What’s NOT COVERED under Original Medicare?

Medicare is great insurance but it doesn’t cover everything! What are some of the major gaps in Medicare?

Deductibles, Copays & Coinsurance

Medicare will provide comprehensive coverage, but there are still costs associated. These are of course: premiums, deductibles, copays and coinsurance.

Your premium is what you will pay on a monthly basis to keep your insurance active. You will likely not have to pay for Part A, however there is a premium for Part B. The base monthly premium for Part B in 2023 is 164.90. It can be more if you have a higher income.

In addition to premiums to pay to keep your insurance active, there are costs when you actually use your insurance. First there is the deductible. This is the amount that you have to meet out of pocket before your insurance begins to contribute to the cost share.

In 2023, your Part A deductible is $1600. This is applied per benefit period as opposed to annually. Benefit periods can be a little tricky to understand and we do have a video that goes more in depth, but you can think of them as similar to a hospital stay. For example, let’s say you had to be hospitalized in January, you would have to meet that $1600 deductible. If you had to be hospitalized again in October, you would have to meet that deductible again.

The Part B deductible is much easier to understand. In 2023, the Part B deductible is $226 and that is once annually. So, once you’ve met that you are good for the year until your plan resets. If interested, there are Medicare supplement plans that will cover your Part A deductible and depending upon your age, there may be a plan that will cover your Part B deductible as well. 

There are also coinsurance and copays which are determined by the type of care and original cost. For Medicare Part A, your length of stay is also a factor in your coinsurance.

Benefits

Now let’s discuss the benefits not offered by Original Medicare.

Part A will cover your hospital needs such as:

• Inpatient Care
• Skilled Nursing Facility Care
• Nursing Home Care
• Hospice Care
• Home Health Care

Part B will cover your hospital needs such as:

• Medically necessary services
• Preventative Services
• Clinical Research Studies
• Ambulatory Services
• Durable Medical Equipment
• Mental Health
• ***Limited Prescription Drugs

Dental, Vision & Hearing 

Since Original Medicare does not cover dental, vision, or hearing, many people assume that a Medigap plan will. This is simply not the case. Medigap or Medicare Supplement plans are simply a financial solution to the financial gaps or Original Medicare. So you will pay an extra premium to help cover deductibles, copays and coinsurance but they will not offer additional benefits not already offered by Original Medicare such as dental, vision, hearing, and prescription drugs. 

In the past, this was especially problematic for those with hearing loss. Many people in retirement experience some degree of hearing loss eventually needing hearing aids. Unfortunately, Medicare just doesn’t cover hearing aids. Luckily, now there are many hearing aids available over the counter for a fraction of the price.

For vision, Medicare would cover medical vision needs such as glaucoma testing but not prescription glasses. Luckily, private vision plans are relatively inexpensive.

There is no dental coverage with Medicare.  And dental care really is crucial to overall health. In fact not brushing your teeth when hospitalized has been shown to be a leading cause of non-ventilator-related pneumonia. Like vision insurance, private dental insurance is readily available and much less expensive than people think. You can also look into dental savings plans to save extra money if your dentist will accept a dental savings plans.

Medicare supplement plans do not cover these types of benefits, but Medicare Advantage plans may. Medicare Advantage plans must offer you at least the same benefits as Original Medicare, but many offer additional benefits as well. However, there are drawbacks to these types of plans which we discuss in other videos so please do not be lured in without doing proper research. 

Prescription Drugs 

Finally, another major benefit missing from Original Medicare is prescription drug coverage. Now there are some exceptions, for example:

Chemotherapy

Some anticancer oral medication

Vaccinations administered in a doctor’s office

Insulin if administered via pump

Anything else will require a Part D plan which is specially a prescription drug plan. Again, you will have an additional monthly premium and possibly a deductible to meet. Your coinsurance or copays will be determined by the tier of your medication. There are 5 tiers. The higher the tier, the higher the price.