What Does Medicare Actually Cover? A Plain-English Guide for Florida Seniors

Medicare covers hospital stays, doctor visits, and drugs — but gaps exist. Here's exactly what each part pays, and what you'll still owe in 2026.

Author: Lynsey Brennan, Licensed Medicare Advisor | FL License #G007269 | Published June 23, 2026 Reading time: 7 min read

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Quick Answer

Medicare is divided into parts — A, B, C, and D — and each one covers something different. Original Medicare (Parts A and B) handles most hospital and doctor costs, but it doesn't cover everything, and there's no cap on what you could owe out of pocket without extra coverage. Most Florida seniors add a Medicare Advantage plan or a Medigap supplement to fill those gaps.

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Key Takeaways

• Part A covers inpatient hospital care; Part B covers outpatient services and doctor visits — but both come with deductibles and cost-sharing.
• The 2026 standard Part B premium is $202.90/month, with a $283 annual deductible (CMS, November 2025).
• Over 56% of Florida Medicare beneficiaries are enrolled in a Medicare Advantage plan (CMS Medicare Monthly Enrollment, 2024) — see our Florida Medicare data for more context.
• For 2026, the Medicare Part D annual out-of-pocket threshold is $2,100 (CMS Final CY 2026 Part D Redesign Program Instructions).
• Choosing between Medicare Advantage and a Medigap supplement involves real trade-offs — cost, flexibility, and network access all matter.

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Table of Contents

1. Part A: Hospital Coverage 2. Part B: Medical and Outpatient Coverage 3. Part D: Prescription Drug Coverage 4. What Medicare Doesn't Cover 5. Medicare Advantage vs. Original Medicare in Florida 6. Medicare Supplement (Medigap): Filling the Gaps 7. When to Review Your Coverage

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Part A: Hospital Coverage {#part-a-hospital-coverage}

Medicare Part A is often called "hospital insurance." It covers:

• Inpatient hospital stays — room, nursing care, meals, and most services during an admitted stay
• Skilled nursing facility (SNF) care — but only after a qualifying 3-day inpatient hospital stay, and only for a limited time
• Home health care — when ordered by a doctor and deemed medically necessary
• Hospice care — for individuals with a terminal diagnosis

Most people don't pay a premium for Part A if they or their spouse worked and paid Medicare taxes for at least 10 years. However, you will pay a hospital deductible — check the 2026 Medicare costs page for the current amount, since it adjusts annually.

One important note: after 60 days in the hospital, you start paying daily coinsurance. After 90 days, you're drawing on a limited "lifetime reserve" of 60 days. There's no cap on what you could owe — which is one reason so many people add extra coverage.

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Part B: Medical and Outpatient Coverage {#part-b-medical-and-outpatient-coverage}

Part B covers the kind of care most people use most often:

• Doctor visits (primary care and specialists)
• Outpatient procedures and surgery
• Lab work and diagnostic imaging
• Durable medical equipment (wheelchairs, walkers, oxygen)
• Preventive services — including an annual wellness visit, mammograms, and certain cancer screenings at no cost to you

In 2026, the standard Part B premium is $202.90/month, with an annual deductible of $283 (CMS, November 2025). After the deductible, Medicare typically pays 80% of the approved amount, and you pay the remaining 20% — with no out-of-pocket cap under Original Medicare alone.

That 20% can add up fast, especially with a hospitalization or ongoing specialist care. That's the gap most seniors want help closing.

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Part D: Prescription Drug Coverage {#part-d-prescription-drug-coverage}

Part D is optional, but skipping it usually costs you later — both in higher drug costs and potential late-enrollment penalties.

Key things to know for 2026:

• $2,100 annual out-of-pocket threshold for 2026 — the 2025 $2,000 threshold is indexed to $2,100 for 2026 under the redesigned Part D benefit. After you reach it, you enter the catastrophic phase with no cost sharing for covered Part D drugs.
• Covered insulin cost sharing is limited — in 2026, the monthly amount is the lesser of $35, 25% of the applicable negotiated price, or 25% of the maximum fair price when applicable.
• Plans vary widely by premium, deductible, and which drugs are covered (the "formulary"). A plan that works well for your neighbor may not cover your specific medications.

You can learn more about how Part D works, including how to check if your drugs are covered, on the Part D drug coverage guide.

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What Medicare Doesn't Cover {#what-medicare-doesnt-cover}

This surprises a lot of people. Original Medicare does not cover:

• Routine dental care — cleanings, fillings, dentures
• Routine vision — eye exams for glasses or contacts, eyeglasses themselves
• Hearing aids — or routine hearing exams
• Long-term custodial care — help with bathing, dressing, or eating in a nursing home setting (this is different from skilled nursing)
• Most care received outside the U.S.

Some Medicare Advantage plans do offer dental, vision, and hearing benefits — that's part of their appeal. But coverage levels vary considerably from plan to plan, and what looks good on paper may have limits in practice.

