Medicare covers hospital stays, doctor visits, and some medical equipment, but not everything

Medicare is divided into four parts, and each one covers different things. Part A pays for inpatient hospital care, skilled nursing facilities, hospice, and some home health services. Part B covers doctor visits, outpatient care, lab tests, and preventive screenings. Part D covers prescription drugs. Part C (Medicare Advantage) is an alternative to Parts A and B offered by private insurers, and the coverage varies by plan.

What Medicare does not cover is just as important to know. It does not pay for routine dental work, eyeglasses, hearing aids, long-term custodial care in a nursing home, or most physical therapy beyond a limited number of visits. Understanding these boundaries helps you plan for out-of-pocket costs and decide whether you need supplemental coverage.

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 will pay out-of-pocket for these unless you buy supplemental coverage.
  • You pay a deductible before Medicare starts paying, and you share the cost of most services through copayments or coinsurance.
  • Preventive services like annual wellness visits, cancer screenings, and vaccinations are covered at no cost to you when you use an in-network provider.
  • Medicare Advantage plans (Part C) may cover some services Original Medicare does not, but you must use their network of doctors and hospitals.

What Part A covers: Hospital and skilled nursing care

Part A pays for inpatient hospital stays after you meet your deductible. In 2024, the Part A deductible is $1,632 per benefit period (the amount varies year to year). Once you have paid it, Medicare covers all approved hospital charges for the first 60 days of a stay. After 60 days, you begin to share the cost through daily coinsurance amounts.

Part A also covers up to 100 days in a skilled nursing facility if you are admitted directly from a hospital stay of at least three days. You pay nothing for the first 20 days, and then a daily coinsurance amount for days 21 through 100. Skilled nursing means you need daily nursing or rehabilitation services — not just help with daily living tasks.

Hospice care is covered under Part A when a doctor certifies that you have a terminal illness and have chosen comfort care over curative treatment. Part A also covers some home health services, such as part-time nursing care or physical therapy, when ordered by your doctor and provided by a Medicare-certified agency.

What Part B covers: Doctor visits, outpatient care, and preventive services

Part B covers visits to your doctor, specialist appointments, outpatient surgery, emergency room visits, and diagnostic tests like X-rays and blood work. You pay a monthly premium for Part B (the standard amount in 2024 is $164.90, but it varies based on your income). After you meet your annual deductible ($240 in 2024), Medicare typically pays 80 percent of the approved amount, and you pay 20 percent as coinsurance.

Preventive services are covered at no cost when you see an in-network provider. These include an annual wellness visit, cancer screenings (mammogram, colonoscopy, Pap test), cardiovascular screenings, diabetes screenings, bone density tests, and vaccinations such as the flu shot, pneumonia vaccine, and shingles vaccine. You do not pay a copay or coinsurance for these services, even before you meet your deductible.

Part B also covers durable medical equipment such as wheelchairs, walkers, oxygen equipment, and diabetic supplies, though you typically pay 20 percent coinsurance after your deductible. Mental health services, including therapy and psychiatric visits, are covered at the same rate as other doctor visits.

What Part D covers: Prescription drugs

Part D is prescription drug coverage offered by private insurers approved by Medicare. You must enroll in a Part D plan during your initial enrollment period or during the annual open enrollment period (October 15 to December 7 each year). If you do not enroll when you are first may be able to access and do not have other creditable drug coverage, you may pay a late enrollment penalty for as long as you have Part D.

Part D plans vary in which drugs they cover and how much you pay. Each plan has a formulary — a list of covered medications — and drugs are placed in tiers with different copay amounts. You typically pay a monthly premium, a yearly deductible (which varies by plan), and then a copay or coinsurance for each prescription. Once your total out-of-pocket spending reaches a certain amount (called the catastrophic threshold), Medicare pays most of the cost for the rest of the year.

Not all drugs are covered by all plans. If your doctor prescribes a drug that is not on your plan's formulary, you can ask your doctor to prescribe an alternative, or you can request an exception from your plan. Some plans require prior authorization before they will pay for certain medications.

What Medicare does not cover

Dental care is not covered by Original Medicare. This includes cleanings, fillings, root canals, dentures, and tooth extractions. Some Medicare Advantage plans offer limited dental coverage, but you will typically pay out-of-pocket or buy a separate dental plan.

Vision care is not covered, including routine eye exams, eyeglasses, and contact lenses. Medicare does cover cataract surgery and some other eye conditions that are medical problems rather than refractive errors. Some Medicare Advantage plans include vision coverage.

