Medicare 101: How Does Medicare Work

Get the Most From Your Medicare Supplement or Medicare Advantage plan by Understanding How Medicare Works

How does Medicare work? Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

While Medicare will pay for most medical expenses, there are huge gaps that could be financially devastating if you need medical treatment, with an unlimited maximum out-of-pocket.

This is why most people on Medicare either a) get a Medicare supplement policy to help cover the extra health care costs that Medicare does not pay; or b) get a Medicare Advantage plan, which will provide their Medicare benefits while also putting a cap on out-of-pocket costs. Understanding how Medicare works will help you decide what type of coverage you need.

Understanding How Medicare Works

How Does Medicare Work?

How does Medicare work?The Original Medicare Plan is a fee-for-service plan (generally, a fee is charged each time you get a service) managed by the Federal government.

Here are the general rules for how it works:

  • You use your red, white, and blue Medicare card when you get healthcare.
  • You can go to any doctor, supplier, hospital, or other facility that accepts Medicare and is accepting new Medicare patients.
  • You may have supplemental coverage, such as a Medicare supplement (also known as a Medigap policy) or a Medicare Advantage plan that offers Medicare through a private insurance company, and may pay costs Original Medicare does not cover.
  • You can purchase Medicare Supplement insurance or Medicare Advantage from private insurance carriers through this website. Medicare Advantage plans often come with no monthly premium, but they may have higher deductibles and do restrict the doctors and hospitals you can go to.

The Different Parts of Medicare

You can get the most from your Medicare benefits by understanding how Medicare works, learning what it covers, and by taking advantage of all that Medicare has to offer.

Medicare has the following parts:

Medicare Part A 

(Hospital Insurance) helps cover your inpatient care in hospitals. Part A also helps cover skilled nursing facilities, hospice, and home healthcare if you meet certain conditions.

Medicare Part C 

(Medicare Advantage Plans) is another way to get your Medicare benefits. It combines Part A, Part B, and sometimes Part D (prescription drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare. These plans must cover medically-necessary services. However, plans can charge different copayments, coinsurance, or deductibles for these services.

Medicare Part B

(Medical Insurance) helps cover medically-necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse. There is a $203 deductible, then Medicare pays its share (usually 80%), and you pay your share (coinsurance or co-payment—usually 20%) for Part B-covered services and supplies.

Medicare Part D 

(Medicare Prescription Drug Coverage) helps cover prescription drugs. This coverage may help lower your prescription drug costs and protect against higher costs in the future.

What Services Does Medicare Cover?

Medicare covers certain medical services and supplies in hospitals, doctors’ offices, and other healthcare settings. Services are either covered under Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance). If you have both Part A and Part B, these services and supplies must be covered as long as they are reasonable and necessary for your health, no matter what type of Medicare plan you have.

What Is Part A (Hospital Insurance)?

Part A helps cover the following after a $1,408 deductible:

Hospital Care Semi-private room, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. This includes inpatient care you get in acute care hospitals, critical access hospitals, inpatient care as part of a clinical research study, and mental healthcare. This doesn’t include private-duty nursing or a television or telephone in your room. It also doesn’t include a private room, unless medically necessary. Inpatient mental healthcare in a psychiatric hospital is limited to 190 days in a lifetime.
Blood Starting with the 4th pint of blood you get at a hospital or skilled nursing facility during a covered stay. The first three pints are not covered.
Home Health Services Limited to reasonable and necessary part-time or intermittent skilled care or continuing need for physical therapy, occupational therapy, or speech-related pathology ordered by the doctor and provided by a Medicare-certified home health agency. Home health services may also include medical social services, home health aide services or other services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical supplies for use at home.
Hospice Care For people with a terminal illness who are expected to live 6 months or less if the disease runs its normal course. Coverage includes drugs, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare (like grief counseling) for terminal and related conditions. Hospice care is usually given in your home (or other facility where you may live). Medicare covers some short-term inpatient stays (for pain and symptom management) and inpatient respite care (care given to a hospice patient so the usual caregiver can rest).
Skilled Nursing Facility Care
Semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury) for up to 100 days in a benefit period. To get care in a skilled nursing facility, you must need skilled care like intravenous injections or physical therapy. Medicare does not cover long-term care or custodial care in this setting.

