Medicare covers hospital stays, doctor visits, and prescription drugs, but not everything

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 parts, and each part covers different things. Part A covers hospital care. Part B covers doctor visits and outpatient services. Part D covers prescription drugs. Part C (Medicare Advantage) is an alternative way to get Parts A and B through a private insurance company, usually bundled with Part D.

What Medicare pays for depends on which parts you have and which specific service you need. A colonoscopy is covered. A routine eye exam for glasses is not. A hospital stay for pneumonia is covered. A stay in a nursing home for custodial care is not. Understanding what your specific parts cover before you need care saves you from unexpected bills and helps you plan for out-of-pocket costs.

Key Takeaways

  • Medicare Part A covers inpatient hospital care, skilled nursing facility stays after hospitalization, hospice, and some home health care.
  • Medicare Part B covers doctor office visits, preventive care, outpatient surgery, lab tests, and medical equipment like wheelchairs and oxygen.
  • Medicare Part D covers prescription medications, and you choose a plan during the annual enrollment period or when you first turn 65.
  • Medicare does not cover dental care, vision care, hearing aids, long-term custodial care in nursing homes, or most cosmetic procedures.
  • You pay premiums, deductibles, and copayments depending on which parts you have and which services you use.

What Medicare Part A covers

Part A covers inpatient hospital stays — meaning you are admitted to the hospital and stay overnight. It pays for your room, meals, nursing care, and most hospital services. It also covers the first 100 days of skilled nursing facility care after a hospital stay of at least three days, though you pay a daily copayment after day 20. Skilled nursing means you need daily nursing or rehabilitation services, not just help with daily activities.

Part A also covers hospice care if you have a terminal illness and choose comfort care instead of treatment, and some home health services when ordered by your doctor and provided by a Medicare-approved agency. Home health is free under Part A if you meet the criteria — you must be homebound, under a doctor's care, and need skilled nursing or therapy services.

Part A has a deductible you pay once per benefit period (the hospital stay plus 60 days after discharge). In 2024, that deductible is $1,632, though this amount changes each year. After you pay the deductible, Part A covers most hospital costs for the first 60 days. Days 61 through 90 require a daily copayment. Beyond 90 days, you pay the full cost unless you use lifetime reserve days, which are limited.

What Medicare Part B covers

Part B covers doctor office visits, whether your doctor is in a hospital, clinic, or private practice. It pays for preventive care visits and screenings — annual wellness exams, mammograms, colonoscopies, blood pressure checks, and diabetes screenings are covered at no cost to you if your doctor accepts Medicare. It covers lab tests and imaging like X-rays and ultrasounds when medically necessary.

Part B also covers outpatient surgery, emergency room visits, and urgent care. It pays for durable medical equipment — wheelchairs, walkers, oxygen equipment, diabetic supplies, and similar items — when your doctor prescribes them. It covers mental health services, including therapy and psychiatric visits. Physical therapy and occupational therapy are covered when ordered by your doctor for a medical condition.

Part B has a monthly premium (in 2024, the standard premium is $164.90 per month, though higher earners pay more). You also pay an annual deductible (in 2024, $240). After you meet the deductible, you typically pay 20% of the cost for most services, and Medicare pays 80%. For some preventive services, you pay nothing after the deductible is met.

What Medicare Part D covers

Part D is prescription drug coverage. You choose a Part D plan during the annual enrollment period (October 15 to December 7 each year) or when you first turn 65. Different plans cover different drugs at different costs, so comparing plans before you enroll matters. Each plan has a formulary — a list of drugs it covers — and you can search your medications on Medicare.gov to see which plans cover them.

Part D plans have a monthly premium, an annual deductible (which varies by plan), and copayments or coinsurance for each prescription. Once you and Medicare together spend a certain amount on drugs in a calendar year, you enter the "donut hole" — a coverage gap where you pay a higher percentage of drug costs. After you spend enough out of pocket to reach the catastrophic coverage threshold, Medicare covers most of your drug costs for the rest of the year.

If you do not enroll in Part D when you first turn 65 and you do not have other creditable drug coverage, you pay a late enrollment penalty if you sign up later. The penalty is about 1% of the national average Part D premium for each month you were not covered, and it is added to your premium permanently.

