The Core Coverage Medicare Provides

Medicare covers hospital stays, doctor visits, lab tests, imaging, and many preventive services at no cost to you once you meet your deductible. Part A (hospital insurance) pays for inpatient hospital care, skilled nursing facilities, hospice, and some home health services. Part B (medical insurance) covers doctor visits, outpatient care, durable medical equipment, and preventive screenings. Part D (prescription drug coverage) pays for medications you take at home, though the amount varies by plan and by which drugs you take.

What you actually pay depends on which parts you have and which plan you chose. Original Medicare (Part A and Part B together) has deductibles, copayments, and coinsurance. Medicare Advantage plans (Part C) bundle hospital and doctor coverage into one plan, often with lower out-of-pocket costs but a narrower network of doctors. The coverage gaps are real and common — Medicare does not cover dental, vision, hearing aids, or long-term care, and you may hit a coverage limit on prescription drugs partway through the year.

Key Takeaways

  • Medicare Part A covers hospital stays and skilled nursing; Part B covers doctor visits and outpatient care; Part D covers prescription drugs — each has its own deductible and cost-sharing rules.
  • Preventive services like cancer screenings, vaccines, and wellness visits are covered at no cost under Part B if you see an in-network provider.
  • Medicare does not cover dental work, vision care, hearing aids, long-term care in a nursing home, or most cosmetic procedures.
  • You may owe money out of pocket for emergency care outside the United States, mental health services beyond a certain number of visits, and some types of rehabilitation.
  • Prescription drug coverage (Part D) has a coverage gap in the middle of the year where you pay more, and the drugs covered vary by plan.

Hospital and Inpatient Care Under Part A

Part A covers a hospital stay from the day you are admitted through discharge, minus a deductible you pay once per benefit period (a benefit period starts when you enter the hospital and ends 60 days after you leave). If you stay longer than 60 days, you owe a daily coinsurance amount. After 90 days, you can use lifetime reserve days — 60 additional days Medicare will pay for, but only once in your lifetime, and you owe a higher coinsurance for each one.

Part A also covers up to 100 days in a skilled nursing facility (a facility that provides medical care, not just room and board) if you were hospitalized for at least three days first. You pay nothing for days 1 through 20, then a daily coinsurance for days 21 through 100. If you need custodial care — help with bathing, dressing, eating — rather than skilled nursing, Medicare stops paying.

Home health services are covered if a doctor orders them, you are homebound, and the care is skilled (wound care, physical therapy, injections). You pay nothing for home health visits themselves, though you may owe coinsurance for equipment. Hospice care is covered if a doctor says you have six months or less to live; you pay a small copayment for drugs and respite care but nothing for the hospice services themselves.

Doctor Visits and Outpatient Services Under Part B

Part B covers office visits with your doctor, specialist visits, emergency room care, urgent care, outpatient surgery, and diagnostic tests like blood work and X-rays. You pay a yearly deductible first, then 20 percent coinsurance for most services (your doctor or the facility bills Medicare, Medicare pays 80 percent, you owe 20 percent). The exception is preventive services — annual wellness visits, cancer screenings, vaccines, and certain other preventive tests — which are covered at no cost if you use an in-network provider.

Mental health services are covered the same way as physical health services under Part B, but there are limits. You can see a psychiatrist, psychologist, or licensed clinical social worker, and Medicare pays 80 percent after your deductible. However, some plans or providers may have restrictions on the number of visits per year or require prior approval from Medicare before you start treatment.

Durable medical equipment — wheelchairs, walkers, oxygen, diabetic supplies, continuous positive airway pressure (CPAP) machines — is covered if a doctor prescribes it. You pay 20 percent coinsurance after your deductible. Some equipment requires Medicare's prior approval before you buy or rent it, so ask your doctor to check with Medicare first.

Prescription Drug Coverage Under Part D

Part D is optional but important: if you do not enroll when you first become may be able to access for Medicare, you may owe a penalty for every month you go without it. Each plan covers a different list of drugs (called a formulary), so the same medication may be covered under one plan but not another. You choose a Part D plan during your initial enrollment period or during the annual open enrollment period in October and November.

Part D has four cost stages. First, you pay a monthly premium and then a deductible (which varies by plan, up to a maximum set by Medicare). Next, you and your plan split the cost of drugs — you pay a copayment or coinsurance, your plan pays the rest. Then, once you and your plan have spent a certain amount together, you enter the coverage gap (also called the "donut hole"), where you pay a higher percentage of drug costs. Finally, once your out-of-pocket spending reaches a yearly limit, catastrophic coverage kicks in and you pay only a small copayment for the rest of the year.

The drugs covered, the copayments, and the coverage gap all vary by plan and change every year. Before you enroll, check whether your current medications are on the plan's formulary and what you will owe for them. If a drug is not covered, you can ask your doctor to request an exception, though Medicare does not always grant one.

