What Does Medicare Cover?

Knowing what a certain Medicare plan covers, can help you get a better clarity of what might be the ideal option for you.

Medicare is the insurance plan provided by the federal government for people who are 65 years old and more, along with those who have disabilities and people who have end stage renal disease (ESRD), a type of kidney failure. The Medicare plan is divided into four parts: A, B, C, and D. Each part covers various elements of healthcare. You can sign up for one or more Medicare parts, but the most popular ones are parts A and B, commonly known as original Medicare. They cover most of the services. People normally also have to pay a monthly premium, however, this also majorly relies upon income. What does Medicare cover? When it comes to healthcare, it is essential to know what is covered and what is not. Since Medicare is divided into multiple parts, it can be confusing to know which part will give you the right coverage. This article will talk about what all four Medicare parts cover in detail.

Medicare Health Insurance

Medicare is a health insurance program that is backed by the United States federal government. It caters to U.S. citizens who are 65 years old or above, as well as some younger individuals with disabilities. Keep in mind that Medicare and Medicaid are two different programs. The latter provides health and other services to eligible low-income people of all ages.

Original Medicare

Original Medicare incorporates Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You pay for services as you get them. At the point when you get the services you want, you will pay a deductible toward the beginning of every year, and you typically pay 20% of the expense of the Medicare-approved service, called coinsurance. Assuming that you need drug inclusion, you can add a separate drug plan (Part D). Original Medicare pays for a lot, however not all, of the expense for covered medical services and supplies. A Medicare Supplement Insurance (Medigap) policy can assist with paying a portion of the excess medical services costs, like copayments, coinsurance, and deductibles. Some Medigap policies additionally cover benefits that Original Medicare does not, for instance, clinical care when you travel outside the U.S.

Medicare Advantage

Medicare Advantage is an “across the board” option in contrast to Original Medicare. These “bundled” plans incorporate Part A, Part B, and typically Part D as well. Most plans offer additional advantages that Original Medicare does not cover — like vision, hearing, dental, and more. Medicare Advantage Plans have yearly contracts with Medicare and should adhere to Medicare’s coverage rules. The plan should inform you about any changes before the beginning of the next enrollment year. Every Medicare Advantage Plan can charge distinctive out-of-pocket costs. They can likewise have various principles for how you get services.

Medicare prescription drug coverage (Part D)

Medicare drug coverage helps pay for prescription medications you need. To get Medicare drug coverage, you should join a Medicare-approved plan that offers drug coverage (this incorporates Medicare drug plans and Medicare Advantage Plans with drug coverage). Each plan can differ in cost and in the specific medications it covers, however, it should give at least a standard degree of coverage set by Medicare. Medicare drug coverage incorporates conventional and brand-name drugs. Plans can vary the list of prescription medications they cover (called a formulary) and how they place drugs into various “tiers” on their formularies. Plans have distinctive monthly premiums. You will likewise have other expenses throughout the year in a Medicare drug plan. The amount you pay for each medication relies upon which plan you pick.

What does Medicare cover?

Part A

Generally, Part A covers:

Inpatient care in a hospital

Medicare Part A (Hospital Insurance) provides coverage for inpatient hospital care under the following circumstances:

  • In specific situations, the Utilization Review Committee of the hospital approves your stay while you are in the hospital.
  • The hospital accepts Medicare.
  • You are admitted to the hospital as an inpatient after being officially ordered by a doctor, who says that you require inpatient hospital care to treat your illness or injury.

Hospital services covered by Medicare include:

  • Drugs as part of your inpatient treatment (including methadone for opioid use disorder)
  • General nursing
  • Meals
  • Semi-private rooms
  • Some other hospital services and supplies as part of your inpatient treatment

During a person’s lifetime, inpatient mental health care in a psychiatric hospital is restricted to 190 days. Inpatient hospital care includes care you get in:

  • Acute care hospitals
  • Critical access hospitals
  • Inpatient rehabilitation facilities
  • Inpatient psychiatric facilities
  • Long-term care hospitals
  • Inpatient care as part of a qualifying clinical research study

