What is Covered by Medicare?

Medicare is the federal program that helps American seniors age 65 years or older cover health care costs. Disability or another special situation can qualify those under 65. 

Medicare also covers individuals with ESRD (End-Stage Renal Disease) – a permanent kidney failure that requires a transplant or dialysis.

What is covered by Medicare? Start with Benzinga’s guide for a breakdown of health care expenses covered by Medicare. Medicare coverage for many tests, items and services can depend on where you live. If you know you have special healthcare needs, it is vitally important to work with a knowledgeable expert who understands what is covered and what is not.

Medicare and the Health Insurance Marketplace

The Health Insurance Marketplace is for individuals who do not have health coverage. When you have health coverage through Medicare, the Marketplace doesn't affect your Medicare choices or benefits. Simply explained, this means that no matter how you get Medicare, whether through  Original Medicare or a Medicare health plan (such as Medicare Advantage or a Medicare Supplement plan), you won’t have to make any changes to your current Medicare coverage.

If you have family and friends without health coverage, point them to HealthCare.gov to learn about enrolling through the Marketplace.

Medicare Covered Expenses

Medicare provides important choices in how you get benefits.  Individuals have multiple options which include Original Medicare (Part A and Part B) or a Medicare-approved plan.  These can vary quite significantly in what they cover and what they cost.  For example, some Medicare Advantage plans today also provide prescription drug coverage and other benefits like dental, vision, hearing and more.

Different parts of Medicare help cover the expenses of specific services.

You’re automatically enrolled in Medicare Part A when you apply for the federal health program. 

If you are in a Medicare Advantage (MA) Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. 

Medicare Part A is designed to cover inpatient care in a hospital, skilled nursing facility care, hospice care and some limited home health care.  There are limitations and these are explained well in the Medicare & You Handbook which is distributed yearly to all covered individuals.

Many people don’t have to pay a premium for Medicare Part A since it’s already paid in the form of Medicare tax deductions from your paycheck. Medicare Part A isn’t entirely free. For example, there is a deductible every time you’re admitted to a hospital. The deductible changes every year – the deductible is $1,484 for 2021.

You may purchase a Medigap or Medicare Plan G policy to cover the deductible and a few out-of-pocket costs. Medicare Part A covers:

• Inpatient hospital care. Medicare Part A covers inpatient hospital care expenses when you’re admitted as an inpatient after an official doctor’s order. The hospital must accept Medicare.
• Skilled nursing facility care. Medicare Part A pays for skilled nursing care expenses incurred in a skilled nursing facility for a limited time. You must have qualifying hospital stay and some days left in your benefit period to use. You pay $0 for days 1–20: then $185.50 for days 21–100: $185.50.  Medicare does not pay for days 101 and beyond.
• Nursing home care. Medicare Part A covers nursing home care, except custodial care which is what most nursing homes offer.
• Hospice care. Medicare Part A will cover hospice care expenses if:

o   Your regular doctor and hospice doctor certify that you’re terminally ill.

o   You give consent to palliative care (for comfort)

o   You sign an agreement picking hospice care to treat your terminal illness

• Home health care. Medicare Part A covers eligible home health services including physical therapy, occupational therapy, medical social services and more.

Medicare Part B (Medical Insurance)

Medicare Part B covers 2 main services:

• Preventive services. Part B covers health care to prevent illness or detect it early enough when treatment is likely to work best. You generally pay nothing for a majority of preventative services if you use a health care provider who accepts Medicare assignment.
• Medically necessary services. Services and supplies required to diagnose or treat your condition are covered.

Part B also covers things like:

• Ambulance services. Part B pays for ambulance transportation when you need to reach a hospital, skilled nursing facility or critical access hospital for medically necessary services. It may also pay for rapid ambulance transportation that ground transportation can’t provide, like transportation in a helicopter.
• Clinical research studies. Medicare Part B covers costs like office visits, tests and qualifying clinical research studies. Clinical trials test how different types of medical care work and whether they are safe. Research studies may involve surgical treatments, diagnostic tests, medicine or new variations of patient care.
• Durable medical equipment (DME). Medical insurance covers any medically necessary durable medical equipment prescribed by a doctor for home use. This may include blood sugar test strips and monitors, crutches, commode chairs and hospital beds.
• Outpatient prescription drugs. Part B covers limited outpatient prescription drugs, including those you wouldn’t typically administer to yourself. These drugs include antigens prepared by a doctor and are administered by an instructed person or drugs infused through an infusion pump.
• Mental health care. Medicare Part B helps pay for covered outpatient mental health services, including family counseling, medication management and psychiatric evaluation. It may also cover partial hospitalization under certain conditions and your doctor certifies the need for inpatient treatment.

