What does Medicare cover?

Did you know there are four parts to Medicare? Many Medicare beneficiaries are not aware there are different parts of Medicare or that each part covers different services. Additionally, each part has its own out-of-pocket costs. In this article, we’ll break it down so that you better understand what each part covers and what cost-sharing you can expect to see.

Who does Medicare cover?

In order to be eligible for Medicare, you must either be 65 or older, diagnosed with End-Stage Renal Disease or ALS or have been collecting Social Security Disability Insurance for at least 24 months. Each part of Medicare (A, B, C, and D) covers different health services and treatments. Compare Medicare coverage by part in the table below.

Note: This is not an exhaustive list of Medicare coverage.

What does Medicare Part A cover?

Part A is your hospital insurance, also known as inpatient coverage. Coverage includes inpatient hospital care, some hospice, and some care you receive in a skilled nursing facility. 

Part A does not cover the following:

• A private inpatient room or private nursing care
• A television, telephone, or personal items in your room
• The first three pints of blood, unless the hospital gets it from a blood bank for free, you arrange to replace it by donating blood. However, some Medigap policies cover the cost.
• The cost of skilled nursing facility stays if you’re enrolled in Original Medicare and haven’t spent at least three days in the hospital as an admitted patient. If you’re in the hospital “under observation,” you may not qualify for a skilled nursing facility stay.
• The cost of a long-term stay in a nursing home or assisted living facility

What does Medicare Part B cover?

Part B is your medical insurance, also known as your outpatient medical coverage. Coverage includes outpatient care (including mental health care), doctor visits, preventive services, and certain durable medical supplies. 

The cost of most services under Part B is covered 80%. To get most of your Medicare Part A and Part B cost-sharing covered, you can enroll in a Medicare Supplement insurance plan, also known as a Medigap policy. 

Part B does not cover the following:

• Routine vision, hearing, or dental services, except medically necessary services like cataract surgery
• Routine foot care, unless a physician deems it’s medically necessary (such as diabetic foot care)
• Long-term custodial care (short-term care is covered by Medicare if you qualify)
• Most medical services outside of the U.S.

What does Medicare Part C cover?

These private insurance plans pay for your medical care instead of Original Medicare. Medicare Advantage plans cover the same services as Medicare Part A and Part B. Most plans also include prescription drug coverage. Additionally, some have expanded benefits like dental care (including dentures) and hearing and vision insurance.

This biggest misconception about Medicare Advantage plans is that the cost-sharing is the same as Original Medicare, Part A, and Part B. While Medicare Advantage plans must cover the same services as Part A and Part B, there are several caveats, such as the carrier deciding how much of that service’s cost they will cover, having to use a network of doctors, getting prior approval, etc.

So, while Part B may cover 80% of the service, your Medicare Advantage plan may only cover 60% in addition to having an additional copay. Since each carrier has its own summary of benefits, it may be difficult for beneficiaries to predict their cost-sharing. 

One benefit to these plans is that most come with a maximum out-of-pocket limit (MOOP), unlike Part A and Part B. However, these limits are usually more than what a beneficiary on a limited income can afford, and they continue to increase year over year.

Part C does not cover the following:

• Services by out-of-network providers (Medicare Advantage has a much more limited network of providers than Original Medicare)
• Certain items and drugs without prior authorization

RELATED: Original Medicare vs. Medicare Advantage

What does Medicare Part D cover?

Part D is your optional prescription drug coverage. It will also cover some vaccines. Each Part D Medicare plan comes with a drug formulary, which is a list of covered drugs.

If your out-of-pocket costs are high with Medicare, you can get a prescription discount with SingleCare. Note: You can use SingleCare coupons instead of Medicare, but your out-of-pocket costs with SingleCare will not be applied to your Medicare deductible. You cannot use both SingleCare and Medicare on the same prescription.