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Medicare Advantage vs. Original Medicare in Florida {#medicare-advantage-vs-original-medicare-in-florida}

Florida has one of the highest Medicare Advantage enrollment rates in the country. As of 2024, 56.1% of Florida Medicare beneficiaries are enrolled in a Medicare Advantage plan (CMS Medicare Monthly Enrollment, 2024). Nationally, that figure is about 54% (CMS, 2024).

Medicare Advantage plans (Part C) bundle Parts A, B, and usually D into one plan offered by a private insurer. They often include extras like dental and vision. The 2026 Medicare Advantage in-network out-of-pocket maximum is capped at $9,250 (CMS, Final CY 2026 Part C bid-review memorandum, Table 3) — which is meaningful protection compared to Original Medicare's unlimited exposure.

The trade-off? Most Advantage plans use networks — HMOs or PPOs — meaning you may need referrals or may pay more to see out-of-network providers. If you travel frequently or split time between states, that network restriction can matter.

Compare your options carefully using our Medicare Advantage guide or the Medicare Advantage vs. Supplement breakdown.

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Medicare Supplement (Medigap): Filling the Gaps {#medicare-supplement-medigap-filling-the-gaps}

Medigap plans work alongside Original Medicare — they're sold by private insurers and help cover cost-sharing like deductibles and that 20% coinsurance.

In Florida, popular Medigap options include Plan G (which covers most gaps except the Part B deductible) and Plan N (which typically has lower premiums but includes some copays). Premiums vary by age, insurer, and where you live, so comparison shopping genuinely matters.

With Medigap, you keep the broad flexibility of Original Medicare — any doctor or hospital that accepts Medicare, anywhere in the country — which some people strongly prefer.

Our Medicare Supplement guide walks through how each plan letter works and what questions to ask when comparing.

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When to Review Your Coverage {#when-to-review-your-coverage}

Coverage needs change. Your health changes. Plans change their formularies, premiums, and networks every year. The Annual Enrollment Period (October 15 - December 7) is your main window to switch plans for the following year, but there are also Special Enrollment Periods tied to life events.

Even if you're happy with your current plan, a quick review each fall can confirm you're still in the right fit — or flag something worth changing. You can check Medicare enrollment periods to see what windows apply to your situation.

Use the plan comparison tool to see what's available in your zip code, or browse the Medicare FAQ for quick answers.

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Frequently Asked Questions

Q: Does Medicare cover dental care in Florida? A: Original Medicare (Parts A and B) does not cover routine dental services like cleanings, fillings, or dentures. Some Medicare Advantage plans include dental benefits, but the scope of that coverage varies widely by plan — it's worth reading the details before assuming a plan's dental coverage meets your needs.

Q: What is the out-of-pocket maximum for Medicare Advantage in 2026? A: CMS has set the 2026 Medicare Advantage in-network out-of-pocket maximum cap at $9,250 (CMS, Final CY 2026 Part C bid-review memorandum, Table 3). Individual plans may set their own maximum lower than that cap. Once you hit that limit, the plan pays 100% of covered in-network services for the rest of the year.

Q: Is there a cap on Part D drug costs in 2026? A: Yes. The Medicare Part D annual out-of-pocket threshold is $2,100 for 2026. After you reach that threshold, you enter the catastrophic phase with no cost sharing for covered Part D drugs. Cost sharing for covered insulin is also limited under Medicare rules.

Q: Can I have both a Medicare Advantage plan and a Medigap policy? A: No — you cannot use a Medigap supplement alongside a Medicare Advantage plan. Medigap is designed to work with Original Medicare only. If you want to switch from Advantage to Original Medicare plus a Medigap plan, timing and eligibility rules apply, so it's worth talking through your specific situation before making any changes.

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The Bottom Line

Medicare covers a lot — but not everything, and the cost-sharing under Original Medicare alone can be significant. Understanding what each part covers, what you'll owe, and how Advantage plans or Medigap supplements change that picture is the first step to making a confident decision. If you're unsure whether your current coverage still fits, or you're new to Medicare and figuring this out for the first time, I'd be glad to help.

Schedule a free Medicare review — no pressure, no jargon, just a straightforward conversation about your options.

Call or text: 561-247-0678

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Sources

• CMS Medicare Monthly Enrollment, 2024 — Florida and national Medicare Advantage enrollment figures
• CMS, November 2025 - 2026 standard Part B premium ($202.90/month) and Part B deductible ($283)
• CMS, Final CY 2026 Part C Bid Review Memorandum (April 16, 2025), Table 3 — 2026 maximum in-network out-of-pocket limit for HMO and PPO plans ($9,250)
• CMS Final CY 2026 Part D Redesign Program Instructions - $2,100 annual out-of-pocket threshold and 2026 covered-insulin cost-sharing limits

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This article is for educational purposes and is not affiliated with or endorsed by the federal Medicare program or any government agency. HealthPlan Connect is a private, licensed Medicare advisory service. FL License #G007269.