Why does Medicare have so many coverage gaps, and is it designed that way on purpose?

Question

Tony Capraro III · Accepted Answer

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Larry Dalton · Answer

In 1965, the government set up Medicare to help primary care for those over 65 with healthcare costs. President Johnson set it up to share healthcare costs between the government and beneficiaries. This was called the cost-sharing approach, with the intent to help control Medicare abuse and overcharge by discouraging unnecessary use of the services.

Today, with healthcare costs rising, the original design has revealed six major gaps in its coverage. Therefore, yes, I think it was designed this way in the beginning, which makes it very confusing today. You need to make sure you have the right coverage and can’t afford the coverage of these gaps.

Ben Washington · Answer

so many coverage gaps, and is it designed that way on purpose? Medicare Coverage Gap for Medicare Part D has been eliminated. The coverage gap was to help reduce cost carrier and shift to the senior and the Part. D manufacturer.

Answered by Ben Washington on April 8, 2025

Broker Licensed in IL, FL, MN, SC, TX & WI

Answered by Ben Washington Medicare Insurance Agent

Amy Putrino · Answer

When clients ask me this question, I usually answer, "To keep me busy". Seriously, it is an ever changing maze of rules and regulations. Once you think you have everything figure out, the government changes something and throws a curve ball. Working with an independent insurance advisor, allows you to reach out if you have an issue or a question and any point during the year.

Answered by Amy Putrino on March 25, 2025

Agent Licensed in RI, CT, FL & 11 other states

Answered by Amy Putrino Medicare Insurance Agent

Tai Thao · Answer

Yes, it was design as a foundational safety net to protect older American from high cost of Medical care.

Justin Lucas · Answer

CMS still wants the person to have some skin in the game. If it doesnt cost you to go to the doctor you will run to the doctor for every cough you have, but if you have a cost associated with it you may not run to the doctor for every cough.

Answered by Justin Lucas on May 8, 2025

Broker Licensed in IN, FL, IA & 11 other states

Answered by Justin Lucas Medicare Insurance Agent

Steven Bleicher · Answer

You are a bit behind the times. The problematic “Donut Hole” (Rx’s) has been eliminated by the Inflation Reduction Act of 2023/24. This was a gap where folks would reach a certain dollar cost for their drugs & their copays would go up. Now in 2025, the maximum out of pocket amount is $2,000.00, tops! This is for both generics & brand name drugs. That is a great help for those less fortunate.

Answered by Steven Bleicher on June 4, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Valentina Gatewood · Answer

I would need to understand what is meant by coverage gaps in order to understand the questions. Original Medicare comes with two parts A&B.

Harold Randolph · Answer

Good Question. The overall cost of healthcare is a staggering number. The coverage gaps are there so that you provide some of the cost share. So the answer is yes. 

Part A has a period deductible while Part B has a small annual deductible and an 80/20 coinsurance with unlimited out of pocket maximum. 

It can become confusing with all the changes but reaching out and having a Broker can help make sure that feel less of the out of pocket with the right plans and options.

Denise Berg · Answer

Original Medicare was designed to provide Hospital Services and Doctor Services. However, with those gaps in coverage, Medicare Advantage and Medicare Supplement plans were offered help fill in some of the gaps. With most Medicare Advantage plans offering Dental, Vision and Hearing; and Medicare Supplements plans providing additional benefits for the Hospital and Doctor Services portions.

Answered by Denise Berg on April 2, 2025

Broker Licensed in CO, AL, AZ & 15 other states

Answered by Denise Berg Medicare Insurance Agent

Linda Davies · Answer

While various parts of Medicare provide widespread health coverage, these do not always pay 100% of the cost of what it covers. For example, there may be deductibles for:

Part A hospital services
Part B doctor and outpatient services
Part D prescription drugs

After these deductibles are paid, there are often gaps in what Medicare will pay for your covered health care, such as:

Part A of Medicare has expensive copays for people with long stays in hospitals and skilled nursing facilities.

Part B of Medicare pays only 80% of covered expenses for the costs of doctors, durable medical equipment and other outpatient expenses.

Copays and drug costs charged by Part D drug plans can differ among Part D insurers, even for the same drug.

Glenn Alterman · Answer

It is designed to allow all qualified people on during their specific time or specific enrollment available

Michael Martin · Answer

When Medicare was created in 1965, it was designed to offer basic health insurance for seniors, not to cover everything. 

Medicare’s structure creates space for private insurance companies to offer supplemental coverage (like Medigap or Medicare Advantage). This public-private hybrid model was intentional—it allows the government to provide a foundation, while the private market fills in the gaps.

Kelly Corbin · Answer

The gaps arise from the structure of the program and its cost-sharing mechanisms. Medicare does cover a broad range of medical services, but it does not cover everything. Persons on Medicare are responsible for certain out-of-pocket expenses like deductibles, copayments, and coinsurance. These gaps are not intentionally designed to cause hardship. They occur due to policy choices and cost-sharing which anre intended to balance affordability and comprehensiveness.

Answered by Kelly Corbin on May 24, 2025

Agent Licensed in MS

Answered by Kelly Corbin Medicare Insurance Agent

Why does Medicare have so many coverage gaps, and is it designed that way on purpose?

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