When you try to figure out what services are covered by Medicare and which ones might leave you with surprise bills, it can be hard to know where to start. Medicare is an essential health insurance plan for millions of seniors, but it doesn’t cover everything. Being aware of these coverage gaps will help you make more informed decisions about your healthcare and avoid unexpected costs.
Understanding Medicare’s Four Parts
There are four parts to Medicare, each designed to address a distinct healthcare need. Part A covers hospital stays and care for individuals who are already in the hospital. Part B covers medical services that are not provided in a hospital setting. Part C offers private plan options, and Part D pays for prescription drugs. Knowing how these parts work together will help you make smart choices about your health insurance.
Medicare Part A: Hospital Insurance
Medicare Part A pays for hospital stays and other related services. Most people don’t have to pay extra for Part A because they already paid for it through payroll taxes.
Part A covers critical hospital-related services like:
- Hospital stays for inpatients, which include meals and semi-private rooms
- Care in a skilled nursing facility after a qualifying stay in the hospital
- Care for people who are dying in hospice
- Home health services for people who can’t leave their homes
- Inpatient care in religious hospitals that don’t provide medical care
These services form the basis of Medicare’s hospital coverage.
Part A doesn’t cover long-term custodial care, upgrades to private rooms (unless medically necessary), personal convenience items, or most care that is not in the United States.
Medicare Part B: Medical Insurance
Part B includes outpatient medical care and preventive care that help keep you healthy when you’re not in the hospital.
Part B covers a lot of regular medical services, such as:
- Visits to the doctor, consultations with specialists, and care outside of the hospital
- Blood tests and cancer screenings are examples of preventive services.
- Things like wheelchairs and oxygen tanks that are used in medicine
- Ambulance services are available when needed for medical reasons
- Services for mental health and drug abuse treatment
This comprehensive outpatient coverage enables seniors to effectively manage their daily health needs.
Sadly, Part B has big holes in it. Part B doesn’t cover routine dental care, eye exams and glasses, hearing aids, or most cosmetic procedures.
Medicare Part C: Medicare Advantage Plans
Medicare Advantage plans are private insurance plans that must offer at least the same coverage as Original Medicare. Many offer better benefits, like coverage for prescription drugs, dental and vision care, hearing aids, and wellness programs. However, these plans typically require you to visit specific networks of doctors and hospitals.
Medicare Part D: Prescription Drug Coverage
Part D helps pay for prescription drugs, but the amount of coverage varies from plan to plan. The “donut hole” is a part of each plan’s formulary and cost structure, where you may have to pay more out-of-pocket until you reach the catastrophic coverage threshold.
What Original Medicare Doesn’t Cover
If you’re not ready, the gaps in Original Medicare coverage can be significant and expensive.
These are some of the most essential services that Original Medicare usually doesn’t cover:
- Routine dental care, like cleanings, fillings, and false teeth
- Eye exams for glasses, contacts, and glasses
- Hearing tests and hearing aids to help fit hearing aids
- Long-term care in nursing homes for people who need it
- Healthcare received in other countries
These coverage gaps indicate that seniors often require additional coverage.
Real-World Coverage Scenarios
Think about Maria, a 68-year-old Medicare recipient who needs dental work. Her dentist says she needs a $1,200 crown, but Original Medicare does not cover this routine dental care. Without extra coverage, Maria has to pay for everything herself.
Medicare Part A paid for Robert’s hospital stay when Maria’s husband had chest pain. Part B paid for his visits to the emergency room, diagnostic tests, and consultations with specialists. They only paid the coinsurance and deductibles for their Medicare coverage.
Comparing Coverage Options
| Coverage Area | Original Medicare | Medicare Advantage | Medigap + Original Medicare |
| Hospital stays | Covered with a deductible | Covered with plan rules | Deductible often covered |
| Doctor visits | 80% after deductible | Varies by plan | Usually 100% covered |
| Prescription drugs | Not covered | Often included | Requires a separate Part D |
| Dental care | Not covered | Sometimes included | Not typically covered |
| Vision care | Limited coverage | Sometimes included | Limited coverage |
This comparison shows how different Medicare options handle various healthcare needs.
Strategies for Filling Coverage Gaps
Before they need care, smart Medicare beneficiaries make plans for gaps in coverage.
Some common strategies include buying a Medigap policy, selecting a Medicare Advantage plan with additional benefits, purchasing separate dental and vision insurance, contributing to a health savings account, and comparing prescription drug plans during open enrollment.
These methods help ensure you don’t get surprised by unexpected medical bills.
Making Informed Medicare Decisions
It is essential to understand what Medicare covers and what it does not, to plan your healthcare effectively. Medicare covers a wide range of medical services, but it doesn’t cover dental, vision, hearing, or long-term care. If you’re not prepared for these gaps, they could cost you a significant amount of money.
The key to effective Medicare planning is to understand your limits early on and explore other coverage options. You can fill in most coverage gaps with Medigap insurance, Medicare Advantage plans, and other extra options. Assess your healthcare needs, review the different plans, and select the one that best protects your health and finances.
Every year, Medicare rules and plan options change. To ensure you’re getting the best deal, review your coverage during open enrollment each year.