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What Are the Original Medicare Coverage Gaps?

original Medicare coverage gaps

Original Medicare includes Part A and Part B coverage. It provides many medical and hospital services. While this is true, a person will also have to pay the cost-sharing amounts based on Medicare standards. There are some medical costs that Original Medicare will not cover.


Coverage Gaps in Original Medicare


One of the primary coverage gaps that occur in Original Medicare is coverage for prescription drugs. Some people do not realize that Medicare Part A and Part B coverage will not cover most of the prescription medications that are taken home.


Usually, Medicare Part A will cover medications a person receives when they are an inpatient at a skilled nursing facility or a hospital. Sometimes, Medicare Part B will provide limited outpatient coverage for some of the prescriptions a person takes that they receive from the doctor’s office, such as chemotherapy or intravenous drugs.


Keep reading below to see the costs that, in most cases, are not covered by Original Medicare.


Usually, Original Medicare will not cover the following costs:


  • Health coverage for individuals outside the country
  • Routine vision services like contacts, glasses, or eye exams
  • Nursing home care
  • Routine hearing care services, including hearing aids
  • Routine dental services like fillings, dentures, cleanings, or oral exams
  • Routine foot care


Cost Sharing with Original Medicare


Even if you are receiving services covered by Medicare, there are limits to the coverage provided. It will be necessary for a person to pay out of their own pocket for these “gaps” in coverage.


For example, with Medicare Part A, a person may receive full coverage for treatment from a skilled nursing facility for the initial 20 days of every benefit period. After that point, an individual must pay the daily coinsurance rate if the stay at the nursing facility extends from 21 up to 100 days. Past day 101, a person’s Medicare coverage is used, and a person must pay all related costs unless they have another type of coverage.


Cost-sharing will usually include expenses such as:


  • Part A deductible
  • Part A coinsurance costs
  • Part B copayment and coinsurance costs
  • Part B deductible


Medicare Supplement insurance plans may help offset some of these costs, but it is dependent on the plan that is purchased. It is also necessary to be aware that Original Medicare does not have any out-of-pocket limit during the year. There is no limit to the medical costs each year, even if the expenses result in hundreds of thousands of dollars in fees.


What Are the Solutions to Medicare Coverage Gaps?


There are a few options when someone is trying to avoid the coverage gaps seen with Medicare plans. For example, if a person wants to remain with their Original Medicare coverage by receive assistance with cost shaving along with coverage gaps, then Medicare Supplement insurance is a smart investment. Private insurance companies sell this, and the plans will work with Original Medicare plans to cover some out-of-pocket costs, such as deductibles and copayments.


If you need assistance covering prescription drug costs, I can help you look into Medicare Part D coverage. This is a stand-alone plan that will help with medication costs. It is a good idea to enroll when someone is initially eligible for Part D, or someone may owe a late-enrollment penalty when a person signs up.


Another viable option is to have Part A or Part B services provided through Medicare Advantage plans. This is an alternative method to receive the Original Medicare benefits, as these plans deliver both Part A and B benefits through a private insurance company that is Medicare-approved. Even if someone enrolls in a Medicare Advantage plan, they are still in the Medicare program.


Some Medicare Advantage plans will also cover additional benefits, such as hearing services, dental care, vision care, prescription drugs, and specific wellness programs. An added benefit of Medicare Advantage plans is that they have a maximum out-of-pocket limit, which means there is a cap on the out-of-pocket costs. The limit could vary from one plan to the next.


In many cases, Medicare will work with other insurance types, such as retiree insurance, employer-based coverage, and veteran benefits. The types of coverage may help and fill in some of the gaps present in Medicare insurance. Take time to consider all the factors mentioned here to find the right plan for a your needs and budget, as this is going to pay off in the long run.


Don't leave your Medicare to Chance


Coverage gaps can be a scary thing, since they tend to surprise people who chose coverage without being fully informed. When you choose to work with my team, we take your needs and concerns as the first consideration. We show you plans that avoid coverage gaps and give you options based on what you need.


