Medicare covers hospital stays, doctor visits, and some prescription drugs, but not everything

Medicare is divided into four parts, and each one covers different things. Part A covers hospital care. Part B covers doctor visits and outpatient services. Part D covers prescription drugs. Part C (Medicare Advantage) is an alternative to Parts A and B offered by private insurance companies. What you pay depends on which parts you have and which services you use.

Medicare does not cover dental work, vision care, hearing aids, or long-term care in a nursing home. It also does not cover most routine foot care, cosmetic surgery, or acupuncture. If you need these services, you either pay out of pocket or buy a separate policy called a Medigap plan or a Medicare Advantage plan, which may include some of these benefits.

Key Takeaways

  • Part A covers hospital stays, skilled nursing facility care, hospice, and some home health services after a hospital stay.
  • Part B covers doctor office visits, preventive care, lab tests, imaging, and outpatient procedures, and you pay a monthly premium plus a share of each service.
  • Part D covers prescription drugs through a separate plan you choose, and the cost depends on which drugs you take and which plan you pick.
  • Medicare does not cover dental, vision, hearing aids, or long-term nursing home care, and you will need other insurance or out-of-pocket money for these.
  • Medigap plans and Medicare Advantage plans fill some of the gaps in Original Medicare coverage, but they have different costs and networks.

What Part A covers: Hospital and facility care

Part A pays for inpatient hospital stays, skilled nursing facility care after a hospital stay, hospice care, and some home health services. You do not pay a monthly premium for Part A if you or your spouse paid Medicare taxes for at least 10 years while working. Most people get Part A automatically when they turn 65.

When you are admitted to a hospital, Part A covers your room, meals, nursing care, and most tests and procedures. You pay a deductible (a set amount you pay before Medicare starts paying) for each hospital stay. In 2024, that deductible is $1,632, but this amount changes each year. If you stay longer than 60 days in one hospital stay, you also pay a daily coinsurance amount (a share of the cost) for days 61 through 90.

Part A also covers up to 100 days in a skilled nursing facility if you were hospitalized for at least three days first. You pay nothing for the first 20 days, and then you pay a daily coinsurance amount for days 21 through 100. After 100 days, you pay the full cost yourself.

What Part B covers: Doctor visits and outpatient care

Part B covers doctor office visits, preventive care visits, lab tests, X-rays, imaging, outpatient surgery, and emergency room visits. You pay a monthly premium for Part B (in 2024, the standard premium is $164.90 per month, but this varies based on your income). You also pay an annual deductible before Part B starts paying, and then you typically pay 20% of the cost of most services after that.

Part B covers preventive services at no cost to you if you have not met your deductible. These include annual wellness visits, cancer screenings, blood pressure checks, diabetes screening, and vaccines. Once you have met your deductible, you pay 20% of the Medicare-approved amount for most other Part B services.

Part B does not cover routine dental care, eye exams for glasses or contacts, hearing aids, or most foot care. It also does not cover most physical therapy or occupational therapy unless it is medically necessary and ordered by a doctor. If you need these services, you pay out of pocket or buy a Medigap or Medicare Advantage plan that includes them.

What Part D covers: Prescription drugs

Part D is prescription drug coverage you choose from private insurance companies. You must enroll in a Part D plan when you first become may be able to access for Medicare, or during the annual enrollment period (October 15 to December 7 each year). If you do not enroll when you are first may be able to access and you do not have other drug coverage, you may pay a penalty when you do enroll later.

Each Part D plan has a different list of covered drugs, called a formulary. Before you choose a plan, check whether your current medications are on the plan's formulary and what tier (cost level) they are on. Tier 1 drugs are usually the cheapest, and higher tiers cost more. You pay a monthly premium, an annual deductible (which varies by plan), and then a copay or coinsurance for each prescription.

Part D plans have a coverage gap, sometimes called the "donut hole." Once you and your plan have spent a certain amount on drugs in a year, you enter the gap and pay more out of pocket until you reach a catastrophic coverage level. In 2024, the gap begins after you and your plan have spent $5,850 combined. Once you reach $7,050 in out-of-pocket costs, catastrophic coverage kicks in and you pay only a small copay for the rest of the year.

