Medicare covers hospital stays, doctor visits, and prescription drugs, but not everything

Medicare is a federal health insurance program for people 65 and older, some younger people with disabilities, and people with end-stage renal disease. It has four parts, and each covers different things. Part A covers inpatient hospital care, skilled nursing, hospice, and home health. Part B covers doctor visits, outpatient care, and medical equipment. Part D covers prescription drugs. Part C (Medicare Advantage) is an alternative way to get Parts A and B through a private insurer, often with Part D included.

What Medicare does not cover matters as much as what it does. It does not pay for routine dental work, vision exams, hearing aids, long-term custodial care in a nursing home, or most prescription drugs unless you have Part D. It does not cover medical care outside the United States. Costs vary: you pay a monthly premium for Part B and Part D, a deductible before coverage starts, and a percentage of costs after that.

Key Takeaways

  • Part A covers hospital stays and skilled nursing care; Part B covers doctor visits and outpatient services; Part D covers prescription drugs; Part C is a private alternative that bundles A and B.
  • Medicare does not cover dental, vision, hearing aids, long-term nursing home care, or medical care outside the United States.
  • You pay a monthly premium for Part B and Part D, a yearly deductible, and then a percentage of costs (coinsurance or copayment) for most services.
  • Medigap (supplemental insurance) can cover some costs Medicare does not, but it is a separate policy you buy from a private insurer.

What Part A covers: Hospital and skilled nursing care

Part A covers inpatient hospital stays, including room, meals, and standard nursing care. You pay a deductible per hospital stay (the amount changes yearly), and then Medicare covers the full cost for the first 60 days. Days 61 through 90 require a daily coinsurance payment from you. After 90 days, you can use lifetime reserve days, which are a limited pool you can draw from once in your life.

Part A also covers skilled nursing facility care — care in a nursing home where you receive skilled medical treatment, not just help with daily living. You must have been in a hospital for at least three days first, and the care must be for the same condition you were hospitalized for. Medicare covers the first 20 days fully, then requires a daily coinsurance payment for days 21 through 100. After 100 days, you pay the full cost yourself.

Hospice care and home health services are also covered under Part A when ordered by a doctor. Home health includes skilled nursing, physical therapy, and occupational therapy in your home. Hospice covers pain management and comfort care when a doctor says you have six months or less to live.

What Part B covers: Doctor visits and outpatient services

Part B covers visits to doctors, specialists, and other healthcare providers. It covers outpatient hospital services, emergency room visits, and urgent care. It also covers preventive services like annual wellness visits, cancer screenings, and vaccinations at no cost to you (no deductible or coinsurance). Diagnostic tests, lab work, and imaging like X-rays and MRIs are covered.

Part B pays for medical equipment and supplies: wheelchairs, walkers, oxygen, diabetic testing supplies, and similar items. It covers mental health services, including therapy and psychiatric visits. Physical therapy, occupational therapy, and speech therapy are covered when medically necessary and ordered by a doctor.

You pay a monthly premium for Part B (the amount depends on your income). You also pay a yearly deductible, and then Medicare covers 80 percent of most services while you pay 20 percent. Some preventive services have no cost to you at all.

What Part D covers: Prescription drugs

Part D is prescription drug coverage. You enroll through a private insurance company that contracts with Medicare, and the drugs covered and the costs vary by plan. Most Part D plans have a monthly premium, a yearly deductible, and then a tiered cost structure: you pay less for generic drugs, more for brand-name drugs, and the most for specialty drugs.

There is a coverage gap called the "donut hole." Once you and your plan have spent a certain amount on drugs in a year, you enter the gap and pay a higher percentage of drug costs until you reach a catastrophic coverage threshold. After that, Medicare covers most of the cost. The amounts change yearly.

Not all drugs are covered. Each plan has a formulary — a list of covered drugs. If your doctor prescribes a drug not on the formulary, you can ask the plan for an exception, but there is no may provide it will be approved. You can switch Part D plans once a year during the annual enrollment period.