If you feel this article helped you, please share it! And if you have any questions, you can contact me and I will personally answer any question you have.

How Can Your Current Medicare Plan Change Next Year?

By John Ellis • 19 Dec, 2022
Many people are reluctant to change their Medicare Part D or Medicare Advantage plan coverage year-to-year. However, millions of Medicare beneficiaries will see significant changes in their Medicare costs and coverage. If you are staying with your current Medicare plan into next year, please be sure to review your plan’s Annual Notice of Change (ANOC) letter and use this list to help you look for important coverage changes that might impact your coverage next year. And remember, there are no health-related questions should you decide to change your Medicare Advantage plan or Medicare prescription drug plan (however, Medicare Advantage Special Needs Plans require that you meet the plan’s specific “need”). Your Medicare Plan May No Longer Be Offered Next Year Many folks are currently enrolled in a Medicare Advantage plan (MA or MAPD) that will no longer be available next year. We can help you determine what will be happening with the plans you are looking at, or the ones you are currently enrolled in. You May Be Automatically Reassigned to a Different Medicare Plan Next Year Every year, many people enrolled in Medicare Advantage and/or Part D Standalone plans are automatically "crosswalked" into another plan for next year. Normally, you will be notified if you are in this group but we are more than happy to help you know for sure. Your Medicare Plan May Change It's Name Sometimes, your Medicare plan (no matter what type it is) may be changing its name. Along with a name change, it could also have different features. Your Monthly Medicare Part D Premium May Be Increasing Many Medicare beneficiaries will see their monthly Medicare Part D premium increase 20% or more. Some people currently enrolled in a Part D plan will see their plan premium double next year. The good news is that there is a group of people that will see a premium decrease of 10% to 63% next year. Please keep in mind that in addition to lower-premium Part D plans, there may be low- or $0 premium Medicare Advantage plans (MAPDs) available in your area. Your Plan’s Initial Deductible May Increase Typically, the Medicare Part D deductible increases year-over-year. The exact amount can also depend on your situation. Your Medicare plan’s Initial Coverage Limit (ICL) may change Almost all stand-alone 2022 Medicare Part D plans use the standard Initial Coverage Limit (ICL), though some 2022 Medicare Advantage plans offer an ICL other than the standard — ranging higher and lower. Your drug plan’s ICL sets the boundary between your Medicare Part D plan’s Initial Coverage Phase and the Donut Hole or Coverage Gap. The ICL is measured by the total retail value of your prescription drug purchases. You can contact American Senior Benefits for detailed information on the Medicare Advantage plans that have an increased or decreased Initial Coverage Limit. Your Medicare Plan’s Cost-Sharing Can Vary Significantly Between “Preferred” and “Standard” Network Pharmacies Year-over-year, certain stand-alone Medicare prescription drug plans (PDPs) will use different cost-sharing for preferred vs. standard network pharmacies. As an example, your plan might have a co-payment of $0 for a Tier 1 medication at preferred network pharmacies and, for the same Tier 1 drug, a $5 co-pay when purchased at a standard network pharmacy. Your Medicare Advantage plan's Maximum Out-of-Pocket (MOOP) Limit May Change The Medicare Advantage plan MOOP threshold limits how much you will spend on co-payments and co-insurance for in-network, eligible Medicare Part A and Part B coverage. It can often change year-over-year for plans and it is important to be aware of these changes. The Bottom Line for Medicare Enrollees If you decide to stay with your current Medicare Part D or Medicare Advantage plan into next year– AND you understand how your Medicare plan is changing – you do not need to do anything – you will be automatically re-enrolled into your Medicare plan along with any changes your plan is making for the coming year. If your Medicare plan is being terminated in coming year and you are not merged or “crosswalked” to another Medicare plan, you may be without Medicare plan coverage on January 1st. We are always happy to clear up any confusion when it comes to these Medicare changes that you should be aware of, so please feel free to reach out whichever way is most preferable for you.

