What Does or Doesn't Medicare Cover?

Original Medicare (Medicare Parts A and B) along with a Part D prescription drug plan pays for a lot, but it doesn’t cover everything. You still need to understand what you’re responsible to pay.

Original Medicare (Parts A and B) has no stop-loss coverage, meaning there’s no limit on the amount you could end up paying out of your own pocket each year for hospital or other medical expenses. To address that, you need a Medicare Supplement, also called a Medigap plan, or a Medicare Advantage (Part C) plan that includes an annual out-of-pocket limit on what you’re responsible for paying.

It bears repeating: Original Medicare (Parts A and B) has no annual out-of-pocket maximum built in that stops you from paying.

Your Medicare Part A hospitalization and skilled nursing costs:
A $1,484 deductible (in 2021) to meet for each benefit period you have during a year. It’s not an annual deductible, and you could have more than one benefit period during a year. After meeting your deductible for that benefit period, you will be responsible for:

$0 coinsurance payment per day for an inpatient hospitalization for days 1-60
$371 per day for days 61-90
$742 per day for days 91 and beyond. Those are your lifetime reserve days.

You get 60 of these lifetime reserve days, after which you are responsible for all your costs.

Your Medicare Part B medical insurance costs:

A small deductible ($203 in 2021)
A 20% coinsurance payment after you meet that deductible. That means beyond your deductible, you are responsible for 20% of the cost of whatever Medicare Part B covers.

Seriously consider a Medicare Supplement or Medicare Advantage plan that includes an out-of-pocket maximum.

No. You need to purchase Medicare Part D prescription drug coverage. You can purchase that coverage through Medicare-approved private insurance companies as a standalone plan to pair with Original Medicare (Parts A and B) or through a Medicare Advantage plan that includes Part D coverage. Premiums will vary.

Penalty for Late Part D Enrollment - Be sure to enroll in your Medicare Part D coverage when you first become eligible. If you wait to enroll in Medicare drug coverage, you could face a penalty of 1% added to your monthly premium for every month you delayed coverage.

Yes. Through Medicare Part B medical insurance. Some services like the flu shot are offered at no cost to you. With others, like certain screenings, you will have to pay 20% of the expense, but the Part B deductible doesn’t apply. Your cost varies by service.

Dental – Generally not, though Part A may pay for certain dental services when you’re in the hospital.
Vision – Not routine eye exams or costs for contacts or glasses. Part B may cover some preventive and diagnostic exams for conditions like glaucoma or diabetes.
Hearing – Not routine hearing exams or any costs for hearing aids. Part B may cover a hearing or balance exam if ordered by your doctor for a medical reason.

Note: Some Medicare Advantage (Part C) plans include dental, vision and hearing services as a part of the plan. If getting help with those expenses is important, look into Medicare Advantage plans in your state.

Generally not. For the most part, Medicare covers only medically necessary expenses, and since much of assisted living, nursing or long-term care deals with activities of daily living, those expenses fall outside of Medicare’s scope. Medicare might cover medically necessary skilled nursing care at an eligible facility, but only for a specific medical reason and often only for a limited period of time.

Yes. Medicare covers many of the expenses of hospice care if you …

Have less than six months to live.
Accept comfort care instead of care to cure your illness.
Sign a statement that you’re choosing hospice care instead of other Medicare-covered treatments for your illness.

Yes. Through Medicare Part B medical insurance. If your doctor prescribes medically necessary equipment for you, Medicare covers part of that expense. Your costs for the equipment would include your Part B deductible ($203 in 2021) if you haven’t met it for the year and 20% of the equipment cost beyond your deductible.

No. Medicare, generally speaking, covers only what is medically necessary.

No. Holistic medicine techniques like acupuncture and massage therapy are not covered.

Obviously this is just a partial list of what Medicare will or likely won’t cover. Be sure to research those areas of coverage most important to you. Also, consider a Medicare Supplement plan or Medicare Advantage plan to address some of your needs that Original Medicare can’t.

For more information

https://www.medicare.gov/coverage/hospital-care-inpatient.html

https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html

https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html

https://www.medicare.gov/coverage/preventive-and-screening-services.html

https://www.medicare.gov/coverage/dental-services.html

https://www.medicare.gov/coverage/eye-exams.html

https://www.medicare.gov/coverage/hearing-and-balance-exam-and-hearing-aids.html

https://www.medicare.gov/coverage/long-term-care.html

https://www.medicare.gov/coverage/hospice-and-respite-care.html

https://www.medicare.gov/coverage/durable-medical-equipment-coverage.html

https://www.medicare.gov/what-medicare-covers/not-covered/item-and-services-not-covered-by-part-a-and-b.html

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

Last Updated: 1.7.2022 12:01AM ET Y0066_211206_013335

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What Does or Doesn't Medicare Cover?

Medicare Advantage Plans as Low as $0 per monthF36

For more information

Medicare Advantage Plans as Low as $0 per month^F36