What Medicare does not cover

Medicare does not cover dental care — cleanings, fillings, extractions, dentures, and root canals are your responsibility. It does not cover routine vision care or eyeglasses, though it does cover one pair of glasses or contact lenses after cataract surgery. Hearing aids and hearing exams are not covered, though some Medicare Advantage plans offer limited hearing benefits.

Medicare does not cover long-term custodial care in a nursing home or assisted living facility. If you need help with daily activities like bathing, dressing, or eating but do not need skilled medical care, Medicare does not pay. This is one of the largest gaps in Medicare coverage and is why many people buy long-term care insurance or plan to pay out of pocket.

Medicare does not cover most cosmetic procedures, weight loss surgery, acupuncture (with rare exceptions), or routine foot care. It does not cover most over-the-counter medications or supplements. It does not cover travel outside the United States, except in limited circumstances in Canada and Mexico.

How much you pay out of pocket

Your out-of-pocket costs depend on which parts you have and which services you use. If you have Original Medicare (Parts A and B), you pay premiums, deductibles, and copayments or coinsurance. Part A has an annual deductible per benefit period. Part B has an annual deductible and then you pay 20% coinsurance for most services. Part D has a monthly premium, annual deductible, and copayments that vary by plan and change as you move through the coverage phases.

Many people buy a Medigap policy (supplemental insurance) to cover some of the costs Medicare does not pay, such as copayments and coinsurance. Medigap premiums are separate from Medicare premiums. Others choose Medicare Advantage (Part C), which is an all-in-one alternative to Original Medicare offered by private insurance companies. Medicare Advantage plans usually have lower or no premiums than Original Medicare, but they have different copayments, deductibles, and networks of doctors.

There is no annual limit on what you pay out of pocket under Original Medicare, which is why some people buy Medigap. Medicare Advantage plans do have annual out-of-pocket maximums, meaning once you reach that limit, the plan pays 100% of covered services for the rest of the year.

Preventive services covered at no cost

Medicare Part B covers certain preventive services with no copayment or coinsurance after you meet your deductible — or with no deductible at all for some services. These include an annual wellness visit, mammograms, colonoscopies, blood pressure screening, diabetes screening, cholesterol screening, bone density testing, and depression screening. Flu shots, pneumonia shots, and shingles shots are also covered at no cost.

The exact services covered and how often you can have them change, so ask your doctor which preventive services are right for you and whether Medicare covers them. Your doctor's office can also check your coverage before your visit. Taking advantage of these free preventive services can catch health problems early when they are easier and less expensive to treat.

When to contact Medicare or your doctor

Contact Medicare if you have questions about what a specific service costs, whether a procedure is covered, or if you receive a bill you think Medicare should have paid. You can call 1-800-MEDICARE (1-800-633-4227), visit Medicare.gov, or use the Medicare app. Have your Medicare card handy when you call.

Ask your doctor's office before any procedure or test whether it is covered by your Medicare plan and what you will pay. If your doctor recommends a service that Medicare does not cover, ask whether there is a covered alternative or whether you can pay out of pocket. Some doctors will give you a notice in advance if they think Medicare will not pay, so you can decide whether to proceed and pay yourself.

Frequently Asked Questions

Does Medicare cover physical therapy?

Yes, Part B covers physical therapy and occupational therapy when your doctor orders them for a medical condition. You pay your Part B copayment (usually 20% after the deductible). Medicare limits the number of visits per year, though your doctor can request more if medically necessary.

What happens if I do not have Part D and need prescription drugs?

You pay the full cost of prescriptions out of pocket. If you enroll in Part D later, you will pay a late enrollment penalty added to your premium permanently. You can enroll during the annual enrollment period or if you have a may have access to life event like losing other drug coverage.

Does Medicare cover glasses after cataract surgery?

Yes, Part B covers one pair of eyeglasses or contact lenses after cataract surgery. Routine eye exams for glasses and contact lenses for other reasons are not covered. Some Medicare Advantage plans offer additional vision benefits.

Will Medicare pay for a nursing home?

Medicare covers the first 100 days of skilled nursing facility care after a hospital stay of at least three days, but only if you need skilled medical care or rehabilitation, not just help with daily activities. Long-term custodial care is not covered. Medicaid may cover nursing home costs if you meet income and asset limits.

Can I see any doctor with Medicare?

With Original Medicare (Parts A and B), you can see any doctor who accepts Medicare. With Medicare Advantage, you must use doctors in the plan's network, except in emergencies. Check your plan documents or call your plan to confirm a doctor is in network before scheduling.