 

Inpatient care in hospitals. This includes critical access hospitals and inpatient rehabilitation facilities, inpatient stays in a skilled nursing facility (not custodial or long-term care), hospice care services, home healthcare services, and inpatient care in a Religious Nonmedical Healthcare Institution (coverage is related to non-medical, non-religious parts of care).

You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.  If you aren’t eligible for premium-free Part A, you may be able to buy it if you meet one of these conditions:

  • You didn’t work or didn’t pay enough Medicare taxes while you worked and you are age 65 or older
  • You are disabled and have returned to work

Note: Currently, the Part A premium for people who must buy Part A can cost up to $458 each month. In most cases, if you choose to buy Part A, you must also have or enroll in Part B and pay the monthly Part B premium. If you have limited income and resources, your state may help you pay for Part A and/or Part B.

When Can You Sign Up for Part A?

If you get benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Part A starting the first day of the month you turn age 65. If you are under age 65 and disabled, you will automatically get Part A after you get disability benefits from Social Security or RRB for 24 months.

Your Medicare card will be mailed to you about 3 months before your 65th birthday or your 25th month of disability benefits. People with ALS (Amyotrophic Lateral Sclerosis, or Lou Gehrig’s disease) automatically get Part A the month their disability benefits begin.

If you aren’t eligible for premium-free Part A, you can buy Part A during the following times:

  • Initial Enrollment Period: the 7-month period that begins 3 months before your 65th birthday and ends 3 months after your 65th birthday.
  • General Enrollment Period: from January 1 – March 31 each year
  • Special Enrollment Period: if you have group health coverage through your employer or union, or that of your spouse, you may qualify for a special enrollment period.

How does Medicare work?What Is Part B (Medical Insurance)?

Part B helps cover medically-necessary services like doctors’ services, outpatient care, and other medical services Part A doesn’t cover. Part B also covers some preventive services. If you aren’t sure if you have Part B, look at your Medicare card. If you have Part B, MEDICAL (PART B) is printed on your card.

How Much Does Part B Cost?

You pay the Part B premium each month. Most people enrolling today pay a monthly premium of $144.60. However, your monthly premium will be higher if your individual income is more than $87,000, or if you file a joint tax return for income exceeding $174,000. Higher Part B premiums are based on a sliding scale.

When Can You Sign Up for Part B?

If you aren’t getting Social Security or RRB benefits, and you want to get Part B, you will need to sign up for Part B when you are close to age 65. If you didn’t sign up for Part B when you first became eligible, you may be able to sign up during one of these times:

General Enrollment Period

The General Enrollment Period is from January 1 to March 31 each year. Your coverage will begin on July 1. However, the cost of your Part B will go up 10% for each full 12-month period you could have had Part but didn’t sign up for it, unless you qualify for a Special Enrollment Period (see below). You may have to pay this late-enrollment penalty as long as you have Part B.

Special Enrollment Period

If you wait to sign up for Part B because you or your spouse are working and have group health plan coverage based on that work or if you are disabled and you or a family member are working and have group health plan coverage based on that work, then you can sign up for Part B any time while you have group health plan coverage based on current employment or during the 8-month period that begins the month the employment ends, or the group health plan coverage ends, whichever happens first.

What Is the Part B Late-Enrollment Penalty?

If you don’t sign up for Part B when you are first eligible, the cost for Part B may go up 10% for each full 12-month period you could have had Part B but didn’t sign up for it. If you delay taking Part B because you or your spouse (or a family member, if you are disabled) are working and have group health plan coverage based on that work, you may not have to pay the higher premium.

