Gaps In Medicare Coverage

(For 2015)


Gaps in Inpatient Hospital Coverage:

  • $1,260 deductible on first admission to hospital in each benefit period.

  • $315 daily coinsurance for days 61 through 90.

  • All charges for coverage after 90 days in any benefit period unless there are "lifetime reserve" days available and used.

  • $630 daily coinsurance for each lifetime reserve day used.

  • For the first three pints of whole blood or units of packed cells used in connection with covered services unless the blood is replaced. To the extent the blood deductible is met under one part of Medicare, it does not have to be met under the other part.

  • For a private hospital room, unless medically necessary, and for a private nurse.

  • For personal convenience items such as a telephone or television in a hospital room.

  • For non-emergency care in a hospital that does not participate in Medicare.

  • For care received outside the United States and its territories, except under limited circumstances in Canada and Mexico.

Gaps in Inpatient Psychiatric Hospital Coverage:

  • For all care after you have received 190 days of such specialized treatment in a psychiatric hospital in your lifetime (even if you have not yet exhausted your coverage for inpatient care in a general hospital).

  • The gaps in general hospital coverage also apply to psychiatric hospital coverage.

Gaps in Skilled Nursing Facility Coverage:

  • $157.50 daily coinsurance for days 21 through 100 in each benefit period.

  • All costs after 100 days in a benefit period.

  • All costs for care that is less than the level of care Medicare covers in a skilled nursing facility.

  • All costs if you were not transferred to the skilled nursing facility in a timely manner after a qualifying hospital stay.

  • For care in a general nursing home, or in a skilled nursing facility not approved by Medicare, or for just custodial care in a Medicare-approved skilled nursing facility.

  • The 3-pint blood deductible (see list of gaps under inpatient hospital care above).

Gaps in Home Health Coverage:

  • For full-time nursing care and drugs.

  • For meals delivered to your home.

  • Twenty percent of the Medicare-approved amount for durable medical equipment, plus charges in excess of the approved amount on unassigned claims.

  • For homemaker services that are primarily to assist you in meeting personal care or housekeeping needs.

Gaps in Hospice Coverage:

  • Limited charges for inpatient respite care and outpatient drugs.

  • Deductibles and coinsurance when regular Medicare benefits are used for treatment of a condition other than the terminal illness.

Gaps in Doctor and Medical Supplier Coverage:

  • $147 annual deductible.

  • Generally, 20% coinsurance and permissible charges in excess of Medicare- approved amount.

  • 50% of the Medicare-approved amounts for most outpatient mental health treatment.

  • All charges for most services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury.

  • All charges for most self-administrable prescription drugs and immunizations, except for pneumococcal, influenza and hepatitis B vaccinations, and certain oral cancer drugs.

  • All charges for routine physicals and other screening services, except for periodic mammograms and Pap smears.

  • All charges for most dental care and dentures.

  • All charges for acupuncture treatment.

  • All charges for routine eye examinations or eyeglasses, except prosthetic lenses after cataract surgery.

  • All charges for hearing aids or routine hearing loss examinations.

  • All charges for care outside the United States and its territories, except in certain instances in Canada and Mexico.

  • All charges for routine foot care except when a medical condition affecting the lower limbs (such as diabetes) requires care by a medical professional.

  • All charges for services of naturopaths, Christian Science practitioners, immediate relatives, or charges imposed by members of your household.

  • Unless replaced, all charges for the first 3 pints of whole blood or units of packed cells used in each year in connection with covered services. To the extent the 3-pint blood deductible is met under Part A, it does not have to be met under Part B.

Copyright 1998-2015  McClaren & Associates.  All Rights Reserved.
Last modified: February 06, 2015