MEDICARE COVERAGE GAPS
HAVE UNLIMITED EXPOSURE TO
DEDUCTIBLES, CO-PAYS & CO-INSURANCE
GAPS IN ORIGINAL MEDICARE COVERAGE - 2023:
PART A: Covers inpatient hospital care, skilled nursing facility, home health agency and hospice care except for: $1600 co-pay per condition, and $400-$800 daily co-pays for more than 60 days in a hospital or $200 daily for more than 20 days in a skilled nursing facility.
PART B: Covers outpatient hospital care, physician's and surgeon's services, laboratory tests, x rays and imaging, certain preventive care and screening, most physical and occupational therapy, radiation therapy and many transplants except for: annual deductible of $226 and 20% co-insurance.
Non-Covered Services: Long term nursing care, custodial care, dentures, dental care, eyeglasses and hearing aides.
Maximum Out of Pocket (MOOP) - Unlimited
PRIVATE INSURANCE PLANS COVER THE GAPS
Selecting CMS Regulated Private Insurance Plans:
MEDICARE SUPPLEMENT PLANS (MedSups/Medigap): CMS standardized Plans are offered by private insurance companies for premiums where medical services are available nationwide through any provider who accepts Medicare assignment. Medigap acts as a secondary insurance to cover the Original Medicare gaps, deductibles, co-pays and co-insurance, in whole or in part depending on the Plan, and offer additional coverage benefits including international emergency services. Maximum-out-of-pocket costs (MOOP) are limited to a range of $0 to $6,490, depending on the Plan.
MEDICARE ADVANTAGE PLANS (Part C): A managed-care alternative to the Original Medicare Part A and Part B fee-for-service plan where a private insurance company receives a capitation fee from Medicare and becomes the primary payor through the insurance companies' networks including HMO's, PPO's, Regional PPO's, PFFS plans and Special Needs Plans (SNP's). Coverage must be actuarially equivalent to Original Medicare and is typically offered at a $0 premium. Some plans in some zip codes offer to refund, in whole or part, the Part B premium beneficiaries typically pay through a deductiuon to their Social Security benefit. Maximum-out-of-pocket costs (MOOP) however are typically $8,300 in-network and $10,000 out-of-network. Additional benefits and lower MOOP may be offered by some plans subject to a premium.
PRESCRIPTION DRUG PLANS (Part D): Voluntary coverage of most FDA approved, self-administered prescription drugs to individuals enrolled in Part B subject to premium payments, deductibles and co-payments.