 

Part B Helps Cover the Following:
Part B Costs for Covered Services and Items
Part B Deductible Currently, you pay the first $148.50 yearly for Part B-covered services or items.
Blood In most cases, the provider gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.
You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.
Clinical Laboratory Services You pay $0 for Medicare-approved services.
Home Health Services You pay $0 for Medicare-approved services. You pay 20% of the Medicare-approved amount for durable medical equipment.
Medical and Other Services
You pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you are a hospital inpatient), outpatient therapy*, most preventive services, and durable medical equipment.
Mental Health Services
You pay 20% of the Medicare-approved amount for most outpatient mental health care in 2021.
Other Covered Services You pay copayment or coinsurance amounts.
Outpatient Hospital Services You pay a coinsurance or copayment amount that varies by service for each individual outpatient hospital service. No copayment for a single service can be more than the amount of the inpatient hospital deductible.

*There may be limits on physical therapy, occupational therapy, and speech-language pathology services. If so, there may be exceptions to these limits.
Note: All Medicare Advantage Plans must cover these services. Costs vary by state.

Medically-necessary services. This means the item or service is needed for the diagnosis or treatment of your medical condition.

Preventive services. Services that help prevent or lessen complications from a condition you already have, find health problems early when treatment works best, or manage a medical problem.

What You Pay for Medicare Part B-Covered Services?

Costs for Part B services vary depending on the type of service you get and the type of plan you choose. General cost information is provided in the Part B coverage charts for the Original Medicare Plan below.

Part B-Covered Services:

This symbol identifies preventive services:

Abdominal Aortic Aneurysm Screening A one-time screening ultrasound for people at risk. Medicare only covers this screening if you get referral for it as a result of your one-time “Welcome to Medicare physical exam. See “Physical Exam.” You pay 20% of the Medicare-approved amount.
Ambulance Services Emergency ground transportation when you need to be transported to a
hospital or skilled nursing facility for medically-necessary services, and transportation in any other vehicle could endanger your health. Medicare will pay for transportation in an airplane or helicopter if you require immediate and rapid ambulance transportation that ground transportation can’t provide.
In some cases, Medicare may pay for limited non-emergency transportation if you have orders from your doctor. Medicare will only cover services to the nearest appropriate medical facility that is able to give you the care you need. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Ambulatory Surgical Centers
Facility fees for approved surgical procedures provided in an Ambulatory Surgical Center (facility where surgical procedures are performed, and the patient is released within 24 hours). You pay 20% of the Medicare-approved amount (except for screening flexible sigmoidoscopies and screening colonoscopies, for which you pay 25%), and the Part B deductible applies. You pay all facility charges for procedures Medicare doesn’t allow in ambulatory surgical centers.
Blood In most cases, the provider gets blood from a blood bank at no charge, and you won’t have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else. You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.
Bone Mass Measurement (Bone Density) Helps to see if you are at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Cardiovascular Screenings Helps detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. No cost for the test, but you generally have to pay 20% of the Medicareapproved amount for the doctor’s visit.
Chiropractic Services (limited) Helps correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Clinical Laboratory Services Includes certain blood tests, urinalysis, some screening tests, and more. No cost to you.
Clinical Research Studies Clinical research studies test different types of medical care, like how well a cancer drug works. They help doctors and researchers see if the new care works and if it’s safe. Medicare covers some costs, like doctor visits and tests, in qualifying clinical research studies. You pay 20% of the Medicareapproved amount, and the Part B deductible applies.
Colorectal Cancer Screenings

To help find precancerous growths and help prevent or find cancer early, when treatment is most effective. One or more of the following tests may be covered. Talk to your doctor.

  • Fecal Occult Blood Test-Once every 12 months if age 50 or older. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.
  • Flexible Sigmoidoscopy-Generally, once every 48 months if age 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. You pay 20% of the Medicare-approved amount..
  • Colonoscopy-Generally once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. No minimum age. You pay 20% of the Medicare-approved amount.
  • Barium Enema—Once every 48 months if age 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare-approved amount.

Note: If you get a screening flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare-approved amount.

