Published by Term Insurance Brokers — an independent brokerage licensed in 35+ states. Updated May 15, 2026.
Quick Answer: Original Medicare (Parts A and B) does NOT cover: (1) an out-of-pocket maximum — your exposure is unlimited, (2) the Part A hospital deductible, (3) the Part B 20% coinsurance on most outpatient services, (4) prescription drugs (requires separate Part D plan), (5) routine dental, vision, and hearing, (6) long-term custodial care, and (7) most care received outside the United States. Medigap (Medicare Supplement) plans fill most of these gaps; Part D, dental/vision/hearing plans, and long-term care insurance fill the rest.
What Is Original Medicare? (Quick Refresher)
Original Medicare consists of 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 they form the foundation of Medicare — but the gaps are larger than most new enrollees expect.
What Are the 7 Biggest Gaps in Medicare Coverage?
Gap 1: There Is No Out-of-Pocket Maximum
Unlike employer health plans and ACA marketplace plans, Original Medicare has no annual out-of-pocket maximum. If you have a catastrophic year — a long hospitalization, cancer treatment, or a series of expensive procedures — your share of costs keeps climbing with no ceiling. This is arguably the single biggest financial risk in Original Medicare.
Gap 2: The Part A Hospital Deductible
For 2026, the Part A inpatient deductible is roughly $1,676 per benefit period (not per year). If you’re hospitalized twice in a year for unrelated conditions, you can owe this deductible twice. After 60 days in the hospital, daily coinsurance kicks in — and after 90 days, lifetime reserve days are used, charged at a much higher daily rate.
Gap 3: The Part B 20% Coinsurance
After meeting the small annual Part B deductible (~$257 in 2026), you pay 20% of the Medicare-approved amount for most outpatient services with no cap. For a routine office visit, that’s manageable. For ongoing chemotherapy, dialysis, or a $50,000 outpatient procedure, that 20% becomes $10,000 — with no out-of-pocket maximum to stop the bleeding.
Gap 4: Prescription Drugs (Part D Required Separately)
Original Medicare does not cover most prescription medications. You must enroll separately in a Part D prescription drug plan through a private insurer. Choosing the right plan matters: the monthly premium is only part of the cost. The formulary (which drugs are covered), tier structure (your cost share), and pharmacy network all affect what you actually pay over the year.
Gap 5: Dental, Vision, and Hearing
Original Medicare covers almost none of this. Routine cleanings, fillings, dentures, eye exams, glasses, and hearing aids are not covered. Hearing aids alone can run $2,000–$6,000 per pair. Major dental work can easily exceed $5,000. These are predictable retirement expenses that fall entirely outside Medicare.
Gap 6: Long-Term Custodial Care
This is the gap most people misunderstand until it’s too late. Medicare covers up to 100 days of skilled nursing care after a qualifying hospital stay — that’s short-term rehabilitation. It does not cover long-term custodial care — help with bathing, dressing, eating, and other activities of daily living that many people need as they age. The national median cost of a private nursing home room exceeds $115,000/year. Assisted living and home care, while less expensive, still add up to tens of thousands annually.
Gap 7: Care Outside the United States
Original Medicare does not cover most healthcare received while traveling outside the U.S. If you travel internationally or split your year between countries, you’ll need supplemental travel medical insurance or a Medigap plan that includes foreign travel emergency coverage (Plans G, F, and a few others include this benefit).
How Do You Fill the Gaps in Medicare?
| Gap | What Fills It |
|---|---|
| No out-of-pocket max, Part A & B deductibles/coinsurance | Medicare Supplement (Medigap) plan |
| Prescription drugs | Standalone Part D plan |
| Dental, vision, hearing | Standalone dental/vision/hearing plan (or some Medicare Advantage plans) |
| Long-term custodial care | Long-term care insurance or hybrid life/LTC policies |
| Foreign travel emergencies | Medigap Plan G or F (foreign travel benefit) or standalone travel medical |
The most common approach is the “Original Medicare + Medigap + Part D” combination, which provides predictable monthly costs and minimal surprises. Medicare Advantage is an alternative that bundles Parts A, B, often D, plus some extras — but typically with network restrictions and prior authorization requirements.
Why Does the Decision at Age 65 Matter So Much?
Your one-time Medigap Open Enrollment Period — six months starting the first day of the month you turn 65 and are enrolled in Part B — is the easiest time to buy a Medicare Supplement plan with no medical underwriting. Wait past that window, and most states allow insurers to deny you or charge more for health conditions. For the full breakdown, see our guide on the best age to buy a Medicare Supplement plan.
Key Takeaways
- Original Medicare has no out-of-pocket maximum — your exposure is unlimited without a supplement.
- The Part B 20% coinsurance is uncapped and can become very expensive for serious illnesses.
- Prescription drugs (Part D), dental, vision, hearing, long-term care, and foreign travel are all separate.
- The most common gap-filling strategy is Medigap + Part D + dental/vision/hearing plan.
- Buy your Medigap plan during your six-month Open Enrollment Period at 65 to avoid underwriting.
Get a Free Medicare Review
Term Insurance Brokers represents multiple top-rated Medigap and Part D carriers. We walk you through every plan available in your ZIP code with no pressure and no cost. Call us at 703-665-9133 or visit our contact page for a free Medicare consultation.
Authoritative Resources
- Medicare.gov — What Part B Covers
- Medicare.gov — Part D Prescription Drug Coverage
- NAIC — Choosing a Medigap Policy Guide
Related Resources
- Best Age To Buy a Medicare Supplement Plan
- Medicare Supplement Insurance — TIB
- Long-Term Care Insurance — TIB
Term Insurance Brokers is an independent brokerage licensed in 35+ states. We are not affiliated with any single insurance company.