Sarah thought she was ready for retirement. At 67, she had Medicare and felt protected. Then her husband had a stroke.
The hospital bills? Medicare covered most of those. But the real shock came later. Her husband required assistance with daily tasks, such as bathing and eating. Medicare said no to paying for this care.
The cost: $6,000 per month.
Sarah isn’t alone. Millions of Americans face huge medical bills because they don’t know about Medicare coverage gaps. These gaps can wipe out your savings fast.
Here’s what you need to know to protect yourself.
What Original Medicare Actually Covers (The Reality Check)
Medicare has two main parts. Part A covers hospital stays. Part B covers doctor visits and outpatient care.
Sounds good, right? But here’s the catch.
Medicare follows the 80/20 rule. They pay 80% of approved costs. You pay 20%. That might seem fair until you see the real numbers.
In 2025, Medicare Part A has a $1,676 deductible per benefit period. Part B has a $240 deductible. The monthly premium for Part B is $185 for most people.
But here’s the bigger problem. Original Medicare has no out-of-pocket maximum. Your 20% share can add up to thousands or even tens of thousands of dollars.
A heart surgery that costs $100,000? You could pay $20,000 out of pocket. A cancer treatment that costs $200,000? Your share might be $40,000.
This is why many people buy extra insurance. But first, you need to know exactly what Medicare doesn’t cover.
The 7 Biggest Medicare Coverage Gaps That Drain Your Savings
Here are the seven coverage gaps that cost seniors the most money. We’ll show you exactly what you’ll pay and how to protect yourself from each one.
1. Long-Term Care and Daily Living Help
This is the biggest gap. Medicare only covers skilled nursing care for a short time. You must first spend three days in the hospital. Then Medicare covers up to 100 days in a nursing home.
But most seniors need custodial care. This means help with eating, bathing, and getting dressed. Medicare doesn’t pay for this type of care at all.
What Medicare covers for nursing home care:
- Days 1-20: Medicare pays 100% (if you qualify)
- Days 21-100: You pay $204 per day in 2025
- Days 101+: You pay everything
What you’ll actually pay:
- Private nursing home room: $9,733 per month average
- Semi-private room: $8,669 per month average
- Home health aide: $25-30 per hour
- Adult day care: $1,690 per month average
A study by the Department of Health and Human Services found that 70% of people over 65 will need long-term care services. The average person needs care for three years. For women, it’s 3.7 years.
The real cost: If you need three years of nursing home care, you could spend $350,000 or more out of pocket.
2. Dental, Vision, and Hearing Care
Medicare doesn’t cover routine dental care. No cleanings. No fillings. No crowns. You pay 100% of these costs.
Dental costs you’ll pay:
- Routine cleaning: $75-200
- Basic filling: $90-250
- Crown: $800-1,500
- Root canal: $700-1,400
- Dentures: $1,000-4,000
- Dental implant: $3,000-5,000
Vision care is also out. Medicare doesn’t cover eye exams for glasses. It doesn’t pay for glasses or contacts either.
Vision costs you’ll pay:
- Comprehensive eye exam: $100-250
- Basic glasses: $200-500
- Designer frames: $300-800
- Progressive lenses: $400-700
- Contact lenses: $200-400 per year
Hearing aid costs:
- Basic hearing aids: $2,000-4,000 per pair
- Premium hearing aids: $4,000-8,000 per pair
- Replacement every 5-7 years
- Hearing test: $100-300
If you need major dental work, you could spend $10,000 or more in one year. Many seniors delay needed care because of the cost.
3. Prescription Drug Coverage Gaps
If you have Medicare Part D, you have drug coverage. But there’s a coverage gap called the “donut hole.”
How the donut hole works in 2025:
- You pay your deductible (up to $545)
- You pay copays until total drug costs reach $5,030
- In the coverage gap, you pay 25% for brand drugs and 25% for generics
- You’re out of the gap when your out-of-pocket costs hit $8,000
- After $8,000, you pay 5% or small copays
Real examples of expensive drugs:
- Revlimid (cancer): $16,000+ per month
- Humira (arthritis): $5,500+ per month
- Eliquis (blood thinner): $500+ per month
- Insulin: $300+ per month without coverage
For expensive drugs, this gap hits fast. Some cancer drugs cost $10,000 per month. You could hit the gap in your first month and pay thousands out of pocket.
4. International Travel Coverage
Medicare doesn’t work outside the United States. If you get sick while traveling, you pay for everything.
What you could face abroad:
- Heart attack treatment in Europe: $50,000-100,000
- Broken leg treatment in Japan: $15,000-25,000
- Appendectomy in Mexico: $8,000-15,000
- Medical evacuation flight: $25,000-100,000
- ICU stay in Canada: $3,000-5,000 per day
Countries where Medicare doesn’t work:
- All countries except the U.S.
- Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are covered
- Even U.S. territories have limited coverage
Travel insurance can cover this, but Medicare won’t. Many seniors learn this the hard way when they get sick on vacation.
5. Emergency Transportation Limits
Medicare covers ambulance rides only when “medically necessary.” But the rules are strict. If you could have taken other transportation safely, Medicare might not pay.
Ground ambulance coverage:
- Medicare pays 80% of the approved amount
- You pay 20% plus any amount above Medicare’s approved rate
- Average cost: $400-1,200 per ride
- Your share: $100-400 typically
Air ambulance problems:
- Medicare might cover part of the cost
- You could still owe $10,000-20,000
- Average air ambulance bill: $39,000
- Some bills reach $50,000-100,000
A study by the Government Accountability Office found that air ambulance bills often surprise patients. Many people get bills for $20,000-50,000 even with insurance. The study showed that patients rarely choose their air ambulance company, yet they get stuck with huge bills.
