Medicare covers hospital stays, doctor visits, and some preventive care, but not everything

Medicare is federal health insurance for people 65 and older, and it pays for a wide range of medical services — but the word "covers" can be misleading. Medicare Part A pays for inpatient hospital care, skilled nursing facilities, and hospice. Part B pays for doctor visits, outpatient services, and some equipment. Part D covers prescription drugs. But Medicare does not pay for dental work, vision care, hearing aids, or long-term custodial care in a nursing home. You pay a share of most services through deductibles, copays, and coinsurance.

What Medicare pays depends on which parts you have, which type of service you need, and whether you see a provider who accepts Medicare. A service that Medicare covers in full under one circumstance might require you to pay under another. Understanding what falls under each part, and what you owe, prevents surprises at the doctor's office or pharmacy.

Key Takeaways

  • Medicare Part A covers hospital inpatient care and skilled nursing; Part B covers doctor visits and outpatient care; Part D covers prescription drugs; Part C (Medicare Advantage) combines all three but often has different rules and networks.
  • Medicare does not cover dental, vision, hearing aids, or long-term nursing home care, though some Medicare Advantage plans offer limited dental or vision benefits.
  • You pay a deductible before Medicare starts paying, and then you share the cost through copays or coinsurance for most services.
  • Preventive services like annual wellness visits, cancer screenings, and vaccines are covered at no cost to you when you see a participating provider.
  • If you see a provider who does not accept Medicare, you may pay the full bill and receive no reimbursement.

What Part A covers: Hospital and skilled nursing care

Part A covers inpatient hospital stays, including room, meals, and standard nursing care. It also covers care in a skilled nursing facility (not a regular nursing home) if you are admitted directly from a hospital stay of at least three days and need daily skilled care — such as wound care or physical therapy — not just help with daily living. Part A covers up to 100 days in a skilled nursing facility per benefit period, though you pay coinsurance after day 20.

Part A also covers hospice care if you have a terminal illness and your doctor certifies you have six months or less to live. Home health care is covered under Part A if you are homebound, under a doctor's care, and need skilled nursing or therapy — not just help with housework or personal care.

You pay a deductible for each hospital stay ($1,632 in 2024, though this amount changes yearly). After that, Medicare pays the full cost for days 1 through 60. Days 61 through 90 require a daily coinsurance payment from you. Beyond 90 days, you can use lifetime reserve days, but those also require coinsurance and are limited.

What Part B covers: Doctor visits and outpatient services

Part B covers visits to doctors, specialists, and other providers who accept Medicare. It pays for office visits, emergency room care, outpatient surgery, diagnostic tests like X-rays and blood work, and durable medical equipment such as wheelchairs, walkers, and oxygen. Part B also covers mental health services, including therapy and psychiatric visits, at the same rate as physical health visits.

Preventive services covered at no cost include an annual wellness visit, cancer screenings (mammogram, colonoscopy, Pap test), bone density scans, cardiovascular screening, diabetes screening, and vaccines like flu, pneumonia, and shingles. You pay nothing for these when you see a participating provider, even before you meet your deductible.

For other Part B services, you pay an annual deductible ($240 in 2024) and then 20 percent coinsurance after that. Your provider bills Medicare first, and Medicare pays its share; you owe the coinsurance. If your provider does not accept Medicare assignment, you may owe more.

What Part D covers: Prescription drugs

Part D is prescription drug coverage offered by private insurance companies approved by Medicare. It covers most prescription medications, but not all — some drugs require prior approval from your plan, and some may not be covered at all. Each plan has a formulary, which is the list of drugs it covers, and you can view your plan's formulary on its website or by calling the plan.

You pay a monthly premium for Part D, a yearly deductible (which varies by plan), and then a copay or coinsurance for each prescription. The amount you pay depends on which "tier" the drug is on — generic drugs usually cost less than brand-name drugs. Once you and your plan spend a combined total on drugs, you enter the "coverage gap" (sometimes called the "donut hole"), where you pay a higher percentage until you reach catastrophic coverage, at which point Medicare pays most of the cost.

If you do not sign up for Part D when you first become may be able to access, you may pay a penalty if you join later, unless you have other creditable drug coverage.

What Medicare does not cover

Dental care is not covered by Original Medicare (Parts A and B). This includes cleanings, fillings, root canals, extractions, dentures, and bridges. Some Medicare Advantage plans offer limited dental benefits, but they are usually capped at a low annual amount.

