What does Medicare cover?

Don't be left wondering what your Medicare plan covers. It doesn't have to be confusing.

The federal government administers Parts A and Parts B through Original Medicare. If you choose a Medicare Advantage plan (Part C), a private insurance company administers Parts A and B, and additional benefits that aren’t available in Original Medicare.  Part D plans cover prescription drugs. Once you are enrolled in Part A and Part B, you can choose Original Medicare or a Medicare Advantage plan based on your specific needs.

01

Medicare Part A (Hospital Coverage)

Chemotherapy (Inpatient)

Medicare will cover chemotherapy in several different forms, including intravenous and oral applications. You can receive this as an inpatient (Part A), outpatient (Part B), or as an at-home medication (Part D). If costs are too high, you may decide to add Medicare Supplement Insurance (Medigap) or switch to a Medicare Advantage plan to help pay for the high costs of cancer treatments.

Dialysis Services

You are eligible for Medicare before you turn 65 if you have end-stage renal disease, though there may be other eligibility requirements. Medicare covers the cost of dialysis and kidney transplants. You can also sign up for Medicare Advantage plans to cover these costs. There may be additional coinsurance and premium fees. To read more about Dialysis services, visit Medicare.gov.

Emergency Room Visits

Original Medicare will typically cover at least a portion of your emergency room visits. Whether Medicare Part A or Part B covers the stay depends on if you are admitted or not. If you are admitted at least two nights, Medicare Part A will cover it. If you are not admitted, Medicare Part B kicks in. You pay a copayment for each emergency department visit and a copayment for each hospital service. If your doctor admits you to the same hospital for a related condition within 3 days of your visit, you do not pay the copayment because your visit is considered part of your inpatient stay.

Home Health Care

Home Health Care coverage on Medicare is needs-based and may have limits to what exactly is covered. It is best to verify that your needs will be covered by Medicare, and if Part A, Part B, or a Medicare Advantage plan will cover it.

Hospice

If you meet hospice qualifications, you are covered by Medicare Part A.

Hospitals (Inpatient)

Medicare Part A, in combination with part B can significantly reduce your hospital costs, but will not cover the entire bill. You can help supplement those costs not covered by Part A and Part B with Medicare Supplement Insurance (Medigap).

Knee Replacement

Since a knee replacement typically requires at least a short hospital stay, you'll want to look at your hospital coverage to understand which part of Medicare may cover this service. Inpatient surgery will be covered by Part A. If the surgery is outpatient, that would be covered by Part B. Neither Part A nor Part B will cover the pain medication necessary after surgery. Medicare Advantage would cover knee replacement surgery plus any rehabilitative services required post-surgery.

Mental Health (Inpatient)

Medicare Part A would cover some hospital related costs if mental health treatment is provided as an inpatient. Medicare Part B would cover some preventive checks for mental health issues on an annual basis and some treatments.

Occupational Therapy

Medicare Part A covers inpatient occupational therapy (OT), while Medicare Part B covers outpatient OT. In both instances, it must be deemed medically necessary to help you perform day-to-day tasks. OT received at home to help you return to normal life after an injury or illness is typically covered by Part A.

Palliative Care

Palliative care is specialized medical care for people living with a serious illness. This type of care is covered by Medicare. Which part of Medicare covers each service depends on the specific service.

Radiation Therapy (Inpatient)

Medicare Part A and B will help cover your costs of radiation therapy (typically used as a cancer treatment). Medicare Advantage can also be used to help cover costs. Which specific part of Medicare covers your treatment depends on the type of plan you have as well as where you are receiving the treatment. Read more about Radiation therapy coverage on Medicare.gov.

Skilled Nursing Facility

Medicare Part A covers all costs for the first 20 days and then a portion of the costs for days 21 through 100. After that, you are responsible for 100% of the costs. Skilled Nursing care can include things like occupational and physical therapy that would help a person recover after an injury or illness. Medicare will not pay for custodial care, which is help with things like bathing, dressing and transferring.

Surgery (Inpatient)

After your deductible is met, Original Medicare will pay for 80% of the medically necessary surgeries. You will be responsible for the remaining 20% of the costs. Part A covers inpatient surgeries while Part B covers outpatient operations.

Weight Loss (Bariatric) Surgery

Medicare covers some bariatric surgical procedures, like gastric bypass surgery and laparoscopic banding surgery, when you meet certain conditions related to morbid obesity. With any Medicare coverage related to this surgery, you will be responsible for paying some costs, including premiums, deductibles and coinsurance. Part A covers hospital-related expenses, Part B covers medically necessary treatments and equipment and Part D covers drugs related to the treatments. Medicare Advantage can also be used to cover the same as Part A, B and D with the potential to cover additional charges.

