Which Medicare out-of-pocket expenses are not covered by Part A and B?
Many pre-retirees mistakenly believe Medicare covers all medical bills. Identifying specific gaps like copays and deductibles is crucial for planning Medigap coverage.
✓ Accepted answer
Medicare Part A and Part B do not cover deductibles, copayments, coinsurance, and most routine dental, vision, hearing, and long-term care expenses.
- Out-of-pocket thresholds: Beneficiaries must pay the Part B deductible and 20% coinsurance for most professional services. If annual out-of-pocket spending exceeds the Part B catastrophic threshold, Part B typically pays 100% of eligible costs.
- Dental and vision exclusions: Routine dental care, eyeglasses, and hearing aids are not covered. For 2026, expect to pay approximately $2,500 to $4,000 annually for basic dental check-ups, cleanings, and corrective vision items if you lack Medigap coverage.
- Long-term care gap: Skilled nursing care is limited to 100 days after a qualifying hospital stay. Beyond this, or for assisted living, you will pay full market rates, which average $6,500 per month in US facilities as of 2026.
- Prescription costs: Part B does not cover most prescription drugs. Without Part D or a supplemental plan, a retiree may face $4,000 to $6,000 in annual medication costs before hitting a coverage gap.
- Supplemental recommendation: The Fidelity 25th Annual Retiree Health Care Cost Estimate projects a 65-year-old retiring in 2026 will need $185,500 for healthcare. A Medigap Plan G or N is recommended to bridge the Part B 20% coinsurance and deductibles.
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