I Have Medicare A and B—What Else Do I Need?

Key Coverage Gaps in Original Medicare

Original Medicare, encompassing Medicare Part A and Part B, leaves significant coverage gaps that can expose beneficiaries to substantial out-of-pocket costs. Without careful planning or supplemental Medicare coverage, seniors and caregivers must contend with the following:

• Prescription drugs: Original Medicare does not include coverage for retail pharmacy medications. It will only help pay for drugs administered during inpatient stays (Part A) or certain outpatient drugs like chemotherapy (Part B).
• Vision, dental, and hearing: No routine eye exams, eyeglasses, hearing exams, hearing aids, dental cleanings, or dentures are included.
• Long-term nursing home care and alternatives: Original Medicare covers only short-term skilled nursing facility care following hospitalization but does not cover extended or custodial nursing home care.
• International health coverage: Medicare provides no coverage for medical care received abroad, except for a few rare emergency situations from U.S. providers.
• No out-of-pocket maximum: There is no cap on deductibles, copayments, or coinsurance, exposing beneficiaries to unlimited costs-especially for chronic or catastrophic health needs.

These longstanding coverage gaps place a significant financial burden on people with chronic conditions or those facing unexpected medical events. According to recent data, 22% of Medicare beneficiaries spend over $2,000 annually out-of-pocket without supplemental coverage.

Prescription Drug Coverage (Part D)

Medicare Part D is a voluntary prescription drug benefit managed by private insurers. It covers most outpatient prescription drugs through a formulary, which is an approved drug list organized by cost-sharing tiers:

• Preferred generics
• Non-preferred generics
• Preferred brand-name drugs
• Non-preferred brands
• Specialty or high-cost drugs

For 2026, key features of Part D include:

• Annual deductible up to $615 (may be less, depending on plan).
• After reaching $2,100 in out-of-pocket costs, the plan covers 100% of further covered drugs for the year.
• Tiers often require prior authorization or step therapy (trying less expensive alternatives before progressing to more costly medications).
• Some drugs are excluded: OTC medications, most vitamins, weight loss or ED prescriptions, and hospital-administered drugs (covered by Part A or B).
• Late enrollment without other credible coverage triggers permanent penalties added to your premium.

You may enroll in Part D separately with Original Medicare or as part of a Medicare Advantage plan (MAPD). For more detail on plan structures and how to select the right option, review this guide on choosing Medicare supplemental insurance.

Vision, Dental, and Hearing Coverage

Original Medicare does not provide routine coverage for vision, dental, or hearing services, leaving beneficiaries responsible for regular checkups, corrective eyewear, dentures, or hearing aids. This can lead to significant out-of-pocket spending, especially for seniors managing chronic oral or eye conditions. However, Medicare Advantage plans frequently offer these benefits:

• Dental coverage for preventive care, cleanings, and sometimes restorative work.
• Annual vision exams, glasses or contacts allowances.
• Hearing exams and some coverage toward hearing aids.

Availability and extent of these benefits depend on the specific Medicare Advantage plan selected. For the latest on dental, you can consult Does Medicare Have Dental Coverage in 2025? to see what’s changing and what to expect.

Long-Term Nursing Home Care and Alternatives

Medicare is limited in its support for long-term care. It only pays for short-term skilled nursing care following qualifying hospitalization events-typically up to 100 days, and only when skilled medical care is required daily. Custodial care, such as assistance with eating, bathing, or dressing (even in a nursing home setting), is not covered. Instead, you must pay out-of-pocket or seek alternative funding:

• Medicaid: For low-income individuals, Medicaid provides robust long-term care coverage in nursing homes and, in some states, for home and community-based services.
• Private long-term care insurance: Some purchase standalone policies prior to retirement, but options are limited and can be expensive.
• Personal savings or family support often bridge the remaining gap for those ineligible for Medicaid.

Understanding who pays first when Medicare and Medicaid overlap is essential. Explore Who Pays First: Medicare or Medicaid? for more on payer rules and coordination.

International Health Coverage and Options

Original Medicare does not cover routine health care abroad. Emergency coverage is sometimes possible, such as when a U.S. hospital is the nearest facility or when traveling between Alaska and another state via Canada. Otherwise, all overseas doctor or hospital visits must be paid out of pocket.

• Medigap: Some plans (C, D, F, G, M, and N) provide up to $50,000 lifetime for emergency international care, typically covering 80% of eligible costs after a small deductible.
• Medicare Advantage: Limited to plan networks, which usually do not include foreign providers. Some plans may offer emergency coverage while traveling, but this varies widely.
• Travel insurance: Seniors who plan frequent travel abroad often invest in short-term medical travel insurance.

If you are considering coverage while abroad, learning about your Medigap options can be vital. Find details and enrollment steps in our Medigap Part N Coverage guide.