02

Medicare Part B (Medical Services)

Acupuncture

Medicare Part B covers up to 12 acupuncture visits in 90 days, but only for chronic low back pain. You can potentially received an additional 8 sessions if you show improvement. If your doctor decides your chronic low back pain isn’t improving or is getting worse, then Medicare won't cover your additional treatments. No more than 20 acupuncture treatments can be given per year.

Allergy Testing

Medicare Part B covers medically necessary allergy tests (such as skin, blood and food testing) when prescribed by Medicare-approved physicians. Allergy shots, or allergen immunotherapy, are sometimes covered by Medicare or Medicare Advantage.

Blood Work & Lab Tests

If a doctor certifies that blood work and/or lab tests are medically necessary, they would be covered by Medicare Part B. This coverage may vary based on your geographic location.

Cardiac Rehab

Once you've met your deductible, you'll have to pay a 20% copayment for cardiac rehabilitation. Medicare Part B covers cardiac rehab if you've had at least one of the following conditions:

  • A heart attack in the last 12 months
  • Coronary artery bypass surgery
  • Current stable angina (chest pain)
  • A heart valve repair or replacement
  • A coronary angioplasty (a medical procedure used to open a blocked artery) or coronary stent (a procedure used to keep an artery open)
  • A heart or heart-lung transplant
  • Stable chronic heart failure
Cataract Surgery

Medicare does not typically cover all of the costs associated with Cataract Surgery. It can cover part of the surgery and corrective lenses after the surgery after your Part B deductible.

Chemotherapy (Outpatient)

You pay a copayment for hospital outpatient chemotherapy covered under Part B. For chemotherapy given in a doctor's office or clinic, you will have to pay 20% of the Medicare-Approved Amount, as well as the Part B deductible. Many people may choose to add Medicare Supplement Insurance (Medigap) or switch to Medicare Advantage to help cover the high out-of-pocket costs associated with cancer treatment.

Chiropractic Services (Limited)

Medicare Part B covers manual manipulation of the spine by a chiropractor or other qualified provider if deemed medically necessary to correct a subluxation (when one or more of the bones of your spine move out of position). You will be responsible for paying 20% of the Medicare-Approved Amount and the Part B deductible. Medicare doesn't cover other services or tests a chiropractor orders, including X-rays, massage therapy, and acupuncture.

Chronic Care Management (CCM)

Medicare may pay for a health care provider’s help to manage chronic conditions if you have 2 or more serious chronic conditions that are expected to last at least a year. You may pay a monthly fee, and the Part B deductible and coinsurance apply. If you have supplemental insurance, or have both Medicare and Medicaid, it may help cover the monthly fee.

Dermatology (Medically Necessary)

Unless your dermatology care is considered medically necessary, Medicare Part A and Part B won't cover dermatology. While Medicare does not cover annual skin checks, if you or your doctor discover something that needs further evaluation, Medicare would cover that.

Dialysis Services

You are eligible for Medicare before you turn 65 if you have end-stage renal disease, though there may be other eligibility requirements. Medicare covers the cost of dialysis and kidney transplants. You can also sign up for Medicare Advantage plans to cover these costs. There may be additional coinsurance and premium fees.

Durable Medical Equipment (DME)

Medicare Part B covers medically necessary DME if your doctor prescribes it for use in your home. If your supplier works with Medicare, you pay 20% of the Medicare-Approved Amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment. You may be able to rent or buy the equipment. If your doctor or supplier is not enrolled to work with Medicare, Medicare will not pay the claims submitted by them. Some examples of DME that Medicare covers are:

Emergency Room Visits

Original Medicare will typically cover at least a portion of your emergency room visits. Whether Medicare Part A or Part B is what covers the stay depends on if you are admitted or not. If you are admitted at least two nights, Medicare Part A will cover it. If you are not admitted, Medicare Part B kicks in. You pay a copayment for each emergency department visit and a copayment for each hospital service. You also pay 20% of the Medicare-Approved Amount for your doctor's services, and the Part B deductible applies.

E-Visits

Medicare Part B covers E-Visits with your doctors and certain other practitioners. You are responsible for paying 20% of the co-pay and your deductible.

