Medicare covers hospital stays, doctor visits, and some preventive care, but not everything
Medicare is divided into four parts, and each covers different things. Part A covers inpatient hospital care, skilled nursing facilities, and hospice. Part B covers doctor visits, outpatient care, and some medical equipment. Part D covers prescription drugs. Part C (Medicare Advantage) is an alternative to Parts A and B offered by private insurers, and coverage varies by plan.
What Medicare does not cover includes most dental work, vision care, hearing aids, long-term custodial care in a nursing home, and most prescription drugs unless you have Part D. You pay out of pocket for these, or you buy supplemental coverage (called Medigap) to fill some gaps.
The amount you pay depends on which parts you have, whether you chose Original Medicare or Medicare Advantage, and whether you have Medigap or employer coverage. Your costs also depend on your income and when you enrolled.
Key Takeaways
- Part A covers hospital stays and skilled nursing care; Part B covers doctor visits and outpatient services; Part D covers prescription drugs.
- Medicare does not cover dental, vision, hearing aids, or long-term nursing home care, and you pay out of pocket unless you buy additional coverage.
- Original Medicare (Parts A and B) lets you see any doctor who accepts Medicare, while Medicare Advantage plans limit you to in-network providers.
- Medigap policies fill gaps in Original Medicare coverage but do not work with Medicare Advantage plans.
- Your costs vary based on your income, enrollment timing, and which coverage you choose.
What Part A covers
Part A covers inpatient hospital care, meaning you stay overnight in a hospital bed. It pays for the room, meals, nursing care, and most tests and procedures done while you are admitted. Part A also covers up to 100 days in a skilled nursing facility after a hospital stay of at least three days, though you pay a daily copay after day 20.
Part A covers hospice care if you are terminally ill and your doctor certifies you have six months or less to live. It pays for pain management, comfort care, and some medications related to your terminal condition.
Part A does not cover a private room unless medically necessary, a private nurse, or a television or phone in your room (though hospitals often provide these). It does not cover custodial care — help with bathing, dressing, or eating — unless it is part of skilled nursing care you need after a hospital stay.
What Part B covers
Part B covers doctor visits, whether in an office, urgent care clinic, or hospital outpatient department. It pays for diagnostic tests ordered by your doctor, such as blood work and imaging. It covers some preventive services at no cost to you, including annual wellness visits, cancer screenings, and vaccinations.
Part B also covers durable medical equipment such as wheelchairs, walkers, oxygen equipment, and diabetic supplies. It pays for mental health services, including therapy and psychiatric visits. It covers some rehabilitation services, such as physical therapy after an injury or stroke, though there are limits on how many visits you can have.
Part B does not cover routine dental care, eye exams for glasses or contacts, hearing aids, or most foot care (though it does cover diabetic foot care). It does not cover cosmetic surgery or most weight-loss surgery. You typically pay 20 percent of the cost after you meet your annual deductible.
What Part D covers and how to choose a plan
Part D covers prescription drugs at pharmacies. Each plan has a list of covered drugs called a formulary, and the drugs on that list change from year to year. Your out-of-pocket costs depend on which tier the drug is on — generic drugs usually cost less than brand-name drugs.
Part D has a coverage gap 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 a higher percentage of the cost until you reach catastrophic coverage, where your costs drop again. The amounts change each year.
You must enroll in Part D when you first become may be able to access for Medicare, or during the annual open enrollment period (October 15 to December 7). If you delay without having other drug coverage, you pay a penalty for as long as you have Medicare. You can switch plans once a year during open enrollment.
What Medicare Advantage (Part C) covers differently
Medicare Advantage is an alternative to Original Medicare offered by private insurance companies. It must cover everything Part A and Part B cover, but it does so through the insurance company's network of doctors and hospitals. If you go out of network, you pay more or the plan does not cover it at all.
Many Medicare Advantage plans include Part D drug coverage, dental, vision, or hearing benefits that Original Medicare does not cover. However, you pay a monthly premium to the insurance company in addition to your Part B premium, and your copays and deductibles may be higher than in Original Medicare.