What Medicare Does Not Cover

Medicare does not cover dental care — cleanings, fillings, root canals, extractions, dentures — with rare exceptions for dental work done in a hospital as part of another covered procedure. Vision care is not covered: eyeglasses, contact lenses, eye exams for glasses, and most eye surgery are your responsibility. Hearing aids and hearing exams for the purpose of fitting hearing aids are not covered, though some Medicare Advantage plans offer limited hearing benefits.

Long-term care in a nursing home is not covered by Medicare. If you need custodial care — help with daily activities but not skilled medical care — you pay out of pocket or through Medicaid (if you meet income and asset limits). Cosmetic surgery is not covered unless it is reconstructive (for example, after an accident or cancer surgery). Routine foot care, weight loss programs, and most acupuncture are not covered.

Care outside the United States is generally not covered, with limited exceptions for emergency care in Canada or Mexico if you are traveling directly to or from the United States. Experimental treatments and some newer drugs may not be covered until Medicare reviews them. If you travel or live part of the year outside the country, check with your plan about what happens to your coverage.

Medicare Advantage Plans and Extra Coverage

Medicare Advantage (Part C) is an alternative to Original Medicare. Instead of Part A and Part B, you enroll in a private insurance plan that covers hospital and doctor care. Most Medicare Advantage plans include Part D (prescription drugs) and often add benefits Medicare does not cover — dental, vision, hearing, fitness programs, or transportation to medical appointments. However, you are limited to doctors and hospitals in the plan's network, and you may need prior approval from the plan before certain procedures.

If you want coverage for services Medicare does not pay for — dental, vision, hearing — you have two routes. With Original Medicare, you can buy a Medigap (supplemental insurance) plan, which pays some or all of the coinsurance and deductibles Medicare leaves you with, but Medigap does not cover dental, vision, or hearing. With Medicare Advantage, some plans include these benefits, but the coverage is usually limited (for example, a dental benefit might cover one cleaning per year, not a full dental plan).

Coverage Limits and Prior Approval

Some services require Medicare's prior approval before you receive them. Your doctor or hospital usually requests this, but if they do not, you can ask them to. Common services that need prior approval include certain surgeries, some imaging tests, durable medical equipment, and rehabilitation services. If you receive a service without prior approval and Medicare denies it, you may owe the full cost.

Rehabilitation services — physical therapy, occupational therapy, speech therapy — are covered if medically necessary, but there are limits. Medicare covers up to 60 days of inpatient rehabilitation in a hospital or facility. Outpatient rehabilitation is covered, but some plans or providers may limit the number of visits per year. If your doctor says you need more therapy than Medicare covers, you can appeal the decision or pay out of pocket.

If you receive emergency care outside the United States, Medicare covers it only if it was truly an emergency and you were traveling directly to or from the United States. Routine care, planned procedures, and non-emergency care abroad are not covered. Travel insurance or a plan that covers international care can fill this gap if you travel frequently.

How to Find Out What Your Specific Plan Covers

Your coverage depends on which parts of Medicare you have and which plan you chose. If you have Original Medicare (Part A and Part B), you can call Medicare at 1-800-MEDICARE or visit Medicare.gov to see what is covered. If you have a Medicare Advantage plan, call the plan directly or check your plan's website — coverage varies widely by plan, and what one plan covers another may not.

Before you have a procedure or buy equipment, ask your doctor or the provider to check with Medicare or your plan to confirm coverage. This takes a few days but can save you hundreds of dollars. If Medicare or your plan denies coverage, you have the right to appeal. Your doctor can help you file an appeal and provide medical evidence that the service is necessary.

Frequently Asked Questions

Does Medicare cover physical therapy?

Yes, if a doctor orders it and it is medically necessary. Inpatient rehabilitation is covered up to 60 days; outpatient physical therapy is covered, though some plans limit visits per year. Ask your doctor to check with Medicare or your plan before you start to confirm how many visits are covered.

What happens if I need surgery and Medicare says no?

You can appeal Medicare's decision. Your doctor can file an appeal on your behalf and provide medical records showing the surgery is necessary. The appeal process takes time, so ask your doctor to start it as soon as you receive the denial. If the appeal fails, you can pay out of pocket or seek a second opinion.

Does Medicare cover mental health treatment?

Yes, under Part B. You pay 20 percent coinsurance after your deductible for visits with a psychiatrist, psychologist, or licensed clinical social worker. Some plans may limit the number of visits per year or require prior approval, so check with your plan first.

Will Medicare pay for a wheelchair or walker?

Yes, if a doctor prescribes it as medically necessary. You pay 20 percent coinsurance after your deductible. Medicare may require prior approval before you buy or rent the equipment, so ask your doctor to check first.

What if I go to an out-of-network doctor?

With Original Medicare, you can see any doctor who accepts Medicare, regardless of network. With Medicare Advantage, you usually pay more or nothing is covered if you see an out-of-network doctor, except in emergencies. Check your plan's rules before you schedule an appointment.