Medicare Part C (Medicare Advantage)

Medicare Part C, also known as Medicare Advantage, is an all-inclusive alternative to Original Medicare. This plan is offered by private insurance companies that contract with Medicare to offer Original Medicare (Part A and Part B) benefits. This bundled plan may also include Medicare Part D (prescription drug coverage).

Medicare Advantage (MA) plans pay for all Medicare services. Some plans may also provide extra coverage like vision, dental, hearing and wellness programs. Your Advantage Plan can choose to exclude the cost of services that aren’t medically necessary under the Medicare rules. Medicare Advantage Plans may have lower out-of-pocket costs than the Original Medicare.

Each year, MA plans set the amount they charge for premiums, deductibles, and services. The plan (rather than Medicare) decides how much you pay for the covered services you get. What you pay may change only once a year, on January 1.

Medicare Advantage Plans are generally categories into these 2 options:

• Health Maintenance Organization (HMO) Plans. HMO plans require you to obtain care and services from providers in your plan’s network. Excluded services include emergency care, out-of-area dialysis and out-of-area urgent care.
• Preferred Provider Organization (PPO) Plans. PPO plans have in-network doctors, other health care providers and hospitals. You’ll pay less if you use hospitals, doctors and other health care providers who are part of the plan’s network.

Medicare Part D (Prescription Drug Coverage)

Medicare Part D provides prescription drug coverage that isn’t included in Original Medicare Parts A and B. There are 2 ways to get prescription drug coverage once you’re enrolled in Medicare:

• Medicare Part D Plan: You may buy a standalone Medicare prescription drug plan to cover your prescription drug costs.
• Medicare Advantage Plans (Part C): Many Medicare Advantage plans also include prescription drug coverage.

Plans may vary the list of prescription drugs covered, so be sure to check each plan’s formulary.

Medicare pays for most of your senior health care needs, but you’ll need to plan ahead to pay out-of-pocket for these medical expenses not covered by Medicare.

Long-Term Care

Medicare doesn’t cover medical and non-medical services provided to people who can’t perform the basic activities of daily living like bathing or dressing. Long-term care services may be provided at home, in a nursing home or in an assisted living facility. Individuals may need long-term care at any age. Medicare will cover all your medical needs but not custodial care.  A good place to learn more about long-term care insurance costs is on the American Association for Long-Term Care Insurance website.

Cosmetic Surgery

Medicare doesn’t cover cosmetic surgery and any expenses incurred after undergoing a cosmetic surgery procedure. This includes any procedures undertaken to improve your appearance. Medicare may cover the immediate medically feasible repair of an accidental injury or improvement of the functioning of a specific body part.

Dental Services

Original Medicare doesn’t cover items and services related to the treatment, care, filling, removal or replacement of the teeth and any structures directly supporting them. Some Medicare Advantage plans will provide dental coverage. Consider purchasing an individual dental insurance plan if your advantage plan doesn’t cover dental work.

Routine Physical Checkups

Medicare doesn’t cover these routine services:

• Eye examinations for fitting, prescribing or changing eyeglasses
• Physical examinations performed without a specific symptom, sign, beneficiary complaint or 3rd-party requirements
• Hearing aids and hearing aid examinations
• Eyeglasses and contact lenses
• Immunizations, with some exceptions

Routine Foot Care and Supportive Devices

Medicare won’t cover these foot care services and supportive devices:

• Routine foot care services, including cutting corns, trimming, clipping or cutting nails and other hygienic maintenance foot care
• Treatment of flat foot
• Orthopedic shoes and other supportive feet devices

Overseas Treatment

Original Medicare and most advantage plans provide no coverage for any medical costs incurred outside the United States. Some Medicare supplemental plans will cover some overseas treatment costs.

Personal Comfort Items and Services

Medicare doesn’t cover personal comfort items since they don’t meaningfully contribute to the treatment of your injury or illness. Personal comfort items may include televisions and radios. Home safety items like stair lifts, medical emergency alert systems and grab bars in bathrooms are also not covered.  These may be covered by some long-term care insurance policies.

Acupuncture

Acupuncture is a technique used to stimulate specific points on the body. Medicare doesn’t cover acupuncture for any condition other than lower back pain.

Best Medicare Options

If you qualify for Medicare, it’s crucial that you understand the different plan and enrollment options at your disposal. Explore a few of our best choices and obtain a quote before Medicare enrollment arrives.

Get Started with Medicare

Getting Medicare is a huge milestone – you will get help with your health care costs. While all medical expenses aren’t covered, you have various choices for how you get Medicare coverage. Answering these questions will help you choose the right coverage option:

• How well does the plan cover the services I need?
• How do my other health coverages work with Medicare?
• Do I need to join a Medicare Prescription Drug Plan?
• How much are my deductibles, premiums and other costs?

Still not sure where to begin your search? Start with Benzinga’s free quote tool by entering your ZIP code.