Bridging the Gap: When Medicare Isn’t Enough

About one in five Medicare enrollees age 65 and older were underinsured in 2022, according to the Commonwealth Fund Biennial Health Insurance Survey. Rising health care costs make it difficult to pay deductibles and out-of-pocket costs. Millions of Americans rely on Medicare to provide them with essential health coverage. However, Medicare does not cover 100% of services, so it can leave beneficiaries on their own to find ways to bridge the gap of what’s not covered.  

We’ll shed some light on the gaps in Medicare and review some options you may not have considered, including resources like Boomer Benefits, which help seniors navigate their coverage options.

Understanding the Gaps in Medicare

Depending on which plans you choose, Medicare can include hospitalization, medical services, drug coverage, and possibly more.

Here is a breakdown of the various Medicare Parts:

· Part A: Hospitalization

· Part B: Outpatient services

· Part C: Medicare Advantage

· Part D: Prescription Drug Coverage

Original Medicare consists of Parts A and B. The alternative to Original Medicare is Medicare Advantage, which is a bundled plan that includes Parts A and B, and usually your Part D coverage. Depending on your plan, you can also get vision, dental, hearing services, gym memberships, and other benefits.

Out-of-Pocket Costs

In addition to your premium, you’ll have out-of-pocket costs like deductibles, copayments, and coinsurance fees. If you have Original Medicare, you’ll also have to pay out of your pocket for vision, dental, hearing services, and long-term care.

The deductible for Medicare Part A is $1676 per benefit period. A benefit period begins on the day you’re admitted to the hospital or skilled nursing facility, and ends when you haven’t needed hospital or skilled nursing care for 60 days in a row or longer.

Hospital inpatient stay costs vary depending on how long you stay.

The following rates apply:

· Days 1-60: $0 after paying $1676 deductible

· Days 61-90: $419

· Days 91-150: $838

· Days 150 and beyond: 100% of costs

Skilled nursing care:

· Days 1-20: $0.

· Days 21-100: $209.50 each day.

· Days 101 and beyond: You pay all costs

The other 2025 deductibles are:

Part B deductible: $257 in 2025

Part D deductible: Varies depending on your plan, but the max a plan can charge is $590 in 2025.

Most Medicare Advantage plans have $0 or low deductibles for medical services. Medicare Advantage plans cannot exceed a maximum out-of-pocket cost of $9,350 per calendar year.

Unfortunately, there is no out-of-pocket maximum for Original Medicare.

The various out-of-pocket costs for Medicare can add up quickly. Individuals with chronic conditions and those who frequently need medical services often suffer financially. In the worst-case scenarios, Medicare beneficiaries may have to choose between taking care of their health and meeting their basic needs, such as housing, food, and utilities.

Funding Options to Bridge the Gap

While neither Original Medicare nor Medicare Advantage plans cover 100% of beneficiaries’ expenses there are various ways to cover the gaps. Medigaps are supplemental health plan sold by private insurance companies that helps cover the remaining costs after Medicare pay. They are only available for people who have Original Medicare. You cannot have both a Medigap and Advantage plan.

Vision, dental, hearing, well-care services, and other benefits are included in the plan. The trade-off is that you may have to have a primary care physician approve specialist visits, and these plans can often have network restrictions.

Those who can continue their health insurance benefits when they retire can use their employer-sponsored retiree plans as a supplement to Original Medicare. Medicare will be the primary coverage, and the retiree plan is the secondary insurance.

Certain people with lower incomes can apply for Supplemental Security Income or Medicaid. When you combine Medicare and Medicaid, both of these plans work together to give low-income seniors excellent coverage.

What coverage is right?

Overall, you have to consider the scope of your medical needs when choosing what type of plan is right for you. Some factors to consider when choosing the components of your Medicare plan are your budget for premiums and out-of-pocket costs, your health needs, including vision, dental, and hearing services, and network restrictions. Whichever plans you choose, it’s important to compare them and get the most for your money.

Manage Your Healthcare with Medicare and Supplements

While Original Medicare offers comprehensive standard coverage, you can’t count on it to cover the entirety of the bill. Medicare supplements can help cover some of the extra costs, like copays, coinsurances, and the remaining 20%. It’s also beneficial to set some funds aside for a future date when your medical costs may mount up.

What works for you this year may be inadequate next year. Each year, insurance companies change their plans and may offer some new ones. Beneficiaries enrolled in Advantage plans or Part D drug plans can shop their coverage during the Medicare Annual Enrollment Period, which runs from October 15th to December 7th. You’ll find it beneficial to review your health needs and plan every year to decide whether to make changes. By bridging the Medicare gap, you are in the best position to protect your health and financial security. More importantly, it gives you peace of mind in knowing you can maintain the best health possible.