Genetic Testing

Medicare will cover certain types of genetic testing called Next Generation Sequencing, molecular diagnostic genetic test and PGx. Medicare will also cover cancer genetic tests for acquired or inherited cancer (ie: inherited breast or ovarian cancer, advanced stage III or IV cancer). The tests must be deemed medically necessary and ordered and received by a physician who is FDA approved. It is always best to check with your Medicare coverage provider before any genetic testing is done.

Home Health Care

Medicare will only cover certain home health care services. It is best to verify specific services directly with your Medicare coverage provider. You may also read more about Home Health Care coverage on Medicare.gov.

Immunosuppressive Drugs

Immunosuppressive Drugs can reduce the risk of organ rejection (some charges covered by Part B) as well as manage autoimmune and inflammatory conditions (some charges covered by Part D). If you have Medicare because you qualify due to End Stage renal disease (ESRD), Medicare Part B will cover the costs of immunosuppressive drugs after you get a kidney transplant. The procedure must take place in a Medicare-approved facility and coverage will end 36 months after you leave the hospital. If you have Medicare due to age or disability, Medicare Part B will cover the costs of these drugs for the rest of your life if: you had an organ transplant, that transplant occurred at a Medicare-approved facility, and you had Part A at the time of the surgery.

Insulin

You pay 100% for insulin (unless used with an insulin pump, then you pay 20% of the Medicare-Approved Amount, and the Part B deductible). You may be able to get coverage on insulin with a Medicare Part D plan, or a Medicare Advantage plan with drug coverage that participates in the insulin savings model. Participating plans offer a maximum copayment of $35 a month for insulin supplies. These plans can offer coverage choices that include multiple types of insulin at a maximum copayment of $35 for a month's supply.

Knee Replacement

Since a knee replacement typically requires at least a short hospital stay, you'll want to look at your hospital coverage to understand which part of Medicare may cover this service. Inpatient surgery will be covered by Part A. If the surgery is outpatient, that would be covered by Part B. Neither Part A nor Part B will cover the pain medication necessary after surgery. Medicare Advantage would cover knee replacement surgery plus any rehabilitative services required post-surgery.

Mental Health (Outpatient)

Medicare Part A would cover some hospital related costs if mental health treatment is provided as an inpatient. Medicare Part B would cover some preventive checks for mental health issues on an annual basis and some treatments.

MRI

Magnetic resonance imaging, or MRI, is covered by Medicare when prescribed by a Medicare-approved doctor and performed at a facility that accepts Medicare assignment. The specific cost will vary based on the type of scan, location, and other treatments needed with your test. Medicare Part A would cover inpatient MRIs, while Part B will help pay for outpatient MRIs. Medicare Advantage may offer at least the same coverage as Original Medicare, but many plans have different payment structures.

Palliative Care

Palliative care is specialized medical care for people living with a serious illness. This type of care is covered by Medicare. Which part of Medicare covers each service depends on the specific service.

Prescription Drugs (Limited)

Medicare Part A and Part B do not typically coverage over-the-counter prescription drugs. You can add Medicare Part D through a private insurance company to get prescription drug coverage. Part D plans can vary by state so it is important to know if your particular prescription drug is covered in your plan. Medicare Part B covers a limited number of outpatient prescription drugs under limited conditions. To learn more about Medicare Prescription Drug coverage, visit Medicare.gov.

Second Surgical Opinions

Medicare Part B will cover a second opinion on surgery by a doctor who accepts Medicare in some cases for medically necessary, non-emergency surgery. Medicare will also help pay for a third opinion if the first and second are different. You will be responsible for paying the 20% copayment and the Medicare Part B deductible applies.

Surgery (Outpatient)

After your deductible is met, Original Medicare will pay for 80% of the medically necessary surgeries. You will be responsible for the remaining 20% of the costs. Part A covers inpatient surgeries while Part B covers outpatient operations.

Telehealth & Telemedicine

Medicare Part B covers certain telehealth services. You pay a 20% copayment and the Part B deductible.

Therapy Services

Medicare covers several types of therapy, including but not limited to mental health, physical therapy, occupational therapy, speech therapy and behavioral therapy. You are responsible for a 20% copayment as well as the Medicare Part B deductible.

Transportation & Ambulances

Medicare covers emergency transportation if it’s medically necessary or reduces further health risk. You are responsible for a 20% copayment as well the Medicare Part B deductible. In some cases, Medicare may pay for limited, medically necessary, nonemergency ambulance transportation if you have a written order from your doctor stating that ambulance transportation is medically necessary. For example, someone with End-Stage Renal Disease may need medically necessary ambulance transport to a facility that furnishes renal dialysis.