Skilled nursing facility care

Medicare Part A (Hospital Insurance) also provides coverage for skilled nursing care in specific circumstances for a restricted amount of time (on a short-term basis) under the following conditions:

  • Your doctor has ordered that you require daily skilled care. It must be provided by, or under the supervision of, skilled nursing or therapy staff.
  • You get these skilled services in an SNF that is certified by Medicare.
  • You have a qualifying hospital stay
  • You have Part A and still have some days left in your benefit period to use.
  • You need a nursing facility’s skilled services for a medical condition that is either:
  • A condition that began while you were getting care in the SNF for a hospital-related medical condition (for instance, if you develop an infection that requires IV antibiotics while you are getting SNF care)
  • A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it was not the reason you were admitted to the hospital.

Skilled care is nursing and therapy care that can only be safely and efficiently provided by, or given under the supervision of, professionals or technical personnel. It is medical coverage which is given when you need skilled nursing or skilled therapy to treat, manage, and observe your condition, and understand your care. Services covered by Medicare include, but are not restricted to:

  • Ambulance transportation (when other transportation endangers your health) to the nearest supplier of needed services that aren’t available at the SNF
  • Dietary counseling
  • Meals
  • Medications
  • Medical social services
  • Medical supplies and equipment used in the facility
  • Occupational therapy (if needed to meet your health goal)
  • Physical therapy (if needed to meet your health goal)
  • Semi-private room (a room you share with other patients)
  • Skilled nursing care
  • Speech-language pathology services (if they’re needed to meet your health goal)
  • Swing bed services

Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)

Medicare does not provide coverage for custodial care, given that it is the only care you need. Nursing home care is usually custodial care. Custodial care assists you with everyday activities such as, bathing, dressing, using the bathroom, and eating, or personal needs that could be carried out safely and practically without professional skills or training.

Hospice care

To meet all requirements for hospice care, a hospice specialist and your primary care physician (given that you have one) should confirm that you are critically ill. In most cases, it has to be a terminal illness which implies that you have a life expectancy of half a year or less. At the point when you agree to hospice care, you are actually agreeing to comfort care (palliative care) rather than care to cure your disease. Moreover, you will also be required to sign a statement choosing hospice care rather than other advantages Medicare covers to treat terminal sickness and various related conditions. Medicare-certified hospice care is typically provided in your home or other facility where you live, for instance, a nursing home. Contingent upon your terminal sickness and related conditions, the plan of care your hospice team makes can incorporate any or all of these services:

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  • Aide and homemaker services
  • Dietary counseling
  • Doctors’ services
  • Drugs for pain management
  • Durable medical equipment for pain relief and symptom management
  • Inpatient respite care, which you get in a Medicare-approved facility (for instance, inpatient facility, hospital, or nursing home), so that your normal caregiver (like a family member or friend) can get some rest. Your hospice provider will arrange this for you. Each time you get respite care, you can stay up to 5 days. Keep in mind that you can get respite care more than once, however, only on an occasional basis.
  • Medical supplies, like bandages or catheters
  • Nursing and medical services
  • Occupational therapy services
  • Physical therapy services
  • Short-term inpatient care for pain and symptom management. This care needs to be in a Medicare‑approved facility, for instance, hospice facility, hospital, or skilled nursing facility that contracts with the hospice.
  • Social services
  • Speech-language pathology services
  • Spiritual and grief counseling for you and your family
  • Other extra services Medicare covers to handle your pain and other symptoms associated with your terminal illness and related conditions, as your hospice team suggests.

Medicare does not provide coverage for room and board if you get hospice care within your own home or in another facility where you live (for instance, a nursing home).

Home health care

Medicare Part A (Hospital Insurance) provides coverage for qualified home health services such as:

  • Injectable osteoporosis drugs for women
  • Medical social services
  • Occupational therapy
  • Part-time or intermittent home health aide services (personal hands-on care)
  • Part-Time Or “Intermittent” Skilled Nursing Care
  • Physical therapy
  • Speech-language pathology services

Typically, a home health care agency arranges the services your doctor requests for you.

Part B

Part B typically provides coverage for two types of services:

  • Medically necessary services: Services or supplies that are required to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment will probably work best.

