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Why Does Original Medicare Have So Many Coverage Gaps?


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Summary:
Original Medicare, Part A and Part B, covers a wide range of hospital and medical services. Still, you typically have to pay cost-sharing amounts under Medicare. There are also medical costs that Original Medicare doesn’t generally cover.

Original Medicare coverage gaps

One of the coverage gaps in Original Medicare is prescription drug coverage. Many people don’t realize that Medicare Part A and Part B don’t cover most prescription medications you take at home.

Medicare Part A usually covers medications you get while an inpatient in a hospital or skilled nursing facility setting. Medicare Part B may offer limited outpatient coverage for some prescription drugs you normally get at a doctor’s office (such as intravenous or chemotherapy drugs).

You might have to pay all other prescription drug costs unless you’re enrolled in Medicare Part D (prescription drug coverage) or have other insurance.

Original Medicare also doesn’t generally cover costs like:

  • Routine vision care, such as eye exams, glasses, or contacts (with some exceptions)
  • Routine dental services, including oral exams, cleanings, dentures, and fillings
  • Routine foot care
  • Routine hearing care, including hearing aids
  • Nursing home care (if all you need is personal care, or help with daily living tasks)
  • Health coverage if you’re out of the country

Original Medicare cost-sharing

Even for Medicare-covered services, there are limits to your Medicare coverage. You may need to pay out-of-pocket costs for these “Medicare coverage gaps.”

For example, Medicare Part A may fully cover skilled nursing facility treatment for the first 20 days of each benefit period. After that, you pay a daily coinsurance if your skilled nursing facility stay extends from 21 to 100 days. However, from day 101 onward, your Medicare coverage is used up, and you might pay all costs unless you have other coverage.

Cost-sharing may include expenses like:

  • Part A coinsurance costs for hospital, and skilled nursing facility care
  • Part B coinsurance and copayment costs
  • Part A deductible
  • Part B deductible

A Medicare Supplement insurance plan may help with these costs, depending on which plan type you buy. Also, be aware that Original Medicare doesn’t have an annual limit on your out-of-pocket costs. There’s no limit to your medical costs per year, even if your expenses total hundreds of thousands of dollars.

Original Medicare coverage gaps: are there solutions?

You might have a few choices when it comes to avoiding some of Medicare’s coverage gaps.

  • Do you want to stay with Original Medicare, but get help with cost sharing and coverage gaps like overseas travel coverage? A Medicare Supplement insurance plan might be an option for you. Sold by private insurance companies, these plans work alongside Original Medicare to cover certain out-of-pocket costs, like copayments and deductibles. You can view all 10 standardized plan types available in most states here. You need to stay enrolled in Original Medicare. Learn more about Medicare Supplement insurance.
  • If you’d like help with prescription drug costs, you may want to think about enrolling in a Medicare Part D prescription drug plan, a stand-alone plan that helps with medication costs. It’s a good idea to enroll when you’re first eligible for Part D, or you could owe a late-enrollment penalty when you do sign up.
  • Another option is to get your Part A and Part B services through a Medicare Advantage plan. As an alternative way to get your Original Medicare benefits, these plans deliver your Part A and Part B benefits through a private, Medicare-approved health insurance company. You’re still in the Medicare program if you enroll in a Medicare Advantage plan.

Many Medicare Advantage plans also cover extra benefits like prescription drugs, routine vision or dental care, hearing services, or wellness programs. As an added benefit, each Medicare Advantage plan has a maximum out-of-pocket limit, so there’s a cap on your yearly out-of-pocket costs. This limit may vary from one plan to another.

Medicare may work with other types of insurance you might have, such as veteran benefits, employer-based coverage, or retiree insurance. These types of coverage may help fill some of the gaps in your Medicare insurance.

Finding Medicare plan options

If you’re ready to explore different options, eHealth’s plan finder tool lets you do so right from your phone, computer, or tablet. Take a look at Medicare plan options in your area by entering your zip code into the tool to get started.

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