People say a version of this at the kitchen table every winter: my plan is good, I did the research, and I still paid $4,000 out of pocket last year. It is almost never said angrily. It is said the way you say something that does not add up, because the person did do the research, and the plan is good, and the money went out of the account anyway.
On a public consumer Medicare question site somebody asked it more directly: “What’s the most important question I should be asking about Medicare that I probably haven’t thought of yet?” Here is our answer. The important question is not which plan is good. It is which gap your plan leaves, because Original Medicare is not a comprehensive plan and was never designed to be one. It is a payment system with holes in specific, predictable places, and the holes are of two very different kinds.
Original Medicare puts no annual limit on what you pay in Part B coinsurance. You pay 20% of the cost for each Medicare-covered service, in a quiet year and in a catastrophic one, for the 2026 plan year. Every other number in this article is smaller than that one.
Source: Medicare.gov — Medicare costs, 2026 plan yearThe two kinds of gap, and why the difference decides everything
A cost-sharing gap is something Medicare covers and then hands you part of the bill for. The 20% coinsurance, the deductibles, the daily hospital and nursing-facility amounts. These are the gaps that supplemental insurance is genuinely built to close, because the underlying service is already a covered benefit and the only question is who writes the cheque.
A category gap is different. It is something Original Medicare is not built to pay for at all, so there is no coinsurance to fill in — there is simply no benefit sitting underneath. Routine dental work is the obvious one. Long-term custodial care is the expensive one. Sorting your worries into those two buckets is the single most useful thing you can do before you spend another dollar on coverage, because the two buckets are solved by completely different products, and the wrong product does nothing at all.
What does Original Medicare actually make you pay in 2026?
Here is the whole cost-sharing ledger for the 2026 plan year, from CMS and Medicare.gov. Read it once slowly. Most people have never seen these numbers in one place, and the shape of the list is the argument.
| What it is | 2026 amount | How often you pay it |
|---|---|---|
| Part B coinsurance | Usually 20% of the cost for each Medicare-covered service | Every service, all year, with no annual cap |
| Part B annual deductible | $283 | Once per calendar year |
| Standard Part B premium | $202.90 a month | Every month |
| Part A premium | $0 for most people; $311 a month at the reduced buy-in rate with 30+ quarters; $565 a month at the full rate | Every month, if you have to buy in |
| Part A inpatient hospital deductible | $1,736 | Per benefit period, not per year |
| Part A coinsurance, hospital days 61–90 | $434 a day | Each day, within a benefit period |
| Part A coinsurance, lifetime reserve days 91–150 | $868 a day | Each day, and you only ever get 60 of them |
| Skilled nursing facility coinsurance, days 21–100 | $217 a day | Each day of extended care in a benefit period |
Two details in that table are the ones people get wrong. First, the Part A hospital deductible is charged per benefit period, not per year, so a bad year with two separate admissions months apart can bring it around twice. Second, the lifetime reserve days are lifetime. Once you have used the 60, they are gone for good, and $868 a day is what they cost while you have them.
Why the 20% with no ceiling is the gap that hurts
Twenty per cent sounds survivable, and on a $180 office visit it is. The trouble is that 20% is a percentage, not an amount, and Original Medicare puts no annual roof over the total. A year of chemotherapy, a cardiac workup, a course of infusions or an orthopaedic repair with follow-up imaging are all Part B events, and 20% of a large number is a large number. There is no point in the calendar where Original Medicare says you have paid enough now.
That single design feature is why Medicare supplement insurance exists at all, and why the comparison between a supplement and a Medicare Advantage plan is really a comparison of two different ways to install a ceiling. We wrote the long version of that decision in our guide to Medicare Advantage versus a Medicare supplement, and it is worth reading before you read the rest of this.
The hospital side, when a year goes badly
The Part A numbers are the ones that read like a bad novel. You pay the $1,736 inpatient deductible for the benefit period. Days 1 through 60 carry no additional daily coinsurance. From day 61 through day 90 you owe $434 a day. Past day 90 you begin spending lifetime reserve days at $868 a day, and there are only 60 of those in your whole life. If you then move to a skilled nursing facility, days 21 through 100 of extended care cost $217 a day in the 2026 plan year.
Add days 61 to 90 at $434 and the arithmetic gets uncomfortable fast, and that is before a single Part B service inside the same hospitalisation. This is the part of Medicare that most people have never modelled, because nobody plans for a 70-day admission. The supplements that close this gap close it completely, which is exactly why they are worth understanding rather than dismissing as an extra premium.
The drug gap now has a ceiling. The medical gap still doesn’t.
