What does Medicare cover (and not cover)?

Generally, Medicare Part A (also known as hospital insurance) can cover inpatient hospital care, nursing facility care, nursing home care, hospice care and home healthcare.¹

Medicare Part B (also known as medical insurance) offers coverage for medically necessary and preventive care services. Medically necessary services diagnose and treat health problems. It can include Durable Medical Equipment (DME), mental healthcare or ambulance services.² Preventive care services are health treatments that prevent illness or detect problems at an early stage, like flu shots or cancer screenings.³

There are some things Original Medicare won’t cover. Generally, most vision, dental and hearing services are not covered by Medicare Parts A and B. Other services not covered by Medicare Parts A and B include:⁴

• Routine physical exams
• Cosmetic surgery
• Long-term care
• Dentures

Medicare Part C is also known as Medicare Advantage. Medicare Advantage plans are provided by private companies with approval from Medicare. These plans include all your Part A and Part B coverage and often provide extra coverage for services not included in Original Medicare. Medicare Advantage plans may offer coverage for vision, hearing, dental and wellness services. Many Medicare Advantage plans also provide prescription drug coverage (also known as Part D).⁵

Original Medicare does not include coverage for prescription drugs, but you can buy a stand-alone prescription drug plan to help manage your drug costs. Prescription drug plans—called Medicare Part D—are only available through private companies like Humana. Premiums and the list of covered drugs—called a formulary—will vary by plan.⁶

Many Medicare Advantage plans include prescription drug coverage, in addition to all the benefits provided by Original Medicare Part A and Part B. Many offer affordable or even $0 monthly plan premiums, but you must continue to pay the Medicare Part B premium.

An important note: If you want coverage for prescription drugs, you must sign up as soon as you’re eligible, unless you have what’s called “creditable” prescription drug coverage elsewhere. For example, if you’re still working and covered by your employer or your spouse’s employer sponsored health coverage, you may be able to wait.

Does Medicare cover nursing homes and long-term care facilities?

Original Medicare generally doesn’t cover the cost of a nursing home, assisted living or long-term care facility. Medicare Part A does cover care provided in a skilled nursing facility with certain conditions and time limitations.

If you qualify for it, Medicaid, which is administered by states under federal guidelines, may cover nursing home care. You may need to exhaust your personal resources on medical care before you are eligible.

Does Medicare cover hearing care?

Medicare Part B may cover diagnostic hearing and balance exams—tests your doctor requires if you need medical treatment. However, Medicare doesn’t cover routine hearing exams, hearing aids or fittings.⁷

Many Medicare Advantage plans, however, do include coverage for routine dental, vision and hearing care, including glasses and hearing aids.

Does Medicare cover hospice?

Medicare covers hospice care if the following conditions are met:

1. Your doctor certifies that you are terminally ill, meaning that your life expectancy is 6 months or less.
2. You consent to receiving palliative care to make you comfortable versus care to try to cure your illness.
3. You sign a consent form to receive hospice care instead of other Medicare-covered treatments for your terminal condition.⁸

Does Medicare cover home health?

Medicare does help cover some in-home health services, including:

1. Skilled nursing care
2. Physical therapy
3. Speech pathology
4. Occupational therapy

To be eligible, you must be under the care of a doctor and treated under a plan of care that is monitored and reviewed by your doctor. Also, your doctor will need to certify that you need certain eligible in-home services.

Medicare will not pay for 24-hour in-home care or meals delivered to you at home. It also doesn’t cover help for what’s called “activities of daily living,” like bathing, getting dressed, using the toilet, eating or moving from place to place within your home.⁹

Does Medicare cover medical devices?

Medicare Part B (medical insurance) helps cover the cost of medically necessary durable medical equipment if your doctor prescribes it for use in your home. Your copays and deductibles will still apply.

There is a long list of items covered, including:

1. Crutches
2. Walkers
3. Wheelchairs
4. Blood sugar monitors and test strips
5. Commode chairs
6. Infusion pumps and supplies
7. Oxygen equipment and supplies
8. Continuous Glucose Monitors (CGMs)—examples include Dexcom and Libre
9. Insulin pumps and supplies

Before renting or purchasing any medical equipment, be sure to ask if the retailer or supplier participates in Medicare. Medicare will only provide coverage through suppliers who participate in the Medicare program.¹⁰

Does Medicare cover elective procedures?

Services that are not considered medically necessary are generally not covered by Medicare Part A or Part B. For example, breast augmentation for cosmetic reasons isn’t covered by Medicare, but reconstructive surgery after a mastectomy is covered.¹¹

Medicare won’t cover Lasik surgery just to avoid the need for glasses. But treatment for chronic eye conditions like cataracts or glaucoma may be covered if your doctor considers it to be medically necessary.

Always err on the side of caution! Confirm your coverage before you commit to a procedure you’re unsure about.

Does Medicare cover pre-existing conditions?

Original Medicare generally covers most pre-existing conditions. For some conditions, such as end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), you could be eligible for Medicare before you turn 65.

Know your options. Do your homework. Take some time to understand your Medicare plan.

Remember that Medicare Advantage plans are required by law to offer all the benefits of Original Medicare, but most plans offer much more.

Knowing which types of common medical costs are not covered will be helpful when planning for your out-of-pocket medical costs.