Medicare Gaps
Learn About The Gaps In Coverage With Original Medicare
Original Medicare
Medicare, while providing essential healthcare coverage for millions of Americans, has significant coverage gaps that can leave beneficiaries exposed to out-of-pocket costs. These gaps arise primarily from the structure of Original Medicare (Parts A and B) and the absence of comprehensive coverage for all healthcare needs. The key gaps include:
No Out-of-Pocket Maximum:
Original Medicare does not have an annual limit on out-of-pocket expenses. Beneficiaries are responsible for coinsurance and copayments for services, which can accumulate, particularly in the case of chronic illnesses or extended hospital stays.
Prescription Drugs (No Part D Coverage)
Original Medicare does not cover most prescription drugs unless administered in a hospital setting. Beneficiaries must purchase a Part D plan or a Medicare Advantage plan that includes prescription drug coverage to help with these costs. Not enrolling into Part D can later cost you a penalty if you did not have creditable coverage in place. See our '“Prescription Drug Coverage Part D” page for more information about the late enrollment penalty.
Long-Term Care (Custodial Care)
Medicare provides limited coverage for short-term skilled nursing care, but it does not cover long-term custodial care, such as assistance with daily activities in nursing homes or at-home care, which can result in significant personal costs for those needing extended care.
No Coverage for Routine Vision, Dental, or Hearing
Original Medicare does not cover routine vision exams, dental care, or hearing aids, leaving individuals to pay for these essential services out of pocket, or seek supplemental insurance for coverage.
Medicare Part A Gaps (Hospital Insurance)
Hospital Deductible: Medicare Part A requires beneficiaries to pay a deductible for each benefit period. In 2025, this deductible can be over $1,600 per benefit period, which can be a significant cost if multiple hospitalizations occur in a year. The deductible changes annually. Got to medicare.gov to see the updated rates every year.
Extended Hospital Stays: After 60 days in the hospital, Medicare requires beneficiaries to pay coinsurance, and after 90 days, patients must use "lifetime reserve days," which are limited. Once these are exhausted, beneficiaries must pay the full cost.
Skilled Nursing Facility Care: Medicare only covers the first 20 days in a skilled nursing facility fully. From day 21 to day 100, beneficiaries are responsible for a daily copayment, and after 100 days, all costs fall on the patient.
Medicare Part B Gaps (Medical Insurance)
20% Coinsurance: For most doctor visits, outpatient care, and durable medical equipment, Medicare Part B covers 80% of approved costs, leaving beneficiaries responsible for the remaining 20%, which can become substantial over time.
Part B Deductible: Beneficiaries must also pay an annual deductible for Part B services, which in 2025 can cost over $240. This deductible changes annually. Go to Medicare.gov for the updated information
Foreign Travel Coverage:
Original Medicare offers very limited coverage for medical services received outside of the United States, leaving beneficiaries at risk if they require healthcare while traveling abroad.
Conclusion
To address these gaps, many beneficiaries opt for Medigap (Medicare Supplement Insurance) policies, which help cover some of the out-of-pocket costs not paid by Medicare, such as coinsurance and deductibles. Alternatively, some individuals enroll in Medicare Advantage (Part C) plans, which often provide additional benefits like prescription drugs, vision, and dental coverage, though these plans may have network restrictions.
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