Part D is the one place where the story got better. For CY2026 the annual out-of-pocket threshold is $2,100. Once your out-of-pocket spending on covered Part D drugs reaches it, you are done paying for covered drugs that year. No Part D plan may carry a deductible above $615, and in the initial coverage phase you pay 25% coinsurance until you hit the threshold. Insulin is capped separately at $35 for a month’s supply with no deductible, and no more than $105 for a three-month supply.
The scale of what that ceiling holds back is easier to see in the spending data than in the rules. In CY2025, gross Part D spending on apixaban — sold as Eliquis — was $24.05 billion across 4,806,752 beneficiaries, an average of $5,002.90 each. That is gross spending before manufacturer rebates, not what Medicare paid, and it includes the plan’s share as well as yours. But it tells you that a single common blood thinner runs into thousands of dollars a year per person, and the $2,100 threshold is the thing standing between that number and your bank account. Our article on the Part D out-of-pocket cap works through how the phases actually run.
People still say “the $2,000 cap” because that was the 2025 figure. The verified CY2026 amount is $2,100. If a mailer or a sales call quotes you $2,000 for 2026, the person talking to you has not updated their script.
Does a Medicare Advantage plan close the gap?
It installs a ceiling, which Original Medicare does not have, and that is a real and important difference. But “there is a cap” and “the cap is low” are two different sentences, and the marketing rarely distinguishes between them. The CY2026 landscape data shows the median in-network maximum out-of-pocket at $6,750 across Duval, Clay, St. Johns and Nassau counties, $3,900 in Broward, with plans ranging up to $9,250. In Fulton and Chatham counties in Georgia, the median is $9,250 — the top of the range is the middle of the market.
Two people can hold plans with identical $0 premiums, one in Fort Lauderdale and one in Savannah, and be carrying a $5,350 difference in worst-case in-network exposure. Neither of them was told that at the point of sale, because the premium is the number on the mailer and the cap is on page nine of the summary of benefits. If you live in Duval County and you are shopping on premium alone, the cap is the number you are not looking at.
What a Medicare supplement fixes, and what it leaves alone
A Medicare supplement, still called Medigap by everyone in the industry and almost nobody else, works on the cost-sharing gaps only. It sits behind Original Medicare and pays some or all of the deductibles, the coinsurance and the daily hospital amounts. It does not add a benefit that Medicare does not have. That is the whole design, and it is why the letter plans are standardised and comparable in a way that almost nothing else in insurance is.
Florida publishes its own 2026 parameters for the plans that carry their own limits, and they are worth knowing before anyone quotes you a letter.
| Plan feature | 2026 amount | What it means for you |
|---|---|---|
| Plan K annual out-of-pocket maximum | $8,000 | Plan K cost-shares with you until you reach this, then pays |
| Plan L annual out-of-pocket maximum | $4,000 | Same structure as K, at half the ceiling |
| High-Deductible Plan F and High-Deductible Plan G deductible | $2,950 | You pay this yourself before the policy pays anything |
| Plan N copays | Up to $20 for Part B physician office visits and up to $50 for emergency room visits | A lower premium in exchange for small copays at the point of care |
| Foreign travel emergency benefit | Pays 80% of billed charges after a $250 deductible, subject to a $50,000 lifetime maximum | The one place a supplement touches care outside the United States |
Notice what that table does not contain. There is no dental row, no hearing-aid row, no long-term-care row. A supplement is a cost-sharing instrument. If your worry is a $6,000 implant, no letter on that list is going to help you, and anyone selling you one on that basis is selling. If you are weighing two of the common letters against each other, our comparison of Plan G against Plan N for 2026 gets into the trade-off in detail.
The categories Medicare is not built to pay for
Three category gaps come up in nearly every conversation we have: routine dental, vision and hearing care; long-term custodial care, meaning help with daily living rather than skilled medical treatment; and care received outside the United States, beyond limited exceptions. These are the gaps where no amount of cost-sharing coverage helps, because there is nothing underneath to share.
We are going to be careful here, and you should be careful with anyone who is not. The precise coverage rules and the exact wording of the exceptions are federal rules that change, and we do not print a rule we cannot cite to a primary document. Confirm the current rules for your own situation at Medicare.gov, or by calling 1-800-MEDICARE. In Florida you can also get free, unbiased one-to-one counselling from SHINE, the state’s Serving Health Insurance Needs of Elders program, on 1-800-963-5337. They do not sell anything, and we send people there regularly.
Dental, vision and hearing: the gap people feel first
This is the category gap that shows up soonest, because teeth and eyes do not wait for a catastrophic year. It is also the one most often quoted back to us as a reason to choose a particular Medicare Advantage plan, since many of them bundle some dental, vision and hearing allowance into the plan. That can be genuinely useful. It can also be an allowance that covers a cleaning and evaporates at the first crown.