When Medicare won’t pay:
- If other transportation were available and safe
- If the ambulance took you to a non-emergency location
- If the ride wasn’t to the nearest appropriate facility
6. Alternative and Complementary Medicine
Medicare covers very little alternative care. Most treatments are considered “not medically necessary.”
What Medicare covers (limited):
- Chiropractic care: Only spinal adjustments
- Acupuncture: Only for chronic low back pain (up to 12 sessions)
What Medicare doesn’t cover:
- Massage therapy: $75-150 per session
- Naturopathic treatments: $100-300 per visit
- Herbal supplements: $20-100+ per month
- Homeopathy: $80-200 per visit
- Aromatherapy: $50-120 per session
- Reflexology: $40-100 per session
Annual costs for common alternative treatments:
- Weekly massage: $3,900-7,800 per year
- Monthly naturopathic care: $1,200-3,600 per year
- Daily supplements: $240-1,200 per year
Many seniors use these treatments for pain management or wellness. But you’ll pay every penny yourself.
7. Cosmetic and Most Elective Procedures
Medicare doesn’t cover cosmetic surgery. It also doesn’t cover procedures it deems “not medically necessary.”
Never covered cosmetic procedures:
- Face lifts: $7,000-15,000
- Tummy tucks: $6,000-12,000
- Breast augmentation: $5,000-10,000
- Liposuction: $3,000-8,000
- Hair transplants: $4,000-15,000
Sometimes covered, sometimes not:
- Skin cancer removal (usually covered)
- Reconstructive surgery after cancer (usually covered)
- Varicose vein treatment (covered if medically necessary)
- Sleep apnea surgery (covered if other treatments failed)
The gray area problem: Medicare decides what’s “medically necessary.” Sometimes they say no to procedures your doctor recommends. Always get pre-approval in writing before any surgery.
Examples of denied procedures:
- Knee replacement for “mild” arthritis
- Cataract surgery if vision is “good enough”
- Back surgery for chronic pain without nerve damage
Always check if Medicare considers a procedure necessary before you schedule it. Getting approval after the fact is much harder.
Medigap Insurance: Your First Line of Defense
Medigap insurance helps fill Medicare coverage gaps. These are private insurance plans that work with Original Medicare.
There are 10 standard Medigap plans. Each state (except Massachusetts, Minnesota, and Wisconsin) offers the same plans. The plans are labeled with letters: A, B, C, D, F, G, K, L, M, and N.
Plan G is the most popular. It covers:
- Part A hospital deductible
- Part A hospice coinsurance
- Part B coinsurance (your 20% share)
- First three pints of blood
- Part A coinsurance for skilled nursing facility care
- 80% of emergency care during foreign travel
Plan G doesn’t cover the Part B deductible ($240 in 2025). You pay that yourself.
Plan N is cheaper but has some copays. You pay $20 for doctor visits and $50 for emergency room visits.
Medigap costs vary by location and age. In most areas, Plan G costs $100-300 per month. Plan N costs $80-200 per month.
Important: You have guaranteed rights to buy Medigap when you first get Medicare Part B. After that, insurance companies can deny you coverage or charge more if you have health problems.
Medigap doesn’t cover:
- Long-term care
- Dental care
- Vision care
- Hearing aids
- Prescription drugs
Medicare Advantage: Alternative Coverage with Trade-offs
Medicare Advantage plans replace Original Medicare. These are private plans that must cover everything Original Medicare covers. Many also include extras like dental, vision, and hearing coverage.
The good news: Most Medicare Advantage plans have out-of-pocket maximums. In 2025, the maximum is $8,850 for medical services.
The trade-offs:
- You must use doctors and hospitals in the plan’s network
- You might need referrals to see specialists
- Plans can change their coverage and costs each year
- If you move, you might need to switch plans
Medicare Advantage works best if:
- You want predictable costs
- You’re okay with network restrictions
- You want some dental and vision coverage
- You don’t travel much outside your plan’s area
Original Medicare plus Medigap works better if:
- You want to see any doctor who takes Medicare
- You travel frequently
- You want coverage that stays the same year after year
Additional Insurance Options to Fill Remaining Gaps
Even with Medigap or Medicare Advantage, some gaps remain. Here are ways to fill the biggest holes in your coverage.
Long-term care insurance: Buy this before you need it. Costs vary by age and health. A 55-year-old might pay $2,000-3,000 per year for a good policy.
Dental insurance: Standalone dental plans cost $20-50 per month. They help with routine care but have annual limits (usually $1,000-2,000).
Vision insurance: These plans cost $10-20 per month. They help with eye exams and glasses, but savings are often small.
Travel medical insurance: If you travel outside the U.S., buy travel medical insurance. Annual plans cost $100-500.
Critical illness insurance: These plans pay cash if you get cancer, have a stroke, or heart attack. You can use the money for any expenses.
Action Plan: 5 Steps to Protect Yourself from Medicare Gaps
Don’t wait until you’re facing a medical crisis. Start planning now to avoid financial disaster later.
Step 1: Calculate Your Risk
Look at your family health history. Do your parents have Alzheimer’s? Did anyone need long-term care? This helps you plan for likely expenses.
Step 2: Compare Your Options
Use Medicare.gov to compare plans in your area. Look at total costs, not just premiums. Include deductibles, copays, and out-of-pocket maximums.
Step 3: Consider Additional Insurance
If long-term care runs in your family, buy long-term care insurance early. If you travel internationally, get travel medical coverage.
Step 4: Build a Healthcare Emergency Fund
Even with good insurance, you’ll have out-of-pocket costs. Save $10,000-20,000 in a separate healthcare fund.
Step 5: Review Annually
Medicare rules change. Insurance plans change. Review your coverage every fall during open enrollment (October 15 – December 7).
