Blog - Gaps in Coverage

The Scope of Coverage Gaps

Original Medicare (Parts A and B) generally excludes several services that many seniors require for daily well-being. Notable omissions include:

Routine Care: Most dental, vision and hearing services are not covered. This includes routine cleanings, tooth extractions, dentures, eye exams for prescription glasses, and hearing aids.

Long-Term and Custodial Care: Medicare does not cover long-term care—such as stays in an assisted living facility or nursing home—when the care is primarily "custodial" (help with daily activities like bathing, dressing, or eating).

Prescription Drugs: Original Medicare does not include coverage for most prescription medications taken at home.

Other Exclusions: Routine physical exams, cosmetic surgery, and alternative treatments like massage therapy are typically excluded from coverage.

Managing Costs

Beyond specific services, Original Medicare leaves "financial gaps" in the form of out-of-pocket costs. There is no annual limit on your total out-of-pocket expenses for coinsurance, copayments, and deductibles, which can lead to significant financial risk during a major health event.

How to Bridge the Gaps

To address these limitations, many beneficiaries look toward supplemental options:

Medicare Supplement Insurance (Medigap): These private policies act as "glue" for Original Medicare, helping to pay for the out-of-pocket cost gaps like deductibles and coinsurance.

Medicare Advantage (Part C): These plans are an alternative to Original Medicare. They often "bundle" Part A, Part B, and sometimes Part D into one plan and frequently offer extra benefits like dental, vision, and fitness programs.

Part D Plans: Since prescription drugs are not covered by Original Medicare, you can enroll in a standalone Part D plan to manage medication costs.

Ultimately, reviewing these gaps annually helps you ensure that your coverage aligns with your personal health needs and financial situation.