What does Medicare Part A and Part B cover?
A line by line look at what Original Medicare pays for, plus the well known items it does not touch.
Original Medicare is broad, and it is also full of specific rules about when something is covered. Here is the practical version.
What Part A pays for
- Inpatient hospital care, including your room, meals, nursing and drugs given to you as an inpatient
- Skilled nursing facility care, but only after a qualifying inpatient hospital stay, and only for a limited number of days
- Hospice care for a terminal diagnosis, which is one of the most generous benefits in the program
- Some home health care, when you are homebound and a doctor certifies you need skilled care
- Inpatient care in a religious non medical health care institution
Part A has a deductible per benefit period rather than per year. A benefit period ends after you have been out of the hospital and out of skilled nursing for 60 days straight. Two separate hospitalizations in one year can mean paying that deductible twice.
What Part B pays for
- Doctor visits, both primary care and specialists
- Outpatient surgery and same day procedures
- Lab work, blood tests, X-rays, MRIs and CT scans
- Emergency room and urgent care visits
- Durable medical equipment: wheelchairs, walkers, hospital beds, oxygen, CPAP, diabetic testing supplies
- Physical, occupational and speech therapy
- Ambulance transport when other transport would endanger your health
- Mental health care, including outpatient counseling
- Some limited prescriptions administered in a clinic, like infusions and injections you cannot give yourself
Preventive care, which is free
Part B covers a long list of preventive services at no cost to you when you use a provider who accepts Medicare assignment.
- An annual wellness visit
- Flu, pneumococcal, COVID and hepatitis B vaccines
- Cardiovascular and diabetes screening
- Mammograms, colorectal cancer screening, prostate screening
- Bone density testing, depression screening, obesity counseling
The annual wellness visit is not a physical. It is a planning appointment for reviewing medications and risk factors. People book it expecting an exam and are surprised. Ask what kind of appointment you are scheduling.
The 20 percent
After you meet the annual Part B deductible, Medicare pays 80 percent of the approved amount for most services and you pay the other 20 percent. There is no cap on your share.
That is the whole reason supplements and Advantage plans exist. Covered at 80 percent is not the same as covered.
What Original Medicare does not cover
- Routine dental care, dentures, most vision care and eyeglasses, hearing aids and exams to fit them
- Long term custodial care, meaning help with bathing, dressing and daily living
- Most care received outside the United States
- Cosmetic surgery, acupuncture beyond a limited chronic back pain benefit, and routine foot care
- Prescriptions you fill at a pharmacy, which is what Part D is for
Some of these gaps are filled by Medicare Advantage plans as extra benefits. See the dental, vision and hearing question for what is actually realistic.
Common follow-up questions
Does Medicare cover an annual physical?
Not a traditional head to toe physical. It covers a Welcome to Medicare visit in your first year and an annual wellness visit after that, both of which are planning appointments rather than exams.
Is skilled nursing the same as a nursing home?
No, and this is a costly mix up. Medicare covers skilled nursing rehabilitation for a limited period after a hospital stay. It does not cover long term residence in a nursing home.
Does Medicare cover me in Mexico?
Generally no. Original Medicare stops at the border with very narrow exceptions. This matters a lot here, so ask before you travel.
Want this looked at properly?
We are an independent agency in McAllen serving Hidalgo, Cameron and Starr counties. No cost to talk it through.
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