What Medicare covers and what it doesn't

Medicare Part A covers hospital stays, skilled nursing facility care after a hospital stay, hospice, and some home health services. Part B covers doctor visits, outpatient care, lab tests, and certain preventive services. Part D covers prescription drugs through a plan you choose. Part C (Medicare Advantage) is an alternative to Original Medicare that bundles Parts A, B, and D through a private insurer, often with added benefits like dental or vision.

Medicare does not cover routine dental work, eyeglasses, hearing aids, or long-term custodial care in a nursing home. It also does not cover most prescription drugs unless you have Part D coverage. Costs vary depending on which parts you have and which plan you choose within each part.

Key Takeaways

  • Part A covers hospital and skilled nursing care; Part B covers doctor visits and outpatient services; Part D covers prescription drugs you select through a plan.
  • You must enroll in Medicare during your initial enrollment period, which starts three months before the month you turn 65, or you may face permanent penalties.
  • Original Medicare (Parts A and B) has no network restrictions, but Medicare Advantage (Part C) requires you to use in-network providers except in emergencies.
  • Your out-of-pocket costs depend on your plan choice and include deductibles, copays, and coinsurance amounts that vary year to year.
  • You can change your Medicare coverage during the Annual Enrollment Period from October 15 to December 7 each year, or during other special enrollment windows if you have a may have access to life event.

When you turn 65 and how to sign up

Your initial enrollment period begins three months before the month you turn 65 and ends three months after. You can sign up online at Medicare.gov, by phone at 1-800-MEDICARE, or in person at your local Social Security office. If you delay signing up past this window without a valid reason, you will owe a permanent penalty added to your Part B and Part D premiums for as long as you have Medicare.

If you are still working and covered by your employer's health plan at 65, you may be able to delay Part B enrollment without penalty. You will need to show proof of employer coverage when you do enroll. Talk to your employer's benefits office about how this works with your specific plan before you turn 65.

How much Medicare costs each month

Part A has no monthly premium for most people who paid Medicare taxes while working. Part B has a monthly premium that changes each year; in 2024 it starts at $174.70 for most people, but higher earners pay more. Part D premiums vary by plan and range widely depending on which drugs are covered and which insurer you choose. Medicare Advantage plans often have no monthly premium or a low one, but you still pay the Part B premium.

Beyond the monthly premium, you also pay a deductible before Medicare starts to pay, copays when you see a doctor or fill a prescription, and coinsurance (a percentage of the cost). These amounts change each year. Original Medicare Part A has a deductible of $1,740 per hospital stay in 2024, and Part B has a $240 annual deductible. Medicare Advantage plans set their own deductibles and copays, which may be lower or higher than Original Medicare.

Original Medicare versus Medicare Advantage

Original Medicare (Parts A and B) lets you see any doctor or hospital that accepts Medicare, anywhere in the country. There is no network, so you have the most freedom to choose providers. You pay a deductible and coinsurance for each service. If your costs get very high, catastrophic coverage kicks in after you spend $8,550 out of pocket in 2024.

Medicare Advantage (Part C) is sold by private insurance companies and bundles Parts A, B, and usually D into one plan. Most Advantage plans have lower or no monthly premiums and lower copays than Original Medicare, but you must use in-network doctors and hospitals except in emergencies. Some plans include dental, vision, or hearing coverage that Original Medicare does not. The trade-off is less flexibility and potentially higher costs if you need out-of-network care.

Prescription drug coverage and how to choose a plan

Part D is prescription drug coverage you buy separately from a private insurer if you have Original Medicare. If you have Medicare Advantage, drug coverage is usually included. You choose your Part D plan during the Annual Enrollment Period (October 15 to December 7) or when you first turn 65. The plan you pick determines which drugs are covered, how much you pay, and which pharmacies you can use.

Use the Medicare Plan Finder tool at Medicare.gov to compare plans based on the specific drugs you take. Enter your prescriptions and it will show you the estimated cost under each plan. Plans change their drug lists and costs every year, so you should review your coverage each fall even if you have been happy with your plan. If you delay enrolling in Part D without a valid reason, you will owe a permanent penalty on top of your premiums.

Changing your coverage if your situation changes

You can change your Medicare coverage during the Annual Enrollment Period from October 15 to December 7 each year. Changes take effect January 1. Outside this window, you can make changes only if you have a may have access to life event, such as losing employer coverage, moving out of your plan's service area, getting married or divorced, or having a significant change in income.

If you experience a may have access to event, you usually have 60 days to make a change. Contact Medicare at 1-800-MEDICARE or your current plan to report the event and find out what changes you can make. Some people may have access to for Special Enrollment Periods that let them switch plans at other times of year. Keep records of any life changes in case you need to prove them later.

What to ask your doctor and when to call Medicare

Before any procedure or test, ask your doctor whether it is covered under your specific Medicare plan and what your out-of-pocket cost will be. Ask whether the facility or lab is in-network if you have Medicare Advantage. If your doctor prescribes a drug that is not on your Part D plan's formulary (the list of covered drugs), ask whether there is a similar drug that is covered or whether your plan will make an exception.

Call Medicare at 1-800-MEDICARE if you receive a bill you think Medicare should have paid, if you are denied coverage for a service, or if you have questions about your coverage. You can also file an appeal if you disagree with a coverage decision. Keep all bills and explanation of benefits statements so you have documentation if you need to dispute a charge.

Frequently Asked Questions

Do I have to enroll in Medicare when I turn 65?

Yes, unless you are still covered by an active employer health plan. If you do not enroll during your initial enrollment period and you are not covered by employer insurance, you will owe a permanent penalty on your Part B and Part D premiums for as long as you have Medicare. Contact your employer's benefits office before you turn 65 to confirm your coverage status.

Can I use my Medicare in other states or countries?

Original Medicare is accepted nationwide, so you can see any Medicare-accepting doctor or hospital anywhere in the United States. Medicare Advantage plans are usually limited to a specific service area, so you may not be covered if you travel or move. Medicare does not cover care outside the United States except in very limited situations near the border. Check your plan's rules before traveling.

What happens if I cannot afford my Medicare premiums and copays?

Several programs may help. Medicare Savings Programs pay some or all of your Part B and Part D premiums and cost-sharing if your income is low. The Extra Help program helps pay for Part D prescriptions. Medicaid may also help if you may have access to based on income and assets. Contact your state Medicaid office or call 1-800-MEDICARE to learn whether you may have access to for any of these programs.

How do I know if my doctor accepts Medicare?

Use the Medicare Provider Search tool at Medicare.gov or call your doctor's office directly and ask. If you have Medicare Advantage, also ask whether the doctor is in-network under your specific plan. Some doctors accept Medicare but have limited availability for new patients, so ask when you call whether they are taking new Medicare patients.

What should I do if I think Medicare made a billing error?

Contact Medicare at 1-800-MEDICARE with your claim number and explanation of benefits statement. You can also file a formal appeal if you disagree with a coverage decision or denial. Keep copies of all bills, receipts, and correspondence. If the error involves your plan (Medicare Advantage or Part D), contact your plan's customer service first, as they handle appeals for plan-specific decisions.