The honest way to evaluate it is to read the actual dollar allowance and the actual list of covered procedures in the plan documents, then compare that against what your dentist says is coming in the next two years. A stand-alone dental, vision and hearing policy through our supplemental coverage is the other route, and for someone with real dental work ahead it is often the cleaner one. For someone with excellent teeth and no history, it is money spent on a risk that is not theirs.
Long-term custodial care: the biggest uncovered risk in the list
Skilled nursing care after a qualifying hospital stay is a Medicare benefit with the cost sharing shown above — $217 a day for days 21 through 100 of extended care in a benefit period, for the 2026 plan year. Custodial care is a different thing entirely: help with bathing, dressing, meals and mobility, indefinitely, with no medical treatment attached. That is the expensive scenario families actually face, and it is not what those Part A numbers are describing.
Long-term care insurance exists for exactly this gap. It is also the product we recommend least often, because it is expensive, it is medically underwritten, and for many households the honest answer is that the premium would be better spent elsewhere. Whether it fits depends on your assets, your family situation and your health at the time you apply. It is a real conversation, not a checkbox, and it deserves an hour rather than a phone pitch.
Care outside the United States
Original Medicare is a domestic program, and coverage outside the United States is limited. For a Jacksonville household that spends part of the year abroad or takes a cruise every spring, that is a live issue rather than an abstraction. The one place standard supplemental coverage reaches it is the foreign travel emergency benefit built into several Medigap letters, which in Florida for the 2026 plan year pays 80% of billed charges after a $250 emergency medical deductible, subject to a $50,000 lifetime maximum.
Read that sentence twice. Eighty per cent, after a deductible, up to fifty thousand dollars for the rest of your life. It is a meaningful benefit and it is not travel insurance. If international travel is a regular part of your year, the gap is real and the fix is usually a separate travel medical policy, not a different Medigap letter.
The gaps get concrete when you already have a condition
Gaps are abstract until they attach to something you are actually being treated for. County-level health estimates make that concrete. In Duval County the CDC PLACES 2023 estimates put arthritis at 23.4% crude and 25.2% age-adjusted among adults, high blood pressure at 33.7% and 35.4%, diagnosed diabetes at 11.8% and 12.8%, and COPD at 6.5% and 7.0%.
Every one of those conditions is managed with recurring Part B services and recurring prescriptions, which is another way of saying every one of them meets the 20% coinsurance repeatedly across a year. Nassau County carries the highest high-cholesterol estimate of the five counties we serve most, at 42.0% age-adjusted, and Broward carries the highest diabetes estimate at 11.4% crude and 13.5% age-adjusted. If you are one of those people, your gap is not theoretical and your plan choice is not a coin flip.
| County | Measure | Crude / age-adjusted estimate |
|---|---|---|
| Duval | Arthritis among adults | 23.4% / 25.2% |
| Duval | High blood pressure among adults | 33.7% / 35.4% |
| Duval | Diagnosed diabetes among adults | 11.8% / 12.8% |
| Duval | COPD among adults | 6.5% / 7.0% |
| Nassau | High cholesterol, ever screened | 33.8% / 42.0% |
| Broward | Diagnosed diabetes among adults | 11.4% / 13.5% |
So which gaps are actually worth insuring?
Here is the part most agency articles will not write. Nobody needs all five supplemental products. Dental, vision and hearing; hospital indemnity; short-term medical; disability income; long-term care. There is a version of this website’s business model where we tell you that each of them fills a dangerous hole and you should hold all of them. That version would be dishonest, and you would eventually work it out.
The right question is narrower and harder: which gap does your plan leave, at the size you would actually feel. If you hold a Medicare supplement, your cost-sharing gap is largely closed and your remaining exposure is almost entirely category gaps. If you hold a Medicare Advantage plan with a $6,750 in-network cap, your category gaps may be partly bundled and your cost-sharing exposure is the number on that cap. Those two people should buy completely different things, and one of them should probably buy nothing.
| If you hold | Your cost-sharing gap is | Your remaining exposure is mostly |
|---|---|---|
| Original Medicare with no supplement | Wide open — 20% Part B coinsurance with no annual cap | Everything in the cost-sharing ledger, plus every category gap |
| Original Medicare with a Medigap letter | Largely closed, depending on the letter | Dental, vision and hearing, long-term custodial care, care abroad |
| A Medicare Advantage plan | Capped at the plan’s in-network maximum out-of-pocket, a $6,750 median in Duval for 2026 | Whatever the plan’s bundled allowances do not stretch to, plus custodial care |
| A Medicare Advantage plan and a stand-alone dental policy | Capped as above | Long-term custodial care, care abroad, and out-of-network exposure |
How to work out which gap your own plan leaves
You do not need us for this part, and you do not need a quote. You need last year’s bills, which most people already have in a drawer or an email folder. Give it forty-five minutes with a pen.
