Most people approaching 65 assume Medicare will cover their medical costs the way an employer plan did. It won’t — at least not entirely.
Original Medicare is a strong foundation, but it leaves real gaps in coverage that can result in significant out-of-pocket costs. Understanding what those gaps are — and how to fill them — is the difference between predictable healthcare expenses and surprise bills that arrive at the worst possible time.
Here’s what Original Medicare doesn’t cover, and what your options are for filling the gap.
A quick refresher on what Medicare actually is
Original Medicare has two parts. Part A covers hospital stays, skilled nursing facility care, hospice, and some home health services. Part B covers doctor visits, outpatient care, preventive services, and durable medical equipment.
Together, Parts A and B form the base of your Medicare coverage. But they’re not the whole picture — and the gaps are bigger than most people expect.
Gap 1: There’s no out-of-pocket maximum
This is the gap that catches people off guard more than any other.
Original Medicare has no annual cap on what you can spend out of pocket. If you have a serious illness or a long hospital stay, your share of the costs can keep adding up with no ceiling. Employer plans almost always have an out-of-pocket maximum that limits your annual exposure — Medicare does not.
For people on a fixed retirement income, unlimited financial exposure to medical costs is one of the biggest risks in retirement planning. It’s also one of the easiest gaps to address with supplemental coverage.
Gap 2: The Part A hospital deductible
Every time you’re admitted to a hospital under Original Medicare, you’re responsible for the Part A deductible — currently $1,676 per benefit period in 2025. A benefit period resets after you’ve been out of the hospital for 60 consecutive days, which means if you’re admitted twice in a year with a long gap between stays, you could owe two separate deductibles.
For longer stays, additional daily copays kick in after day 60 and increase further after day 90. A serious hospitalization can result in thousands of dollars in cost-sharing under Original Medicare alone.
Gap 3: The Part B 20% coinsurance
After you meet the relatively modest Part B annual deductible ($257 in 2025), Medicare pays 80 percent of approved costs for outpatient services. You’re responsible for the remaining 20 percent — with no cap.
For routine doctor visits, that’s manageable. For ongoing cancer treatment, chemotherapy, dialysis, or major outpatient procedures, that 20 percent can become a significant monthly cost. Coinsurance on a $50,000 outpatient procedure is $10,000 — and there’s no out-of-pocket maximum to stop it.
Gap 4: Prescription drugs
Original Medicare does not cover most prescription medications. Part D — the prescription drug benefit — is a separate program that you enroll in through a private insurance company.
Without a Part D plan, you’d pay full retail price for every prescription. With one, you have predictable monthly costs and a structured benefit. Choosing the right Part D plan for your specific medications is one of the most important decisions you’ll make at 65, because the monthly premium is only part of the cost — the formulary, tier structure, and pharmacy network all affect what you actually pay over the year.
Gap 5: Dental, vision, and hearing
Original Medicare covers almost none of these. Routine dental cleanings, fillings, dentures, eye exams, glasses, and hearing aids are not covered benefits.
Hearing aids alone can cost $2,000 to $6,000 per pair. Dentures, crowns, and major dental work can run into the thousands. These are predictable expenses for retirees that fall entirely outside Original Medicare.
Gap 6: Long-term care
This is the gap people understand the least until they need it.
Original Medicare does not cover long-term custodial care — the daily assistance with activities like bathing, dressing, and eating that someone might need as they age or after a serious illness. Medicare will cover up to 100 days of skilled nursing care after a qualifying hospital stay, but that’s short-term rehabilitation, not long-term care.
If you or a spouse end up needing extended care at home, in an assisted living facility, or in a nursing home, those costs come out of your own pocket — and they add up quickly. The national median cost of a private nursing home room is over $100,000 per year.
Long-term care insurance is a separate product entirely, and it’s worth a separate conversation with an advisor who specializes in it.
Gap 7: Care outside the United States
Original Medicare generally does not cover medical care received outside the US. For retirees who travel internationally, this is a meaningful gap. Some Medicare Supplement plans include limited foreign travel emergency coverage, which is worth considering if travel is part of your retirement plans.
How to fill the gaps
There are two main approaches, and which one is right for you depends on your priorities.
Medicare Supplement (Medigap) plans are sold by private insurance companies and work alongside Original Medicare to cover the deductibles, coinsurance, and copays that Medicare leaves to you. The most comprehensive plans — Plan G being the most popular for new enrollees — cover virtually all of the out-of-pocket exposure under Parts A and B.
With a Medigap plan, you can see any doctor or hospital that accepts Medicare nationwide, you have predictable monthly costs, and you’re protected from large hospital and outpatient bills. You’ll also need a separate Part D plan for prescriptions, and dental, vision, and hearing coverage would either be standalone policies or paid out of pocket.
Medigap tends to suit people who want maximum flexibility and predictability and don’t mind paying a higher monthly premium.
Why the decision at 65 matters so much
The single most important window in Medicare planning is your Medigap Open Enrollment Period — the six months that begin when you’re 65 and enrolled in Part B. During that window, you can buy any Medigap plan available in your state with no medical underwriting, regardless of your health history.
After that window closes, most states allow carriers to medically underwrite you for a Medigap plan. That means if your health has declined, you may not be able to buy the plan you want — or you may pay a much higher premium.
This is why getting the decision right at 65 matters so much. The plan you choose initially is the easiest plan you’ll ever qualify for. Waiting to figure it out — or settling for whatever a friend recommended — can cost you flexibility and money for the rest of your life.
Get your free Medicare review today
At Term Insurance Brokers, we help clients sort through Medicare every day. We represent multiple top-rated carriers across Medigap plans and we’ll walk you through your options without pressure.
There’s no cost for a Medicare review and no obligation to enroll. We do the legwork — you make the decision.
Call us at 703-665-9133 or visit terminsurancebrokers.com for your free Medicare consultation today.
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