What Medicare Health Coverage Includes

Medicare is a federal health insurance program for people 65 and older, some younger people with disabilities, and people with end-stage renal disease. It has four main parts, each covering different types of care. Part A covers hospital stays, skilled nursing care, hospice, and some home health services. Part B covers doctor visits, outpatient care, medical equipment, and preventive services. Part D covers prescription drugs. Part C, also called Medicare Advantage, is an alternative way to get Parts A and B coverage, often bundled with Part D and sometimes dental or vision benefits.

What Medicare pays for depends on which parts you have and what type of service you need. A doctor visit under Part B, for example, typically requires you to pay a copay or coinsurance after you meet your annual deductible. A hospital stay under Part A requires a one-time deductible per benefit period, then Medicare covers most costs for the first 60 days. Understanding what each part covers helps you know what out-of-pocket costs to expect and whether you need additional coverage.

Key Takeaways

  • Medicare Part A covers hospital, skilled nursing, and hospice care; Part B covers doctors and outpatient services; Part D covers prescription drugs; Part C bundles A and B through private insurers.
  • You pay deductibles, copays, and coinsurance amounts that vary by service type and which parts of Medicare you have.
  • Preventive services like annual wellness visits, cancer screenings, and vaccines are covered at no cost under Part B when you see an in-network provider.
  • If Original Medicare does not cover a service, you may be able to purchase a Medigap policy or choose Medicare Advantage to fill the gaps.
  • Your coverage and costs change if you switch between Original Medicare and Medicare Advantage, so reviewing your plan each year during open enrollment is important.

How Part A and Part B Work Together

Most people on Medicare have both Part A and Part B, sometimes called Original Medicare. Part A is usually free because you or your spouse paid Medicare taxes while working. Part B requires a monthly premium, which is deducted from your Social Security check unless you choose to pay separately.

When you use a service, you pay a share and Medicare pays a share. For a doctor visit, you typically pay a copay (a set amount like $15 or $20) or coinsurance (a percentage of the bill). For a hospital stay, you pay a deductible for the first 60 days, then nothing for days 61–90, then a daily coinsurance amount for days 91–150. After 150 days, you pay the full cost unless you have additional coverage. The exact amounts change each year.

Part B also has an annual deductible you must meet before Medicare starts paying. Once you meet it, you typically pay 20 percent coinsurance for most services, and Medicare pays 80 percent. This structure means your costs can add up quickly if you have many doctor visits or need hospital care, which is why many people buy supplemental coverage.

Preventive Care at No Cost

Medicare Part B covers certain preventive services with no copay or coinsurance when you see a provider who accepts Medicare. These include an annual wellness visit (sometimes called a "Welcome to Medicare" visit if you are new to Medicare), which lets you review your health history and create a plan with your doctor. You also get covered screenings for cancer, heart disease, diabetes, and bone density loss, plus vaccines for flu, pneumonia, and shingles.

The catch is that the service must be listed as preventive and you must see an in-network provider. If your doctor orders additional tests during a preventive visit — for example, blood work beyond what the preventive screening includes — you may owe a copay for that extra service. Ask your doctor in advance if any tests or services will be billed separately so you know what to expect.

Part D Prescription Drug Coverage

Part D covers prescription medications through private insurance plans that contract with Medicare. You choose a plan during your initial enrollment or during the annual open enrollment period in October and November. Plans vary widely in which drugs they cover, what you pay at the pharmacy, and which pharmacies are in their network.

Most Part D plans have a deductible, then you pay a copay or coinsurance for each prescription. Once your total out-of-pocket spending reaches a certain amount (called the "catastrophic threshold"), you pay a small copay for the rest of the year. If you do not have Part D coverage when you first become may be able to access and do not join later, you may pay a penalty for each month you go without it, even if you do not take many medications.

You can switch Part D plans once a year during open enrollment, so if your medications change or your plan's costs rise, you can look for a better option. Use the Medicare Plan Finder tool on Medicare.gov to compare plans based on your specific prescriptions and preferred pharmacies.

