Medicare Coverage Gaps

Medicare coverage gaps are the specific costs and services Original Medicare (Part A and Part B) does not pay for, including most dental, vision, and hearing care, long-term custodial care, most care outside the United States, and the uncapped 20% Part B coinsurance. Original Medicare is the federal fee-for-service program run directly by the Centers for Medicare & Medicaid Services (CMS), covering hospital stays under Part A and outpatient medical care under Part B. Knowing where these gaps fall before you enroll helps you budget accurately and decide whether to add a Medicare Supplement (Medigap) policy, switch to Medicare Advantage, or buy standalone coverage for what Original Medicare leaves out.

This guide breaks down the major medicare coverage gaps in Original Medicare, the three main ways seniors fill them, and what to budget for even after adding supplemental coverage.

Major gaps in Original Medicare

Original Medicare pays for a defined set of hospital and medical services. Everything outside that list is a cost you cover yourself unless you have supplemental coverage. The main medicare coverage gaps are:

• Routine dental, vision, and hearing care. Cleanings, fillings, eye exams, glasses, and hearing aids are not covered. You need a Medicare Advantage plan with these benefits built in or a standalone policy.
• Long-term custodial care. Help with daily activities like bathing, dressing, and eating is not covered. Original Medicare pays for short-term skilled nursing after a qualifying hospital stay, not ongoing custodial care. Long-term care insurance is a separate product entirely.
• Most care outside the United States. Original Medicare generally does not pay for care received overseas. Some Medigap plans add limited foreign travel emergency coverage as a supplemental benefit.
• Cosmetic procedures. Elective cosmetic care is not covered unless it's medically necessary, such as reconstruction after an accident or mastectomy.
• Most prescription drugs. Original Medicare does not include an outpatient drug benefit. You need a standalone Part D plan or a Medicare Advantage plan that includes drug coverage.
• Your 20% Part B coinsurance. After you meet your Part B deductible, you owe a share of most outpatient costs. According to Medicare.gov, Original Medicare Part B pays 80% of the Medicare-approved amount for most covered services, leaving you responsible for the remaining 20% coinsurance with no annual out-of-pocket cap. A Medigap or Medicare Advantage plan caps this exposure.

Three ways to fill the medicare coverage gaps

You have three main paths to cover what Original Medicare leaves out. Each works differently, so the right choice depends on your health needs, budget, and which providers you want to keep.

• Medicare Supplement (Medigap). A Medigap policy is private supplemental insurance that pays some or all of your Original Medicare cost-sharing, such as Part B coinsurance and deductibles, depending on the plan letter you choose. Medigap does not include drug coverage, so you pair it with a standalone Part D plan. See how Plan G compares to Plan N and review your guaranteed issue rights before you apply, since medical underwriting can apply outside your initial enrollment window.
• Medicare Advantage. A Medicare Advantage (Part C) plan replaces Original Medicare and is administered by a private insurer approved by Medicare. Most Advantage plans bundle in dental, vision, hearing, and drug coverage, but you're generally limited to the plan's network. Compare the tradeoffs in our Medicare vs. Medicare Advantage guide.
• Standalone or supplemental coverage. If you keep Original Medicare without Medigap, you can still buy separate dental, vision, hearing, or hospital indemnity policies to cover specific gaps as needed.

What to budget for even with supplemental coverage

No combination of Medigap, Medicare Advantage, or standalone policies eliminates every cost. Even with strong supplemental coverage, plan for:

• Your annual Part B premium, which is deducted from Social Security automatically if you're already collecting benefits
• Your annual Part B deductible before coverage kicks in
• Your Part D drug deductible and copays, which vary by plan and drug tier
• Out-of-pocket costs on extras like a new pair of hearing aids or a dental procedure, even under an Advantage plan's allowance

For the full cost breakdown by part, see how much Medicare costs. If your income is limited, a Medicare Savings Program may help cover your premiums and cost-sharing.