You do not have to pay anything for most preventive services if you get them from a health care provider who accepts assignments. Part B covers items like:

Clinical research

Clinical research studies (also known as clinical trials) test how well various kinds of healthcare work and whether or not they are safe. For example, how well does a cancer drug work? Clinical research studies can include diagnostic tests, surgical treatments, medicine, or new types of patient care. They may:

  • Compare different treatments for the same condition to see which one is better
  • Study how well new treatments and tests benefit patients
  • Study new ways to use existing treatments

Ambulance services

Medicare Part B (Medical Insurance) provides coverage for ground ambulance transportation when you need to be carried to a hospital, critical access hospital, or skilled nursing facility for medically fundamental services, and transportation in some other vehicle could put your health at risk. Medicare might pay for emergency ambulance transportation in a plane or helicopter to a hospital on the off chance that you need prompt and quick ambulance transportation that ground transportation cannot give. Now and again, Medicare might pay for restricted, medically essential, non-emergency ambulance transportation in the event that you have a written order from your doctor expressing that ambulance transportation is medically fundamental for you. For instance, somebody with End-Stage Renal Disease might require medically necessary ambulance transport to a facility that provides renal dialysis.

Durable medical equipment (DME)

Medicare Part B (Medical Insurance) provides coverage for medically important DME if your doctor prescribes it for use in your home. DME that Medicare covers includes, but is not restricted to:

  • Blood sugar meters
  • Blood sugar test strips
  • Canes
  • Commode chairs
  • Continuous passive motion devices
  • Continuous Positive Airway Pressure (CPAP) devices
  • Crutches
  • Hospital beds
  • Home infusion services
  • Infusion pumps & supplies
  • Lancet devices & lancets
  • Nebulizers & nebulizer medications
  • Oxygen equipment & accessories
  • Patient lifts
  • Pressure-reducing support surfaces
  • Suction pumps
  • Traction equipment
  • Walkers
  • Wheelchairs & scooters

Mental health

Inpatient

Mental health care services provide assistance with conditions like depression and anxiety. You can get access to these services either in a general hospital or in a psychiatric hospital that only caters to people with mental health conditions. If you are in a psychiatric hospital (instead of a general hospital), Part A will only cover 190 days of inpatient psychiatric hospital services during your lifetime.

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Outpatient

Medicare Part B (Medical Insurance) provides coverage pay for the following outpatient mental health services:

  • An annual “Wellness” visit. Contact your doctor or other health care provider about changes in your mental health. They can go over your changes year to year.
  • A one-time “Welcome to Medicare” preventive visit. This visit incorporates a review of your possible risk factors for depression.
  • Certain prescription drugs that are not typically “self administered” (medicines you would normally take on your own), for instance, some injections.
  • Diagnostic tests.
  • Family counseling, if the main goal is to help with your treatment.
  • Individual and group psychotherapy with doctors or certain other authorized professionals permitted by the state where you get the services.
  • Medication management.
  • One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
  • Partial hospitalization.
  • Psychiatric evaluation.
  • Testing to find out if you are getting the services you need and if your current treatment is helping you.

Part B also provides coverage for outpatient mental health services for treatment of inappropriate alcohol and drug use.

Partial hospitalization

Partial hospitalization gives an organized program of outpatient psychiatric services as an option in contrast to inpatient psychiatric care. It is more exceptional than care you get in a doctor’s or therapist’s office. You get this treatment during the day, and you do not need to remain there for the rest of the night. Medicare helps cover partial hospitalization services you get through a hospital outpatient office or a community mental health center. As part of your partial hospitalization program costs, Medicare might cover the following:

  • Individual patient training and education about your condition
  • Occupational therapy that is part of your mental health treatment

Medicare partial hospitalization coverage is only applicable if the doctor and the program accept  assignment.

