Medicare Coverage

Many people getting started with Medicare are surprised to learn that Medicare does not cover all healthcare services. On this page, we’ll outline what services Medicare covers and those it doesn’t cover so you are not surprised when it comes time to get the care you need.

Medicare Inpatient Care

Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. covers medically necessary inpatient hospital care. This is any care you receive as an admitted hospital inpatient.

Inpatient careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition. begins when you are formally admitted into the hospital by a physician. This is an important distinction, because your costs will be different if you are treated as a hospital outpatient.

When you are a hospital inpatient, Part A covers:

• A semi-private room and meals
• General nursing care
• Medically necessary medications
• Other hospital services and supplies

Medicare does not cover:

• Private duty nursing
• A private room (unless medically necessary)
• Personal care items (shampoo, razors, etc.)
• A television or telephone in your room

If you have Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage., your Part A deductible covers all costs for the the first 60 days of your benefit periodA benefit period is a method used in Original Medicare to measure a beneficiaries use of hospital and skilled nursing facility (SNF) services. With each new benefit period, the beneficiary is charged a new benefit.... After the 60th day, you pay a daily hospital coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. .

The current Part A benefit period deductible is $1,632. The hospital inpatient coinsurance for days 61-90 is $408. For day 91 and beyond you pay $816 per day. If you have a Medicare Advantage plan, the plan sets your deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., copays, and coinsurance.

While you are hospitalized, Part B cover the outpatient provider services and medications you receive as an inpatient. In most cases, you pay a separate 20% coinsurance for these services. If you have a private plan, the plan sets your out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for all Part B services.

Outpatient Hospital Care

It is not necessary to be admitted to a hospital to receive care. When you are not admitted, covered services include but are not limited to:

• Observation services
• Emergency room and outpatient clinic services, including same-day surgery
• Mental health care
• Hospital-billed laboratory tests
• Preventive and screening services
• Blood transfusions
• Certain drugs
• Medical supplies, such as splints and casts
• X-rays and other radiation services

In some cases, you may stay in the hospital overnight without being formally admitted. For instance, you may be in the hospital receiving emergency room services. Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. covers all medically necessary care when you have not been formally admitted to the hospital as an inpatient.

How Your Inpatient/Outpatient Status Affects Your Costs

Your admission status—inpatient or outpatient—directly affects what you pay for X-rays, supplies, drugs, lab tests, and hospital staff services. It also affects your coverage in a skilled nursing facility (SNF) following a hospital stay.

You’re an outpatient when you receive emergency department services, observation services, or outpatient surgery, lab tests, or X-rays. You can be an outpatient even if you spend one or more nights in the hospital. You’re only an inpatient when a doctor writes an order to formally admit you as an inpatient.

As an inpatient, you pay a single deductible ($1,632) that covers your hospital costs. However, if you are treated in a hospital, for example a car accident, but you are not admitted, and your treatment runs the bill up to $30,000, those costs will be billed to you under Part B.

If you have Original Medicare, your share of that bill is 20%. If you have Medicare Advantage, your out-of-pocket costs are determined by the plan.

NOTE: Your copaymentA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service. for an outpatient hospital service can’t be higher than the inpatient deductible. But your total costs for all outpatient services may be more than the inpatient deductible.

If you are an outpatient for more than 24 hours, you must receive a Medicare Outpatient Observation Notice (MOON) that lets you know you’re an outpatient for observation services. The MOON will explain why you’re an outpatient instead of an inpatient. It should also explain how this may affect what you pay.

Hospice Care

You qualify for hospiceHospice is a special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. coverage if you have Medicare Part A and meet the following conditions:

1. Your hospice doctor and your primary care doctor certify that you’re terminally ill with a life expectancy of 6 months or less.
2. You accept palliative care for comfort instead of care to treat your illness.
3. You sign a statement choosing hospice care for your terminal illness and related conditions.

Medicare-certified hospice care is generally available in your home or facility near where you live. You may also choose hospice care in an inpatient hospice facility.

Once you choose hospice care, your hospice benefit will usually cover everything you need. You may have to pay for room and board if you live in a facility (like a nursing home) and choose to get hospice care. You pay a copayment of up to $5 for each prescription for outpatient drugs for palliative care and symptom management.

Outpatient Medical, Surgical Services, and Supplies

Medicare Part B covers medically-necessary services. This includes your doctors’ office visits, tests, outpatient careOutpatient Care is medical care that does not require an overnight stay at the hospital. Medicare Part B provides coverage for Outpatient Care., home health services, durable medical equipment, and other medical services. It also covers many preventive care services.

The medically-necessary services covered by Part B (including all Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B).) include:

• Abdominal Aortic Aneurysm Screening
• Ambulance Services
• Blood
• Bone Mass Measurement (Bone Density)
• Cardiac Rehabilitation
• Cardiovascular Screenings
• Chiropractic Services (limited)
• Clinical Laboratory Services
• Clinical Research Studies
• Colorectal Cancer Screenings
• Defibrillator (Implantable Automatic)
• Diabetes Screenings
• Diabetes Self-Management Training
• Diabetes Supplies
• Doctor Services
• Durable Medical Equipment (like walkers)
• EKG Screening
• Emergency Department Services
• Eyeglasses (limited)
• Federally-Qualified Health Center Services
• Flu shots
• Foot Exams and Treatment (Diabetes-related)
• Glaucoma Tests
• Hearing and Balance Exams
• Hepatitis B Shots
• HIV Screening
• Home Health Services
• Kidney Dialysis Services and Supplies
• Kidney Disease Education Services
• Mammograms (screening)
• Medical Nutrition Therapy Services
• Mental Health Care (outpatient)
• Non-doctor Services
• Occupational Therapy
• Outpatient Medical and Surgical Services and Supplies
• Pap Tests and Pelvic Exams (includes clinical breast exam)
• Physical Exams (annual wellness visits)
• Physical Therapy
• Pneumococcal Shot
• Prescription Drugs (limited)
• Prostate Cancer Screenings
• Prosthetic/Orthotic Items
• Pulmonary Rehabilitation
• Rural Health Clinic Services
• Second Surgical Opinions
• Smoking Cessation (counseling to stop smoking)
• Speech-Language Pathology Services
• Surgical Dressing Services
• Telehealth
• Tests (other than lab tests)
• Transplants and Immunosuppressive Drugs

