You’re Signed Up for Medicare—But That Doesn’t Mean You’re Covered Completely

Key Takeaways

• You’re enrolled in Medicare in 2025, but Original Medicare (Parts A and B) leaves significant gaps that can expose you to high out‑of‑pocket costs and services not covered at all.

• Understanding coverage timelines, out‑of‑pocket responsibilities, and supplemental options (Part D, Medigap, Medicare Advantage) helps you avoid surprises and maintain comprehensive protection.

Why Original Medicare Isn’t All‑Inclusive

Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance). While these two components cover many hospital and physician services, they do not cover everything. You pay premiums, deductibles, coinsurance, and copayments—and certain services are excluded entirely.

Part A: Limits and Costs

• Premiums (2025): Most people pay no Part A premium if they or a spouse have at least 40 quarters of Medicare-covered employment; otherwise, premiums range from $284 to $518 per month based on work history.

• Deductible (2025): You pay $1,676 per benefit period before Medicare begins covering inpatient hospital costs.

• Coinsurance: After day 60 of a hospital stay, you pay $419 per day for days 61–90 and $838 per day for lifetime reserve days.

• Gaps: Skilled nursing facility beyond 100 days, long‑term care, and most dental, vision, hearing, and routine foot care are excluded.

Part B: Out‑of‑Pocket Responsibilities

• Premium (2025): The standard premium is $185 per month; higher‑income beneficiaries may pay more due to IRMAA.

• Deductible (2025): You pay $257 annually before Medicare covers outpatient services.

• Coinsurance: After the deductible, you generally pay 20% of approved amounts for doctor services, outpatient therapies, and durable medical equipment.

Common Coverage Gaps in 2025

1. Prescription Drugs: Original Medicare does not cover outpatient prescription drugs. Without Part D, you pay the full cost at the pharmacy.

2. Vision, Dental, Hearing: Routine exams, glasses, dentures, hearing aids, and exams are not covered.

3. Long‑Term Care: Custodial care in nursing homes or assisted living is excluded.

4. Home‑Health Visits: While some skilled home‑health services are covered, extended custodial care at home is not.

5. Foreign Travel: Emergency care abroad is limited.

How to Fill the Gaps

Prescription Drug Coverage (Part D)

• Enrollment Window: You have a 7‑month Initial Enrollment Period (IEP) around your 65th birthday year (3 months before, the month of, and 3 months after).

• General Enrollment: If you miss IEP, you enroll January 1–March 31, with coverage starting July 1 and potential late‑enrollment penalties based on how long you were without creditable coverage.

• Costs: Part D premiums vary by plan; you pay an annual deductible (up to $590 in 2025) and coinsurance or copays until you reach the $2,000 out‑of‑pocket cap, after which catastrophic coverage begins.

Medigap (Supplemental Insurance)

• Purpose: Medigap plans supplement Original Medicare by covering some or all Part A and B cost sharing and providing limited foreign travel emergency coverage.

• Timing: You have a 6‑month Medigap Open Enrollment Period beginning the first month you’re both 65 or older and enrolled in Part B.

• Premiums: Monthly costs vary by plan type (A–N), your location, age, and tobacco use. General ranges in 2025 are $50–$200 per month.

• Restrictions: Medigap doesn’t cover non‑Medicare benefits like Part D drugs or services under Medicare Advantage.

Medicare Advantage (Part C)

• Structure: Private insurers contract with Medicare to provide at least the same benefits as Original Medicare and often include Part D drug coverage and extra benefits (e.g., dental, vision).

• Enrollment Period: You can join or switch plans during the Annual Enrollment Period (October 15–December 7) each year; changes take effect January 1.

• Costs and Networks: Premiums, deductibles, and out‑of‑pocket limits vary by plan; you typically must use network providers except for emergencies.

Enrollment Deadlines and Important Dates

• Initial Enrollment Period (IEP): 7 months around your 65th birthday—coverage begins the first day of the month you turn 65, if you enroll early enough.

• General Enrollment Period: January 1–March 31; coverage effective July 1, plus possible penalties.

• Annual Enrollment Period (AEP): October 15–December 7; apply to Medicare Advantage and Part D plans for the following year.

• Medicare Advantage Open Enrollment Period: January 1–March 31; allows one change between Medicare Advantage plans or back to Original Medicare.

• Special Enrollment Periods (SEPs): Triggered by life events like moving, losing employer coverage, or qualifying for Medicaid; timing varies by event.

Planning for Out‑of‑Pocket Costs

• Estimate annual costs by adding premiums, deductibles, and expected coinsurance. For example, if you have Part A deductible ($1,676) and Part B deductible ($257), plus a Part D deductible ($590), you could pay over $2,500 before coverage kicks in.

• Out‑of‑Pocket Maximums: Original Medicare has no maximum, but Medicare Advantage plans cap annual in‑network costs (often between $1,000 and $7,500).

• Budgeting Tip: Factor in preventive services (covered at 0% coinsurance), wellness visits, and chronic care management to reduce out‑of‑pocket spending.

Maximizing Your Medicare Coverage

• Use Preventive Services: In 2025, Medicare covers annual wellness visits, screenings (e.g., mammograms, colonoscopies), and vaccines at no cost to you.

• Care Coordination: Enroll in chronic care management programs if you have multiple chronic conditions; these programs can help reduce hospital readmissions.

• Review Annually: Compare your plan’s costs and benefits each year—plan offerings and premiums change in October for the following calendar year.

Staying Confident in Your Medicare Plan

Medicare in 2025 provides essential hospital and medical coverage, but without supplemental protections, you face potential financial exposure and gaps in services. Health needs and budgets vary, so review your options:

• Part D for Medications ensures you’re protected against high drug costs and helps you avoid the coverage gap.

• Medigap gives predictable cost sharing with standardized benefits across insurers.

• Medicare Advantage can bundle your benefits with extra perks but requires network adherence.

By understanding timelines and out‑of‑pocket responsibilities, you maintain control over your health coverage and avoid surprises.

Next Steps for Comprehensive Protection

Contact a licensed agent listed on this website for personalized guidance on selecting the right supplemental plan, understanding costs, and meeting enrollment deadlines. They can help you compare options, clarify benefits, and complete applications before critical deadlines.