Medicare Advantage plans can change their coverage, copays, and networks each year. You can switch to a different plan or back to Original Medicare during the annual open enrollment period.
Medigap coverage and when to buy it
Medigap (also called Supplement Insurance) is sold by private insurers and fills gaps in Original Medicare coverage. It pays some or all of your copays, coinsurance, and deductibles. Medigap does not work with Medicare Advantage — you can have either Original Medicare plus Medigap, or Medicare Advantage, but not both.
There are ten standardized Medigap plans, labeled A through N. Each plan covers the same benefits regardless of which insurance company sells it, though the premium varies by company and by your age and location. Plan G and Plan N are the most common choices for people newly may be able to access for Medicare.
You have the best rates and easiest enrollment if you buy Medigap within six months of turning 65 and enrolling in Part B. After that window, insurers can charge you more based on your health history or deny you coverage altogether. If you have employer coverage when you turn 65, you may have a different enrollment window — ask your employer's benefits office.
Costs you pay out of pocket
In Original Medicare, you pay a monthly premium for Part B (the amount depends on your income), an annual deductible before Part B coverage starts, and 20 percent coinsurance for most services after the deductible. Part A is free if you or your spouse paid Medicare taxes for at least 10 years, but you pay a deductible if you are admitted to the hospital.
In Medicare Advantage, you pay a monthly premium to the insurance company, a deductible (which may be zero), and copays for each visit or service. Your total out-of-pocket costs are capped at a maximum amount per year, after which the plan covers everything.
Part D premiums, deductibles, and copays vary by plan. If your income is below a certain threshold, you may may have access to for programs that help pay Part B and Part D costs — ask your local Social Security office or call 1-800-MEDICARE.
When to contact Medicare or your doctor
Call 1-800-MEDICARE if you are unsure whether a specific service or drug is covered under your plan, if you receive a bill you think Medicare should have paid, or if you want to appeal a coverage denial. Medicare staff can answer questions about your coverage and help you understand your costs.
Contact your doctor's office before a procedure or test to confirm they accept your Medicare plan and whether you need a referral. Ask whether the service is covered and what you will owe out of pocket.
If you are having trouble paying for a covered service, ask your doctor's office about payment plans or financial information programs. Some hospitals and clinics have programs for patients with limited income.
Frequently Asked Questions
Does Medicare cover physical therapy?
Part B covers physical therapy ordered by your doctor, but there are limits. Medicare sets a yearly cap on how much it will pay for physical therapy combined with occupational therapy and speech therapy. Your doctor can request an exception if you need more visits, and Medicare will review the request.
Does Medicare cover eye exams and glasses?
Medicare does not cover routine eye exams, eyeglasses, or contact lenses. It does cover one eye exam every two years if you have diabetes, and it covers intraocular lenses if you have cataract surgery. Some Medicare Advantage plans include vision coverage — check your plan documents.
Does Medicare cover hearing aids?
Original Medicare does not cover hearing aids or hearing exams for the purpose of fitting hearing aids. Some Medicare Advantage plans offer hearing benefits, though they often have limits on how much they will pay. You pay out of pocket or look for programs in your state that help seniors afford hearing aids.
Does Medicare cover nursing home care?
Medicare covers up to 100 days in a skilled nursing facility after a hospital stay of at least three days, but only if you need skilled care such as wound care or physical therapy. It does not cover custodial care — help with daily living — in a nursing home. Long-term nursing home care is usually paid out of pocket or through Medicaid if your income is low enough.
What happens if I do not enroll in Medicare when I turn 65?
If you delay enrolling in Part B without having other health coverage, you pay a penalty of 10 percent of your Part B premium for each year you were may be able to access but did not enroll. The penalty is permanent. Part A has a similar penalty if you delay without coverage. If you have employer coverage, you may have a grace period — ask your employer's benefits office.