Defibrillator (Implantable Automatic) For some people diagnosed with heart failure. You pay 20% of the Medicare approved amount for the doctor’s services. You pay a copayment but no more than the Part A hospital stay deductible if you get the device as a hospital outpatient. The Part B deductible applies.
Diabetes Screenings

Checks for diabetes. These screenings are covered if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests are also covered if you answer yes to two or more of the following questions:

  • Are you age 65 or older?
  • Are you overweight?
  • Do you have a family history of diabetes (parents, siblings)?
  • Do you have a history of gestational diabetes (diabetes during pregnancy), or did you deliver a baby weighing more than 9 pounds?

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. No cost for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor’s visit.

Diabetes SelfManagement Training For people with diabetes. Your doctor or other healthcare provider must provide a written order. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Diabetes Supplies Including blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes in some cases). Insulin is covered only if used with an insulin pump. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Note: Insulin and certain medical supplies used to inject insulin, such as syringes, may be covered by Medicare prescription drug coverage (Part D).
Doctor Services Services that are medically necessary includes outpatient and some doctor services you get when you are a hospital inpatient) or covered preventive services. Doesn’t cover routine physicals except for the one-time “Welcome to Medicare physical exam. See “Physical Exam. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Durable Medical Equipment (like walkers) Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds your doctor orders for use in the home. You pay 20% of the
Medicare-approved amount, and the Part B deductible applies. You must get your covered equipment or supplies from a supplier enrolled in Medicare. You should also check if the supplier is a participating supplier. Participating suppliers must accept assignment, and your out-of-pocket costs may be less.
Skilled Nursing Facility Care
Includes semi-private room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a 3-day minimum inpatient hospital stay for a related illness or injury). To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn’t cover long-term care or custodial care in this setting.
NEW EKG Screening Medicare covers a one-time screening EKG if you get a referral for it as a result of your one-time “Welcome to Medicare physical exam. See “Physical Exam.” You pay 20% of the Medicare-approved amount, and the Part B deductible applies. An EKG is also covered as a diagnostic test.
Emergency Room Services When you believe your health is in serious danger. You may have a bad injury, a sudden illness, or an illness that quickly gets much worse. You pay a specified copayment for the hospital emergency department visit, and you pay 20% of the Medicare-approved amount for the doctor’s services. The Part B deductible applies.
Eye Exams for People with Diabetes Checks for diabetic retinopathy once every 12 months by an eye doctor who is legally allowed by the state to do the test. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Eyeglasses (limited) One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Federally-Qualified Health Center Services Includes many outpatient primary care and preventive services you get through certain community-based organizations.You pay 20% of the Medicare-approved amount.
Flu Shots Helps prevent influenza or flu virus. Covered once a flu season in the fall or winter. You need a flu shot for the current virus each year. No cost to you for the flu shot if the doctor accepts assignment for giving the shot.
Foot Exams and Treatment If you have diabetes-related nerve damage and/or meet certain conditions. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Glaucoma Tests
Helps find the eye disease glaucoma. Covered once every 12 months for people at high risk for glaucoma. You are considered high risk for glaucoma if you have diabetes, a family history of glaucoma, are African-American and age 50 or older, or are Hispanic and age 65 or older. An eye doctor who is legally authorized by the state must do the tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Hearing and Balance Exams If your doctor orders it to see if you need medical treatment. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Note: Medicare doesn’t cover hearing aids and exams for fitting hearing aids.
Hepatitis B Shots Helps protect people from getting Hepatitis B. This is covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (ESRD), or a condition that increases your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Home Health Services Limited to medically-necessary part-time or intermittent skilled nursing care, or
physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor must order it, and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort. No cost to you for home health services. For Medicare-covered durable medical equipment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Kidney Dialysis Services and Supplies For people with End-Stage Renal Disease (ESRD). Medicare covers dialysis either in a facility or at home when your doctor orders it. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
NEW Kidney Disease Education Services Medicare may cover kidney disease education services if you have kidney disease, and your doctor refers you for the service. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Mammograms (screening) A type of X-ray to check women for breast cancer before they or their doctor may be able to find it. Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39. You pay 20% of the Medicare-approved amount.
Medical Nutrition Therapy Services Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Mental Healthcare (outpatient) To get help with mental health conditions such as depression, anxiety, or substance abuse. Includes services generally given outside a hospital or in a hospital outpatient department, including visits with a doctor, psychiatrist, clinical psychologist, or clinical social worker, and lab tests. Certain limits and conditions apply.
What you pay will depend on whether you are being diagnosed and monitored or whether you are getting treatment.

