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 insurance companies, and coverage varies by plan.
What Medicare does not cover is just as important to know. It does not cover routine dental work, vision exams, hearing aids, long-term custodial care in a nursing home, or most prescription drugs unless you have Part D. Many seniors find they need a supplemental policy (called Medigap) to cover the gaps that Medicare leaves behind.
The amount you pay out of pocket depends on which parts you have, which plan you chose, and whether you have reached your deductible or out-of-pocket maximum for the year. Costs reset on January 1 each year.
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 many seniors buy Medigap policies to fill these gaps.
- Your out-of-pocket costs depend on your deductible, copayments, and coinsurance amounts, which vary by plan and reset each January.
- Preventive services like cancer screenings, vaccines, and wellness visits are covered at no cost when you use an in-network provider.
- If you have a Medicare Advantage plan (Part C), coverage rules are different from Original Medicare and depend on your specific plan.
What Part A Covers
Part A covers inpatient hospital stays, including semiprivate rooms, meals, and standard nursing care. It also covers up to 100 days in a skilled nursing facility after a hospital stay of at least three days, though you pay coinsurance after day 20. Hospice care for terminally ill patients is covered under Part A as well.
Part A does not cover private duty nursing, a private hospital room (unless medically necessary), or custodial care — the help with bathing, dressing, and eating that many seniors need in a nursing home. If you stay in a nursing home longer than 100 days, you pay the full cost yourself.
What Part B Covers
Part B covers doctor visits, whether in an office or hospital outpatient department. It covers diagnostic tests like blood work and imaging, mental health counseling, physical therapy, and durable medical equipment such as wheelchairs and oxygen. It also covers some preventive services at no cost, including annual wellness visits, cancer screenings (mammogram, colonoscopy, Pap smear), bone density scans, and vaccines.
Part B does not cover routine eye exams, eyeglasses, hearing tests, or hearing aids. It does not cover routine dental cleanings or dentures. It does not cover most over-the-counter medications. You pay a monthly premium for Part B, a yearly deductible, and then 20 percent coinsurance for most services after you meet the deductible.
What Part D Covers
Part D is prescription drug coverage offered by private insurance companies approved by Medicare. Each plan has a different list of covered drugs (called a formulary), and the drugs are sorted into tiers with different copayment amounts. You choose a Part D plan during the annual enrollment period, which runs from October 15 to December 7 each year.
Part D does not cover all drugs — your plan's formulary determines what is covered. If your doctor prescribes a drug not on your plan's list, you can ask your doctor to prescribe an alternative, or you can request an exception from your insurance company. Part D coverage has a coverage gap (sometimes called the "donut hole") where you pay more out of pocket once you reach a certain spending threshold, though this gap has been shrinking in recent years.
What Medicare Advantage (Part C) Covers Differently
Medicare Advantage plans are offered by private insurance companies and cover everything Original Medicare (Parts A and B) covers, plus usually prescription drugs and some extras like dental or vision. However, the copayments, coinsurance, and deductibles are set by the insurance company, not by Medicare, so they vary widely from plan to plan.
Most Medicare Advantage plans require you to use doctors and hospitals in their network. If you see an out-of-network provider, you may pay more or the visit may not be covered at all. Some plans require referrals from your primary care doctor before you see a specialist. These rules are spelled out in your plan's Summary of Benefits and Coverage, which you receive when you enroll.
Gaps Medicare Does Not Cover
Medicare does not cover long-term custodial care — the ongoing help with daily living that many seniors need as they age. This includes nursing home care beyond 100 days, assisted living, and in-home aides for bathing and dressing. Some seniors buy long-term care insurance to cover these costs, though premiums can be high and policies have strict rules about when benefits begin.
Medicare also does not cover routine dental work, vision exams, eyeglasses, hearing aids, or most over-the-counter medications. It does not cover travel outside the United States (except in limited circumstances in Canada and Mexico). Many seniors buy a Medigap policy to cover some of these gaps, particularly the coinsurance and copayments that Original Medicare leaves behind.
How Medigap Policies Fill the Gaps
Medigap policies are sold by private insurance companies and are designed to cover costs that Original Medicare does not — mainly copayments, coinsurance, and deductibles. There are ten standardized Medigap plans, labeled A through N, and each covers a different combination of gaps. Plan G, for example, covers your Part B deductible and 20 percent coinsurance, while Plan N covers most coinsurance but not your Part B deductible.
Medigap policies do not cover dental, vision, hearing aids, or long-term care. They also do not work with Medicare Advantage plans — if you have a Medicare Advantage plan, you cannot buy a Medigap policy. The best time to buy Medigap is within six months of turning 65 and enrolling in Part B, because insurance companies must accept you without medical underwriting during this window.
Preventive Services Covered at No Cost
Medicare Part B covers many preventive services at no cost when you use a provider who accepts Medicare. These include an annual wellness visit with your primary care doctor, blood pressure screening, cholesterol screening, diabetes screening, colorectal cancer screening (colonoscopy or other methods), breast cancer screening (mammogram), cervical cancer screening (Pap smear), bone density screening, and vaccines including flu, pneumonia, and shingles.
The key word is "preventive" — these are services meant to catch disease early, not to treat disease you already have. If your doctor finds something during a preventive visit and you need follow-up testing or treatment, that follow-up may not be free. Ask your doctor ahead of time whether a test is preventive or diagnostic, because the cost to you is different.
Frequently Asked Questions
Does Medicare cover my prescription medications?
Only if you have Part D prescription drug coverage. Part D is optional and is sold by private insurance companies. Each plan covers a different list of drugs, so you need to check whether your specific medications are covered before you enroll. You can change your Part D plan once a year during the annual enrollment period.
Will Medicare pay for my hearing aids?
No. Medicare does not cover hearing aids, hearing tests, or fitting services. Some Medigap plans and Medicare Advantage plans may offer limited hearing benefits, but Original Medicare does not. You pay the full cost of hearing aids yourself, which typically ranges from a few hundred to several thousand dollars per pair.
Does Medicare cover dental work?
No. Original Medicare does not cover routine dental cleanings, fillings, extractions, dentures, or root canals. Some Medicare Advantage plans include dental benefits, but they are usually limited to cleanings and exams. You can buy a standalone dental plan, but it is separate from Medicare and has its own premiums and coverage rules.
What happens if I need care outside the United States?
Original Medicare does not cover care outside the United States, except in limited circumstances in Canada and Mexico near the U.S. border. If you travel internationally, you may want to buy a travel health insurance policy for the duration of your trip. Some Medicare Advantage plans offer limited emergency coverage abroad, so check your plan documents.
Does Medicare cover physical therapy?
Yes, Part B covers physical therapy when it is ordered by your doctor for a medical condition. You pay 20 percent coinsurance after you meet your yearly deductible. However, Medicare limits the number of visits or the amount it will pay in a calendar year, depending on the type of therapy and your condition. Your doctor or therapist can tell you whether you have reached your limit.