Limited outpatient prescription drugs

Medicare Part B (Medical Insurance) provides coverage for a restricted number of outpatient prescription drugs under limited conditions. Typically, Part B covers drugs you would not normally give to yourself, such as those you get at a doctor’s office or  hospital outpatient setting. Here are some examples of drugs that Part B covers:

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  • Blood clotting factors: Medicare provides coverage for clotting factors you give yourself via injection, if you have hemophilia.
  • Drugs used with an item of durable medical equipment (DME): Medicare provides coverage for drugs infused through DME, such as an infusion pump or a nebulizer, if the drug used with the pump is practical and necessary.
  • Erythropoiesis-stimulating agents: Medicare assists in paying for erythropoietin via injection if you have End-Stage Renal Disease (Esrd) or if you need this drug to treat anemia related to certain other conditions.
  • Injectable and infused drugs: Medicare pays for most of these when given by an authorized medical provider because they are not typically self administered.
  • Injectable osteoporosis drugs: Medicare provides coverage for an injectable drug if you are a woman with osteoporosis who meets the eligibility for the Medicare home health benefit and has a bone fracture that a doctor confirms was because of post-menopausal osteoporosis. However, a doctor must certify that you cannot give yourself the injection or that you cannot learn how to give yourself the drug via injection. Medicare will not cover the home health nurse or aide to provide the injection unless family and/or caregivers are unable or unwilling to give you the drug by injection.
  • Intravenous Immune Globulin (IVIG) provided in home: Medicare assists in paying for IVIG if you have a diagnosis of primary immune deficiency disease. A doctor needs to first decide that it is medically safe and appropriate for the IVIG to be given in your home. Part B covers the IVIG itself. However, Part B does not pay for other items and services associated with you getting the IVIG at home.
  • Oral anti-nausea drugs: Medicare assists in paying for oral anti-nausea drugs you use as part of an anti-cancer chemotherapy treatment if they are administered before, at, or within 48 hours of chemotherapy or are used as a full therapeutic replacement for an intravenous anti-nausea drug.
  • Oral cancer drugs: Medicare assists in covering some oral cancer drugs you take by mouth if the same drug is available in injectable form or if it is a prodrug of the injectable drug. A prodrug is an oral form of a drug that, upon ingestion, breaks down into the same active ingredient found in the injectable drug. As new oral cancer drugs become available, Part B may provide coverage for them. If Part B does not cover them, Part D does.
  • Oral End-Stage Renal Disease (ESRD) drugs: Medicare assists with covering some oral ESRD drugs if the same drug is available in injectable form and the Part B ESRD benefit covers it.
  • Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps cover the costs of certain nutrients if you cannot absorb nutrition through your intestinal tract or take food by mouth.
  • Self-administered drugs in hospital outpatient settings: Medicare may also cover some self-administered drugs. Medicare covers these drugs if you need them for the hospital outpatient services you are getting.
  • Shots (vaccinations): Medicare provides coverage for flu shots, pneumococcal shots, Hepatitis B shots, and some other vaccines when they are directly related to the treatment of an injury or illness.
  • Some antigens: Medicare assists in covering for antigens if they are prepared by a doctor and are administered by a properly instructed person (who could also be the patient) under expert supervision.
  • Transplant / immunosuppressive drugs: Medicare helps to pay for transplant drug therapy if it has helped pay for your organ transplant.

Part C

Certain plans may even provide extra coverage for health-related perks, like gym memberships and meal delivery services after you have been released from a hospital.

Inpatient coverage

The inpatient coverage you will get with Medicare Part C will at least be similar to those of Medicare Part A. These services include:

  • hospice care
  • inpatient hospital care
  • inpatient mental health services
  • inpatient rehabilitation services
  • limited home healthcare
  • limited stays in a skilled nursing facility

Outpatient coverage

When it comes to outpatient coverage, your Part C plan must cover at least what your Medicare Part B will cover, which includes:

  • doctor’s appointments, including specialists
  • durable medical equipment like wheelchairs and home oxygen equipment
  • emergency ambulance transportation
  • emergency room care
  • imaging tests, such as MRIs and X-rays
  • laboratory testing, such as blood tests and urinalysis
  • mental health counseling
  • occupational, physical, and speech therapy
  • vaccinations for flu, hepatitis B, and pneumococcal disease

Any extra coverage for these services will be highlighted by the specific plan you opt for. For instance, some plans offer basic vision exams, while others have allowances for prescription eyeglasses or contact lenses.

