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What Medicare Does and Does Not Cover

What is Medicare?

When it comes to healthcare, it’s important to know what is covered and what isn’t. Because there are so many different plans for Medicare, it can be confusing to know which plan will give you the right coverage. Fortunately, there are some tools that can make it easier for you.

Medicare is the insurance plan offered by the federal government for people aged 65 and over, as well as people with disabilities, and people who have permanent kidney failure.

There are four parts to the Medicare plan: A, B, C, and D. Each part covers different aspects of healthcare. You can enroll in one or more parts of Medicare, but the most common parts people enroll in are Parts A and B, as these cover the majority of services. People usually have to pay a monthly premium, but this varies widely based on income.

Medicare Part A

Medicare Part A, also called “original Medicare,” is the insurance plan that covers hospital stays and services. It also covers stays in skilled nursing facilities, walkers and wheelchairs, and hospice care. It even covers home healthcare services if you’re unable to get to a hospital or skilled nursing facility. If you need a blood transfusion, Part A covers the cost of the blood.

Medicare Part A covers hospital inpatient costs. However, just because you visit a hospital doesn’t mean that you’re an inpatient. An overnight stay doesn’t mean you’re an inpatient either.

  • You’re an inpatient when you’re formally admitted to a hospital with a doctor’s order.
  • You’re an outpatient if you receive any type of hospital services without being formally admitted to a hospital with a doctor’s order. This may include emergency services, outpatient surgery, lab tests, and X-rays. In these cases, you’re an outpatient even if you stay overnight at the hospital.

Make sure you know if you’re an inpatient or outpatient, as this will affect your coverage.

Also, Medicare Part A will only cover a skilled nursing facility if you have a qualifying inpatient hospital stay — three consecutive days resulting from a formal inpatient admission order written by your doctor.

What Medicare Part A costs

Depending on your income, you may have to pay a premium for Part A coverage. You may also have to pay copayments or a deductible for any services under Medicare Part A. You can apply for assistance or help if you can’t pay. Beginning in 2017, in general, these are the costs for each service:

  • Hospital services: $1,316 for up to 60 days, $329 per day for 61-90 days, and $658 per day for stays beyond 91 days
  • Skilled nursing facilities: No charge for the first 20 days, $164.50 per day for 21-100 days, and all costs after 101 days
  • Hospice care: No charge for hospice care, $5 copayment for medication, and 5 percent for inpatient respite care (periodic care so your caretaker can rest)

Remember, you have to be approved for these services and you have to make sure you are in an approved facility.

Medicare Part B

Medicare Part B is also a part of “original Medicare” and it covers your doctor services and preventive healthcare, such as yearly doctor visits and tests. People often have Parts A and B together to get the most coverage. For example, if you stay in a hospital, the stay would be covered under Medicare Part A and the doctor’s services would be covered under Part B.

Part B covers a wide range of tests and services, including:

  • screening for cancer, depression, and diabetes
  • ambulance and emergency department services
  • influenza and hepatitis vaccinations
  • electrocardiograms (ECGs)
  • medical equipment
  • some drugs, diabetes supplies, and some prescriptions for eyewear

What Medicare Part B costs

If you have Part A, chances are you will have to also buy Part B coverage as well. For Part B beginning in 2017, most people will have to pay a monthly premium of $134 a month. This could be more or less depending on your income.

Some services are covered under Medicare Part B at no additional cost to you if you see a doctor that accepts Medicare. If you need a service outside of what is covered by Medicare, you will have to pay for that service. Services from doctors who do not accept Medicare may cost more and you might have to pay the full amount up-front. If some of the cost is covered, you will get paid back through a claims process.

Medicare Part C

Medicare Part C plans, also called Medicare Advantage plans, are supplemental plans that provide more coverage for an additional cost. They are private insurance plans approved by Medicare that fill in the gaps in services and hospital care. People with Medicare Part C must already be enrolled with Parts A and B.

Under these plans, you can get prescription drug coverage, dental and eye coverage, and other benefits.

You usually pay a premium for these plans, and you have to see doctors within your network. Otherwise, copayments or other fees may apply. The cost depends on the type of plan you select.

Medicare Part D

Medicare Part D is the plan that covers prescription drugs not covered by Part B, which are typically the kind of medications that need to be administered by a doctor, like an infusion or injection. This plan is optional, but many people choose to have it so their medications are covered.

The cost for Medicare Part D varies depending on what kinds of medications you take, the plan you have, and which pharmacy you choose. You will have a premium to pay and, depending on your income, you may have to pay additional costs. You may also have to make copayments or pay a deductible.

What’s not covered

While Medicare covers a wide range of care, not everything is covered. Most dental care, eye exams, hearing aids, acupuncture, and any cosmetic surgeries are not covered by Medicare Parts A and B.

Long-term care is also not covered by Medicare. If you think you or a loved one will need long-term care, consider a separate long-term care (LTC) insurance policy.

The takeaway

If you’re getting ready to enroll in Medicare, be sure you select the plan that best fits your healthcare needs. If you’re already enrolled and unsure about what’s covered, use the Medicare website to see if your treatment is covered. Don’t be afraid to ask questions!

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