Why Doesn’t Medicare Cover 100% of My Medical Bills?

Why Doesn’t Medicare Cover 100% of My Medical Bills?

Medicare is a critical program that provides health insurance for millions of Americans, especially those over the age of 65 and certain younger individuals with disabilities. While it offers essential coverage, it does not cover all medical costs, leaving beneficiaries responsible for a portion of their healthcare expenses. These out-of-pocket costs can include deductibles, copayments, and coinsurance. Understanding why Medicare doesn’t cover 100% of your medical bills and exploring ways to manage these costs is crucial for those who rely on the program.

What is Medicare and Who Does It Cover?

Medicare is a federal health insurance program that provides coverage for approximately 63 million Americans. It primarily serves individuals over the age of 65, but it also covers certain younger people with disabilities or specific conditions like end-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Medicare is divided into four parts:

  • 📌Part A: Hospital insurance, which covers inpatient care in hospitals, skilled nursing facilities, and some home health care.

  • 📌Part B: Medical insurance, covering outpatient care such as doctor visits, outpatient surgeries, and some preventive services.

  • 📌Part C: Medicare Advantage, which is an alternative to Original Medicare and offered by private insurance companies. Part C plans often include additional benefits like vision, dental, and prescription drug coverage.

  • 📌Part D: Prescription drug coverage, also offered through private insurance companies, covering the cost of prescription medications.

While Medicare covers a wide range of healthcare services, it does not cover everything. Many services, treatments, and items are either partially covered or not covered at all.

Out-of-Pocket Costs Under Medicare

Despite its broad coverage, Medicare beneficiaries are still responsible for certain out-of-pocket costs. These include:

1. Hospital Stays (Part A): Medicare Part A covers inpatient care in hospitals, but you must pay certain fees:

  • Deductible: In 2025, the Part A deductible is $1,676 for each benefit period. A benefit period begins when you are admitted to the hospital and ends when you haven’t received inpatient care for 60 consecutive days.

  • Copayments: If you are hospitalized for extended periods, you will have to pay a daily copayment. For days 61 to 90, the cost is $419 per day. If your stay extends beyond 90 days, you will need to pay $838 per day, unless you have “lifetime reserve days” remaining.

2. Skilled Nursing Facility Care (Part A): If you require skilled nursing facility care after a hospital stay, Part A provides coverage, but with limits:

Days 1-20: Covered at less cost (except for the Part A deductible).

Days 21-100: You pay $204 per day.

Days 101 and beyond: You pay all costs

3. Outpatient Care (Part B): Part B covers a variety of outpatient services, including doctor visits, outpatient surgeries, and preventive services like flu shots and cancer screenings. However, it comes with the following costs:

  • Deductible: In 2025, the Part B deductible is $233.

  • Coinsurance: After meeting the deductible, you are responsible for 20% of the Medicare-approved amount for most services.

4. Prescription Drugs (Part D): Medicare does not cover prescription drugs under Original Medicare (Parts A and B). To receive coverage, you must enroll in Part D, which is offered through private insurers.

  • Deductible: The maximum deductible for Part D plans in 2025 is $590.

  • Copayments/Coinsurance: Depending on the plan and the medications, you may pay a copayment or coinsurance for your prescriptions.

Why Doesn’t Medicare Cover 100% of Medical Costs?

There are several reasons why Medicare does not cover all medical costs:

1. Cost-Sharing Philosophy☘️: Medicare is designed to operate on a cost-sharing basis. Beneficiaries are responsible for part of their healthcare costs to reduce the overall financial burden on the system. This also helps keep premiums more affordable for all participants.

2. Limited Coverage☘️: While Medicare covers many healthcare services, it does not cover everything. For example, it typically does not cover routine dental care, most vision care, or hearing aids, unless they are medically necessary. You may need additional coverage for these types of services.

3. Focus on Medically Necessary Services☘️: Medicare is intended to cover medically necessary services—those that are essential for health maintenance or treatment. Non-essential services or those deemed less critical to a person’s well-being may not be covered under Medicare.

4. Preventing Overuse of Services☘️: The requirement for beneficiaries to share costs encourages more responsible use of healthcare services. By reducing unnecessary or excessive usage, Medicare aims to make the healthcare system more efficient and sustainable in the long term.

Real Case Example👩‍🦳

Ms. Zhang, 68, recently experienced back pain and was hospitalized for treatment. She stayed in the hospital for 70 days. The first 60 days were covered by Medicare under Part A, but from day 61 to day 70, she had to pay $419 per day. Additionally, she was prescribed several medications, for which she needed to enroll in a Part D plan. While her Part D plan helped cover some of the costs of her prescriptions, she was still responsible for copayments. To reduce out-of-pocket expenses, Ms. Zhang decided to purchase a Medigap plan, which helped cover most of the coinsurance and deductibles that Medicare didn’t pay. This significantly lowered her overall healthcare costs.

Options for Additional Coverage

To help fill the gaps left by Medicare, there are options such as Medigap and Medicare Advantage:

  • Medigap: These are supplemental insurance plans that help pay for out-of-pocket costs like deductibles, coinsurance, and copayments. Medigap plans are offered by private insurance companies and come in standardized plans (e.g., Plan A, Plan B) with different levels of coverage.

  • Medicare Advantage (Part C): Medicare Advantage plans are offered by private insurance companies and provide the same coverage as Original Medicare (Parts A and B), with additional benefits such as vision, dental, and prescription drug coverage. Some Medicare Advantage plans may have lower out-of-pocket costs compared to Original Medicare, but they may come with network restrictions or require more coordination of care.

Conclusion👇

Websites like ehealthinsurance you can learn more.Medicare provides vital health coverage for millions of Americans, but it does not cover all medical costs. Beneficiaries may still need to pay deductibles, coinsurance, and copayments for many services. Understanding why Medicare doesn’t cover 100% of medical bills can help you better plan for out-of-pocket expenses. Exploring options like Medigap and Medicare Advantage plans can help fill in the gaps and reduce your healthcare costs, ensuring that you get the care you need without financial surprises.