Summary: Though Medicare provides coverage for many services and items, it does not cover everything. Fortunately, there are many options when it comes to supplementing your coverage. By understanding what Medicare covers, you can ensure you get the care you need without breaking the bank. Estimated Read Time: 6 min
What Does Medicare Cover?
Medicare provides coverage for medically necessary healthcare services. The amount of coverage you have will depend on which parts of Medicare you are enrolled in. Medicare Part A and Medicare Part B make up Original Medicare and provide beneficiaries with hospital and medical coverage.
Medicare Advantage plans (Medicare Part C) provide the same coverage as Original Medicare and may cover services or items that are not covered by Medicare Part A or Part B. Prescription coverage is not included with Original Medicare but can be obtained through a Medicare Part D Prescription Drug plan or a Medicare Advantage plan with prescription coverage. Medicare Supplement plans, sometimes referred to as Medigap, help cover the gaps in costs left behind by Medicare when you receive care.
Understanding what Medicare does and does not cover is essential for ensuring you get coverage that meets your personal healthcare needs. Below we’ll review what services Medicare covers and what options you have for supplementing your coverage.
What Does Original Medicare Cover?
When most people think of basic Medicare coverage, they are probably thinking about Original Medicare. Original Medicare is the portion of Medicare that is provided by the federal government. Original Medicare covers medically necessary inpatient and outpatient services.
Medicare defines medically necessary as “health care services or supplies needed to diagnose or treat an illness, injury, condition, or disease”. In most cases, when you receive medically necessary services in a hospital, doctor’s office, or other health care facility, Medicare will cover it.
Your Original Medicare coverage can be used at any healthcare provider in the U.S. who accepts Medicare. You will be responsible for paying any out-of-pocket costs such as deductibles or copayments when using your coverage.
Medicare Part A provides hospital coverage. Learn more about what is covered by Part A and how much you’ll need to pay for covered services.
Medicare Part B provides medical coverage. Learn more about which services are covered by Part B and what your costs will be.
What Does Medicare Not Cover?
Though Medicare covers many services and items, it does not cover everything. If you need services that are not covered by Medicare, you will need to pay the entire cost out-of-pocket unless you have additional coverage (like a Medicare Advantage plan).
Dental, vision, and hearing services are not covered by Medicare. This includes services and supplies such as routine eye exams, dental cleanings, or hearing aids. Maintaining the health of our ears, eyes, and teeth is crucial as we age.
Fortunately, there are coverage options available for dental, vision, and hearing care. For those who want to keep Original Medicare, there are standalone insurance plans available for dental and vision coverage that you can get in addition to Original Medicare. If you are interested in enrolling in a Medicare Advantage plan or a Medicare Cost plan, there may be plans available in your area that provide this coverage; however, plan availability and coverage options will vary by location.
Original Medicare also does not provide coverage for prescription drugs. This gap in coverage is significant, as paying full price for medications can have a drastic impact on your finances. To get prescription coverage once you enroll in Medicare, you will either need to enroll in a standalone Medicare Part D Prescription Drug plan or enroll in a Medicare Advantage plan that includes drug coverage.
Though Medicare provides coverage for inpatient services and home healthcare, Medicare does not cover long-term care (custodial care). Long-term care typically includes help with basic tasks of everyday life such as dressing and bathing. Coverage for long-term care can be obtained through Medicaid or by purchasing private long-term care insurance.
Another important service that Medicare does not cover is foreign travel healthcare. Original Medicare will not cover any healthcare services received when traveling outside of the U.S. If you plan on traveling abroad and want the peace of mind of having coverage in case of an emergency, you may consider picking up a Medicare Supplement plan. Certain Medicare Supplement plans provide foreign travel emergency coverage.
Other services that Medicare doesn’t cover include:
- Cosmetic surgery
- Massage therapy
- Routine physical exams
Additional Coverage Options for Medicare
Depending on your healthcare needs, you may benefit from supplementing your Medicare coverage. There are a few different ways you can expand your coverage when you have Medicare.
If you decide to keep Original Medicare, you have the option to enroll in a standalone Medicare Part D plan for prescription drug coverage. Additionally, you can also enroll in a Medicare Supplement plan to help with your out-of-pocket costs.
You may choose to receive your hospital and medical coverage through a Medicare Advantage plan instead of Original Medicare. Depending on the plan you enroll in, you may receive coverage for services that aren’t covered by Original Medicare, such as prescription drug coverage. It’s important to remember that if you enroll in a Medicare Advantage plan, you will not be able to enroll in a Medicare Supplement plan. Additionally, if your Medicare Advantage plan does not include drug coverage, you won’t be able to enroll in a standalone Medicare Part D plan (in most cases).
Can You Decline Medicare Coverage?
Having Medicare is not mandatory, though there are a few things you should know before declining coverage:
- Many people do not have to pay a premium for Medicare Part A, so it doesn’t make sense for many to decline Part A coverage.
- If you choose to decline your Medicare Part B and Medicare Part D coverage, you may face a late enrollment penalty if you change your mind later and want to enroll.
- You cannot get a Medicare Advantage plan without having both Medicare Part A and Medicare Part B.
- If you are already receiving Social Security benefits, you will automatically be enrolled in both parts of Original Medicare when you turn 65. If you wish to drop your coverage, you will need to follow the instructions on your welcome packet and mail back your Medicare card.
If you’re considering declining or dropping your Medicare coverage because you are struggling to pay your premiums, there are programs available that can help you with costs. You can contact Medicare directly or contact your State Medical Assistance (Medicaid) office for more information on how you can lower your out-of-pocket costs.
How to Get Help Understanding Medicare Coverage Options
Though Original Medicare provides a solid foundation for healthcare coverage, it doesn’t cover everything. Luckily, there are many options available for expanding your Medicare coverage. Ensuring your coverage meets your individual healthcare needs is essential for reducing your costs and making sure you get the care you need.
Before you begin looking at plans and coverage options, we recommend making a list of your healthcare needs. This can help you get a clear idea of what sort of benefits you want to look for in a Medicare plan. Do you wear glasses? Are you taking medications, and if so, which ones? Do you already have a plan in place for long-term care? Figuring out your needs ahead of time will make comparing plans much easier.
Do you have specific healthcare needs and are unsure if they’re covered by Medicare? Our licensed agents can help you determine if your service or supplies are covered under Medicare and what out-of-pocket costs you’ll be responsible for. You can speak with an agent by calling the number above.
What’s isn’t covered by Part A & Part B?, Medicare. Accessed October 2023
Medicare & You 2024, Medicare. Accessed October 2023
Your Medicare Coverage Choices, Medicare. Accessed October 2023