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Understanding Medicare Parts A and B Coverage Gaps

Medicare Parts A and B Coverage Gaps

Original Medicare offers Part A (hospital insurance) and Part B (medical insurance)—coverage that covers many of your healthcare needs once you enroll. But it doesn’t cover everything.

To help you fill in the gaps, consider these 5 important cost factors.

1. Prescription drugs

Original Medicare doesn’t include prescription drug coverage (though some drugs are covered under Part B). And prescription drugs can be a budget buster. If you want coverage, you have options:

  • You can purchase a stand-alone prescription drug plan to add to Original Medicare
  • You can choose a Medicare Advantage plan that includes coverage for prescription drugs

2. Dental costs

  • Original Medicare does not cover routine dental care, although some dental services while hospitalized and certain emergency procedures are covered
  • Many Medicare Advantage Plans include dental care in their coverage, including preventive care all the way up to root canals and dentures

3. Vision care

  • Routine vision care is not covered by Original Medicare. So if you wear glasses or contacts, you’ll have to pay out of pocket for most exams and eyewear.
  • Part B benefits will cover annual glaucoma screenings for those deemed to be at high risk for this condition. Part B also helps cover cataract surgery and related costs including vision correction products.
  • Many Medicare Advantage plans include coverage for routine eye exams, eyeglasses (frames and lenses) and contact lenses

4. Long-term hospital stays

Medicare Part A covers some of the costs of hospital care but not all. For an extended hospital day, be aware of your limits. For example, in 2021: 

  • You would have had to pay a $1,484 deductible for each “benefit period”*
  • Days 1–60, you pay $0 coinsurance for each benefit period
  • Days 61–90, you pay $371 coinsurance per day of each benefit period
  • Days 91 and beyond, you would have been responsible for paying $742 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)**
  • If you run out of lifetime reserve days, you’ll pay 100% of your costs

*A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). The benefit period ends when you haven't gotten any inpatient hospital care (or skilled care in an SNF) for 60 days in a row. If you go into a hospital or am SNF after 1 benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

** Original Medicare covers up to 90 days of inpatient hospital care each benefit period. You also have an additional 60 days of coverage, called lifetime reserve days. These 60 days can be used only once, and you will pay coinsurance for each one ($742 per day in 2021).

5. Maximum out-of-pocket costs

All Medicare Advantage plans must include a guaranteed annual maximum out-of-pocket cost for covered services.

To discuss your coverage gaps and the best ways to get protection, call us at 304-461-7858. Medicare Annual Enrollment is coming up on October 15th to December 7th and we would be happy to help answer any questions you have.