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Medicare covers inpatient hospital care as well as some lab tests and surgeries. It also covers preventative care, doctor visits and prescription drugs. Below you’ll find a comprehensive guide on what does Medicare cover and what it doesn’t.
Medicare is a federal health insurance program designed for those 65 and older. Though it can also cover some younger people with specific illnesses or disabilities.
Medicare can be confusing. As you look at the various options and choices within Medicare, it’s good to understand what each part of the program covers. This will help you make an educated decision about your healthcare needs.
Part C, also known as Medicare Advantage, offers additional coverage. Part C provides all-in-one plans that combine Parts A and B, and often include Part D for prescription drug coverage.
Part D focuses solely on prescription drug coverage. It helps reduce the cost of medications for enrollees.
Now that you have some basics, let’s go into a little more detail.
What Is Medicare?
Medicare is a government-funded health insurance program for people who are 65 or older. It also covers some younger people with disabilities and those with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare is designed to provide affordable healthcare coverage and offers various options for you to choose from, based on your needs.
There are two main ways to get Medicare coverage: Original Medicare and Medicare Advantage. Each year, you can choose which way you get your health coverage and make adjustments if needed.
It’s important to note that Medicare does not offer plans for couples or families; you’ll have to make your own choices independently.
What Does Medicare Cover?
Medicare covers a wide range of medical and health-related products, services and treatments. What exactly is covered depends on a few key factors. They are:
- What type of Medicare coverage you have
- Where you live
- The reason you need the product, service and/or treatment
Let’s dig a little deeper into each of these factors below.
What Kind of Medicare Coverage You Have
There are a number of different types or parts of Medicare coverage. You may have heard about Part A, Part B, etc. when it comes to Medicare. Each one of those covers different things. Here is an overview of what each part covers.
Inpatient Hospital Care
This covers inpatient care at long-term hospitals, inpatient mental health hospitals, critical access hospitals and acute care hospitals.
In these settings, Medicare Part A will typically cover: a semi-private room, meals, general nursing care, physical therapy, occupational therapy, prescription drugs/medical supplies, specialty unit care (ie. Intensive care) , lab/imaging tests and operating room services.
Skilled Nursing Home Facility Care
If a stay at a skilled nursing facility is required, Medicare Part A generally covers: a semi-private room, meals, skilled nursing care, prescription drugs/medical supplies, ambulance transport (if medically required).
Nursing Home Care
Medicare Part A may cover nursing home care for a limited time if skilled nursing care is required. The usual coverage includes: a semi-private room, meals, general nursing care, physical therapy, occupational therapy, and prescription drugs/medical supplies
Part A also covers hospice care for those with a terminal illness with less than 6 months to live. The specific things covered for hospice include: care to manage symptoms/control pain for those with terminal illness, prescription drugs/medical supplies, general nursing care, and doctor services.
Home Health Care
Home health care coverage is limited to those who have been discharged from an inpatient hospital stay but still require care during recovery. In this situation, Medicare Part A typically covers: physical therapy, occupational therapy, skilled healthcare, and prescription drugs/medical supplies.
Next we’ll look at what Medicare Part B covers. Broadly, Part B covers medically necessary services like outpatient care as well as preventative services.
The list below is a partial list of what Part B covers. For a complete, updated list of what’s covered visit the official Medicare website.
- Doctor visits
- Some prescription drug coverage
- Vaccines including flu, tetanus, Hepatitis B and pneumonia shots
- Emergency Department services
- Home health services
- Physical therapy / Occupational therapy
- Ambulance services
- Chiropractic treatment
- Mental health services
- Some medical equipment like walkers and hospital beds
- Outpatient Medical & Surgical Services
- Smoking Cessation
- Some lab tests
- Annual wellness visit with your primary care provider
- Some cancer screenings
- Diabetes screening, supplies and services and, if you qualify, prevention program
- Depression screenings
- Alcohol abuse screenings and counseling
Part C (Medicare Advantage)
Medicare Part C is offered by private health insurance companies. It’s also known as Medicare Advantage. It covers what Parts A & B do but can also offers some extra services and benefits the other Parts don’t.
In addition to what Part A & B cover, Part C may cover:
- Prescription drugs you take at home
- Dental care including routine cleanings, x-rays and dentures
- Vision care that may include contacts and eyeglasses
- Hearing care that may include hearing aids
- It may also provide gym memberships and meal delivery services
Lastly we come to Medicare Part D. Part D is basically prescription drug coverage. It is offered by private insurance companies. This means the specific drugs covered will differ from plan to plan (though the government does have minimum coverage requirements). Which drugs are covered also depends on what tier of coverage you get.
Also important to know is, no matter what plan you have, Medicare Part D only covers FDA approved prescription drugs.
Where You Live
Your Medicare coverage and what Medicare will pay for can depend on where you live. Your “Original” Medicare coverage – Parts A and B – are national plans. The basic coverage they provide is standard across the United States.
However, that’s not the case with Medicare Advantage plans and Prescription Drug plans offered by private insurance. Coverage for these plans, their costs, what they cover, etc. may vary depending on what state you live in.
Your Reason for Needing a Treatment, Product or Medical Service
What Medicare will cover also depends on why you need a specific treatment, product or medical service.
Let’s take shoe inserts for example. Medicare won’t cover shoe inserts for just anyone. But it will if you need them due to diabetes and severe diabetic foot disease.
Consult with your medical provider to see if their recommended treatment, etc. is covered for someone who has your condition, disease or illness.
Limitations of Medicare Coverage
Medicare is a valuable health insurance program for millions of people in the United States. But it does have its limitations.
Below, we’ll look at what Medicare does not cover, highlighting some crucial gaps in coverage you should be aware of.