To find out if Medicare will cover a service that’s not on this list, visit www.medicare.gov/coverage.

If you have Original Medicare you pay 20% of the Medicare-approved amountA Medicare-approved amount is what Medicare will pay for a covered service. Healthcare providers that agree to Medicare assignment accept the approved amount without excess charges. What Does Medicare-Approved Amount Mean? A Medicare-approved amount is... for your doctor’s or other health care provider’s services. In a hospital outpatient setting, you also usually pay a copayment for each service you receive. There are some exceptions for costly surgical procedures, such as a total knee replacement. For these services, you pay a flat 20%.

9 Types of Services Medicare Does Not Cover

As we age many of us need eye care, dental work, foot care, hearing aids, and other routine care, but Medicare generally won’t pay for any of these services. And if you need extensive long-term carea variety of services that help people with their medical and non-medical needs over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including..., Medicare only covers you for a limited time and under particular circumstances.

Here are the nine type of services that Medicare does not cover that you need to know about.

1. Routine Dental Care

Medicare doesn’t pay for routine dental care, including cleanings and fillings. Dentures, implants, and other types of dental devices aren’t covered either. Medicare Part A does pay for certain dental services received if you are hospitalized, but only if the services are medically necessary. For your routine dental care needs, you’ll need to buy a dental plan or enroll in a Medicare Advantage plan with dental coverage. You can find and compare dental plans for seniors here.

2. Hearing Aids

Most people find it challenging to hear clearly as they age, especially in a noisy environment. Medicare doesn’t cover hearing aids or the exam required to select and fit an appropriate hearing device. However, Medicare might cover an exam if your doctor determines it’s medically necessary (e.g., balance-related). And Medicare covers surgically implanted devices, such as cochlear implants that offer a sense of sound.

3. Routine Eye Exams

Medicare covers eye exams and tests for people with specific conditions, such as an annual glaucoma test for high-risk retirees, a yearly eye exam for diabetic retinopathy, and tests and treatments for age-related macular degeneration. However, vision checks for the purpose of prescribing glasses and contact lenses are not covered. The single exceptionIn a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... to this rule is your “Welcome to Medicare” preventive care visit that you get during the first 12 months you have Medicare Part B.

4. Glasses and Contact Lenses

Most of us need corrective lenses to see clearly as we age, but Medicare doesn’t cover the cost of glasses or contact lenses for most people. But, if you need cataract surgery and your doctor implants an intraocular lens, Medicare will cover one pair of eyeglasses or one set of contact lenses from a Medicare-approved supplier.

5. Routine Foot Care

Medicare covers podiatry services for injuries to the foot, including hammer toes, bunions, and heel spurs. However, Medicare doesn’t cover foot care such as the removal of calluses and corns, nail maintenance, or foot cleaning. Exams and treatment are covered if needed in the treatment of a chronic condition, such as diabetes. This includes custom-molded shoes and inserts for those with severe diabetic foot disease and orthopedic shoes if you have a leg brace.

6. Acupuncture

Many people swear by acupuncture to relieve various ailments, but it’s not covered by Medicare. You can get your chiropractor visits for medically necessary manipulation of the spine covered, but Medicare may not cover other chiropractic services, such as X-rays and massage therapy.

7. Cosmetic Surgery

Medicare doesn’t cover cosmetic surgery unless it’s medically necessary. For example, Medicare will typically pay for the surgery if it is required because of an injury or deformity. Common instances include artificial limbs and their replacement parts, artificial eyes, and breast prosthesis after a mastectomy.

8. Medical Care Received Outside the U.S. and its Territories

Medicare does not cover health services received in another country. However, there are circumstances when Medicare will pay, such as if a foreign hospital is closer than the nearest U.S. hospital for a beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. injured in the U.S. The most common example is receiving emergency medical services in Canada while traveling between the continental U.S. and Alaska. If you plan to travel abroad, buy a Medicare supplement plan or travel insurance.

9. Personal Care & Long-Term Care

Medicare typically won’t cover the cost of personal care services, including help for bathing, dressing, getting out of bed, shopping, housekeeping, meals delivered to your home, or 24-hour assistance at home. If you’re poor you might qualify for custodial careNon-skilled personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. costs through MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States..

Medicare does cover short-term care in a skilled nursing facility if it follows a hospital stay of three or more days. Although you don’t have any cost-sharing during the first 20 days of care, you’ll pay $204 per day for days 21 through 100. Medicare does not cover nursing home stays that exceed 100 days. For this, you’ll need long-term care insurance. For information about LTC coverage, you can read our Long-Term Care insurance guide here.

Summary

Although Medicare covers most of your major medical costs, it doesn’t cover everything. To make sure you have coverage for your dental, vision, hearing, long-term care, and other healthcare needs as you age into retirement, you’ll need to plan ahead and buy additional coverage.