Vision care is not covered by Original Medicare. This includes eye exams for glasses or contacts, eyeglasses, and contact lenses. Medicare does cover treatment for eye diseases like glaucoma or macular degeneration, but not routine vision correction. Some Medicare Advantage plans include limited vision benefits.

Hearing aids are not covered by Medicare, though hearing exams are covered under Part B if medically necessary. Some Medicare Advantage plans offer a small hearing aid benefit, but coverage is usually limited.

Long-term custodial care in a nursing home is not covered by Medicare. Medicare covers skilled nursing care for a limited time after a hospital stay, but not ongoing help with bathing, dressing, eating, or other daily living tasks. Medicaid may cover nursing home care if you meet income and asset limits, but that is a separate program.

Other services not covered include cosmetic surgery, weight loss programs, acupuncture (with rare exceptions), and most over-the-counter medications.

How much you pay: Deductibles, copays, and coinsurance

Medicare is not free. You pay monthly premiums for Part B and Part D, and you share the cost of most services. Part A has no monthly premium if you or your spouse paid Medicare taxes for at least 10 years, but you pay a deductible for each hospital stay.

For Part B, you pay a monthly premium (the standard amount is $164.90 in 2024, but higher earners pay more), an annual deductible, and then 20 percent coinsurance for most services. For Part D, you pay a monthly premium that varies by plan, a yearly deductible, and copays or coinsurance per prescription.

If you have a low income, you may may have access to for programs that help pay your premiums and cost-sharing. These include the may have access to Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the may have access to Individual (QI) program. Your state Medicaid office can tell you whether you may have access to.

Medicare Advantage and Medigap: Different ways to cover gaps

Original Medicare (Parts A and B) leaves gaps in coverage. Two common ways to fill those gaps are Medicare Advantage (Part C) and Medigap (supplemental insurance).

Medicare Advantage is an alternative to Original Medicare offered by private insurance companies. It includes Parts A, B, and usually D in one plan, but it typically has a network of doctors and hospitals you must use (except in emergencies). Many Medicare Advantage plans cover dental, vision, and hearing benefits that Original Medicare does not. However, you usually pay copays for each visit, and you may need prior approval for some services. If you see an out-of-network provider, you may pay the full cost.

Medigap is supplemental insurance sold by private companies that works alongside Original Medicare. It helps pay the deductibles, copays, and coinsurance that Medicare does not cover. Medigap does not cover services that Medicare does not cover — such as dental or vision — but it reduces your out-of-pocket costs for the services Medicare does cover. You pay a monthly premium for Medigap in addition to your Medicare premiums.

How to find out what your specific plan covers

The easiest way to know what your plan covers is to check your plan documents or call your plan directly. If you have Original Medicare, you can view your coverage at Medicare.gov or call 1-800-MEDICARE. If you have Medicare Advantage or Medigap, call the insurance company that sold you the plan — the phone number is on your insurance card.

Before you have a service, ask your doctor's office whether Medicare (or your specific plan) covers it. Many offices can tell you on the spot whether a service is covered and what you will owe. If you are unsure, you can also call Medicare at 1-800-MEDICARE and describe the service; they can tell you whether it is covered under your plan type.

Keep your insurance card with you at all times, and bring it to every doctor visit. Providers use the information on your card to bill Medicare correctly.

Frequently Asked Questions

Does Medicare cover my annual doctor visit?

Yes. Part B covers an annual wellness visit at no cost to you when you see a participating provider. This visit includes a health assessment and a plan to prevent disease. Regular office visits for illness or injury are also covered under Part B, though you pay 20 percent coinsurance after you meet your deductible.

Does Medicare cover physical therapy?

Yes, under Part B. Physical therapy is covered when ordered by your doctor for a medical condition. You pay 20 percent coinsurance after your deductible. Some Medicare Advantage plans may have different copays or require prior approval. Check your plan documents or call your plan to confirm.

Will Medicare pay if I see a doctor who does not accept Medicare?

No. If a provider does not accept Medicare, Medicare will not pay, and you will owe the full bill. Before scheduling an appointment, ask the office whether they accept Medicare. You can also search for Medicare-participating providers at Medicare.gov.

Does Medicare cover over-the-counter medications?

No. Part D covers prescription medications only. Over-the-counter drugs like pain relievers, cold medicine, and antacids are not covered by Medicare, though you can buy them yourself at any pharmacy.

What happens if I cannot afford my Medicare costs?

If you have a low income, you may may have access to for programs that help pay your premiums and cost-sharing. Contact your state Medicaid office or call 1-800-MEDICARE to learn about the may have access to Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, or other information programs in your state.