What’s missing from Original Medicare? (And how you can fill in those gaps)

Apex Blog - What's missing from original medicare

Medicare is the federal health insurance program for those 65 and older, certain younger people with disabilities and for people with End-Stage Renal Disease. Original Medicare (Parts A and B) is the simplest form of Medicare. Part A covers hospital stays, skilled nursing facility care, hospice care and some home health care. Part B covers certain doctor visits, outpatient care, medical supplies, and preventive services. We’ve talked about the different parts of Medicare in a previous blog

Original Medicare is great, but it does leave some significant gaps that may be important to you. Original Medicare Parts A and B usually pay 80 percent of Medicare-approved services, meaning you will have to pay the remaining 20 percent (on top of a yearly deductible). What else is missing from Original Medicare – and how can you fill in those gaps? Let’s take a look.

What’s missing from Original Medicare?

Prescription drug coverage

One big item not covered by Medicare is prescription drugs. Medicare Supplement (Medigap) plans can help you fill in some of the gaps left by Original Medicare, including copayments and deductibles, but these plans do not include prescription drug coverage. If you are taking medications, managing them is important! We want to help you better understand your options.

To get prescription drug coverage, you can enroll in a standalone Part D plan (PDP plan) or a Medicare Advantage plan with Part D coverage (MAPD plan). Both PDP and MAPD plans are offered by private health insurance companies. The federal government requires that certain common types of drugs be covered by Medicare Part D, and after that, individual plans can choose what types of each drug to cover – both generic and brand names. For more details and specifics about Part D, check out our previous blog post.

If you’re wondering what prescriptions are covered by ApexHealth MAPD plans, we want to make it easy for you! Visit our online search tool to find covered prescriptions and pharmacies. Or call (844) 279-0508 (TTY: 711) and ask an ApexAssistant to do the searching for you!

Maximum out-of-pocket limits

Original Medicare does not have a maximum out-of-pocket limit (MOOP). This means that if you are hospitalized several times during the year and/or have a lot of medical expenses, you may end up paying a lot of money. Without a maximum limit on your annual out-of-pocket costs, you won’t be protected from excessive costs. Understanding MOOP is important, but it can be a bit confusing. We dive into this more in a previous blog post.

Some, but not all, Medigap plans have a MOOP. Only Medicare Supplement Plans K and L include annual out-of-pocket limits. These limits are set annually by the Centers for Medicare and Medicaid Services (CMS).

All Medicare Advantage plans, including those offered by ApexHealth, have a MOOP. Each year, CMS sets a limit. This means that a plan can’t set its limit higher than that amount, but it can set a limit for lower. Once your covered medical expenses meet your MOOP, the plan will pay 100 percent of your covered medical costs for the rest of the plan year. Make sure that you check with the plan that you’re interested in to confirm the limit they set.

Dental

Original Medicare does not cover most dental care including cleanings, fillings, tooth extractions and dentures. Medicare Part A may pay for certain dental services received in a hospital (e.g., emergency dental procedures).

Medigap plans also don’t include routine dental care, but most Medicare Advantage plans do. Coverage varies by plan, so be sure to research the plan you’re interested in to see what they offer.

ApexHealth’s Medicare Advantage plans include ApexExtras with first-dollar preventive and comprehensive dental coverage including crowns, dentures, extractions and more. Compare our plans online or reach out at (844) 279-0508 (TTY: 711) to learn more from an ApexAssistant. To find a dentist that’s part of our provider network, try our online search tool.

Vision

Routine vision coverage is not covered by Original Medicare. This means you will have to pay for eyeglasses, contact lenses and annual routine eye exams yourself. Learn more about vision care and how Medicare addresses it by reading our previous blog.

Medigap plans do not include coverage for routine vision care. Medicare Advantage plans often include coverage or allowance for vision care. Just remember coverage varies by plan. Be sure to check with the plan you’re interested in to make sure you get the vision care you need, especially if you wear glasses or contact lenses.

ApexHealth’s Medicare Advantage plans include routine eye exams and ApexExtras including a glasses or contact lens allowance depending on where you live, and which plan you choose. Compare our plans online or reach out to our ApexAssistants at (844) 279-0508 (TTY: 711).

Hearing

Original Medicare does not cover hearing aids or exams for fitting them. This means you will pay the full cost for any hearing aids and exams. Medigap plans also do not cover these services, but some Medicare Advantage plans do. Coverage does vary by plan, so check and see if the plan you’re interested in offers the hearing coverage you need.

With ApexExtras, you will receive first-dollar coverage with an allowance for hearing aids no matter which plan you choose. Compare our plans online or with the help of our ApexAssistants. To find a hearing provider that’s part of our provider network, visit our hearing website or call (844) 279-0508 (TTY: 711) to have an ApexAssistant assist you.

Supplemental benefits

A Medicare Advantage plan will include hospital and medical insurance, prescription drug coverage (in most cases) and additional supplemental benefits that Original Medicare and Medigap plans don’t have. Supplemental benefits vary by plan, so check with the plan you’re interested in to make sure you’re getting the best coverage for your needs. Use the Medicare Plan Finder tool to learn about the different types of benefits each plan offers.

ApexHealth wants to help you make the most of your care with ApexExtras, designed to help you get more out of life. These include over-the-counter (OTC) allowance, free gym memberships and more to help you live life boldly. And don’t forget to ask your ApexAssistant for help! ApexAssistants are here to help make healthcare easy, including helping you make the most of these extras.

If you have any questions or would like help understanding what’s missing from Original Medicare, ApexExtras, and how to fill in coverage gaps, feel free to reach out. Give us a call at (844) 279-0508 (TTY: 711) to speak with a licensed representative or an ApexAssistant. Our hours of operation are Monday through Friday 8 a.m. – 8 p.m. (local time) from Apr. 1 through Sept. 30 and seven days a week 8 a.m. – 8 p.m. (local time) from Oct. 1 through Mar. 31.

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