Original Medicare Has No Annual Out-of-Pocket Cap — The Retirement Healthcare Risk People Underestimate

Medicare helps with various medical expenses, but it’s not a safety blanket that covers all of your expenses. There is no out-of-pocket cap for Original Medicare, which can have significant financial consequences if you incur an exorbitant medical bill.

This cost-sharing model can result in a major retirement-budget threat if the bills get out of control. Here’s what to know.

What ‘no out-of-pocket cap’ means

The lack of an out-of-pocket cap means there is no limit to how much you can pay in medical expenses for a long-term emergency that requires many hospital visits and procedures. For instance, Medicare puts the cost of a hospital stay at $434 per day from days 61 through 90, and it goes up to $868 per day from days 91 through 150. Beyond the 150th day, you pay all costs with no cap in place.

You can get a yearly out-of-pocket limit with Medicare Supplement Insurance (Medigap) or through Medicare Advantage. Medicare Part D has a prescription-drug cap of $2,100, but that only applies to covered drugs, not Part A and Part B medical bills.

How an uncapped bill can disrupt a retirement plan

An uncapped bill can disrupt retirement plans if you accrue expensive medical bills for treatments like chemotherapy, outpatient surgery and multiple hospital stays. A 20% coinsurance will be quite expensive if you accumulate more than $10,000 in medical expenses.

A surprise expense that comes to thousands of dollars can disrupt your withdrawal strategy. You may have to withdraw well above 4% in some years, which can put pressure on future withdrawal rates. Plus, most retirees live on fixed incomes, which offer limited options for income growth, especially if a medical condition makes part-time work infeasible.

High coinsurance can catch retirees by surprise who only budgeted for Medicare premiums, deductibles and prescriptions. And keep in mind that not all health conditions and services are covered by Medicare, including long-term care and dental services.

Ways retirees can limit the exposure

Pairing Original Medicare with a Medigap policy can cover some or most Part A and Part B cost-sharing, depending on the plan. You can also opt for Medicare Advantage, which will have spending caps for Part A and Part B services. However, you will have to weigh provider networks, prior authorization rules and plan-specific costs. Other types of coverage may also apply, such as employer and military coverage.

If you want to buy Medigap, it’s best to do so during the six-month open enrollment period beginning when a person is 65 or older and enrolled in Part B. People who enroll outside of this window may be denied. States can also use medical underwriting and charge more if you get Medigap outside the six-month window.

Medicare has an official comparison tool for people who aren’t sure which policy is right for them. Premiums, deductibles, copays, coinsurance, drug costs and the plan’s out-of-pocket limit are valuable factors to compare when making a decision.