  • For visits to a doctor or other healthcare provider to diagnose your condition, or to monitor or change your prescriptions, you pay 20% of the Medicare-approved amount. .
  • For outpatient treatment of your condition (such as counseling or psychotherapy), you pay 20% in 2014 of the Medicare-approved amount. This co-payment will continue to decrease over the next 3 years.

The Part B deductible applies for both visits to diagnose or monitor your condition as well as treatment.

Note: Inpatient mental healthcare is covered under Part A hospital stays.

Talk to your doctor if you feel sad, have little interest in things you used to enjoy, feel dependent on drugs or alcohol, or have thoughts about ending your life.

Non-doctor Services Medicare covers services provided by non-doctors, such as physician assistants and nurse practitioners. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Occupational Therapy Evaluation and treatment to help you return to usual activities (such as dressing or bathing) after an illness or accident when your doctor certifies you need it. There may be limits on physical therapy, occupational therapy, and speech-language pathology services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Outpatient Hospital Services Services you get as an outpatient as part of a doctor’s care. You may pay more for a doctor’s care in an outpatient department of a hospital than you will pay for the same care in a doctor’s office. You pay a specified copayment for each service. The copayment can’t be more than the Part A hospital stay deductible. The Part B deductible applies.
Outpatient Medical and Surgical Services and Supplies For approved procedures (like X-rays, a cast, or stitches). You pay a copayment for each service you get in an outpatient hospital setting. For each service, this amount can’t be more than the Part A hospital stay deductible. The Part B deductible applies, and you pay all charges for items or services that Medicare doesn’t cover.
Pap Tests and Pelvic Exams (includes clinical breast exam) Checks for cervical, vaginal, and breast cancers. Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. No cost to you for the Pap lab test. You pay 20% of the Medicare-approved amount for Pap test specimen collection, and pelvic and breast exams.
Physical Exam (one- time “Welcome to Medicare physical exam) A one-time review of your health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months you have Part B. You pay 20% of the Medicare-approved amount. When you make your appointment, let your doctor’s office know that you would like to schedule your “Welcome to Medicare physical exam.
Physical Therapy Evaluation and treatment for injuries and diseases that change your ability to function when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Pneumococcal Shot Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this preventive shot once in their lifetime. Talk with your doctor. No cost if the doctor or supplier accepts assignment for giving the shot.
Prescription Drugs (limited) Includes a limited number of drugs such as injections you get in a doctor’s office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or infusion pump) and under very limited circumstances, certain drugs you get in a hospital outpatient department. You pay 20% of the Medicare-approved amount for these covered drugs. If the covered drugs you get in a hospital outpatient department are part of the service you get, you pay the copayment for the services. However, if you get other types of drugs in a hospital outpatient department, what you pay depends on whether you have Part D or other prescription drug coverage, whether the drug is covered by your drug plan, and whether the hospital is in your drug plan’s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient department. Keep in mind that under Part B, you pay 100% for most prescription drugs, unless you have Part D or other drug coverage.
Prostate Cancer Screenings
Helps detect prostate cancer. Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for all men with Medicare over age 50. You pay 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor’s visit. You pay nothing for the PSA test.
Prosthetic/ Orthotic Items Including arm, leg, back, and neck braces, artificial eyes, artificial limbs (and their replacement parts); some types of breast prostheses (after mastectomy); and prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and parenteral and enteral nutrition therapy) when your doctor orders it. For Medicare to cover your prosthetic or orthotic, you must go to a supplier that is enrolled in Medicare. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Includes many outpatient primary care services. You pay 20% of the amount charged, and the Part B deductible applies.
Rural Health Clinic Services Includes many outpatient primary care services. You pay 20% of the amount charged, and the Part B deductible applies.
Second Surgical Opinions Covered in some cases for surgery that isn’t an emergency. In some cases, Medicare covers third surgical opinions. You pay 20% of the Medicareapproved amount, and the Part B deductible applies.
Smoking Cessation (counseling to stop smoking) Includes up to 8 face-to-face visits in a 12-month period if you are diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Speech-Language Pathology Services Evaluation and treatment given to regain and strengthen speech and language skills including cognitive and swallowing skills when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Surgical Dressing Services For treatment of a surgical or surgically-treated wound. You pay 20% of the Medicare-approved amount for doctor services. You pay a fixed copayment for these services when you get them in a hospital outpatient department. You pay nothing for the supplies. The Part B deductible applies.
Telehealth Includes a limited number of medical or other health services, like office visits and consultations provided using an interactive two-way telecommunications system (like real-time audio and video) by an eligible provider who is at a location different from the patient’s. Available in some rural areas, under certain conditions, and only if the patient is located at one of the following places: a doctor’s office, hospital, rural health clinic, federally-qualified health center, hospital-based dialysis facility, skilled nursing facility, or community mental health center. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Tests
Including X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you get the test at a hospital as an outpatient, you pay a specified copayment that may be more than 20% of the Medicare-approved amount, but it can’t be more than the Part A hospital stay deductible.
Transplants and Immunosuppressive Drugs Including doctor services for heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and only in a Medicare-certified facility. Medicare covers bone marrow and cornea transplants under certain conditions
Immunosuppressive drugs are covered if Medicare paid for the transplant, or an employer or union group health plan that was required to pay before Medicare paid for the transplant. You must have been entitled to Part A at the time of the transplant, and you must be entitled to Part B at the time you get immunosuppressive drugs. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
If you are thinking about joining a Medicare Advantage Plan and are on a transplant waiting list or believe you need a transplant, check with the plan before you join to make sure your doctors and hospitals are in the plan’s network. Also, check the plan’s coverage rules for prior authorization.
Travel (healthcare needed when traveling outside the United States) (limited)
Note: Medicare drug plans (Part D) may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant.
Travel (healthcare needed when traveling outside the United States) (limited) For some people diagnosed with heart failure. You pay 20% of the Medicare-approved amount for the doctor’s services. You pay a copayment but no more than the Part A hospital stay if you get the device as a hospital outpatient. The Part B deductible applies.
Travel (healthcare needed when traveling outside the United States) (limited)
Medicare generally doesn’t cover healthcare while you are traveling outside the U.S. (the “U.S. includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). There are some exceptions including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. In rare cases, Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following situations:
1) If an emergency arose within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition
2) If you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency
3) If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists
You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Urgently-Needed Care To treat a sudden illness or injury that isn’t a medical emergency. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

