What Does Medicare Cover?

Medicare Coverage

Medicare covers a large number of medical and healthcare services, but not everything.

You can go to Medicare.gov to find out if a specific service or medical supply is covered by Medicare.

Coverage can vary depending upon where you live.

If the medical supply or service that you need is not listed on the website, you can consult your healthcare provider about whether Medicare will cover you.

Medicare coverage is based on 3 key factors:

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

In general, Medicare Part A covers:

  • Inpatient care in a hospital
  • Skilled nursing facility care
  • Nursing home care (inpatient care in a skilled nursing care facility that’s not custodial or long-term care
  • Hospice care
  • Home health care

In general, Medicare Part B covers two types of services:

  • Medically necessary services: Services or supplies that are needed 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 is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

In general, Medicare Part B covers things like:

  • Clinical research
  • Ambulance services
  • Durable Medical Equipment
  • Mental health
  • Inpatient
  • Outpatient
  • Partial hospitalization
  • Limited outpatient prescription drugs

Medicare Health Plans

Generally, a Medicare health plan is offered by a private company that contracts with Medicare to provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) benefits to people who enroll in the plan.

Medicare health plans include:

  • Medicare advantage plans
  • Other Medicare healthcare plans
  • Medicare Cost Plans
  • Demonstrations/Pilot Programs
  • Programs of All-inclusive Care for the Elderly (PACE)
  • Medication Therapy Management (MTM) programs for complex health needs

Medicare Advantage Plans

Medicare Advantage Plans must cover all of the services that Original Medicare covers.

However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.

In all types of Medicare Advantage Plans, you’re always covered for emergency and urgently needed care.

The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare.

If you’re not sure whether a service is covered, check with your provider before you get the service.

Most Medicare Advantage Plans offer coverage for things that aren’t covered by Original Medicare, like vision, hearing, dental, and wellness programs (like gym memberships).

Plans can also cover more extra benefits than they have in the past, including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, and other health-related services that promote your health and wellness.

Medicare Medical Savings Account Plans

These plans are essentially self-directed medical savings accounts that are similar to Health Savings Accounts.

Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs.

Other Medicare Health Plans

Some types of Medicare health plans that provide health care coverage aren’t Medicare Advantage Plans but are still part of Medicare.

Some of these plans provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, while most others provide only Part B coverage.

Some also provide Medicare prescription drug coverage (Part D).

PACE

Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.

With PACE, you have a team of health care professionals working with you and your family to make sure you get the coordinated care you need.

Usually they care for a small number of people, so they really get to know you.

What Does Medicare Cover FAQs

Medicare is a publicly-available health insurance program run by the U.S. government.
Medicare provides health coverage to those who are 65+ (or if you have a disability, regardless of age). Medicaid by contrast is available for those with very low income.
Typically, everyone who is 65 or older, or suffers from a disability is eligible for Medicare.
Medicare Part A is free for most people. For those who don’t meet the criteria for free Medicare Part A, the cost is $458 per month if you paid Medicare taxes for less than 30 quarters over the course of your working career.