Medicare coverage gaps you might not know about

Original Medicare is a health insurance program for seniors over the age of 65, people with certain disabilities, and those with end-stage renal disease. While Original Medicare covers many healthcare services, it does not cover all costs, leaving beneficiaries with significant out-of-pocket expenses. In this article, we'll explore the cost gaps of Original Medicare.

Part A Cost Gaps

Part A of Original Medicare covers inpatient hospital stays, skilled nursing facility care, hospice care, and limited home health care services. While Part A is free for most beneficiaries, there are still significant cost gaps, including:

1. Deductibles: Beneficiaries must pay a deductible of $1,600 per benefit period in 2023 before Medicare pays for inpatient hospital care.

2. Coinsurance: Beneficiaries are responsible for paying coinsurance for each day they are in the hospital, as well as for skilled nursing facility care.

3. Lifetime Reserve Days: Beneficiaries have a total of 60 lifetime reserve days that they can use if they need to stay in the hospital for more than 90 days in a benefit period. After using these reserve days, beneficiaries are responsible for paying all costs.

Part B Cost Gaps

Part B of Original Medicare covers doctor visits, outpatient services, preventive care, and durable medical equipment. While Part B requires a monthly premium, there are still significant cost gaps, including:

1. Deductibles: Beneficiaries must pay a deductible of $226 in 2023 before Medicare pays for most services.

2. Coinsurance: After meeting the deductible, beneficiaries are responsible for paying 20% of the Medicare-approved amount for most services.

3. Excess Charges: Some healthcare providers may charge more than the Medicare-approved amount, leaving beneficiaries responsible for paying the excess charges.

Part D Cost Gaps

Part D of Original Medicare covers prescription drugs. While beneficiaries can choose from a variety of plans offered by private insurance companies, there are still significant cost gaps, including:

1. Deductibles: Many Part D plans require beneficiaries to pay a deductible before coverage begins.

2. Copayments and Coinsurance: Beneficiaries are responsible for paying copayments or coinsurance for each prescription they fill, depending on the specific plan.

3. Coverage Gap: Once beneficiaries and their plan have spent a certain amount on prescriptions in a calendar year, they enter a coverage gap or "donut hole." During this time, beneficiaries are responsible for paying a higher percentage of the cost of their prescriptions until they reach catastrophic coverage.

Closing the Cost Gaps

While the cost gaps of Original Medicare can be significant, there are ways to close these gaps. Beneficiaries can enroll in a Medicare Advantage plan, also known as Medicare Part C, which provides comprehensive coverage that includes Parts A and B as well as additional benefits like prescription drug coverage and dental services. Another option is to enroll in a Medigap plan, also known as Medicare Supplement Insurance, which helps cover the out-of-pocket costs associated with Original Medicare.