Medicare Advantage as an Alternative

Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies. Instead of going to any doctor who accepts Medicare, you typically use doctors and hospitals in the plan's network. Most Medicare Advantage plans include Part D drug coverage and may offer dental, vision, or hearing benefits that Original Medicare does not.

The trade-off is that you usually pay lower monthly premiums and lower copays than Original Medicare, but you have less flexibility in choosing providers and may need prior approval from the plan before certain services. If you travel frequently or live part of the year in different states, Original Medicare may be more convenient because it works anywhere in the country.

You can switch from Original Medicare to Medicare Advantage or vice versa during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event like moving out of your plan's service area. If you switch to Medicare Advantage, you lose Original Medicare coverage, so understand what you are giving up before you change.

Gaps in Medicare Coverage and Supplemental Options

Original Medicare does not cover dental care, vision exams, hearing aids, long-term care, or routine foot care. It also does not cover the full cost of hospital stays beyond 150 days or skilled nursing care beyond 100 days in a benefit period. Many people buy a Medigap policy (also called a supplement) to cover these gaps and reduce their out-of-pocket costs.

Medigap policies are sold by private insurers and are standardized by the federal government, meaning a Plan G from one company covers the same services as a Plan G from another. The main difference is price. You can buy a Medigap policy anytime, but you have the best rates if you buy within six months of turning 65 and enrolling in Part B. After that window, insurers can charge more based on your health history.

If you have Medicare Advantage, you cannot buy a Medigap policy. Instead, the plan itself covers some gaps through copays and coinsurance limits. Some people also buy long-term care insurance separately to cover nursing home or in-home care, though this is a personal decision based on your assets and family situation.

How to Review and Change Your Coverage

Medicare's open enrollment period runs from October 15 to December 7 each year. During this time, you can switch between Original Medicare and Medicare Advantage, change your Part D plan, or add or drop a Medigap policy. Changes take effect on January 1. If you miss this window, you cannot change your coverage until the next year unless you have a may have access to event like losing employer coverage, moving, or having a major life change.

To review your options, visit Medicare.gov and use the Plan Finder tool, which compares costs and coverage based on your location, prescriptions, and preferred doctors. You can also call 1-800-MEDICARE to speak with a representative, or contact your State Health Insurance information Program (SHIP), which offers free, unbiased counseling about Medicare options. SHIP can help you understand the differences between plans and find one that fits your needs and budget.

Many people do not realize their coverage needs change year to year. A plan that was affordable last year may cost more this year, or a medication you take may move to a higher tier. Reviewing your coverage annually takes an hour or two and can save you hundreds of dollars.

Frequently Asked Questions

Does Medicare cover doctor visits?

Yes, Part B covers doctor visits. You typically pay a copay (a set amount) or coinsurance (a percentage of the bill) after you meet your annual deductible. Preventive visits like annual wellness exams are covered at no cost when you see an in-network provider.

What happens if I do not sign up for Medicare when I turn 65?

If you delay enrolling in Part B or Part D without a valid reason, you may pay a penalty for each month you go without coverage. The penalty is added to your premium permanently. If you have employer coverage when you turn 65, you may be able to delay without penalty, but you must enroll within a certain time after that coverage ends.

Can I use my Medicare coverage outside the United States?

Original Medicare generally does not cover care outside the U.S., except in limited situations like emergency care in Canada or Mexico near the U.S. border. Medicare Advantage plans vary; some offer limited coverage abroad. If you travel internationally, consider purchasing travel health insurance or a plan that covers overseas care.

What is the difference between Medicare and Medicaid?

Medicare is a federal program based on age or disability, regardless of income. Medicaid is a joint federal and state program for people with low income. Some people may have access to for both (called "dual may be able to access"). They are separate programs with different rules, coverage, and costs.

How much does Medicare cost?

Part A is usually free. Part B premiums vary by income; in 2024 the standard premium was $164.90 per month, but higher earners pay more. Part D and Medigap costs depend on the plan you choose. Medicare Advantage plans vary in cost and may have no monthly premium or a low one, but you pay copays when you use services.