A Complete Guide for Lehigh Valley Retirees

If you’re approaching age 65 or recently enrolled, one of the most common questions is:

“What does Medicare actually cover — and what doesn’t it?”

Understanding your Medicare coverage is essential to avoid unexpected medical bills and make informed decisions about supplemental coverage. For retirees in Allentown, Bethlehem, Easton, and throughout the Lehigh Valley, knowing the gaps in Medicare can help you plan smarter.

Here’s a clear, easy-to-understand breakdown of what Medicare covers — and where it leaves you responsible.

What Medicare Covers

Medicare is divided into different parts. Each part covers specific types of care.

Medicare Part A: Hospital Coverage

Part A generally covers:

  • Inpatient hospital stays

  • Skilled nursing facility care (short-term, after hospitalization)

  • Hospice care

  • Limited home health services

Important Notes:

  • Part A does not cover long-term custodial care in a nursing home.

  • There is a hospital deductible per benefit period.

  • Coverage for skilled nursing facilities is limited in days and requires prior hospitalization.

Most beneficiaries qualify for premium-free Part A if they worked and paid Medicare taxes for at least 10 years.

Medicare Part B: Medical Coverage

Part B covers:

  • Doctor visits

  • Outpatient care

  • Preventive services

  • Lab work and diagnostic testing

  • Durable medical equipment (wheelchairs, walkers, etc.)

  • Mental health services

Preventive Services Covered by Medicare:

  • Annual wellness visits

  • Cardiovascular screenings

  • Diabetes screenings

  • Mammograms

  • Colonoscopies

  • Flu and pneumonia vaccines

Part B typically covers 80% of approved services, leaving you responsible for 20% unless you have supplemental coverage.

Medicare Part D: Prescription Drug Coverage

Medicare Part D helps cover:

  • Prescription medications

  • Certain vaccines not covered under Part B

Each Part D plan has:

  • A formulary (list of covered drugs)

  • Pharmacy networks

  • Copays or coinsurance

Drug coverage varies by plan and county, so Lehigh Valley residents may see different options depending on where they live.

Medicare Advantage (Part C)

Medicare Advantage plans bundle:

  • Part A

  • Part B

  • Often Part D

Many plans also include:

  • Dental

  • Vision

  • Hearing

  • Fitness benefits

However, these plans are network-based (HMO or PPO), meaning you may need to use specific doctors and hospitals in the Lehigh Valley.

What Medicare Does NOT Cover

This is where many retirees are surprised.

Original Medicare does not cover:

-Routine Dental Care

  • Cleanings

  • Fillings

  • Dentures

-Routine Vision Care

  • Eye exams for glasses

  • Prescription lenses

-Hearing Aids

  • Hearing exams for fitting

  • Hearing devices

-Long-Term Custodial Care

  • Extended nursing home stays

  • Assisted living facilities

-Most Cosmetic Procedures

-Routine Foot Care (with limited exceptions)

The Biggest Medicare Gap: The 20%

With Original Medicare (Parts A & B), there is no cap on out-of-pocket spending.

That means:

  • You pay deductibles

  • You pay 20% of outpatient services

  • There is no annual maximum limit

This is why many retirees choose:

  • A Medicare Supplement (Medigap) plan
    or

  • A Medicare Advantage plan with an annual out-of-pocket maximum

How Lehigh Valley Residents Fill the Gaps

In Pennsylvania, retirees typically choose one of two paths:

Option 1: Medicare Supplement (Medigap)

  • Works with Original Medicare

  • Covers most or all of the 20%

  • No network restrictions

  • Higher monthly premium, lower surprise costs

Option 2: Medicare Advantage

  • Lower monthly premiums

  • Includes additional benefits

  • Has network limitations

  • Has an annual maximum out-of-pocket limit

The right choice depends on:

  • Your health needs

  • Your doctors

  • Your prescription medications

  • Your budget

Common Medicare Coverage Misunderstandings

Many Lehigh Valley retirees believe:

  • Medicare covers nursing home care indefinitely (it does not)

  • Dental and vision are included automatically (not under Original Medicare)

  • All doctors accept all Medicare Advantage plans (networks matter)

  • Medicare is completely free (there are premiums and cost-sharing)

Understanding these details early can prevent costly surprises.

Why Reviewing Your Coverage Matters

Healthcare needs change over time.

Even if you feel healthy today, reviewing your Medicare coverage annually helps ensure:

  • Your prescriptions are covered affordably

  • Your preferred doctors remain in-network

  • Your costs align with your retirement budget

  • You’re not overpaying unnecessarily

Final Thoughts: Medicare Is Strong — But It Has Gaps

Medicare provides excellent foundational coverage for hospital and medical services. However, it does not cover everything.

Understanding what Medicare covers — and what it doesn’t — allows you to make confident, informed decisions about:

  • Supplement plans

  • Medicare Advantage options

  • Prescription coverage

  • Long-term planning

Need Help Reviewing Your Medicare Coverage in the Lehigh Valley?

If you live in the Lehigh Valley and want clarity about your Medicare options, a local review can help you:

  • Identify potential coverage gaps

  • Compare Supplement vs. Advantage options

  • Evaluate prescription drug coverage

  • Align your healthcare with your retirement goals

At Lehigh Valley Medicare Advisors, we specialize in helping Pennsylvania retirees simplify Medicare with confidence.

Your retirement should feel secure — not uncertain.

If you’d like a complimentary Medicare review, schedule today.