Medicare provides broad coverage for many essential healthcare needs, but it does not cover everything. It is important to understand what is and is not included, so you can plan ahead, avoid unexpected expenses, and decide whether a Medicare Advantage plan or a Medicare Supplement (Medigap) plan is right for you. In this post, we outline what Original Medicare covers, where the gaps are, and what options you have for protection from unexpected out-of-pocket costs.
What Does Original Medicare Cover?
Original Medicare has two main parts:
- Part A (hospital insurance): This covers inpatient hospital stays, skilled nursing facility care (under certain conditions), hospice care, and some home healthcare services. Most people do not pay a premium for Part A.
- Part B (medical insurance): Part B covers doctor visits, outpatient care, preventive services, medically necessary services, such as lab work, x-rays, and certain treatments, and durable medical equipment. It requires a monthly premium.
Although Parts A and B together cover a large portion of basic healthcare needs, you should be aware of the limits of Original Medicare.
What Does Medicare Not Cover?
Coverage under Original Medicare stops in certain areas. The following are common exclusions:
- Prescription drugs: Most outpatient prescription medications are not covered. You will need to enroll in a standalone Medicare Part D plan or a Medicare Advantage plan with drug coverage.
- Dental care: Although oral health is key to overall wellness, routine dental exams, cleanings, fillings, crowns, and dentures are not covered by Medicare.
- Vision care: Medicare does not cover routine eye exams, and it will only help pay for eyeglasses or contact lenses after cataract surgery.
- Hearing services: Routine hearing exams are excluded from Medicare coverage.
- Long-term care: If the need is primarily custodial (help with daily activities such as bathing, dressing, or eating) Medicare does not cover extended stays in nursing homes or assisted living facilities.
- Alternative medicine: Services such as acupuncture, naturopathy, and chiropractic care, except spinal manipulation for subluxation (partial dislocation), are not covered under Part B.
What Are Out-of-Pocket Costs with Medicare?
Original Medicare beneficiaries must meet an annual deductible before coverage kicks in. After the deductible is met, you pay coinsurance, which is typically 20% of the Medicare-approved amount for the service under Part B. Certain services may require a flat copayment. These expenses can add up quickly, and there is no maximum out-of-pocket limit with Original Medicare, unless you enroll in a Medigap plan.
How Can You Fill the Coverage Gaps?
Beneficiaries have several options for managing costs and obtaining healthcare services not covered by Medicare:
- Medigap plans are supplemental policies offered by private insurers to help cover out-of-pocket costs with Original Medicare.
- Standalone Part D plans can cover prescription drugs.
- Medicare Advantage (Part C) plans bundle Part A and Part B coverage and often include prescription drug coverage. Many offer benefits not covered by Original Medicare, such as dental, vision, and hearing care.
Work with an Agent at Wm. R Karschner & Sons
We help individuals understand Medicare options and choose plans that fill the gaps in coverage. If you have questions or want to explore additional options, our agents are here to help. You can reach us at (570) 724-4852.