Navigating the world of health insurance can be overwhelming, especially regarding Medicare, the federal health insurance program for individuals aged 65 and older, and certain younger individuals with disabilities. Understanding what Medicare covers is crucial to making informed decisions about your healthcare needs. This guide breaks down the different parts of Medicare and explains what services and treatments are covered under each.

Medicare Parts: The Basics

Medicare is divided into several parts, each covering different aspects of healthcare:

– Medicare Part A (Hospital Insurance): Helps cover inpatient hospital care, skilled nursing facility care, hospice, and some home health services.

– Medicare Part B (Medical Insurance): Covers outpatient care, preventive services, and medically necessary services like doctor visits, lab tests, and physical therapy.

– Medicare Part C (Medicare Advantage): An alternative to Original Medicare (Parts A and B) that includes additional benefits such as dental, vision, and hearing coverage. Part C plans are offered by private insurance companies.

– Medicare Part D (Prescription Drug Coverage): Helps cover the cost of prescription drugs.

Let’s dive deeper into what each part of Medicare covers.

Medicare Part A: Hospital Insurance

Part A primarily covers services related to hospital care. Here’s a breakdown:

1. Inpatient Hospital Care: Medicare Part A covers hospital stays, including semi-private rooms, meals, nursing care, and necessary medications. However, services like private rooms (unless medically necessary) or personal items (such as toiletries) are not covered.

2. Skilled Nursing Facility (SNF) Care: After a qualifying hospital stay (at least three days), Medicare Part A helps cover short-term care in a skilled nursing facility, including rehabilitation services and meals. It’s important to note that long-term care or custodial care is not covered under Part A.

3. Hospice Care: For individuals with terminal illnesses, Medicare Part A covers hospice care, including pain relief, symptom management, and support services for the patient and family. Hospice services can be provided at home, in a nursing facility, or at a hospice center.

4. Home Health Care: Medicare Part A (and sometimes Part B) provides limited coverage for home health services, such as intermittent skilled nursing care, physical therapy, and speech-language pathology.

Medicare Part B: Medical Insurance

Part B covers a wide range of medical services and supplies necessary to diagnose or treat medical conditions. Here’s what Part B covers:

1. Doctor Visits: This includes visits to primary care physicians and specialists for medical conditions and preventive services.

2. Outpatient Care: Medicare Part B covers medically necessary outpatient services like X-rays, lab tests, and surgery performed outside of a hospital setting.

3. Preventive Services: Medicare Part B provides coverage for a variety of preventive services, including screenings for diabetes, cancer, cardiovascular disease, and more. It also covers flu shots, annual wellness visits, and vaccines.

4. Durable Medical Equipment (DME): Items such as walkers, wheelchairs, oxygen equipment, and other medical supplies are covered if deemed medically necessary by your doctor.

5. Mental Health Services: Part B helps cover outpatient mental health services, including counseling and therapy sessions, to support individuals with mental health conditions.

Medicare Part C: Medicare Advantage Plans

Medicare Advantage (Part C) plans are offered by private insurance companies and combine the benefits of Parts A and B. These plans often include extra services not covered by Original Medicare, such as:

– Prescription Drugs: Many Medicare Advantage plans include prescription drug coverage (Part D).

– Dental, Vision, and Hearing: Some Medicare Advantage plans offer routine dental care, vision exams, eyeglasses, and hearing aids.

– Wellness Programs: Additional benefits, such as gym memberships, transportation to medical appointments, and meal delivery, may be included.

It’s important to note that coverage and benefits vary depending on the specific Medicare Advantage plan you choose.

Medicare Part D: Prescription Drug Coverage

Medicare Part D provides coverage for prescription medications. Each Part D plan has a formulary (a list of covered drugs), which is divided into tiers that determine how much you’ll pay for each medication. Medicare Part D helps lower the cost of prescription drugs, but it’s important to compare different plans to ensure your medications are covered.

What Medicare Doesn’t Cover

While Medicare covers many healthcare services, there are several things it does not cover, including:

– Long-term care (Custodial care): If you need help with daily living activities like bathing, dressing, and eating, Medicare generally does not cover these services.

– Routine Dental Care: Unless you have a Medicare Advantage plan that includes dental benefits, Original Medicare does not cover most dental care, procedures, or supplies.

– Hearing Aids and Routine Eye Exams: Original Medicare does not cover hearing aids or the cost of routine eye exams and glasses, although Medicare Advantage plans may offer this coverage.

– Cosmetic Surgery: Medicare does not cover cosmetic procedures unless deemed medically necessary.

Final Thoughts

Understanding what Medicare covers is essential to ensuring you get the healthcare services you need without unexpected out-of-pocket costs. Medicare Parts A and B form the foundation of coverage, but you may want to consider a Medicare Advantage plan for additional benefits. If you take regular prescription medications, a Part D plan is also a good idea.

It is always a good idea to review your Medicare coverage annually, and I’d love to help! Schedule a time to review your coverage today!