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What Medicare Doesn't Cover

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Original Medicare May Not Be Enough

While Original Medicare (Medicare Parts A & B) covers your hospital and medical expenses up to a point, you are liable for all additional costs associated with your care. Those costs are often unpredictable, and depending on the length of your stay or the cost of your procedure, may be significant. It is important to understand the limits of Medicare before deciding which option best fits your current medical and financial situation.
 

No Out-of-Pocket Cap on Medicare Costs

It’s important to know that if you rely on just Original Medicare – Parts A and B – there will be no out-of-pocket spending maximums, or cap, on your Medicare costs.

chart1

 

Medicare Part A: Hospital Insurance

Monthly Premium

Typically $0

(If you or your spouse paid Medicare taxes while employed; otherwise $407)

Deductible

$1,340

per benefit period

Your Share

Hospital and skilled nursing facilities costs depend on your length of stay

Note: A benefit period starts when you enter the hospital or skilled nursing facility for an overnight stay and ends when you have been out for 60 days in a row. Since the Medicare Part A deductible applies to each benefit period (not annually), you can have multiple benefit periods in one year.

 

Hospital Stays

Days

1-60

You Pay

$0

Coinsurance for each benefit period

Days

61-90

You Pay

$335

Coinsurance per day of each benefit period

Days

91

and beyond

You Pay

$670

Coinsurance per each "Lifetime reserve day" for each benefit period (up to 60 days over your lifetime)

Days

Beyond Lifetime reserve days

You Pay

You pay all costs

Note: Inpatient psychiatric care in a freestanding psychiatric hospital is limited to 190 days in a lifetime. You must pay a $1,340 deductible per benefit period.

 

Skilled Nursing Facilities

Days

1-20

You Pay

$0

Coinsurance for each benefit period

Days

21-100

You Pay

$167.50

Coinsurance per day of each benefit period

Days

101

and beyond

You Pay

You pay all costs

Note: There is no out-of-pocket maximum.

 

Medicare Part B: Medical Insurance

Monthly Premium

$109 - $134

(depending on yearly income)

Annual Deductible

$183

Your Share

You are responsible for

20%

of the costs of medical services under Medicare
(B)

Learn more about paying for Medicare

 

Medicare Service and Benefit Limitations

Original Medicare

Offered by the Federal Government

Part

A

 

Hospital Insurance

Covers hospital and nursing home stays, and hospice care.

What's Covered

  • Hospital expenses for inpatient hospital stays (e.g. meals, supplies, tests, accommodations) 
  • Skilled nursing facility care
  • Nursing homes
  • Hospice care
  • Some part-time, medically necessary home health care (physical, occupational, and speech therapy)
  • Some medical equipment (e.g. walkers and wheelchairs)
  • Prescription drugs taken as part of inpatient hospital or skilled nursing facility treatment

Part

B

 

Medical Insurance

Covers doctor services, outpatient hospital care, durable medical equipment, and other medical services.

What's Covered

  • Doctor office visits (primary care and specialists) 
  • Test & laboratory services
  • Outpatient care
  • Medical supplies & durable medical equipment
  • Ambulance & emergency services
  • Limited prescription drug coverage, including injections received in a doctor's office, certain oral cancer drugs, and certain drugs you get in a hospital outpatient setting 
  • You can see any Medicare provider, no referrals required

Part

A

+

Part

B

What's Not Covered

  • Routine eye exams & most eyeglasses 
  • Dental care & dentures (with only a few exceptions)
  • Outpatient prescription drugs prescribed by your doctor
  • Gym memberships or fitness classes
  • Weight management programs
  • Routing hearing tests
  • Custodial care (help with bathing, dressing, using the bathroom & eating) at home or in a nursing home
  • Long-term care (for information about paying for long-term care, visit longtermcare.gov or eldercare.gov
  • Acupuncture
  • Most chiropractic services
  • Most care while traveling outside the United States

How Do You Fill the Gaps

You can protect yourself against Medicare Part A and Part B coverage gaps and expenses by purchasing a Medicare Supplement Plan (often referred to as Medigap insurance) or a Medicare Advantage Plan (Medicare Part C), which often provides extra services, like vision and fitness coverage, not covered by Original Medicare.

 

chart6

 

This chart is for illustrative purposes only and may not represent all potential coverage gaps.
 

Learn how to cover the gaps