Urgent Care

Medicare Part B covers urgent care needed to treat a sudden illness or injury that isn't something you would go to the emergency room for. You are responsible for a 20% copayment as well the Medicare Part B deductible.

Vaccines & Immunizations

A variety of vaccines can be covered by Medicare. It is always best to confirm with your doctor prior to receiving an immunization or vaccine. Here are some examples of vaccine coverage:

  • Flu Shots - Medicare Part B covers an annual flu shot.
  • Hepatitis A Vaccine - only covered by Medicare Part B if given in an inpatient environment. Part D should cover the Hepatitis A vaccine, though you may still need to pay a copayment or coinsurance towards your deductible.
  • Hepatitis B Vaccine - Medicare Part B covers the full cost of the Hep B vaccine if you are a medium to high risk of getting it. If you are low risk, Part B will not cover it. Confirm with your doctor what your risk level is. Medicare Advantage plans may cover the cost.
  • Pneumonia Shots - pneumonia vaccine(s) are either covered by Medicare Part B or a Medicare Advantage plan.
Welcome to Medicare Preventative Visit

Medicare Part B covers a "Welcome to Medicare" preventative visit once within the first 12 months you have Part B. You pay nothing for this visit if your doctor or other qualified health care provider accepts Medicare. The Part B deductible does not apply.

X-Rays

Medicare Part B covers medically necessary diagnostic X-rays. You are responsible for a 20% copayment as well the Medicare Part B deductible. If the X-ray is done in a hospital outpatient setting, you pay a copayment.

03

Medicare Part C (Advantage)

Medicare Part C (Medicare Advantage) generally covers hospital and medical, and benefits that aren’t available in Original Medicare. The important thing to remember is that your plan will have a provider network, and if you receive care outside of that network it will raise your out-of-pocket costs.

Since plans vary so much, it is best to speak to one of our Independent Sales Representatives to find out specific details.

You can also read more about what Medicare Part C (Advantage is) on our Parts of Medicare page.

04

Medicare Part D (Prescription Drugs)

Medicare Part D is run by private insurance companies and covers generic and name-brand prescription drugs. Coverage varies by policy, so it is always best to confirm your specific plans coverage options. Medicare Part D can be purchased in addition to Medicare Part A and B, or in addition to Medicare Advantage.

What Services Does Medicare Cover and Pay For?

The services covered, and paid for, by Medicare are determined in a variety of ways. Coverage and costs are dictated either by federal or state laws. Different local carriers can make decisions on things to cover as well, which is typically decided by whether a service is considered medically necessary or not.

As for paying for services, Medicare will typically pay for most but not all of your costs after you have reached your deductible. Medicare pays 80% of approved costs and you pay 20% of approved costs. If you need extra coverage to fill in the gaps of your out-of-pocket costs, you could look in to purchasing a Medicare Supplement (Medigap) plan.

05

High-Level Overview of Coverage

Part A (Hospital Insurance):

Helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.

Part B (Medical Insurance): 

Helps cover:

  • Services from doctors and other health care providers
  • Outpatient care
  • Home health care
  • Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
  • Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)
Part C (Medicare Advantage):

Medicare Part C, or Medicare Advantage, combines Medicare Part A and Part B, and most include Part D that may offer extra benefits not covered by Original Medicare.

Part D (Drug coverage): 

Helps cover the cost of prescription drugs (including many recommended shots or vaccines). You join a Medicare drug plan in addition to Original Medicare, or you get it by joining a Medicare Advantage Plan with drug coverage. Plans that offer Medicare drug coverage are run by private insurance companies that follow rules set by Medicare.

Medicare Supplemental Insurance (Medigap):

Extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Policies are standardized, and in most states named by letters, like Plan G or Plan K. The benefits in each lettered plan are the same, no matter which insurance company sells it.

Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. This is a solicitation of insurance.  A licensed agent/producer may contact you.  Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and, in some states, to those under age 65 eligible for Medicare due to disability or End-Stage Renal disease.  MasterCare LLC and Insuractive LLC are licensed and certified representatives of Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations and stand-alone PDP prescription drug plans. Each of the organizations they represent has a Medicare contract. Enrollment in any plan depends on contract renewal. The plans they represent do not discriminate on the basis of race, color, national origin, age, disability, or sex.  For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov

Recommended Reading

Learn what is generally not covered by Medicare.

Learn about the different costs associated with the parts of Medicare.

Ready to move forward?  Learn if you're eligible as well as how to enroll in Medicare.