What Original Medicare doesn't cover

Medicare covers a lot — but not everything

Original Medicare (Part A and Part B) covers a broad range of medical services: hospital stays, doctor visits, lab tests, preventive screenings, and more. For many people, it provides a solid foundation of healthcare coverage.

But there are gaps, and they come in two kinds: cost-sharing on services Medicare does cover, and categories of care Medicare does not cover at all. Understanding both is the starting point for deciding whether you want additional coverage.

The cost-sharing gaps

Even when Medicare covers a service, you are often responsible for part of the bill:

• Part A deductible. Inpatient hospital stays come with a deductible — and it applies per benefit period, not per year. If you have separate hospital stays months apart, you can owe it more than once in the same year.
• Part B coinsurance. For doctor visits and outpatient services, you typically owe 20% of the Medicare-approved amount after meeting the annual Part B deductible. The dollar amounts of these deductibles are set by Medicare each year.
• Part B excess charges. If a provider does not accept Medicare assignment, they are permitted to charge up to 15% above the Medicare-approved amount, and that difference is yours to pay. Many providers accept assignment, but not every provider does.
• Skilled nursing facility coinsurance. Medicare covers the first 20 days of a qualifying skilled nursing stay without coinsurance. From day 21 through day 100, a daily coinsurance applies. After day 100, Medicare coverage for that stay ends.

The category gaps

Some kinds of care fall largely outside Original Medicare:

• Routine dental care, vision exams, eyeglasses, and hearing aids
• Prescription drugs you take at home, in most cases — separate prescription drug coverage exists for this
• Long-term custodial care, such as help with bathing and dressing in a nursing home or at home
• Care received outside the United States, with limited exceptions

Why the 20% deserves special attention

Here is the detail that surprises people: the 20% Part B coinsurance has no annual out-of-pocket maximum. There is no ceiling at which Medicare steps in and covers the rest. Twenty percent of a modest bill is manageable. Twenty percent of a year of serious illness is a different matter, because there is no upper limit on what it can add up to.

This is the single biggest reason people look at Medicare Supplement (Medigap) coverage, which is designed to help pay these cost-sharing amounts.

What people do about the gaps

There is no one right answer, but the common approaches are:

• A Medigap plan to help cover the deductibles, coinsurance, and excess charges described above
• A separate prescription drug plan for medications
• Standalone dental and vision coverage, or paying for routine care out of pocket
• Savings set aside for what coverage does not reach

For free, unbiased help understanding your Medicare benefits, you can call 1-800-MEDICARE or contact your local SHINE office, Florida’s free counseling program for seniors.

Want to talk it through?

Understanding the gaps is the first step toward deciding whether additional coverage makes sense for you. If you would like to walk through how these gaps apply to your situation, get in touch — no pressure, no obligation.