What Does Medicare Cover?
Learn which services and care are covered by Part A and Part B coverage.
Medicare consists of Parts A and B, otherwise known as hospital and medical coverage.
Part A hospital insurance covers inpatient care, skilled nursing facility, home health care, surgery, lab tests, and hospice.
Part B medical insurance covers doctor services and outpatient care, as well as home health care, medical equipment, and a variety of preventive services.
Here, we’ll go through the covered services and care provided under Medicare (Parts A and B), so that you have a good understanding of what Medicare covers and how it might apply to your health care.
Medicare Part A Hospital Coverage
Part A is known as your hospital insurance. It is one of two parts that make up Original Medicare, which is the basic coverage provided through enrollment.
Part A helps to cover costs for in-patient care in a hospital and skilled nursing facility, as well as home health care and hospice care services.
Most individuals are eligible for Part A once they reach the age of 65. Some are eligible for Medicare before turning 65, such as in the case of disability or End-Stage Renal Disease.
Most commonly, people do not have to pay a monthly premium for Part A.
If you sign up for Medicare Part A, you will receive coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. We’ll take an in-depth look at each of these options.
1. Inpatient Hospital Care
For those admitted to a hospital by a physician, Part A covers certain services during your stay. This coverage extends for up to 90 days during each benefit period.
You also have an additional 60 lifetime reserve days. For inpatient care at a psychiatric hospital, Part A covers up to 190 lifetime reserve days.
Covered Inpatient Hospital Care Services Include:
Semi-private rooms
General nursing
Drug treatment
Meals
Hospital services and supplies
Inpatient Hospital Care Includes: inpatient care you receive in acute care hospitals, critical access hospitals, rehabilitation facilities, long-term care hospitals, qualifying clinical research studies, and psychiatric hospitals (limited to 190 days in a lifetime).
How to Qualify for Inpatient Hospital Care:
Inpatient stay must be in a Medicare-covered hospital or psychiatric hospital.
A doctor must determine that hospital care is necessary for treatment.
Your Costs (2022):
Your deductible for each benefit period is $1,556.
Once this deductible amount is met:
Days 1 – 60: Your coinsurance costs are $0.
Days 61 – 90: Your coinsurance costs are $389 per day.
Days 91 – 150: Your coinsurance costs are $778 per day.
From day 151 and on you will have used up your lifetime reserve days. Once you have exhausted your lifetime reserve days you are responsible for all costs.
Medicare only pays for these lifetime reserve days once. So, if a new benefit period begins, you will begin paying for all costs after the 90th day.
Long-Term Care Hospital Services:
Part A also covers the cost of care in a long-term care hospital. These are hospitals that specialize in treating patients hospitalized for 25+ days.
This might be a patient using a ventilator for an extended period or a patient with a severe wound or injury.
After discharge from a long-term care hospital, many patients move on to care in a Skilled Nursing Facility or custodial care in a long-term facility.
The cost structure is the same as listed above for inpatient hospital care. However, you do not have to pay an additional deductible if you were already charged one for prior hospitalization in the same benefit period.
Your benefit period starts on the first day of your initial hospital stay and counts toward this deductible. This is common if you have been transferred to long-term care from an acute care hospital or have been admitted to long-term care within 60 days of being discharged from a hospital.
Inpatient Mental Health Care Services:
Part A covers mental health care services received in a hospital that requires inpatient admittance. These services help patients with conditions like depression and anxiety.
The cost structure is the same as listed above for inpatient hospital care. However, for inpatient mental health care your costs will include 20% of the Medicare-approved services you receive while a hospital inpatient.
You can receive this care in a general hospital or a psychiatric hospital that cares specifically for people with mental health conditions. There is no limit to your number of benefit periods when receiving mental health care in a general hospital.
However, if you are an inpatient in a psychiatric hospital, Part A has a lifetime limit of 190 days. Also note that Medicare does not cover private duty nursing, personal items, a private room (unless medically necessary), or a phone or TV in your room.
2. Skilled Nursing Facility Care
Part A covers a range of services provided in a Skilled Nursing Facility by a skilled nurse of therapist. Typically, this care is for when you require skilled nursing or therapy to treat, manage, and observe your condition.
This coverage extends for up to 100 days each benefit period and also covers your room and board in the facility. It does not, however, include custodial or long-term care.
Covered Skilled Nursing Facility Services:
Tube feedings
Wound care
Medications
Medication administration
Medical supplies and equipment used in the facility
Dietary counseling
Medical social services
Swing bed services
Semi-private room
Meals
Ambulance transportation (when your health requires it) to nearest supplier of needed services.