RELATED: Medicare Part D plan updates

Part D does not cover the following:

• Brand-name drugs if a generic is available
• Drugs used to treat anorexia, weight loss, or weight gain
• Over-the-counter medications
• Prescription vitamins (except prenatal vitamins)
• Erectile dysfunction or sexual dysfunction drugs

What does Medicare not cover?

Medicare doesn’t cover everything. Items and services must be considered medically necessary to be covered by Medicare. The following are not covered by Medicare:

• Acupuncture
• Dental services or dentures (unless performed at an inpatient facility) 
• Hearing aids or related services
• Long-term care or custodial care 
• Prescription eyeglasses or related services
• Routine foot care
• Surgery considered cosmetic

Who determines the services that are covered under Medicare?

There are three factors that determine if a service is covered under Medicare:

1. State and federal laws.
2. National coverage decisions made by Medicare.
3. Local coverage decisions are made by companies in each state that process claims for Medicare. These health insurance companies decide whether something is medically necessary and should be covered in their area.

What is considered “not medically necessary”?

A service or item is not considered medically necessary when it’s not consistent with the treatment or diagnosis that’s given by a prescribing physician. A service or item is also not considered medically necessary if it’s considered medically unreasonable or excessive. Examples include cosmetic surgery and weight loss drugs.

Does Medicare pay for everything?

One extremely important fact to know, and another common misconception of Medicare coverage, is that Medicare pays 100% of the costs of your medical services. This is not true. There are many different forms of cost-sharing that the beneficiary is responsible for paying out of pocket. This includes premiums, deductibles, coinsurance, and copays, depending on the parts of Medicare you’re enrolled in. 

RELATED: How much does Medicare cost?

Medicare coverage helpline

If you have questions about your Medicare coverage, a Medicare coverage helpline on medicare.gov is available to all beneficiaries provided by the Centers for Medicare and Medicaid Services (CMS). The phone number is 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. There is also a search engine available on medicare.gov that allows users to search for a test, item, or service to find out if it’s covered by Medicare.

Medicare coverage FAQs

What does Medicare cover for dental?

Original Medicare does not cover routine dental care. Under limited circumstances, Part A may cover dental exams performed by a dentist who’s part of the hospital staff at an inpatient facility. Part B may cover a service or treatment related to a dental procedure performed at an outpatient facility by a physician.

Is an ambulance covered by Medicare?

Medicare Part B will cover transportation via ambulance if it is used during an emergency and you cannot be transported safely by other means.

Does Medicare cover surgery?

Medicare will cover surgery that’s deemed medically necessary. Medicare Part A will cover inpatient surgeries, and Part B will cover outpatient surgeries.

Does Medicare cover knee injections?

Medicare will cover knee injections if the treatment is approved by the FDA. Medicare will usually cover one injection per six months.

Are stress tests covered by Medicare?

If your healthcare provider believes you have heart disease, Medicare will also cover a stress test. This includes both cardiac stress tests and cardiac catheterization for beneficiaries with heart disease.

Does Medicare cover heart scans?

Medicare Part B will cover a heart scan or screening every five years. 

Does Medicare cover ECGs?

Medicare Part B will cover a routine EKG or ECG screening. Part B will cover an EKG or ECG screening if your physician recommends it during your Welcome to Medicare visit. Medicare will cover these tests more often as diagnostic tests if your healthcare provider deems them medically necessary.

Are X-rays covered by Medicare?

Medicare will cover an X-ray if it is considered diagnostic or deemed medically necessary by your healthcare provider. Part A will cover an X-ray if performed at an inpatient facility. Part B will cover an X-ray if performed at an outpatient facility. 

Does Medicare cover long-term care?

Most long-term care is considered custodial care, which includes help with daily activities, such as bathing and dressing. Medicare does not cover custodial care.

Does Medicare pay for haircuts in nursing homes?

Medicare may cover haircuts, shaves, shampoos, and simple hair sets if you’re in a skilled nursing facility and cannot perform these tasks for yourself.