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How to Fill in the Gaps that Medicare Does Not Pay For

If you’re getting ready to transition to Medicare, you are likely trying to figure out what Medicare does and doesn’t cover. Original Medicare is the basis of Medicare coverage – every eligible beneficiary receives Original Medicare, which includes Part A (hospital) and Part B (medical) insurance. Kupuna who decide to go with a Medicare Advantage plan receive their Part A and Part B coverage through this plan. Those who stick with Original Medicare often choose to add other plan(s) to cover some of what Original Medicare doesn’t.

For seniors who are already enrolled in Medicare, now is a great time to look at your Medicare options to ensure you have the best coverage for your needs! (The Annual Enrollment Period runs October 15 through December 7.) Medicare agents are ready to meet with you for a free consultation.


What Services Aren’t Covered by Medicare?


Let’s start by identifying the services that Original Medicare does not cover:


1. Most dental care

2. Hearing aids or fitting exams

3. Vision tests for prescriptions

4. Glasses or contacts

5. Prescription drugs

6. Long-term care

7. Personal care needs

8. Acupuncture and massage

9. Cosmetic surgery

10. Routine foot care

11. Medical care received outside of the U.S.


It’s also important to know that even services that are covered often come with out-of-pocket expenses like coinsurance (a percentage of the cost of service), copays (a fee paid to access the service), and deductibles (a dollar amount that must be met by the patient before coverage kicks in). Original Medicare also does not come with an annual out-of-pocket maximum, which can mean very high bills for someone who has a lot of medical needs.


How to Fill in the Gaps that Medicare Does Not Pay For


There are a few different ways to fill the gaps that Medicare doesn’t pay for. Your needs, preferences, and budget will determine which option(s) make the most sense for you:


1. Medigap


Seniors who choose Original Medicare are encouraged to purchase a Medigap policy to cover some of their out-of-pocket expenses. Also called Medicare supplement insurance, these policies help pay for deductibles, copays, and coinsurance. Each plan comes with its own premiums, coverage, and limitations so it’s important to understand what you’re signing up for. Medigap plans have been standardized at the federal level since 1992 to make it easier for seniors to obtain consistent Medicare supplemental insurance. Available plans are designated A, B, C, D, F, G, K, L, M and N. Medigap plans do not cover cost of prescription drugs or pay for services not covered by Medicare such as hearing aids.


2. Prescription drug plans (Part D)


Most Americans need prescription drugs either on an as-needed basis or as a part of their regular health regimen. Medicare Prescription Drug Plans (Part D) may be purchased from private insurance companies that are contracted with Medicare to provide and manage prescription benefits to beneficiaries. Seniors who choose Original Medicare can purchase a standalone Medicare Prescription Drug Plan to go along with their Medigap plan; those who are enrolled in a Medicare Advantage Plan typically have their Part D needs met there. Part D plans may come with monthly premiums and other out-of-pocket expenses such as copays.


Every Part D Plan and Medicare Advantage Plan must provide certain types of prescription drugs in its formulary, but the list of specific drugs that are covered is ultimately up to the insurance company. There are also some types of drugs that aren’t covered by Medicare, including non-prescription drugs, drugs for sexual dysfunction or fertility, and prescription drugs that haven’t been approved by the FDA.


3. Medicare Advantage plans (Part C)


Medicare Advantage plans are private health insurance plans available to seniors who are eligible for Medicare. Medicare Advantage plans are also sometimes called “MA Plans.” These plans cover Parts A and B of Medicare insurance and typically also include prescription drug coverage and other services such as hearing, vision, and dental that Original Medicare does not cover. MA plans may come with their own monthly premium, deductible, copays, and coinsurance.


Seniors may not be enrolled in both a Medigap Plan and a Medicare Advantage plan. There are two major advantages to MA plans: 1. They provide a sort of “one-stop-shop” option where all your Medicare needs can be met through one plan and 2. They come with an annual out-of-pocket maximum that protects seniors from limitless bills.



Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. We are the only insurance agency in Hawaii contracted with EVERY Medicare Advantage plan, which means we are able to offer unbiased advice; all at no cost to our clients.


At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

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