What Medicare does not cover

Dental work is not covered: cleanings, fillings, extractions, dentures, and root canals are your responsibility. Vision care is not covered: eye exams, glasses, and contact lenses are not paid for, though Part B does cover one pair of glasses or contact lenses after cataract surgery. Hearing aids are not covered, though hearing exams may be.

Long-term custodial care in a nursing home — help with bathing, dressing, and eating when that is the main reason for care — is not covered by Medicare. Skilled nursing care is covered for a limited time after a hospital stay, but ongoing custodial care is not. This is a major gap for many people.

Medical care outside the United States is not covered, with rare exceptions for emergency care in Canada or Mexico if you are traveling directly to or from the United States. Experimental treatments and some elective surgeries are not covered. Routine foot care, weight loss programs, and cosmetic surgery are not covered.

Part C (Medicare Advantage) as an alternative

Part C lets you get your Medicare benefits through a private insurance company instead of the government. The insurer must cover everything Part A and Part B cover, but they can charge different costs and have different rules. Many Part C plans include Part D (drug coverage) and may also cover dental, vision, or hearing — things Original Medicare does not.

The trade-off is that Part C plans usually have networks: you must use doctors and hospitals in the plan's network, or pay more. Some plans require referrals to see specialists. Out-of-pocket costs can be lower than Original Medicare if you use in-network providers, but higher if you do not. Part C plans change their coverage and costs yearly, so you need to review your options during the annual enrollment period.

Medigap: Supplemental insurance to cover gaps

Medigap (also called supplemental insurance) is a policy sold by private insurers that covers some of the costs Medicare does not: deductibles, coinsurance, and copayments. It does not cover dental, vision, hearing aids, or long-term custodial care — those gaps remain. But it can significantly reduce your out-of-pocket costs for hospital stays and doctor visits.

Medigap is separate from Medicare. You buy it directly from an insurance company, and you pay a monthly premium on top of your Medicare premiums. There are ten standardized Medigap plans (labeled A through N), and each covers a different combination of costs. The coverage is the same no matter which insurer sells it, but the price varies by company and by your age and location.

You have a limited window to buy Medigap without medical underwriting: usually six months after you turn 65 and enroll in Part B. If you wait longer, the insurer can deny you or charge more based on your health. You cannot have both Medigap and Part C at the same time.

Frequently Asked Questions

Does Medicare cover preventive care like cancer screenings and vaccines?

Yes. Part B covers preventive services at no cost to you when ordered by your doctor: mammograms, colonoscopies, blood pressure checks, cholesterol tests, and flu and pneumonia vaccines. You do not pay a deductible or coinsurance for these services. Your doctor must order them for them to be covered.

What happens if I need care that Medicare does not cover?

You pay the full cost yourself, unless you have Medigap or Part C coverage that includes it. For example, if you need a crown, you pay the dentist directly. If you need hearing aids, you pay out of pocket. This is why many people buy Medigap or choose Part C plans that offer extra coverage.

Can I use my Medicare in other countries?

No, except in rare cases. Medicare does not cover medical care outside the United States. If you travel abroad and need emergency care, you will pay out of pocket and may be able to file a claim for reimbursement later, but coverage is not may provide. Plan ahead if you travel regularly.

Do I have to enroll in Part D if I do not take prescription drugs?

You do not have to enroll when ready, but if you wait and then need drugs later, you may pay a penalty for late enrollment. The penalty is a percentage of the national average Part D premium, added to your premium for as long as you have Part D. If you are certain you will never need prescription drugs, you can skip it, but most people enroll to avoid the penalty.

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare is run by the federal government and lets you see any doctor or hospital that accepts Medicare. Medicare Advantage is run by private insurers and usually has a network of providers. Original Medicare typically has higher out-of-pocket costs but more flexibility. Medicare Advantage often has lower costs but less choice of doctors.