What Medicare Does Not Cover
While Medicare covers a wide range of essential healthcare services, there are some areas that it doesn’t cover. Below are some of the important services not covered by Medicare:
Medically unreasonable and unnecessary services and supplies: Medicare only covers services and supplies it considers necessary for the diagnosis or treatment of a healthcare issue.
Health care costs for spouses and dependents: Medicare does not cover healthcare services provided to your family members. Each individual must qualify for Medicare separately.
Deductibles and copayments: Medicare beneficiaries are responsible for paying deductibles, copayments, and coinsurance out-of-pocket. These costs can add up over time, especially for those with chronic health conditions or extensive healthcare needs.
Long-term hospitalization: Medicare has limits on the duration of hospital stays it covers. For example, after 60 lifetime reserve days, you’ll need to pay a coinsurance fee of around $800 per day.
Skilled nursing facility care: Medicare only covers skilled nursing facility care when certain conditions are met. Conditions include being admitted to a hospital with a doctor’s order. Even then, there is a limitation on coverage. Medicare pays the full cost for up to 20 days, and from day 21 to 100, you’ll need to pay a share of the cost.
It’s essential to be aware of what Medicare doesn’t cover to plan for your future healthcare needs.
Supplemental insurance, such as Medigap, can help fill in some of these gaps. But be sure to weigh the costs and benefits carefully. You may find it helpful to talk with a healthcare professional or insurance advisor about the best options for your unique situation.
Additional Coverage Options
Medicare Advantage Plans
Medicare Advantage Plans, also known as Medicare Part C, are an alternative to Original Medicare (Part A and Part B). These plans are offered by private insurance companies approved by Medicare.
Part C plans must include all the benefits of Part A and Part B. And, often, they’ll include additional benefits such as prescription drug coverage, dental, and vision care. To enroll in a Medicare Advantage Plan, you must already qualify for Part A and Part B.
When considering a Medicare Advantage Plan, compare the available options, as each plan can vary in coverage and cost. Some key points to consider are:
- Monthly premiums, deductibles, and out-of-pocket costs
- Network of providers (doctors, hospitals, etc.) and if your preferred providers are in-network
- Additional benefits offered, such as dental, vision, or hearing coverage
Medigap, or Medicare Supplement Insurance, is an additional coverage option you can purchase from a private company. These policies help to pay for costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles. You must have both Medicare Part A and Part B to buy a Medigap policy.
Medigap policies do not cover prescription drug benefits. So if you need help with medication costs, you’ll have to enroll in a separate Medicare Part D plan.
When choosing a Medigap policy, consider the following factors:
- The different Medigap plans (A through N) and the specific benefits each plan offers
- Monthly premium costs and potential long-term savings on out-of-pocket expenses
- The insurance company’s reputation and financial stability
Cost of Medicare
Here’s an overview of the different costs involved in Medicare coverage.
Generally, you pay a monthly premium for Medicare coverage. Most people don’t pay a monthly premium for Part A. However, if you don’t qualify for premium-free Part A, you can buy it. Everyone pays a monthly premium for Part B.
Deductibles are the amount you must pay for covered services before Medicare starts to pay. Each year, you may have to pay a deductible for both Part A and Part B. Once you meet your deductible for the year, Medicare typically begins to cover a portion of the costs for approved services.
Co-insurance is the portion of the Medicare-approved amount that you are responsible for after you’ve met your deductible.
For example, let’s say Medicare approves a service that costs $100. If you’ve met your deductible, Medicare might pay 80% ($80). That leaves you responsible for the remaining 20% ($20).
Keep in mind that there’s no yearly limit on what you pay out-of-pocket. Though if you have supplemental coverage like a Medicare Supplement Insurance (Medigap) policy or join a Medicare Advantage Plan, there usually is a limit.
Eligibility for Medicare
You are first eligible to sign up for Medicare three months before you turn 65. However, you may be eligible earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS.
The eligibility criteria for people under 65 vary depending on the disability. Some individuals qualify immediately, while others may need to wait for two years of receiving Social Security Disability Insurance (SSDI) benefits.
For people 65 or older, eligibility is typically based on your work history or your spouse’s work history. Generally, if you or your spouse have worked at least 10 years (or 40 quarters) and paid Medicare taxes, you are eligible for premium-free Part A coverage. If you don’t have enough work credits, you might still be able to buy into the program, but you’ll have to pay a monthly premium.
It’s important to keep in mind that enrolling in Medicare is not automatic. If you’re not already receiving Social Security benefits, you will need to apply for Medicare during the initial enrollment period (IEP). This starts three months before your 65th birthday and ends three months after. Missing this window could lead to late enrollment penalties.
However, if you’re still working or covered under a spouse’s employer health plan, you may qualify for a Special Enrollment Period (SEP) to sign up for Medicare without penalty.
Application and Enrollment
Now that you’re familiar with the basics, it’s time to enroll! (Assuming you’re eligible, of course.)
There are several ways to sign up for Medicare. The easiest and fastest method is to enroll online. Simply visit the Social Security website, where you can also apply for other benefits and financial assistance. To do this, you’ll need to create a secure my Social Security account.
If you’d prefer not to enroll online, you can also call Social Security at 1-800-772-1213. TTY users can dial 1-800-325-0778.
During the enrollment process, it’s important to provide accurate information and documentation to ensure that your application is successful.
A Look At Common Treatments, Medical Services and More That Medicare Covers
People have questions about Medicare coverage for all sorts of specific treatments, services and more. Below you’ll find an ever-growing list of them that you can click on to find out whether Medicare will pay for them. You’ll also find info on costs and pricing as well as some helpful background info about each. We hope you find this useful!