Coverage Gaps and How to Cover Them

Many assume that signing up for Original Medicare (Parts A and B) will cover all they need, but that is not always the case. Both Part A and Part B have coverage gaps, which means you may end up paying more for your expenses than you might expect.

What do Medicare Part A and B cover?

Before we discuss coverage gaps, it’s important to understand what Original Medicare does cover.

Medicare Part A is hospital insurance that covers inpatient care like surgery, lab tests and more. Medicare Part B is medical insurance that covers things like doctors’ services, outpatient care, ambulance services and preventive services.

If you are enrolled in both Medicare Part A and Part B, you have Original Medicare. Every American aged 65 and over is eligible to receive this coverage, or those below 65 who have qualifying conditions. You don’t usually pay a premium for your Part A benefits, but you do pay a premium for Part B.

Are there coverage gaps in Original Medicare?

Original Medicare provides coverage for many different services, but some things are not covered.

One of Original Medicare’s most critical coverage gaps is prescription drug coverage. Many Americans don’t initially realize Original Medicare typically does not include coverage for their prescription medications.

While Medicare Part A coverage usually includes any medication that you would receive while in-patient in a hospital or skilled nursing facility, there is limited coverage for outpatient prescription drugs.

Medicare Part B may cover some drugs that you would receive in a hospital setting, like those that are administered by a nebulizer or injections you can’t give yourself. However, daily, self-dosed medication is not commonly covered.

Other common gaps in Original Medicare are:

· Routine vision care like eyeglasses and exams

· Standard dental services like cleanings or dentures

· Routine foot care

· Long-term care facilities (for personal care or aid with daily tasks)

· Routine hearing tests or hearing aids

· International health coverage

How might Medicare cost sharing affect me?

Medicare cost sharing is exactly like it sounds — sharing the costs of the care you receive. Fact is, Original Medicare only pays a portion of the cost of covered services. You pay the rest. That means even when services are covered by Part A or Part B, you are fully responsible for any additional out-of-pocket expenses associated with care.

For example, if you have Original Medicare and you see your doctor, your Part B coverage might pay 80% of the costs of the visit. You would then be responsible for paying the remaining 20%. Here are a few of the costs that you may have to share with Medicare:

· Part A coinsurance costs for hospital stays and skilled nursing facilities.

· Part B coinsurance and copayments.

· Part A and Part B deductibles.

It’s also very important to note that Medicare does not have an out-of-pocket cost limit per year. Because of that, there’s no limit on what you might have to pay if you have a chronic condition or experience a serious medical emergency.

How do I fill in the coverage gaps?

Despite the coverage gaps, Original Medicare does provide affordable and effective coverage — especially when compared to private insurance you may have had prior to age 65. However, if your Part A and Part B coverage isn’t fulfilling your needs, there are solutions worth considering.

If your copays are overwhelming your wallet or you are interested in international coverage, consider purchasing a Medicare Supplement, or “Medigap” policy. For an additional monthly premium, this option keeps you on Original Medicare and works in conjunction with Part A and Part B to fill in the gaps in your coverage.

Looking for a way to get all of the benefits of Original Medicare while potentially decreasing your costs? Medicare Advantage may be the right option for you.

Offered by private insurance companies, Medicare Advantage plans provide the same coverage as Part A and Part B and more. And unlike Original Medicare, they have a firm limit on your annual out-of-pocket medical expenses and often include additional health and wellness benefits.

Finally, if you have Original Medicare, with or without a Medigap policy, and want help paying for your medications, a Medicare Part D prescription drug plan could be a good option for you. These plans offered by private companies cover the costs of many medically necessary medications, which could add up to big savings for you.

Before you go

We know that finding the right coverage for your needs can feel like a tall task. Please don’t hesitate to reach out for a free consultation from a PlanEnroll licensed insurance agent. We can help you take care of your Medicare coverage gaps and provide you with the peace of mind you deserve.

PlanEnroll is a brand operated by Integrity Marketing Group, LLC and used by its affiliated licensed insurance agencies that are certified to sell Medicare products. PlanEnroll is not endorsed by the Center for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (DHHS), or any other government agency.