Original Medicare pays 80% of approved medical costs for Part B services. You pay the other 20% — and there's no annual cap on what that 20% can total. If you're hospitalized for a major surgery or cancer treatment, your 20% could run into the tens of thousands of dollars.

This gap is why most financial advisors strongly recommend adding either a Medicare Supplement (Medigap) plan or a Medicare Advantage plan to your Original Medicare.

Specific Services Original Medicare Doesn't Cover

1. Routine Dental Care

Original Medicare does not cover routine dental care — no cleanings, X-rays, fillings, tooth extractions, root canals, crowns, bridges, or dentures. This is a significant gap: the American Dental Association reports that nearly 70% of seniors have some form of gum disease, and dental costs for seniors can reach thousands of dollars per year.

Limited exceptions exist: Medicare may cover dental services directly related to major medical procedures (like a heart valve replacement or organ transplant), but routine dental is simply not covered.

How Tucson seniors fill this gap: Medicare Advantage plans increasingly include dental benefits. Standalone dental insurance plans are also available and can be affordable. We can help you find options.

2. Routine Vision Care

Medicare does not cover routine eye exams for eyeglasses or contact lenses, nor does it cover the glasses or contacts themselves. Medicare does cover certain medically necessary eye services — treatment for cataracts, glaucoma, diabetic retinopathy, and macular degeneration — but the routine annual exam for a new prescription is not covered.

How Tucson seniors fill this gap: Many Medicare Advantage plans include vision benefits with an annual allowance for frames and lenses. Standalone vision plans and discount programs like VSP are also options.

3. Hearing Aids and Exams

Original Medicare does not cover hearing exams for the purpose of fitting a hearing aid, and it does not cover hearing aids themselves. Given that hearing aids can cost $2,000–$7,000+ per pair, this gap is financially significant for the estimated 2 in 3 seniors who experience some hearing loss.

How Tucson seniors fill this gap: Many Medicare Advantage plans now offer hearing benefits with an annual allowance. Over-the-counter hearing aids (now FDA-approved for mild to moderate loss) offer a lower-cost alternative.

4. Most Prescription Drugs

Original Medicare (Parts A and B) does not cover most prescription drugs you take at home. This is a major gap — Americans over 65 take an average of 4–5 prescription medications daily. Without Part D drug coverage, your monthly pharmacy bills could be substantial.

How Tucson seniors fill this gap: Medicare Part D (standalone drug plans) or Medicare Advantage plans that include drug coverage (MAPD plans). If you don't enroll in drug coverage when first eligible and don't have other creditable coverage, you'll face a permanent late enrollment penalty.

5. Long-Term Custodial Care

This is perhaps the most financially dangerous gap in Medicare. Medicare covers skilled nursing facility care — but only after a qualifying 3-day hospital stay, only for up to 100 days, and only when you're receiving skilled care (therapy, wound care, IV medications). It does not cover custodial care — help with daily activities like bathing, dressing, eating, and mobility — even in a nursing home setting.

The national median cost of a private room in a nursing home exceeds $9,000/month. For dementia care, costs can be even higher. This is a gap that can devastate family finances in a matter of months.

How Tucson seniors fill this gap: Long-term care insurance (ideally purchased before age 65 while healthy), hybrid life/LTC policies, or strategic financial planning. This is outside the scope of Medicare planning but worth serious attention.

6. Care Received Outside the United States

Original Medicare generally does not cover healthcare you receive outside the U.S. and its territories. If you're a frequent traveler or snowbird who spends time in Mexico or internationally, this gap is real and important.

How Tucson seniors fill this gap: Many Medigap plans (Plans D, G, M, N) cover 80% of foreign travel emergency care up to a lifetime limit of $50,000. Travel health insurance is another option for frequent travelers.

7. Cosmetic Surgery

Medicare doesn't cover cosmetic procedures. However, if a procedure is medically necessary (for example, eyelid surgery that obstructs vision), Medicare may cover it.

8. Routine Physical Exams

Medicare doesn't cover a traditional annual "complete physical." What it does cover is an Annual Wellness Visit (AWV) — a review of your health history, risk factors, and development of a preventive care plan. The AWV is not the same as a physical exam, and additional tests ordered during that visit may have cost-sharing.

9. Acupuncture (Most Cases)

Medicare now covers acupuncture for chronic low back pain (up to 12 sessions in 90 days), but other acupuncture uses are not covered.

10. Foot Care (Routine)

Routine foot care — nail trimming, callus removal, etc. — is generally not covered. Medicare does cover medically necessary foot care when it's related to a covered condition (like diabetes-related nerve damage).

The 20% Has No Limit — And That's the Real Risk

Beyond these specific services, the most dangerous gap is the unlimited 20% coinsurance. Consider these scenarios:

• A hip replacement: Medicare-approved amount ~$30,000 → your 20% = $6,000
• A cardiac bypass: Medicare-approved amount ~$75,000 → your 20% = $15,000
• A cancer treatment year: Medicare-approved amount ~$150,000 → your 20% = $30,000

Without Medigap or Medicare Advantage, you're exposed to those numbers with no ceiling.