- Pull last year’s explanation of benefits statementsEvery one of them, from every provider, for the whole calendar year. Not the bills — the EOBs, which show what was billed, what the plan allowed and what was left to you.
- Add up only the “you may owe” columnIgnore the billed charges, which are theatre. The number you want is the total of what actually landed on you across the year, medical and drug separately.
- Sort every dollar into cost-sharing or categoryA copay, a coinsurance amount or a deductible goes in the cost-sharing column. A dentist, an optometrist, hearing aids, a caregiver or anything you paid cash for because it was not covered goes in the category column. Two totals, that is all.
- Find your plan’s annual cap and write it next to the cost-sharing totalOn a Medicare Advantage plan it is the in-network maximum out-of-pocket in your summary of benefits. On Original Medicare with no supplement, write “none”, because there is not one.
- Ask whether last year was a normal yearIf it was quiet, run the exercise again against the worst plausible year: your plan’s full cap, plus the category items you would still be paying cash for. That is your real exposure, not last year’s number.
- Buy against the bigger column, and only the bigger columnIf the category total dwarfs the cost-sharing total, a supplement is not your answer and a stand-alone dental or hearing policy might be. If it is the other way around, look at the cost-sharing side first. If both totals are small and your worst year is survivable, the honest answer may be that you need nothing at all this year.
Bring your current plan and your prescription list; we’ll do the comparison with you if you would rather not do it alone.
Before and after: an illustrative Jacksonville example
Take a fictional 71-year-old in Arlington we will call Ruth. She holds a $0-premium Medicare Advantage plan, has managed high blood pressure and arthritis for years, and had a heavy medical year followed by two crowns and a new pair of glasses. Everything below is arithmetic on the verified 2026 figures, not a quote and not a real client.
| Before — shopping on premium | After — shopping on the gap | |
|---|---|---|
| What she looked at | The $0 monthly premium on the mailer | The plan’s in-network maximum out-of-pocket, a $6,750 median in Duval for the 2026 plan year |
| Her medical exposure in a heavy year | Unknown to her until the bills arrived | Known, capped, and written on a sticky note on the fridge |
| Her dental and vision spending | Paid in cash, because the plan allowance ran out in March | Covered by a stand-alone dental, vision and hearing policy sized to the work she knew was coming |
| What she bought that she did not need | Nothing yet — she had been quoted three products | Two of the three, declined, because those gaps were not hers |
| What changed about the plan itself | Chosen on premium | Reviewed each autumn against her actual drug list and doctors |
The point of the example is not that Ruth saved money, because we cannot promise that and we are not going to. The point is that she stopped guessing. She bought one thing that matched a gap she could name and turned down two things that did not.
Where to check any of this for free
Everything in this article can be verified without talking to an agent, and you should verify it. Medicare.gov publishes the official cost figures and the Plan Finder tool. 1-800-MEDICARE will answer questions about your own record. Florida’s SHIP program, SHINE, gives free one-to-one counselling on 1-800-963-5337 and has no product to sell you. Those three are the baseline, and any agent who is uncomfortable pointing you at them is telling you something about themselves.
For the wider picture of how the parts fit together in this state, our Florida Medicare guide for 2026 covers the enrollment mechanics that sit underneath all of this, including the October 15 to December 7 annual window.
How we help
We run the gap exercise above with you, using your own statements rather than a generic scenario. We check what your current plan actually caps and what it actually excludes, then we tell you which of the supplemental products are irrelevant to you. That last part is most of the value. We represent a limited set of carriers and we say so; we do not offer every plan available in your area, and any information we provide is limited to those plans we do offer in your area.
McDowell Business Resources is an independent agency, not an insurance carrier, and we are not connected with or endorsed by the U.S. government, CMS or the federal Medicare program. We will tell you honestly if this isn’t the right fit for you.
What you get out of doing this once
You get a number. Not a feeling that you are probably fine, and not a folder of mail you are afraid to throw away — an actual figure for your worst plausible year, and a short list of the gaps that figure does not include. It takes one afternoon and it holds up for a year, and it changes what you do every autumn when the plan documents arrive.
Original Medicare will still have no cap on Part B coinsurance in 2026, and the categories it does not reach will still be outside it. None of that is going to change because you looked. What changes is that you stop buying coverage for other people’s risks. Whatever you decide, decide it on the numbers. If you want help getting to them, we’re here.
Free, no-pressure help with supplemental — in plain language.