The big gaps in Original Medicare

Original Medicare (Parts A + B) is a strong foundation, but it leaves significant gaps. Here are the major ones, ordered by financial impact:

1. Long-term custodial care

Original Medicare does NOT cover ongoing custodial care — assistance with daily activities like bathing, dressing, eating, or moving. This includes most nursing home stays beyond 100 days. The average semi-private nursing home room costs $7,500-$10,000/month in Texas.

How to fill it: Long-Term Care Insurance (separate policy, must qualify based on health). Or self-funding from savings. Medicaid kicks in only after you've spent down most of your assets. This is one of the largest financial planning gaps in retirement.

2. Prescription drugs (taken at home)

Original Medicare covers drugs administered in a clinical setting (chemotherapy, vaccines at the doctor's office) but NOT prescriptions you fill at the pharmacy. With prescription costs averaging $1,200-$2,800/year for the typical Medicare beneficiary, this is significant.

How to fill it: Add a standalone Medicare Part D plan, OR enroll in a Medicare Advantage plan that includes drug coverage built in. Either way, this needs to be addressed at enrollment to avoid late-enrollment penalties.

3. Dental, vision, and hearing

Original Medicare does NOT cover routine dental (cleanings, fillings, extractions, dentures), routine vision (exams, glasses, contacts), or hearing (exams, aids).

Limited exceptions:

• Dental during hospital stay (e.g., extraction before surgery)
• Cataract surgery + one pair of glasses after
• Diagnostic hearing exam ordered by a doctor (not routine)

How to fill it: Many Medicare Advantage plans include some dental/vision/hearing benefits — though the extent varies wildly. Some are $1,500/year dental allowance, others are $500. Standalone dental, vision, and hearing insurance plans exist for people on Original Medicare + Medigap.

4. The Part B 20% coinsurance (no out-of-pocket maximum)

Original Medicare pays 80% of Part B costs (doctor visits, outpatient procedures, durable medical equipment). You pay the other 20%. There is NO annual cap on this. A serious illness with Part B-heavy treatment (chemotherapy, dialysis, complex outpatient procedures) can mean unlimited liability.

How to fill it:

• Medicare Supplement (Medigap): covers most or all of the 20%. Plan G covers everything except the small Part B annual deductible.
• Medicare Advantage: has an out-of-pocket maximum (typically $5,000-$8,300/year), but you pay copays per service along the way.

5. Care outside the United States

Original Medicare provides essentially no coverage when you're outside the US (with rare exceptions for certain border situations and ships in US territorial waters).

How to fill it:

• Medicare Supplement Plans C, D, F, G, M, N include foreign travel emergency coverage (80% to a $50,000 lifetime maximum after a $250 deductible).
• Travel insurance with medical coverage for trips beyond what Medigap covers.

6. Cosmetic surgery

Original Medicare covers reconstructive surgery (after accident or to improve function) but not purely cosmetic procedures.

7. Acupuncture (with one exception) + most alternative medicine

Acupuncture is covered for chronic low back pain (up to 12 visits + 8 more if showing improvement, max 20/year). Other acupuncture, chiropractic beyond manual subluxation correction, naturopathy, massage therapy, and most alternative medicine modalities are not covered.

How to fill it: Some Medicare Advantage plans offer alternative medicine "extras" — vary by plan. Self-pay for the rest.

8. Hearing aids

Hearing aids are not covered by Original Medicare. Diagnostic hearing exams ordered by a doctor are covered; routine hearing exams and the hearing aids themselves are not.

How to fill it: Many Medicare Advantage plans include hearing aid benefits (typically $500-$1,500/year). Costco's hearing aid program is significantly cheaper than retail. Recently OTC hearing aids became available, dropping prices substantially for mild-moderate loss.

9. Routine podiatry + foot care

Original Medicare covers medically necessary foot care (e.g., diabetic foot care) but not routine nail trimming, callus removal, or general podiatry.

10. Most weight-loss programs + cosmetic dental

Limited Medicare coverage for medically supervised weight loss in specific contexts; cosmetic dental procedures (whitening, veneers) not covered.

The under-discussed gap: Part B premium adjustments (IRMAA)

Not technically a "gap," but worth knowing: if your modified adjusted gross income exceeds approximately $103,000 (single) or $206,000 (married joint), your Part B AND Part D premiums increase based on Income-Related Monthly Adjustment Amounts (IRMAA). The income brackets are calculated from your tax return TWO YEARS prior, which can catch people off-guard if they had a high-income year right before retirement.

How to fill it: can't avoid IRMAA if you're above the threshold, but you CAN appeal if you've had a "life-changing event" (retirement, death of spouse, divorce, work reduction) that lowered your income since the tax year used.

Quick reference: gap → solution

Gap	Best fit solution
Part B 20% coinsurance	Medigap (Plan G)
Prescription drugs at home	Part D OR Medicare Advantage with drugs
Dental / vision / hearing	Medicare Advantage extras OR standalone DVH plans
Long-term custodial care	Long-Term Care Insurance + savings + Medicaid spend-down planning
Foreign travel emergency	Medigap C/D/F/G/M/N + travel insurance
Hearing aids	Medicare Advantage hearing benefit OR Costco/OTC

How to think about it

You don't need to fill every gap. Some are unlikely to affect you. But the BIG ones — the 20% coinsurance with no cap, prescription drugs, and (for many people) long-term care — should be addressed before you need them.

The right combination depends on your specific situation. We can help you think through it without a sales pitch.

Related: Medicare 101 · Medigap guide · Medicare Advantage guide