How to Compare Medicare Advantage Plans

By John Ellis • 19 Dec, 2022
When it comes to Medicare Advantage plans, there are several factors to consider. Comparing these plans and knowing what to look at are crucial steps. Keep reading to learn more about Medicare Advantage plans, along with how they work and what you should consider when comparing the different plan options. A variety of benefits is offered by Medicare Advantage, which is also called Medicare Part C. Some people prefer the convenience offered by having all their drug and health benefits covered under one plan rather than enrolling in the stand-alone Medicare Part D coverage. Someone may also be looking for additional benefits that the original Medicare plan does not cover, like routine dental and vision coverage. Keep reading to learn more about Medicare Advantage plans, along with how they work, along with what should be considered when comparing the different plan options. What is a Medicare Advantage Plan? A Medicare Advantage plan is an alternative to Original Medicare, which includes Part A and Part B. Rather than having Medicare benefits provided through a government-run program, people who receive the coverage can obtain it through a Medicare Advantage plan, which is provided by private insurance companies that have been contracted with Medicare. For someone to be eligible to receive Medicare Part C, they must: Currently have Part A and Part B Medicare coverage Reside in the service area for the Medicare Advantage plan being considered Not be end-stage renal disease patients (there are a few exceptions) According to the law, all the Medicare Advantage plans are required to offer, at a minimum, the same amount of coverage as the original Medicare Part A and Part B Plans. However, some plans will cover other benefits, too, like dental, vision, hearing, prescription drugs, or specific health wellness programs. Unlike the original Medicare plans, if someone wants prescription drug benefits, which is provided by Medicare Part D, they should not enroll in a separate Medicare Prescription Drug Plan. A better option is to get the benefit from one of the Medicare Advantage Prescription Drug plans. Not all Medicare Advantage plans will include coverage for prescription drugs, so it is a good idea to double-check with the particular plan being considered. Tips for Comparing Medicare Advantage Plans Since Medicare Advantage plans are provided through any Medicare-approved private insurance company, the cost and the benefits may vary from one plan to another. Also, not all plans will be available in every location. When someone is comparing the Medicare Advantage plan options, there are several things they need to consider. Does the Monthly Premium Provide a Good Value? Some of the Medicare Advantage plans will have premiums that are $0; however, the individual must continue to pay their Medicare Part B premium, along with deductibles, coinsurance, and copayments, that the plan requires. What is the Annual Deductible for you? The annual deductible is another essential factor to consider. Is this something that you are comfortable paying? Are Any Additional Benefits Included? It is also important to consider if additional benefits are offered. This would include things like routine hearing, dental, vision, and other health or wellness plans. Also, find out if a prescription drug is included. Are the existing medications a person takes included with the plan’s formulary or the list of drugs that are covered? Is There a Provider Network Included If it does have a network, it is essential to find out if a person’s current doctors and their health care providers are included. What Is the Plan’s Star Rating? A star rating is one way to determine the performance of the Medicare Advantage plan. Every plan receives a rating of one to five stars. Five stars is the highest rating that a plan can receive. Medicare evaluates all plans based on the five-star rating system, and these scores are calculated yearly. Choosing the Right Medicare Plan for you Each person is unique. This means it is necessary to research each of the Medicare Advantage plan options available and how it works with a person’s budget and health needs. Remember, plan costs, provider networks, service areas, and benefits can all change from one year to another, so it is smart to review a person’s coverage regularly to ensure the plan still works. Take some time to shop around and choose a plan that will help you save the most money. I hope that you learned some valuable information from this article. Choosing a Medicare Advantage plan is a big deal, as you usually won’t be able to change it for up to a year. So you will have whatever coverage you choose for that period. If you find the plan doesn’t cover what you need, you will be stuck paying for it out of pocket. If you think you know someone who might benefit from this article, please share button it. If you'd like to talk about these things or anything else you might have questions about, please contact us whichever way is most comfortable for you.
medicare cost

Overview of Your Medicare Costs (Part 1)

