What Medicare Won’t Pay For (and How You Fill That Gap)

The gap, in plain numbers

Here’s what Original Medicare actually leaves on the table in 2026:

• Part B deductible: $283 a year before Medicare pays anything
• Part B coinsurance: you pay 20% of the Medicare-approved amount for outpatient care, forever, with no ceiling
• Part A hospital deductible: $1,736 per benefit period (and you could hit this more than once a year if you’re readmitted after a 60-day gap)
• Dental, vision, hearing, and custodial long-term care: not covered, period

That last part about the 20% having no cap is the one that catches people off guard. If you have a rough year, a cancer treatment, a series of specialist visits, a hospitalization with complications, that 20% can add up to tens of thousands of dollars. There’s no stop-loss built into Original Medicare. You’re exposed until you die or go broke, whichever comes first, unless you do something about it.

That “something” is either a Medigap policy or a Medicare Advantage plan. They solve the same problem in opposite ways.

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Medigap: you pay more up front, less when things go wrong

A Medigap policy (also called Medicare Supplement) sits on top of Original Medicare. You keep Parts A and B exactly as they are, any doctor or hospital that accepts Medicare will see you, no networks, no referrals, no prior authorization. Then the Medigap plan picks up most or all of what Medicare doesn’t.

Plan G is the most popular one right now. It covers everything except the $283 Part B deductible. In Texas, Plan G runs somewhere in the $130 to $250 a month range statewide, depending on your age, gender, tobacco use, ZIP code, and which carrier you pick, since every company charges a different price for identical, federally standardized coverage. That’s worth shopping around for. Plan N is a bit cheaper, usually $95 to $175 a month across the state, but you’ll pay small copays, up to $20 for an office visit and up to $50 for an ER visit that doesn’t result in admission.

The tradeoff: you’re paying that premium every single month whether you use a dollar of care or not. But once you’ve paid your Part B deductible for the year, you’re essentially done. A heart attack, a knee replacement, a month in the hospital, it doesn’t matter. Your out-of-pocket exposure for the rest of that year is close to zero.

Medicare Advantage: you pay less up front, more if things go wrong

Medicare Advantage (Part C) works the opposite direction. A private insurer takes over your Medicare benefits and often bundles in drug coverage, dental, vision, hearing, even a gym membership. In 2026, about three out of four Medicare Advantage enrollees pay no premium beyond their regular Part B premium. That $0 price tag is the reason so many people sign up without digging further.

But you’re now working inside a network, usually an HMO or PPO, with copays for each visit, and CMS allows plans to set an in-network out-of-pocket maximum as high as $9,250 for 2026 (some plans set it lower; the average across enrollees is closer to $5,400). Once you hit that number, the plan covers 100% of your Part A and B costs for the rest of the year. But you have to get there first, and that number resets every January 1st.

Two people, same diagnosis, different bills

Here’s where this actually gets real. Picture two people, both 68, both diagnosed with the same thing this year, say a hip replacement with a short hospital stay and some physical therapy afterward.

Person A has Plan G. She pays roughly $175 a month (a mid-range Texas premium), or $2,100 for the year, plus the $283 Part B deductible. Total cost for the year, hip replacement and all: about $2,383. It wouldn’t matter if she’d also broken her wrist in March; the number barely moves.

Person B has a $0-premium Medicare Advantage plan with a $6,000 in-network out-of-pocket max. She pays copays for the surgeon, the hospital stay, the anesthesiologist, and every PT visit. In a bad year, those add up fast, and by the time she’s done, she could easily be near that $6,000 ceiling. If she’d also broken her wrist in March, she might hit the max even sooner, but she’s not paying past it.

Now flip it. If neither of them has any real health issues that year, Person A still pays her $2,100+ in premiums no matter what. Person B pays close to nothing beyond her regular Part B premium. For a genuinely healthy year, Medicare Advantage usually wins on cost. For a rough year, Medigap usually wins by a wide margin.

That’s really the whole decision in a nutshell: are you buying predictability, or are you betting on staying healthy?

What Orman’s post doesn’t get into

A few things worth adding to her framing, because they change the math for a lot of people:

• Once you’re past your initial enrollment window, Medigap can require medical underwriting. If you pick Medicare Advantage first and want to switch to a Medigap policy down the road, a health condition could get you charged more or, depending on your state, turned down. Texas doesn’t have guaranteed-issue protections outside a few specific situations, so this decision is easier to walk back in your first year than it is five years in.
• Medicare Advantage networks change every year. Your favorite specialist being in-network this January doesn’t guarantee they’ll be in-network next January. Medigap doesn’t have this problem at all, since it rides alongside Original Medicare’s nationwide acceptance.
• Dental and vision under Medicare Advantage plans often have caps around $1,000 to $1,500 a year, which sounds generous until you need one implant that costs $3,000 to $5,000 on its own. Orman’s right that this is a real gap, but it’s worth knowing the MA “solution” to it is often partial, too.
• Travel and snowbird lifestyles matter here. If you split time between Texas and another state, or you travel a lot, Original Medicare plus Medigap covers you anywhere in the country that accepts Medicare. A Medicare Advantage HMO usually won’t, outside of emergencies.

The honest answer

There isn’t a universally “better” choice here, and I’d be doing you a disservice if I pretended there was. It comes down to your health history, how much monthly premium you’re comfortable carrying, whether you travel, and how much risk you’re willing to sit with. Orman’s core message is right: don’t assume Medicare has you covered, because it doesn’t, not fully. But which tool you use to close that gap is a personal decision, not a one-size-fits-all answer.

If you’re working through this decision and want to talk through your specific situation, that’s exactly the kind of conversation I have with people every day. Feel free to reach out.

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