Original Medicare is good coverage. It is not complete coverage, and the shape of what it leaves out is the reason supplements and Advantage plans exist at all.
This guide describes the gaps. It carries no figures, because every one of them changes annually and a stale number on a licensed producer’s website is worse than none. For current amounts, use Medicare.gov or telephone 1-800-MEDICARE.
The hospital side
Part A covers inpatient hospital stays, and it has a deductible you pay before it begins.
The unusual part is that this deductible is not annual. It applies per benefit period, and a benefit period starts when you go in and ends after you have been out of hospital and out of skilled nursing care for a set stretch. If you are admitted again after that, a new benefit period begins and the deductible applies again. Two admissions in one year can therefore mean paying it twice.
Beyond a certain number of days in a single stay, daily coinsurance begins and rises. There is also a lifetime reserve of extra days that, once used, are gone permanently.
Skilled nursing care after a qualifying hospital stay is covered in full for an initial stretch, then requires daily coinsurance, then stops being covered at all. This is the gap that surprises families most often, usually at the worst possible moment.
The medical side
Part B covers doctors, outpatient care, tests and equipment. It has an annual deductible, and after that Medicare generally pays eighty per cent of the approved amount.
You pay the other twenty per cent. On a routine visit that is small. On chemotherapy, dialysis, or a long course of outpatient treatment, twenty per cent of a large number is also a large number.
The gap that matters most
Original Medicare has no annual limit on what you can be asked to pay.
There is no ceiling. Twenty per cent of an unbounded amount is an unbounded amount. In most years this is theoretical, because most people’s care is modest. In a bad year it is not theoretical at all, and it is the single strongest argument for adding either a supplement or an Advantage plan rather than going without both.
Advantage plans are required to have an annual out-of-pocket maximum. Supplements address the same risk from the other direction, by paying most of what Medicare leaves.
Excess charges
Most providers accept the Medicare-approved amount as full payment — “accepting assignment”. A minority do not, and may bill up to a limited percentage above it. That difference is called an excess charge and it falls to you.
Some states restrict this practice; Ohio, Kentucky and Indiana each treat it in their own way, and it is worth asking rather than assuming. Certain supplement plans cover excess charges and others do not.
What is not covered at all
Original Medicare does not cover routine dental, routine vision, hearing aids, or most long-term custodial care — the help with dressing, bathing and eating that people most often assume Medicare provides. It does not.
Outpatient prescription drugs are not covered by Parts A and B either. That is what Part D is for, and it is bought separately.
Care outside the United States is generally not covered, with narrow exceptions.
The two ways people close the gaps
A Medicare Supplement. A private policy that pays most of what Original Medicare leaves. You keep the freedom to use any provider in the country who takes Medicare, and you pay a monthly premium for the predictability. Drug coverage is bought separately.
A Medicare Advantage plan. A private plan that replaces Original Medicare, with its own cost-sharing structure and a required annual ceiling, usually including drug coverage. You use the plan’s network, and some care needs approval first.
They are different answers to the same problem and there is a separate guide comparing them.
One date to be aware of
When your Part B begins, a six-month window opens during which a supplement must accept you regardless of your health. Once it closes, in most states an insurer may ask health questions and decline you.
That is the only part of this decision that is genuinely hard to undo. It is worth knowing about before the window rather than after it.
Where to get the actual numbers
Every figure in this territory is republished each year. The authoritative sources are Medicare.gov and 1-800-MEDICARE, which is answered around the clock. Your State Health Insurance Assistance Program will also go through it with you, free, with nothing to sell.
If you would rather sit down with somebody and go through your own situation, that is what we do. We will not bring a figure that we cannot show you the source of.
General information, not advice
This guide describes how Medicare generally works. It is not advice about your situation, and rules, dates and figures change — verify anything that matters to a decision against Medicare.gov,1-800-MEDICARE, or your State Health Insurance Assistance Program, all of which are free.
Rights and rules vary by state; this describes Ohio, Kentucky and Indiana. Clearview Medicare Advisers LLC is not connected with or endorsed by the United States government or the federal Medicare program.
Not sure how this applies to you?
Tell us your birthday and whether you are still working. That is usually enough for us to say which periods apply to you and by when. No charge and no obligation.