By John Ellis • 19 Dec, 2022
If you’ve done a little bit of research, you probably have realized that Medicare isn’t going to be free. You will still have expenses related to the level of coverage you have, as well as the type of plans you choose. Choosing Original Medicare or Medicare Advantage is one of these choices for example. In this article, we will provide an overview of your Medicare costs. This will be Part 1 of 2, so keep your eyes out for Part 2 soon! We will start with the Part A Premium. If you aren’t familiar with Part A includes, you can read about it here. Part A Premium The majority of Medicare patients don’t pay monthly premiums for their Part A plans as long as they have been paying Medicare taxes for over 40 quarters. Patients who have paid Medicare taxes for fewer than 30 quarters over their working lives will pay $458 per month. Those who have paid into Medicare for 30 to 39 quarters will pay $252. Medicare-eligible patients may also face 10% higher premiums if they do not enroll in the program as soon as they are eligible. They will continue to pay this higher premium for twice as many years as they have had access to Part A insurance but failed to sign up. Part A Deductible and Coinsurance Before reading on, note that all the information below pertains to original Medicare. Policyholders with Medicare Advantage Plans will also have all of these services covered by insurance, but the costs vary by plan. The deductible and coinsurance, as dictated by Medicare, also tend to increase every year. There is a total deductible cost for Part A during each per benefit period. It will typically increase year-over-year. There are no coinsurance costs for days 1-60 of care in each period. On days 61-90, there is a set coinsurance per day. On days 91 and beyond, the coinsurance cost increases from the rate for days 61-90. Beyond that, patients should expect to pay all costs for coinsurance. Medicare-eligible patients may also face 10% higher premiums if they do not enroll in the program as soon as they are eligible. They will continue to pay this higher premium for twice as many years as they have had access to Part A insurance but failed to sign up. Exceptions to the Rule There are some exceptions to this rule. They include alternate provisions for home health care, hospice care, hospital inpatient stays, and mental health inpatient stays. Home Health Care/ Hospice Care Policyholders who require home health care will pay out-of-pocket for 20% off their durable medical equipment (DME). Medicare will cover the full cost of services. Hospice patients are also held to slightly different standards under Medicare Part A. They should expect to make copayments of $5 or less for prescription drugs while in the home and 5% of the cost of inpatient respite care. Medicare doesn’t cover room and board in non-hospital facilities for hospice patients. Non-hospital facilities include private homes, nursing homes, and long-term care facilities. Not all prescription drugs are covered under Part A. If a prescription drug intended to provide relief for pain or symptoms is not covered by hospice benefits, providers should contact the patient’s Medicare Part D insurance provider to investigate other options for coverage. Hospital and Mental Health Inpatient Stays While in the hospital, Medicare policyholders should expect to pay for optional services. These can include private-duty nursing, television or phone access, and private rooms that are not deemed medically necessary. Otherwise, Medicare costs will be the same as those associated with outpatient care. Patients will have $0 coinsurance for days 1-60 in each benefit period. For days 61-90, the co-insurance will increase. And then from days 91 and beyond, the coinsurance will typically increase again until lifetime reserve limits have been met. Once this happens, you'll be responsible for all costs. Those in the hospital for mental health care will need to pay for 20% of the services provided by doctors and others in this setting. Otherwise, the deductible and coinsurance costs remain the same as those for inpatient hospital stays. There is no limit to benefit periods for mental health coverage in general hospitals. Patients treated in psychiatric hospitals can also have multiple benefit periods. There is, however, a lifetime limit of 190 days. Skilled Nursing Facilities Medicare Part A will pay for 100% of the cost of skilled nursing services for the first 1-20 days for each benefit period. Patients will be charged a coinsurance payment for days 21-100 and will be responsible for paying all costs if the stay is over 100 days. Stay tuned for Part 2, which will go over the Part B cost overview. While not all of this information may apply to you in this moment, needs can change over time and it is important to be aware of what your expenses may look like if/when that day comes. As always, I am here to help address any concerns or questions you have. I hope this article helped you – and if it did, please share it with someone who may also benefit.
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