The Big Gaps in Original Medicare
Original Medicare (Parts A and B) covers a lot, but it has well-known gaps that can leave beneficiaries with substantial out-of-pocket costs. Understanding these gaps before you retire is essential for financial planning.
No Dental Coverage
Original Medicare does not cover routine dental care — cleanings, fillings, extractions, dentures, or most other dental procedures. This is a significant gap: Americans over 65 spend an average of $874/year on dental care out of pocket. The exceptions are very narrow: dental care directly related to a covered medical procedure (e.g., jaw reconstruction after an injury) may be covered.
What to do: Purchase a standalone dental insurance plan (average $30–50/month) or choose a Medicare Advantage plan that includes dental benefits. Dental discount plans are another lower-cost option.
No Vision or Hearing Coverage
Routine eye exams, glasses, contact lenses, and hearing aids are not covered under Original Medicare. Given that about 70% of Americans over 70 have some hearing loss, this is a major gap. Hearing aids typically cost $2,000–$7,000 per pair.
Limited exceptions: Medicare covers annual eye exams for diabetic retinopathy, and cataract surgery with standard lens replacement is covered. Low vision aids and hearing exams related to medical diagnosis may also be covered.
No Long-Term Care Coverage
Perhaps the most consequential gap: Medicare does not cover custodial care (help with bathing, dressing, eating) in nursing homes or at home on an ongoing basis. Medicare only covers skilled nursing facility care for up to 100 days after a qualifying hospital stay — and only if you're making medical progress.
Long-term care is expensive: nursing home care averages $8,500–$9,000/month nationally. Medicaid covers it, but only after you've spent down most of your assets. Long-term care insurance, if purchased early enough, is the main alternative.
The Part A Deductible Trap
The Part A deductible in 2024 is $1,632 per benefit period — and "benefit period" resets each time you're readmitted to a hospital after being out for 60 consecutive days. A person who is hospitalized 3 times in a year with gaps less than 60 days between stays could pay $4,896 in deductibles.
The Part D Donut Hole
The "donut hole" (coverage gap) in Part D has been largely closed by the Inflation Reduction Act, but cost-sharing still applies. In 2024, there's a new $2,000 out-of-pocket cap for Part D drugs — the first time a cap has existed. Above that amount, Medicare covers 100%.
However, reaching that $2,000 threshold still represents significant out-of-pocket spending, and many specialty drugs can push you there quickly.
No Coverage Outside the US
Medicare generally does not cover health care outside the United States (with very limited exceptions near the Canadian or Mexican border). If you travel internationally, you need separate travel health insurance.
How Medigap Fills the Gaps
Medigap (Medicare Supplement) policies are standardized plans lettered A through N. The most popular plans:
- Plan G: Covers almost all Original Medicare cost-sharing (except the $240 Part B deductible). Most comprehensive coverage available to those new to Medicare after January 2020.
- Plan N: Similar to G but you pay up to $20 for office visits and $50 for emergency room visits. Lower monthly premium.
- Plan K/L: Cover a percentage of costs; lower premiums but more out-of-pocket exposure.
Medigap does not cover dental, vision, hearing, or long-term care — it only covers Medicare cost-sharing. For those needs, separate supplemental plans are required.