What Medicare Advantage (Part C) covers instead

Medicare Advantage is an alternative to Original Medicare (Parts A and B). Private insurance companies offer these plans, and they must cover everything Original Medicare covers, but they often add dental, vision, hearing, and fitness benefits. Most Medicare Advantage plans have a network of doctors and hospitals you must use, and you typically pay lower copays than in Original Medicare.

Medicare Advantage plans include prescription drug coverage (Part D) automatically, so you do not choose a separate Part D plan. However, the copays and deductibles in a Medicare Advantage plan are often different from Original Medicare, and the out-of-pocket maximum is usually lower. This means your costs may be more predictable, but you have less choice of doctors and hospitals.

If you switch from Original Medicare to Medicare Advantage, you can usually switch back during the annual enrollment period (January 1 to March 31 each year). If you have a Medigap plan, you must drop it when you enroll in Medicare Advantage, because Medigap plans do not work with Medicare Advantage.

Gaps in Medicare coverage: What you pay yourself

Medicare does not cover dental work, routine eye exams, glasses or contacts, hearing aids, or routine foot care. It also does not cover long-term care in a nursing home (only skilled nursing facility care for a limited time after a hospital stay). Acupuncture, most chiropractic care, and cosmetic surgery are not covered. If you need these services, you either pay the full cost out of pocket or buy a Medigap or Medicare Advantage plan that includes some of them.

Medigap plans are sold by private insurance companies and are designed to pay some of the costs that Original Medicare does not cover, such as deductibles, coinsurance, and copays. There are 10 standardized Medigap plans (labeled A through N), and each one covers a different set of gaps. Medigap plans do not cover dental, vision, or hearing, but they do cover some of the out-of-pocket costs in Original Medicare.

The cost of a Medigap plan varies by age, location, and which plan you choose. You can enroll in a Medigap plan during your initial enrollment period (the six months starting the month you turn 65 and enroll in Part B), and you have the best rates and may provide coverage during this time. If you enroll later, you may pay higher premiums and the insurance company can deny you coverage based on your health history.

Preventive care and screenings at no cost

Medicare Part B covers many preventive services at no cost to you, even before you meet your deductible. These include an annual wellness visit with your doctor, blood pressure screening, cholesterol screening, diabetes screening, colorectal cancer screening (colonoscopy or other tests), breast cancer screening (mammogram), cervical cancer screening (Pap test), and vaccines such as flu, pneumonia, and shingles.

To get these services at no cost, you must go to a doctor or facility that accepts Medicare and is in-network. If you go out-of-network, you may have to pay more. Some preventive services have age or frequency limits — for example, colonoscopy is usually covered every 10 years if the results are normal, and mammograms are covered annually for women 40 and older.

Frequently Asked Questions

Does Medicare cover physical therapy?

Medicare Part B covers physical therapy if it is medically necessary and ordered by a doctor. You pay 20% of the cost after you meet your deductible. However, there are limits on the number of visits covered per year, and your doctor must document that the therapy is helping you improve.

What happens if I need care that Medicare does not cover?

You pay the full cost out of pocket, or you can buy a Medigap or Medicare Advantage plan that covers some of these services. Dental, vision, and hearing are the most common gaps. Some employers offer retiree health plans that cover these services, so check with your former employer if you are retired.

Can I use my Medicare coverage at any hospital or doctor?

In Original Medicare (Parts A and B), you can use any hospital or doctor that accepts Medicare, anywhere in the country. In Medicare Advantage, you must use doctors and hospitals in your plan's network, except in emergencies. Check your plan documents to see which providers are in-network.

Do I have to pay for preventive care visits?

No. Medicare Part B covers many preventive services at no cost, including annual wellness visits, cancer screenings, and vaccines. You do not pay a copay or coinsurance for these services, even if you have not met your deductible. However, if your doctor finds a problem during the visit and treats it, you may have to pay for that treatment.

What is the difference between a copay and coinsurance?

A copay is a fixed amount you pay for a service, such as $25 for a doctor visit. Coinsurance is a percentage of the cost you pay after Medicare pays its share, such as 20% of the cost of an imaging test. Original Medicare typically uses coinsurance, while Medicare Advantage plans often use copays.