The following services are also covered if required to meet your health goal:
Physical therapy
Occupational therapy
Speech-language pathology services
How to Qualify for Skilled Nursing Facility Care:
You have spent 3 consecutive days as an inpatient at a hospital.
You receive your skilled nursing care within 30 days of your inpatient stay.
A doctor has determined you require skilled care on a daily basis.
You need skilled services for a medical condition that is hospital-related or started while receiving care for such a medical condition.
Your Costs (2022):
Days 1 – 20: Your costs are $0 for each benefit period.
Days 21 – 100: Your coinsurance costs are $194.50 per day.
Day 101 and on: You are responsible for all costs associated with this care.
3. Hospice Care
For those that are terminally ill, Part A will cover necessary care to manage symptoms and control your pain. Part A also covers respite care and some medical equipment for use at your home.
This coverage is extended for as long as your healthcare provider determines you need the care. You will find that once you choose hospice care, Part A will generally cover all of your needs.
Covered Hospice Care:
Any items or services needed for pain relief and symptom management
Prescription drugs for pain relief or symptom control
Any medical, nursing, and social services
Durable medical equipment
Short-term inpatient care for pain and symptom management
Short-term respite care up to 5 days at a time
Hospice aide and homemaker services
Physical therapy services
Occupational therapy services
Speech-language pathology services
Dietary counseling
Grief and loss counseling for you and your family
Important Hospice Care Note: Your Part A hospice care does not pay for your stay in a facility unless a short-term stay is determined necessary for pain or symptom management. If this is the case, the facility must be Medicare-approved.
How to Qualify for Hospice:
Both your regular doctor and hospice doctor have certified you are terminally ill with a life expectancy of 6 months or less.
You accept palliative care (aimed at comfort) rather than care aimed at curing your illness.
You choose hospice care through a signed statement rather than other Medicare benefits that treat your terminal illness and other conditions.
Important Note: Once your hospice care begins, Medicare won’t cover the following:
Room and board for hospice care in your home, nursing home, or hospice inpatient facility.
Treatment aimed at curing your terminal illness or related conditions.
Prescription drugs aimed at curing your illness.
Care from a hospice provider not designated by the hospice medical team.
Hospital outpatient care, hospital inpatient care, or ambulance transportation (unless arranged by your hospice team or unrelated to your terminal illness).
Your Costs:
Your cost for hospice care is $0.
Note, however, that Medicare does not cover room and board for hospice care in your home, nursing home, or similar facility. Two other potential costs to be aware of are:
In the case of respite care, you may need to pay 5% of the Medicare-approved amount.
For prescription drugs and other pain relief products, you may need to pay a copayment of no more than $5.
4. Home Health Care
For those that are homebound and in need of skilled care, Part A will cover part-time skilled care in your home.
For daily care, this coverage lasts for up to 100 days. For intermittent care, your coverage is unlimited.
Home Health Care Covers:
Part-time or intermittent skilled nursing care
Part-time or intermittent home health aide services
Medical social services
Physical therapy
Occupational therapy
Speech-language pathology services
Home Health Care May Also Include:
Medical supplies for use at home
Injectable osteoporosis drugs
Durable medical equipment
Important Home Health Care Note: Medicare does not cover personal care such as help bathing, dressing, or using the bathroom when this is the only care that you require.
Additionally, Medicare does not cover 24-hour at home care, meals delivered to your home, or homemaker services.
How to Qualify for Home Health Care:
You are under the care of a doctor, which includes receiving services under a plan created and reviewed by the doctor.
A doctor has certified that you are homebound.
A doctor has certified that you need one or more of the following: Intermittent skilled nursing care (not including drawing blood), physical therapy, occupational therapy, or speech-language pathology.
These services must be specific and determined safe and effective treatment for your condition.
The amount, frequency, and duration of services must be reasonable and require a qualified therapist to perform.
The home health agency caring for you is Medicare-approved.
Important Home Health Care Eligibility Notes:
You are not eligible for home health care if you require more than part-time or intermittent skilled nursing care.
You can leave home under certain conditions, such as for medical treatment, short or infrequent non-medical absences (ex: religious services), and adult day care.
Your Costs:
Your cost for home health care services is $0.
Note, however, that if you require any durable medical equipment, you will be responsible for 20% of its Medicare-approved amount.
Home Health Care Costs Note: Before starting your home health care, your home health agency should detail for you how much of your costs Medicare will pay.
If there are any items or services of your care that Medicare doesn’t cover, your agency should inform you of this too, along with how much you will be required to pay. This notice required of your home health agency is called the Advance Beneficiary Notice.
Medicare Part B Medical Coverage:
Part B is known as your medical insurance. It is the second part of Original Medicare coverage. Part B helps to cover costs for medical services that extend beyond inpatient treatment, such as medically necessary services and preventive services.
