Medicare Coverage Gaps


Medicare covers a lot, but unfortunately, there are several coverage gaps that leave you exposed to serious financial risk. It is important to understand these risks and how to protect yourself against them. 

Part A: Hospital Stays
Hospital Room

The Part A deductible and benefit periods are different than any other insurance arrangement you’ve had in the past, so we’ll give you the numbers along with some examples.

$1,484 deductible per benefit period

Benefit Period
The Part A benefit period begins the day you are admitted as an inpatient to the hospital. The benefit period ends when you haven’t received any inpatient hospital care for 60 days in a row.

Your first 60 days of continuous hospital stays are covered by your deductible.
Once you hit day 61, a copay comes into play.

The copay for days 61-90 is $371 per day.

Lifetime Reserve Days
If your hospital stay extends past 90 consecutive days, your coverage moves into your bank of lifetime reserve days. Medicare gives you a total 60 lifetime reserve days to be used after you reach the 90th consecutive days in the hospital.

The daily copay doubles once you begin using these reserve days. 
The copay for days 90 - 150 is $742 per lifetime reserve day.

Now, if you use all of your lifetime reserve days, whether in one visit or over the course of several years, they are gone for good. Should your initial hospital stay require more than 150 days, you are responsible for 100% of the cost at that point. 

Should you have several hospital stays over the course of several years that require more than a 90 day stay, each day over 90 days depletes your lifetime reserve days number and, once those lifetime reserve days are used up, any the financial responsibility for any further hospital stays past 90 consecutive days are 100% yours. 

The Good News
The good news is that there are specific plans that fill in the gaps left by Medicare that give you more lifetime reserve days than Medicare's allotment. Give us a call to learn more about your options in this regard. 

Part A: Skilled Nursing

The Part A skilled nursing benefit refers to a rehab arrangement where you go in, get better, and get out. The skilled nursing benefit has specific qualifiers, all of which have to be met for Part A to cover the expenses.

Qualifiers (all have to be met):
Taken from

  1. You have Part A and you have days left in your benefit period to use.
  2. You have a qualifying hospital stay.
  3. Your doctor has decided that you need daily skilled care. It must be given by, or under the supervision of, skilled nursing or therapy staff.
  4. You get these skilled services in a Skilled Nursing Facility (SNF) that’s certified by Medicare.
  5. You need these skilled services for a medical condition that’s either:
    • A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it wasn't the reason you were admitted to the hospital. 
    • A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you're getting SNF care)

Days 1 - 20 : $0
Days 21 - 100 : $185.50
Days 101+ : You are responsible for all costs

Filling this Gap

One of the most overlooked and devastating expenses encountered by a large part of the population are short-term and long-term care expenses. Medicare does not cover these expenses. However, there are Short Term and Long Term Care insurance policies that help alleviate these enormous financial costs. 

Call us to learn more about how to protect your wealth and your family's emotional well-being against the impact of these expenses.



Part B: Medical Coverage
GapsDoctor Office Visit

Part B has an annual deductible and you are responsible for 20% of the Medicare fee schedule.


Other financial responsibility
20% of the Medicare fee schedule

Limit or Maximum:
There is no limit nor maximum to the amount on your 20% responsibility.


Part D
Prescription Drug CoveragePill bottles

Part D plans have annual deductibles and as well as copays and coinsurance.

Up to $445 per year

Other financial responsibility
Copays and coinsurance depending on which phase you are in.

Limit or Maximum
There is no limit nor is there a maximum out-of-pocket with prescription drug plans.

Other Medicare Gaps

Wait There's More

There are several other gaps in Original Medicare coverage you’ll want to be aware of and protect yourself from.

Prescription Drugs
We've already covered this with Part D, but just remember that Original Medicare does not cover prescription drugs. You'll need to get a Part D plan for prescription drug coverage.

Dental Services
Dental coverage is not part of Medicare. Luckily, there are several senior dental plans available to help limit your risk on dental coverage.

Routine Vision Care

Vision coverage is not part of Original Medicare. There are individual vision plans available for you to help alleviate vision care costs.

Glasses & Contacts

Medicare does not cover glasses & contacts.

Hearing Aids

There are some hearing aid discount programs and partnership to help alleviate these costs.

Long Term Care Expenses
Long Term Care is an incredibly expensive gap in Medicare that is worth addressing. Long Term Care plans exist to protect you and your estate from these high costs.

Care Outside the U.S.
Need care while traveling outside the U.S.? Medicare doesn’t cover that.

Excess Doctor Charges

If you receive care from a provider who does not participate with the Medicare fee schedule, any excess doctor charges are your responsibility.

Unapproved Charges

Sorry, but that elective, cosmetic plastic surgery procedure isn’t covered by Medicare.

Wrapping it up

Medicare is a wonderful benefit to those who qualify. However, it doesn't cover everything. There are significant gaps that we've outlined that leave you open to some hefty financial costs. 

Luckily, there are ways to fill these gaps in the form of Medicare Advantage plans, Medicare Supplement plans, and other products like Dental, Vision, and Long Term Care insurance plans to protect you against these risks. 

We can walk you through any of these gaps and how to fill them at your convenience. Feel free to give us a call if these concern you or you'd like to prepare for these decisions. 

Senior Benefits Insurance Services

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