I just enrolled in Medicare, and I've got my Part A and B, but I'm hearing there are gaps in coverage. What are these gaps exactly?

Question

Comfort Olude · Accepted Answer

The Original Medicare ( Part A and Part B) only covers part of your healthcare costs. Beneficiaries must enroll in supplemental insurance plans to cover prescription drug costs, deductibles, co-pays, co-insurance, and the lack of a yearly out-of-pocket limit.

The coverage gaps include prescription drug coverage, you can enroll in a stand-alone Part D drug plan.

Other gaps are routine vision, dental, and hearing. Consider enrolling in a Medicare Advantage plan. These plans are an alternative way to get the Original
Medicare, Part A, Part B, and additional benefits.

Mark Cunningham · Answer

The gaps come from Cost Share for Part A, Deductible of $257 and co insurance of 80/20% for Part B. In Part B you are responsible for 20% of the cost which is open ended. This means there is no maximum out of pocket. An example is a $60,000 hospital bill. You would be responsible for 20% or $12,000 of this cost. Provided everything billed is an accepted Medicare expense. I would be happy to go into this in more detail, please call me for further information.

Answered by Mark Cunningham on March 31, 2025

Agent Licensed in CO, FL, GA, NE & WY

Answered by Mark Cunningham Medicare Insurance Agent

Tom Rogala · Answer

Part A & B cover 80% of dr and hospital only.  Most, pick a medigap or advantage plan to cover the other 20% and prescription drugs

David Wynne · Answer

Original Medicare (Parts A and B) covers many basic health services but leaves several important gaps. There’s no annual out-of-pocket maximum, so you could end up paying a lot if you need extensive care. You’re also responsible for deductibles and 20% coinsurance on most services.

It doesn’t cover routine dental, vision, or hearing care, and it excludes most outpatient prescription drugs unless you add a separate Part D plan. Long-term care and medical services outside the U.S. are also not covered.

To help with these gaps, many people choose a Medigap policy or a Medicare Advantage (Part C) plan, which can include extra benefits and limit your out-of-pocket costs.

By working with a Licensed Local agent like myself, we can talk through the options that are available so you can make an informed decision.

Steven Bleicher · Answer

There used to be a gap called the “doughnut hole” regarding drugs. With the Inflation Reduction Act of 2023/24, this has changed. That gap has been fully eliminated in favor of a maximum out of pocket cost of $2,000.00 per year for all of your drugs, both generic and brand name. The next new year, it will begin all over again.

Answered by Steven Bleicher on May 25, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Timothy Brown · Answer

Some of the gaps in Original Medicare (Part A&B) are as follows:
1. Medicare only covers 80% of approved medical charges. You’re responsible for deductibles and the 20% coinsurance. 
2. Medicare does not provide prescription drug coverage. It’s your responsibility to enroll in a stand alone Part D prescription drug plan or enroll in a Medicare Advantage plan that includes prescription drug coverage.
3. OriginalMedicare has NO out of pocket spending limits which is the reason why additional coverage is a necessity. There are 2 plan options that will help mitigate this situation which are a Medicare Supplement (Medigap) plan with a stand alone Medicare Part  D drug plan or a Medicare Advantage(Part C) plan). Note: You cannot enroll in both plans.

Michael Pyers · Answer

Medicare Part B Coinsurance is 20% of the Medicare approved amount and there is no maximum out of pocket. Medicare does not cover certain procedures i.e. cosmetic surgery, routine dental, routine vision, or hearing aids.

Answered by Michael Pyers on May 6, 2025

Broker Licensed in OH & MI

Answered by Michael Pyers Medicare Insurance Agent

Chad Watkins · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/i-just-enrolled-in-medicare-and-ive-got-my-part-a-and-b-but-im-hearing-there-are-gaps-in-coverage-what-are-these-gaps-exactly#chad-watkins

Bill Wheeler · Answer

Original Medicare (Parts A and B) doesn't cover prescription drugs, routine dental, vision, or hearing care, long-term care, or many routine physical exams.

Paul Dzierzanowski · Answer

There are several gaps in Medicare coverage, including: prescription drug coverage; coinsurance and deductibles; foreign travel; routine dental, vision, and hearing; long-term care; and others. To fill these gaps beneficiaries may consider Medicare supplemental insurance or Medicare Advantage plans and other types of senior insurances. To discuss your specific options feel free to call me directly at 239-848-8893.

Answered by Paul Dzierzanowski on April 11, 2025

Agent Licensed in FL

Answered by Paul Dzierzanowski Medicare Insurance Agent

George Kolitsas · Answer

The GAPs in Original Medicare will be the Part A Hospital deducible and Part B Medical 20% that you are responsible for. You can cover these GAPs by purchasing a Medicare Supplemental/MediGap plan offered in your area. Or you can replace Original Medicare with an Medicare Advantage plan that require copays for services as you go to the doctors. These Advantage plans have a Maximum-Out-Of-Pocket that you need to be aware of.