While it is part of Original Medicare, enrollment in Part B is optional. Some individuals choose to defer enrollment if they are working past 65, though Part B can be used in coordination with employer coverage, as well.
If you are eligible for Medicare Part A, then you are also eligible to enroll in Part B coverage.
Part B covers both medically necessary services and preventive services. This includes some of the more expensive services you might experience during a hospital stay, procedures like surgery, radiation, and chemotherapy.
It also covers a number of preventive care measures such as flu shots, colonoscopies, and mammograms.
5. Medically Necessary Services
Medically necessary services include any services and supplies used for diagnosis and treatment of medical conditions.
These services and supplies must meet the accepted standards of medical practice. This includes the use of durable medical equipment like wheelchairs, hospital beds, and oxygen equipment.
Medically Necessary Services Cover:
Wheelchairs
Scooters
Canes
Walkers
Crutches
Patient lifts
Traction equipment
Hospital beds
Pressure-reducing beds and mattresses
Commode chairs
Suction pumps
Oxygen equipment
CPAP devices
Blood sugar monitors and test strips
Infusion pumps and supplies
Lancets and lancet devices
Nebulizers and nebulizer medications
Continuous passive motion devices
Your Costs:
Your costs will depend on a few factors. For starters, does your durable medical equipment supplier accept assignment? If yes, then you pay 20% of the Medicare-approved amount. Also, in this case, the Medicare Part B deductible applies ($233 for 2022).
Another factor is that Medicare may cover the costs in different ways, depending on the type of equipment you require and your qualifying diagnosis. For example: Whether you need to rent or buy the equipment will impact your costs.
Note: Medicare only provides coverage for durable medical equipment if your doctors and equipment suppliers are enrolled in Medicare and meet all of their standards. Also, note that if your suppliers participate in Medicare, they must accept assignment.
However, if your supplier is enrolled in Medicare but not participating, they can choose whether or not to accept assignment.
6. Preventive Services:
Preventive services cover healthcare to prevent illness or detect it early enough for optimal treatment. This includes diagnostic tests like MRIs, EKGs, CT scans, and X-rays.
It also applies to covered screenings such as pap tests, HIV screening, glaucoma tests, hearing tests, diabetes screening, and colorectal cancer screenings.
If your healthcare provider accepts assignment, you often don’t have to pay anything for these preventive services.
Preventive Services Cover:
Abdominal aortic aneurysm screening
Cardiovascular disease screening
Cervical and vaginal cancer screening
Depression screening
Diabetes screening
HBV infection screening
Hepatitis C screening
HIV screening
Lung cancer screening
Prostate cancer screening
Colorectal cancer screening (multi-target stool DNA tests, screening barium enemas, screening colonoscopies, screening fecal occult blood tests, screening flexible sigmoidoscopies)
Mammograms
Alcohol misuse screening and counseling
Obesity screening and counseling
Sexually transmitted infections screening and counseling
Tobacco use cessation counseling
Bone mass measurements
Cardiovascular disease behavioral therapy
Diabetes self-management training
Glaucoma tests
Nutrition therapy services
One-time “Welcome to Medicare” preventive visit
Yearly “Wellness” visit
Shots (flu, hepatitis b, pneumococcal)
Ambulance Services:
Part B also covers ground ambulance services when you need transportation to a hospital, critical access hospital, or skilled nursing facility care for medically necessary services.
Additionally, if you require immediate ambulance transportation that ground transportation can’t successfully provide, then Medicare may pay for emergency airplane or helicopter ambulance transportation. Covered ambulance transportation is always to the nearest appropriate and capable medical facility.
For ambulance service costs, you will pay 20% of the Medicare-approved amount. Additionally, the Part B deductible applies.
Medicare may pay for limited nonemergency ambulance transportation if medically necessary and you have a written order from your doctor stating such.
An example of when this may apply is ambulance transportation to a dialysis facility for patients with End-Stage Renal Disease.
Outpatient Mental Health Care Services:
Part B also helps to pay for several outpatient mental health services that address conditions like depression and anxiety. This care is typically referred to as counseling or therapy.
Part B covers these outpatient mental health services:
Psychiatric evaluation
Medication management
Diagnostic tests
Partial hospitalization
Family counseling (if determined to help with your treatment)
Individual and group psychotherapy with doctors or licensed professionals (depending on what your state allows).
One depression screening per year done in a primary care doctor’s office or clinic that can provide follow-up treatment and referrals.
Certain prescription drugs that aren’t typically self-administered, such as injections.
Testing to determine if your current treatment is helping you.
One-time “Welcome to Medicare” preventive visit that includes a review of possible risk factors for depression.
Annual “Wellness” visit that includes evaluation of your mental health.