Medicare Advantage: Comprehensive Alternative

Medicare Advantage (Medicare Part C) offers an all-in-one alternative to Original Medicare by bundling Part A and Part B benefits-and often Part D prescription drug coverage-into a single plan. Most plans add extra benefits not offered by Original Medicare, including routine vision, dental, and hearing coverage as well as a maximum out-of-pocket cap ($0 premium is available in 67% of plans, though all require you to keep paying the Part B premium, set to $202.90/month in 2026).

Major features include:

• Annual out-of-pocket cap for all covered services (unlike Original Medicare).
• HMO or PPO plan networks determine your provider options. HMO plans require referrals for specialists and restrict care to local providers, while PPOs offer more flexibility at higher cost.
• Best for people comfortable using a provider network, especially those who do not anticipate frequent travel outside their coverage area.

For those seeking all-in-one coverage and budgeting predictability, Medicare Advantage remains a popular choice. However, it’s important to weigh the provider network restrictions against your health and travel needs. Learn about detailed plan comparisons in our step-by-step plan selection guide.

Medigap: How Supplemental Insurance Works

Medigap, or Medicare Supplement Insurance, is designed to fill the largest coverage gaps in Original Medicare-especially copays, coinsurance (like the 20% not paid by Part B), deductibles, and certain emergency medical care abroad. Medigap policies are sold by private insurers and standardized into lettered plans (such as G or N), each covering different levels of out-of-pocket costs.

Key details:

• You must first have Parts A and B to buy Medigap.
• Medigap plans do not include Part D prescription drug coverage or extras such as dental, vision, or hearing-you’ll need to add Part D and other standalones as needed.
• Each Medigap policy covers one person; couples need to buy separate policies.
• Open enrollment for Medigap begins once you turn 65 and have enrolled in Part B; after this, insurers may require health underwriting unless your state mandates otherwise.
• In some states-Connecticut, Maine, Massachusetts, and New York-guaranteed issue rights allow people 65+ to buy plans at any time.

Get specifics on benefits and costs associated with Medigap Plan N in our thorough Medicare Part N Coverage article. Also, if you are wondering whether you can hold both a Medicare Advantage and Medigap plan, be aware that Medicare does not permit this pairing.

Employer/Union and Medicaid: Additional Support

Retiree employer or union plans can serve as additional coverage, either as primary or secondary to Medicare. COBRA coverage is possible but may need careful coordination to avoid coverage overlaps or gaps. For low-income seniors, Medicaid may cover Medicare premiums, deductibles, and most long-term care needs, working alongside Medicare for truly comprehensive protection.

The interaction between Medicare, Medicaid, and other coverage is complex and highly state-specific. For an in-depth review of payer coordination and eligibility, see Who Pays First: Medicare or Medicaid?.

How to Choose the Right Supplemental Coverage

Choosing between Medicare Advantage, Medigap + Part D, or another supplemental path depends on your health, travel habits, provider preferences, and budget. Here’s a data-driven comparison:

Option	Best For	Key Trade-Offs
Medicare Advantage	Want extras (dental/vision/hearing), out-of-pocket cap, potentially lower costs	Provider network limits, less flexibility for travel
Medigap + Part D	Value provider choice, nationwide coverage, frequent travelers	Higher premiums, must enroll separately for vision/dental/hearing
Employer/Medicaid	Retirees with group coverage, low-income individuals	Eligibility based, may require careful coordination

Key enrollment timing tips:

• Initial enrollment: Three months before and after turning 65.
• Annual Open Enrollment: October 15 – December 7 for Advantage and Part D.
• Special enrollment: Certain life changes (like moving or losing employer insurance) trigger special enrollment windows.

Choosing incorrectly or missing deadlines can lead to penalties and costly gaps in coverage. For practical help assessing your needs, consider our in-depth guide to selecting supplemental plans.

Frequently Asked Questions

• Does Part D cover all drugs? No; coverage depends on the plan’s formulary. Both generics and some brands are generally included if listed on your plan’s approved list.
• What happens if I miss enrollment windows? You may face lifelong penalties: 10% of the Part B premium per year delayed, and a Part D late fee added to the monthly premium.
• Can I have both Medicare Advantage and Medigap? No. Federal law prohibits combining these plans; you must choose one supplement path.
• What are the key Part D changes for 2026? A $2,100 out-of-pocket maximum will apply, after which your plan pays 100% for covered prescriptions. Monthly payment spreading for out-of-pocket costs is also optional in many plans.
• Can I lose coverage? Yes. Coverage may be lost due to non-payment of premiums or plan discontinuation. If this happens, special enrollment periods can help you avoid lapses, but delays risk missing drug or outpatient coverage. For steps on how to end your coverage safely, see How to Cancel Medicare Coverage.