Answered by George Kolitsas on June 9, 2025

Broker Licensed in CT

Answered by George Kolitsas Medicare Insurance Agent

Brian Leichner · Answer

In a nutshell, the Gaps in Medicare are many.  You can fill most of the gaps with either a Medicare Supplement plan or a Medicare Part C (Medicare Advantage) plan.  There are actually gaps with both of those too!  
The gaps in Medicare Supplements include Dental, Vision and Hearing as well as my biggest concern of Skilled Care and Recovery Care.  The gaps in Medicare Advantage include Hospital Copays and Cancer.  
May I suggest spending a little time explaining your concerns so we can tailor a plan for you?  402.708.6616 or Brian@ProInsuranceResources.com

Christopher Garcia · Answer

To put it simply these gaps are either costs that are passed on to you such as deductibles or copays. They can also be services that are simply not covered by original medicare such as Dental, Vision, and Hearing Aid coverage. A good medicare agent can help explain these gaps in more detail and show you solutions to help get them covered if need be.

Answered by Christopher Garcia on March 31, 2025

Broker Licensed in NM, AZ, CO & TX

Answered by Christopher Garcia Medicare Insurance Agent

Jeremy Purse · Answer

Without enrolling in a Medicare Advantage or Supplement Plan, you will have to pay the Part A Deductible when admitted to the hospital which is $1,676. You will also have to pay 20% for all of your outpatient procedures covered under Part B. When you are enrolled in a Medicare Advantage or Supplement plan, it will typically cover all of those out of pocket costs.

Answered by Jeremy Purse on May 14, 2025

Broker Licensed in CA, AL, AZ & 5 other states

Answered by Jeremy Purse Medicare Insurance Agent

Don Golding · Answer

Broadly speaking, Part A covers Hospitalization, skilled nursing confinement, and Hospice. There is a Part A deductible, and copays may apply as well.  Part B also has a deductible and covers roughly 80% of covered expenses.  Additionally, there are no maximum out-of-pocket limits. Neither Part A nor Part B covers prescription drugs - Part D.

I recommend looking at either a Supplemental (Medigap) Plan with a separate Part D prescription plan or an Advantage Care plan with drug coverage built in to cover the "gaps" in original Medicare.

Fred Manas · Answer

Medicare coverage gaps refer to the out-of-pocket expenses the subscriber might face beyond what Original Medicare (Part A and B) covers, including deductibles, coinsurance, and copayments. These gaps also encompass areas like prescription drugs, routine vision, dental, and hearing care, as well as some long-term care needs.

Answered by Fred Manas on April 21, 2025

Agent Licensed in NY, CT, DC & 7 other states

Answered by Fred Manas Medicare Insurance Agent

Gary Henderson · Answer

Give me a call and we will over everything with you. This is not a simple one or two sentence answer sadly 
My work phone number is 737-530-4626 pick option 2. I cover every state except New York and Massachusetts 
My name is Gary Henderson

Vachik Chakhbazian · Answer

gaps include prescription drugs, routine dental, vision, and hearing care, and long-term care. To address these, you can enroll in Medicare Advantage (Part C) or Medicare Supplement Insurance (Medigap).

Answered by Vachik Chakhbazian on June 14, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Sam Silva · Answer

Yes, Medicare Parts A and B have gaps in coverage. They do not cover prescription drugs, dental, vision, hearing, long-term care, or care outside the U.S. You’re also responsible for deductibles, copays, and 20% coinsurance for most services. To fill these gaps, many people choose either a Medicare Supplement plan or a Medicare Advantage plan with extra benefits.

Answered by Sam Silva on June 17, 2025

Broker Licensed in FL, GA, NJ & 7 other states

Answered by Sam Silva Medicare Insurance Agent

Steven Rodriguez Giudicelli · Answer

Original Medicare Parts A and B have coverage gaps, most notably in prescription drugs, routine dental, vision, and hearing care. Additionally, beneficiaries face out-of-pocket costs like deductibles and coinsurance for covered services.

Answered by Steven Rodriguez Giudicelli on June 3, 2025

Broker Licensed in FL & TX

Answered by Steven Rodriguez Giudicelli Medicare Insurance Agent

David Treadway · Answer

Here is a condensed listing of the gaps if you were to utilize only original Medicare: https://www.medicare.gov/basics/costs/medicare-costs. You’ll want to manage those costs with either a supplement or an advantage plan.

Answered by David Treadway on June 2, 2025

Agent Licensed in OH, IN, KY & MI, SC, TN & VA

Answered by David Treadway Medicare Insurance Agent

I just enrolled in Medicare, and I've got my Part A and B, but I'm hearing there are gaps in coverage. What are these gaps exactly?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

I just enrolled in Medicare, and I've got my Part A and B, but I'm hearing there are gaps in coverage. What are these gaps exactly?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website