Treatment for inappropriate alcohol and drug use.
If your doctor or health care provider accepts Medicare assignment, there will be zero cost to you for your yearly depression screening. For other visits to your doctor or health care provider for diagnosis and treatment, you will pay 20% of the Medicare-approved amount.
You may be responsible for an additional copayment or coinsurance amount if you receive services in a hospital outpatient clinic or department.
Part B covers your mental health services when you visit with a psychiatrist, doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, and physician assistant.
Additionally, you are only covered when the visit is to a health care provider that accepts assignment. Part B also covers outpatient mental health services provided outside of a hospital, such as in a doctor’s office, health care provider’s office, hospital outpatient department, and community mental health center.
Partial Hospitalization Mental Health Care Coverage:
Part B provides partial hospitalization coverage if you meet the requirements and your doctor certifies that inpatient treatment would otherwise be necessary. Partial hospitalization is a structured program that serves as an alternative to inpatient psychiatric care.
Treatment is provided during the day and is more intense than care you would receive in a doctor’s or therapist’s office.
For each service you receive from a doctor or qualified mental health professional, you will pay a percentage of the Medicare-approved amount (so long as they accept assignment).
Additionally, you will pay coinsurance for each day you receive partial hospitalization services in a hospital outpatient setting or community mental health center. The Part B deductible also applies.
Medicare helps to cover these services when provided through a hospital outpatient department or community mental health center. Along with partial hospitalization costs,
Medicare might help to cover occupational therapy and patient training and education about your condition.
Second Surgical Opinion Coverage:
Part B covers a second opinion for non-emergency surgeries. The second opinion is used to get another doctor’s opinion about your health problem and how it should be treated. Part B will also help to pay for a third opinion if the first and second opinions differ.
For second opinion coverage you will pay 20% of the Medicare-approved amount. If seeking a third opinion, you will pay 20% of the Medicare-approved amount in this case, as well. The Part B deductible applies to this coverage.
Outpatient Prescription Drug Coverage:
Part B covers certain outpatient prescription drugs under limited conditions. The covered drugs are those you wouldn’t typically give yourself, such as those usually administered in a doctor’s office or hospital outpatient setting.
Outpatient Prescription Drugs Covered:
Drugs that are used with durable medical equipment. This might include an infusion pump or nebulizer.
Injectable and infused drugs. Most of these drugs are covered when given by a licensed medical provider.
Injectable osteoporosis drugs. If you are a woman with osteoporosis eligible for home health benefits and a doctor has certified that your bone fracture is related to post-menopausal osteoporosis, Medicare will help cover your costs.
Certain antigens. Medicare will help to pay for antigens, so long as they are prepared by a doctor and provided under proper instruction and appropriate supervision.
Blood clotting factors. If you have hemophilia, Medicare will help pay for clotting factors that are given to yourself by injection.
Erythropoiesis-stimulating agents. If you have End-Stage Renal Disease or need this drug to treat anemia, Medicare helps to pay for erythropoietin by injection.
Oral End-Stage Renal Disease drugs. Some oral End-Stage Renal Disease drugs are covered if available in injectable form and covered under the Part B End-Stage Renal Disease benefit.
Calcimimetic Medications. Medicare helps to covers calcimimetic medications under the End-Stage Renal Disease payment system. This includes Parsabi and Sensipar. Your End-Stage Renal Disease facility is responsible for giving these medications to you, either at their facility or through a pharmacy.
Parental and enteral nutrition. Medicare helps with costs for intravenous nutrition and tube feeding when you are unable to consume food by mouth or absorb nutrition through your intestinal tract.
Intravenous Immune Globulin provided in home. If you have a diagnosis of primary immune deficiency disease, Part B covers Intravenous Immune Globulin (IVIG). A doctor must determine it is medically appropriate for the IVIG to be given at home. Part B solely covers the IVIG itself and does not cover other related items or services.
Vaccinations. Flu shots, Hepatitis B shots, pneumococcal shots are all covered by Medicare. Some other vaccines may be covered if they are directly related to treatment of your injury or illness.
Immunosuppressive drugs. Your transplant drug therapy is covered if Medicare helped to pay for your organ transplant.
Oral cancer drugs. Certain oral cancer drugs may be covered if taken by mouth and the same drug is available in injectable form.
Oral anti-nausea drugs. If your anti-nausea drugs are used as part of an anti-cancer chemotherapeutic regimen, Medicare will help with costs. The anti-nauseas drugs must be administered before, during, or within 48 hours of chemotherapy or be used as a full therapeutic replacement for an intravenous anti-nausea drug.
Self-administered drugs. If you need certain self-administered drugs, such as through an IV, Medicare may help to pay for these drugs if required for the hospital outpatient services you are receiving.