What’s NOT Covered by Part A and Part B?

Much like a traditional health insurance policy, Medicare does not cover all of your medical services. Items not covered include:

  • Acupuncture
  • Chiropractic services (except to correct a subluxation – when one or more of the bones of your spine move out of position – using manipulation of the spine)
  • Cosmetic surgery
  • Custodial care
  • Deductibles
  • Coinsurance
  • Copayments
  • Dental care and dentures (with only a few exceptions)
  • Eye care (routine exam), eye refractions (exam that measures your ability to see at specific distances),
    and most eyeglasses
  • Foot care (routine), like cutting corns or calluses
  • Hearing aids and exams for the purpose of fitting a hearing aid
  • Hearing tests that haven’t been ordered by your doctor
  • Laboratory tests for screening purposes, except those listed above
  • Long-term care – for example, if you only need custodial care in a nursing home
  • Orthopedic shoes (with few exceptions)
  • Physical exams (routine or yearly). Medicare will cover a one-time physical exam within the first 6 months of enrolling in Part B (coinsurance and Part B deductible applies).
  • Prescription drugs. Most outpatient prescription drugs aren’t covered by Part A or Part B. If you need prescription drug coverage, you will also need to purchase Medicare Part D.
  • Syringes or insulin, unless the insulin is used with an insulin pump, but it may be covered by Medicare prescription drug coverage (Part D).
  • Travel (healthcare while you’re traveling outside the United States)