Understanding What's Covered by Medicare

Medicare is a federal health insurance program for people who are 65 or older, as well as certain younger individuals with disabilities. It's made up of four distinct parts, each covering different types of healthcare services. Understanding what each part covers — and what it doesn't — is essential for making informed decisions about your healthcare.

Part A: Hospital Insurance

Medicare Part A covers inpatient care and services you receive inside a healthcare facility. This includes:

• Inpatient hospital stays — semi-private rooms, meals, nursing services, and medications administered during your stay
• Skilled nursing facility care — up to 100 days per benefit period following a qualifying hospital stay
• Hospice care — comfort care for terminally ill patients, including medications for pain management
• Some home health services — part-time skilled nursing care or therapy if you're homebound

Most people don't pay a monthly premium for Part A if they or their spouse paid Medicare taxes while working. However, there are deductibles and coinsurance costs that apply to longer hospital stays.

Part B: Medical Insurance

Part B covers medically necessary outpatient services and preventive care. This includes:

• Doctor's visits — both primary care and specialist appointments
• Outpatient procedures — surgeries, lab tests, X-rays, and diagnostic services
• Preventive services — annual wellness visits, flu shots, cancer screenings, and cardiovascular checks
• Durable medical equipment — wheelchairs, walkers, oxygen equipment, and other medically necessary devices

Part B requires a monthly premium (deducted from your Social Security check for most beneficiaries) and a yearly deductible. After the deductible, you typically pay 20% coinsurance for most services.

Part C: Medicare Advantage

Medicare Advantage plans are offered by private insurance companies as an alternative to Original Medicare. These plans must cover everything Parts A and B cover, but many also include additional benefits such as:

• Dental coverage
• Vision insurance
• Hearing exams and hearing aids
• Wellness programs and gym memberships

Most Medicare Advantage plans also include Part D prescription drug coverage built in. Plans vary by location, and each has its own network of doctors, hospitals, and pharmacies. There are several types of Medicare Advantage plans — including HMOs, PPOs, and Special Needs Plans — each with different rules for how you access care.

Part D: Prescription Drug Coverage

Medicare Part D helps cover the cost of prescription medications. These plans are offered by private insurers and each has its own formulary — a list of covered drugs organized by cost tiers. Key things to know:

• Plans vary in which drugs they cover and how much you pay
• There may be a coverage gap (donut hole) where your costs temporarily increase
• You can compare plans during enrollment periods to find the best fit for your medications

What Medicare Doesn't Cover

Original Medicare has notable gaps. It generally does not cover:

• Routine dental, vision, or hearing care
• Long-term custodial care (nursing home care that isn't skilled nursing)
• Cosmetic surgery
• Most care received outside the United States

To fill these gaps, many beneficiaries add a Medicare Supplement (Medigap) plan to help cover out-of-pocket costs like copays, coinsurance, and deductibles, or choose a Medicare Advantage plan that bundles extra benefits.

Choosing the Right Coverage

The best Medicare coverage depends on your individual health needs, budget, and preferred doctors. Reviewing your options during each enrollment period ensures you're not paying more than necessary or missing out on benefits that could help you. If you're unsure where to start, a local Medicare insurance agent can walk you through your options at no cost.