What Does Original Medicare Not Cover? The Gaps You Need to Know

Understanding Original Medicare

When navigating through healthcare insurance plans, it’s crucial to know what is covered and what isn’t. Original Medicare, which consists of Part A and Part B, offers extensive coverage for many medical services but also has its limitations.

Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health care services. If you or a loved one needs to be hospitalized due to an illness or injury, Part A can help cover the costs of your stay. It also pays for care received at skilled nursing facilities following a hospitalization if certain conditions are met.

Part B covers doctors' services, outpatient care, medical supplies, and preventative care like flu shots or cancer screenings. This part is essential because it includes many routine doctor visits and treatments that you might need throughout the year. For example, if you have an annual check-up with your primary care physician, Part B would typically cover this service.

Coverage Gaps: What Original Medicare Doesn’t Include

While Original Medicare provides robust coverage for hospitalizations and outpatient services, there are several areas where it falls short:

Deductibles

Every year, both Part A and Part B have deductibles that you must meet before the plan starts covering your costs. For hospital stays under Part A in 2023, you will need to pay a $1,600 deductible per benefit period. This means if you are admitted multiple times during the year, you may face this deductible each time.

Under Part B, there is an annual deductible of $226 where you're responsible for all covered services until that amount is met. Afterward, Original Medicare typically covers 80% of approved charges, leaving you to pay the remaining 20%.

Coinsurance and Copayments

Even after meeting your deductibles, you might still have to pay coinsurance or copayments for certain services. For example, if you need a hospital stay under Part A, Original Medicare covers most costs but requires you to pay daily coinsurance amounts after the first 60 days of your stay. These additional expenses can add up quickly and may not be covered by Original Medicare alone.

No Out-of-Pocket Cap

One significant gap in Original Medicare is the lack of an out-of-pocket cap on healthcare spending. This means that if you have a serious health issue requiring extensive treatment, such as long-term hospitalization or multiple surgeries, your expenses could rise substantially without any limit. Unlike some other insurance plans which set a maximum amount you must pay each year, Original Medicare does not offer this protection.

Common Coverage Gaps

Even with the broad coverage offered by Original Medicare, there are several services and situations that people often assume to be covered but actually aren't:

Prescription Drugs

While Part B covers some medications given during doctor visits or hospital stays, most prescription drugs require a separate plan. To cover these expenses, you would need to enroll in a Medicare Part D prescription drug plan.

Routine Dental Care

Routine dental care like cleanings and fillings is not covered by Original Medicare. This means that if you need regular check-ups or treatment for cavities, you’ll have to pay out-of-pocket unless you have additional coverage through a supplemental insurance plan or private dental insurance.

Vision Care

Routine eye exams for glasses and contacts are also not included under Original Medicare. You will need separate vision insurance or to cover these costs from your own pocket if you require eyeglasses or contact lenses.

Hearing Aids

Hearing aids and related services, such as fitting and adjustments, aren’t covered unless they’re part of a treatment plan for another condition that’s covered by Original Medicare. If you have hearing loss but it isn't related to an existing covered medical issue, you’ll need to find alternative ways to cover these expenses.

Why Additional Coverage Is Often Sought

Given the gaps in coverage provided by Original Medicare, many people opt for additional insurance plans to ensure they are fully protected:

Medigap Insurance

Medicare Supplement Insurance (Medigap) is a type of plan that can help fill some of the holes left by Original Medicare. These plans cover deductibles and coinsurance costs under Parts A and B, which can significantly reduce your out-of-pocket expenses.

For instance, if you have a Medigap Plan F, it would pay 100% of your Part A deductible, hospital coinsurance, and hospice care coinsurance. This means that once you meet the requirements for eligibility, you won't need to worry about these costs anymore.

Prescription Drug Coverage

Adding a Part D prescription drug plan can provide coverage for most medications that are not covered under Original Medicare. These plans often have formularies, which list what drugs they cover and how much you will pay for each tier of medication. By choosing the right Part D plan, you can ensure that your prescriptions are affordable.

Vision and Dental Insurance

To fill in gaps related to vision care and dental services, many individuals opt for separate insurance plans specifically designed for these needs. These supplemental policies can cover routine check-ups, eyeglasses, contact lenses, cleanings, and other necessary treatments.

Understanding these coverage gaps is crucial so you can make informed decisions about your healthcare coverage. It’s worth exploring different options to ensure that you have comprehensive protection for all of your health needs.

Not affiliated with or endorsed by the federal Medicare program or any government agency.

Have questions about Medicare? Peter Abilla is a licensed Medicare insurance agent in Utah. There is no cost to work with him.