The Medicare Coverage Gap

Medicare covers several things, but you still share the costs. The cost sharing comes in the form of deductibles and and co-insurance. These out-of-pocket expenses are often called the Medicare coverage gap. You can buy insurance to help you pay for many expenses resulting from a Medicare claim.

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Medicare Coverage Gap Explained

What is the Medigap? – It is the Medicare coverage gap.

The Medicare coverage gap consists of deductibles and co-insurance.

  • Deductibles are the amount you pay before Medicare pays anything.
  • Co-insurance is the amount you pay of the bill for which you are responsible after Medicare pays.

The Medicare coverage gap is different for Medicare Part A and Part B.  Benefit periods also affect your cost of Part A.

Medicare Coverage Gap 1 – Part A Hospital Insurance

Medicare will pay when you go into the hospital. But you will also pay. You will pay, by benefit period:

  • The deductible amount.
  • A daily co-insurance amount for hospital stays of 60 to 90 days.
  • A higher daily co-insurance amount for hospital stays of 91 to 150 days.
  • Any hospitalization past 150 days.
  • The first three pints of blood (unless replaced).
  • Anything during foreign travel.

Medicare Coverage Gap 2 – Skilled Nursing Facility

If you are in a skilled nursing facility for a Medicare covered event, you will pay:

  • A daily co-insurance amount for stays more than 20 days up to 100 days.
  • Any stay beyond 100 days

Medicare Coverage Gap 3 – Home Health Care

If you are receiving home health care paid by Medicare, you will pay:

  • Twenty percent of the cost of durable medical equipment
  • Twenty percent of the cost approved non-skilled care
  • All non-medical personal care services.

Medicare Coverage Gap 4 – Part B Medical Insurance

For medical visits and treatments covered by Medicare, you will pay:

  • A yearly deductible
  • Twenty percent of the Medicare approved amount
  • Fifteen percent of the amount charged above the Medicare approved amount*
  • Twenty percent of the total charges for some outpatient services.

*For Medicare Part B, Medicare pay a fixed amount for medical services. Your provider may agree to this amount. If they do not,  you are responsible for 15% of the added cost.

Medicare A and B do not offer any drug coverage. This is another coverage gap. You can get drug coverage through Medicare Part D. Another choice for drug coverage is through a Medicare Advantage plan (Medicare Part C).

Medicare Coverage Gap 5 – Benefit Periods

Medicare tracks your hospital or skilled nursing facility with benefit periods. A benefit period begins with your admission to the in-patient facility. The benefit period continues until 60 days past discharge. After you stay out of the facility for 60 days, a new benefit period begins. For each new benefit period, you pay for another deductible. There is no limited to the number of benefit periods you receive.

What to do about the Medicare Coverage Gap

The Medicare coverage gap can strain personal finances. MediGap insurance or a Medicare Advantage plan help to defray these costs. Check out the sponsored links or the government website to understand more about the Medicare coverage gap.

Next: Basic Medicare Supplement Insurance