Hearing aids are not covered by Original Medicare, though the cost can be high — hearing aids often range from $1,000 to $6,000 per pair. Some Medicare Advantage plans offer hearing aid coverage. Medicare does cover diagnostic hearing tests if your doctor orders them for a medical reason.

Long-term custodial care in a nursing home is not covered. Medicare covers skilled nursing care for a limited time after a hospital stay, but if you need ongoing help with daily living tasks (bathing, dressing, eating) without a medical need for skilled care, Medicare does not pay. Medicaid may cover long-term nursing home care if you meet income and asset limits, but that is a separate program.

Routine physical therapy beyond a certain number of visits is not covered. Medicare limits coverage to situations where therapy is medically necessary and ordered by your doctor. Once you reach the limit, you pay out-of-pocket.

Other services not covered include cosmetic surgery, weight loss programs, most acupuncture, routine foot care (unless you have diabetes), and most over-the-counter medications.

How cost-sharing works: Deductibles, copays, and coinsurance

Medicare requires you to share the cost of most services. A deductible is the amount you must pay out-of-pocket before Medicare starts paying. Part A and Part B each have their own deductible. A copay is a fixed dollar amount you pay for a specific service — for example, $25 for a doctor visit. Coinsurance is a percentage of the cost you pay after you meet your deductible — for example, 20 percent of the approved amount for a lab test.

These costs add up, which is why many people buy supplemental coverage (also called Medigap). A Medigap policy is sold by private insurers and helps pay the deductibles, copays, and coinsurance that Original Medicare does not cover. There are ten standardized Medigap plans, labeled A through N, and each covers a different combination of costs. Medigap is separate from Medicare Advantage.

If you choose Medicare Advantage (Part C) instead of Original Medicare, you typically pay lower or no premiums, but you must use doctors and hospitals in the plan's network. Your copays and coinsurance may be different from Original Medicare, and you may have an out-of-pocket maximum — a cap on how much you pay in a year.

Preventive services covered at no cost

Medicare covers a range of preventive services at no cost to you when you use an in-network provider and have no copay or coinsurance. These services are designed to catch health problems early, when they are easier and less expensive to treat.

Screenings include mammograms for breast cancer, colonoscopies for colorectal cancer, Pap tests for cervical cancer, and low-dose CT scans for lung cancer if you are a current or former smoker. Cardiovascular screenings include blood pressure checks, cholesterol tests, and EKGs. Diabetes screenings are covered if you have risk factors. Bone density tests (DEXA scans) are covered for women over 65 and men over 70.

Vaccinations covered at no cost include the annual flu shot, pneumonia vaccines (Pneumovax and Prevnar), the shingles vaccine (Shingrix), and the RSV vaccine for adults 60 and older. An annual wellness visit is also covered, during which your doctor reviews your health history, takes your vital signs, and discusses preventive care with you.

Frequently Asked Questions

Does Medicare cover physical therapy?

Medicare covers medically necessary physical therapy ordered by your doctor, but only for a limited number of visits per year. Once you reach the limit, you pay out-of-pocket. If your doctor believes you need more visits, you can request an exception, and Medicare may approve additional sessions if they are medically justified.

Will Medicare pay for my medications if I cannot afford them?

Part D covers prescription drugs, and once your out-of-pocket spending reaches the catastrophic threshold, Medicare pays most of the cost for the rest of the year. If you struggle to pay for medications, talk to your doctor about generic alternatives or ask your Part D plan about patient information programs offered by drug manufacturers.

Does Medicare cover home care if I need help at home?

Medicare covers skilled home health services — such as nursing care, physical therapy, or occupational therapy — ordered by your doctor and provided by a Medicare-certified agency. It does not cover non-medical help with daily tasks like cleaning, cooking, or bathing unless those tasks are part of a skilled service. Medicaid or private pay options may cover custodial home care.

What happens if I need care that Medicare does not cover?

You pay out-of-pocket, or you can look into supplemental coverage. Medigap policies help cover costs that Original Medicare does not. Medicare Advantage plans may cover some services that Original Medicare does not, such as dental or vision care, though coverage varies by plan. Medicaid may also help if you have low income and assets.

Are there limits on how much Medicare will pay?

Medicare Advantage plans have an out-of-pocket maximum — a yearly cap on what you pay. Original Medicare does not have an out-of-pocket maximum, which is why many people buy Medigap coverage. With Medigap, your costs are more predictable because the supplemental plan covers most of what Original Medicare does not.