What the Medicare Gap Means for Your Bills
The Medicare gap is the difference between what Medicare covers and what you actually pay out of your pocket. Medicare Part A and Part B cover many hospital and doctor visits, but they leave you responsible for deductibles, copayments, and coinsurance. They also do not cover dental care, vision exams, hearing aids, or most prescription drugs — unless you have separate coverage for those services.
When you go to the doctor or hospital, Medicare pays its share, but you pay the rest. That "rest" is the gap. For example, Medicare Part B covers 80 percent of most doctor visits after you meet your annual deductible. You pay the other 20 percent. If your doctor's bill is $200, you owe $40 plus any amount over what Medicare considers reasonable.
The gap exists because Original Medicare was designed to cover major medical events, not all health costs. As a result, many seniors buy additional insurance or join a different Medicare plan to reduce what they pay out of pocket.
Key Takeaways
- Original Medicare (Part A and Part B) requires you to pay deductibles, coinsurance, and copayments for covered services.
- Medicare does not cover dental, vision, hearing aids, or most prescription drugs unless you buy separate coverage.
- You can reduce out-of-pocket costs by joining a Medicare Advantage plan or buying a Medigap policy alongside Original Medicare.
- The gap varies depending on which services you use and which type of coverage you choose.
- Understanding your gap helps you budget for healthcare costs and decide which coverage option works best for your situation.
What Original Medicare Leaves You Paying For
Original Medicare has specific out-of-pocket costs built in. For Part A (hospital insurance), you pay a deductible each time you are admitted to the hospital — in 2024, that is $1,676 for the first 60 days. After 60 days in the hospital, you pay coinsurance per day. Part A also does not cover the first three pints of blood you receive unless the hospital or you replace them.
Part B (medical insurance) requires an annual deductible — $240 in 2024 — and then you pay 20 percent coinsurance for most services after that. This means if you see a specialist who charges $500, and Medicare approves $400, you pay $80 (20 percent of $400) plus any amount above $400 that the doctor charges if they do not accept Medicare's approved amount.
Neither Part A nor Part B covers prescription drugs, dental cleanings or fillings, routine eye exams, eyeglasses, hearing tests, or hearing aids. If you need any of these, you pay the full cost unless you have Part D (prescription drug coverage) or a separate dental and vision plan.
How Medicare Advantage and Medigap Address the Gap
Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies. Instead of paying deductibles and coinsurance to Medicare, you pay copayments to the insurance company. Many Medicare Advantage plans include prescription drug coverage, dental, and vision benefits built in. However, you must use doctors and hospitals in the plan's network, and you may need referrals to see specialists.
Medigap (supplemental insurance) works alongside Original Medicare. You keep your Medicare coverage and buy a separate policy from a private insurer to cover the gaps — deductibles, coinsurance, and copayments. Medigap policies are standardized, meaning Plan G from one company covers the same things as Plan G from another company. The price and customer service differ, but the coverage does not.
Medigap does not cover prescription drugs, dental, or vision. If you want those, you buy Part D separately and arrange your own dental and vision coverage. Medicare Advantage often bundles these together, which can be simpler, but the trade-off is less choice of doctors and hospitals.
Costs That Vary by Plan Type
| Cost Type | Original Medicare + Medigap | Medicare Advantage |
|---|---|---|
| Monthly premium | Part B premium + Medigap premium | Part B premium + Advantage premium (often $0) |
| Doctor visit | Copay covered by Medigap (usually $0) | Copay to plan (usually $20–$50) |
| Hospital stay | Deductible covered by Medigap (usually $0) | Copay per day or per stay |
| Prescription drugs | Part D premium + copays | Usually included in plan |
| Dental and vision | You pay full cost or buy separate plan | Often included in plan |
| Out-of-network care | Covered nationwide | Usually not covered |
When the Gap Costs You the Most
The gap affects your wallet most when you have chronic conditions that require frequent doctor visits, hospital stays, or expensive medications. Someone with diabetes who sees an endocrinologist, a primary care doctor, and a cardiologist every few months will pay more in coinsurance under Original Medicare than someone who sees a doctor once a year.
Hospital stays are another area where the gap adds up quickly. A five-day hospital stay under Original Medicare means you pay the Part A deductible ($1,676 in 2024) plus coinsurance for days 4 and 5. With Medigap Plan G, that deductible is covered. With Medicare Advantage, you might pay a per-day copay instead, which could be less or more depending on the plan.
Prescription drugs also create a significant gap. If you take multiple medications, Part D premiums and copays can total hundreds of dollars a year. Some Medicare Advantage plans cover drugs with lower copays, but others have higher costs. Comparing your specific medications across plans is the only way to know which option saves you money.
Questions to Ask Your Doctor or Medicare Counselor
Before you choose a plan, gather information about your healthcare needs. Write down the doctors you see regularly, the medications you take, and any procedures or tests you expect in the next year. Then ask a Medicare counselor or your doctor's billing office these questions:
- What is the total out-of-pocket cost for my medications under Part D versus a Medicare Advantage plan that includes drug coverage?
- If I choose Original Medicare with Medigap, which Medigap plan covers the most gaps for the lowest premium?
- Does my preferred doctor accept Medicare Advantage plans in my area, or would I have to switch?
- What happens to my coverage if I travel or move to another state?
- Are there dental, vision, or hearing benefits I need that neither Original Medicare nor my plan covers?
Frequently Asked Questions
Does Medicare cover everything after I pay my deductible?
No. After you pay the deductible, Medicare covers a percentage of approved services (usually 80 percent for Part B), and you pay the rest. Medicare also does not cover dental, vision, hearing aids, or most prescription drugs at any point, no matter how much you have already paid.
Is Medigap the same as Medicare Advantage?
No. Medigap is supplemental insurance that works with Original Medicare to cover gaps. Medicare Advantage is a replacement for Original Medicare offered by private companies. With Medigap, you keep Medicare and add coverage. With Advantage, you switch to a private plan entirely.
Can I switch from Original Medicare to Medicare Advantage if the gap costs too much?
Yes, but timing matters. You can switch during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event like moving or losing other coverage. Outside these windows, you may be locked into your current plan.
What if I cannot afford the gap and do not may have access to for help?
Talk to your doctor's office about payment plans or sliding-scale fees. Some hospitals and clinics offer financial information based on income. You can also contact your local Area Agency on Aging to learn about programs that may help with healthcare costs.
Does the gap change every year?
Yes. Medicare deductibles, copayments, and premiums change annually, usually in January. Medigap and Medicare Advantage premiums also change. Review your coverage each year during the Annual Enrollment Period to make sure it still fits your needs and budget.