Part D

Each Part D plan has a list of covered medications, called its formulary. On the off chance that your medication is not on the formulary, you might need to demand an exception, pay out of pocket, or document an appeal. A drug category is a group of medications that treat similar symptoms or have similar effects on the body. All Part D plans should incorporate at least two drugs from most categories and should cover all medications accessible in the accompanying classes:

  • Antidepressants
  • Anticancer drugs (unless covered by Part B)
  • Antipsychotic medications
  • Anticonvulsive treatments for seizure disorders
  • HIV/AIDS treatments
  • Immunosuppressant drugs

Part D plans should also provide coverage for most vaccines, apart from vaccines covered by Part B. Some drugs are particularly excluded from Medicare coverage by law, such as drugs used to treat weight loss or gain, and over-the-counter drugs. Note that for certain drugs or under specific situations, your drugs may be covered by Part A or Part B.

What does Medicare not cover?

Many people believe that Medicare covers most health care costs. However, the truth is that Medicare Part A and Part B — also known as Original Medicare — have a lot of coverage gaps. Generally, Original Medicare does not cover:

  • Hearing aids
  • Long-term care (such as extended nursing home stays or custodial care)
  • Most cosmetic surgery
  • Most dental care, notably dentures
  • Medical expenses outside the United States
  • Medical marijuana
  • Massage therapy
  • Most vision care, notably eyeglasses and contacts
  • Prescription drugs
  • Sterilization, including a hysterectomy (unless it’s deemed medically necessary)

There are some exceptions, however, beneficiaries should know what is not covered by Medicare and plan accordingly. Original Medicare does not provide coverage for most prescription drugs. Nevertheless, you can get drug coverage with a standalone Medicare Part D prescription drug plan; or with a Medicare Advantage plan that incorporates prescription drug coverage.

A Medicare Advantage plan, or Part C, is an all-in-one alternative to Original Medicare and is provided by government-approved private insurance organizations. Medicare Advantage plans must give the same minimum level of care as Medicare Part A and Part B. However, they can also bundle other benefits, like prescription drugs, dental, vision and hearing, into a single plan. Nevertheless, coverage for these extra services may be restricted.

Does Medicare cover dental?

Medicare does not give coverage for routine dental visits, teeth cleanings, fillings, dentures or most tooth extractions. Some Medicare Advantage plans cover basic cleanings and X-rays, yet they usually have a yearly coverage cap of about $1,500. You could likewise get coverage from a different dental insurance strategy or a dental discount plan. One option is to build cash in a health savings account before you enroll in Medicare; you can utilize the cash tax-free for medical, dental and other out-of-pocket costs at whatever stage in life. However, keep in mind that you cannot make new commitments to a HSA after you enroll in Medicare.

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Conclusion

Make sure that you understand your Medicare coverage decisions and pick your coverage cautiously. How you decide to get your advantages and who you get them from can influence your out-of-pocket costs and where you can get your care. For example, in Original Medicare, you are covered to go to practically all specialists and clinics in the country. Then again, Medicare Advantage Plans commonly have network limitations, implying that you will probably be more restricted in your selection of doctors and clinics. Notwithstanding, Medicare Advantage Plans can likewise give extra advantages that Original Medicare does not cover, like routine vision or dental consideration.

John Otero

John Otero

John Otero is an industry practitioner with more than 15 years of experience in the insurance industry. He has held various senior management roles both in the insurance companies and insurance brokers during this span of time. He began his insurance career in 2004 as an office assistant at an agency in her hometown of Duluth, MN. He got licensed as a producer while working at that agency and progressed to serve as an office manager. Working in the agency is how he fell in love with the industry. He saw firsthand the good that insurance consumers experienced by having the proper protection. John has diverse experience in corporate & consumer insurance services, across a range of vocations. His specialties include Major Corporate risk management and insurance programs, and Financial Lines He has been instrumental in making his firm as one of the leading organizations in the country in generating sustainable rapid growth of the company while maintaining service excellence to clients.

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