What Does Medicare Cover?
Different levels of Medicare coverage allow for those who are eligible
to choose the part of Medicare that best fits their individual health needs.
Three main factors contribute to Medicare coverage. These include:
- Federal and state laws
- National coverage decisions made by Medicare concerning whether an item or service is covered
- Local coverage decisions made by the companies that process Medicare claims, including decisions on
whether something is medically necessary and should therefore be covered
Medicare Part A Coverage
Medicare Part A provides hospital coverage. This part of Medicare can help pay for healthcare received as
an admitted patient in a hospital or skilled nursing facility. It may also cover nursing home care (excluding
custodial-only care), hospice, and home health services.
Examples of medically necessary inpatient care that may be covered by Part A include:
- Lab tests, X-rays, and radiation treatment needed as an inpatient
- Operating room and recovery room services
- Drugs, medical supplies and equipment needed as an inpatient
- Some blood transfusions as an inpatient
- Physical therapy from home health services
- Hospital meals
Certain items are not covered under Medicare Part A. These include doctor services that you receive as an inpatient and custodial
care (help with dressing, bathing, eating, etc). Most doctor services you receive in the hospital are covered under Medicare Part B.
Medicare Part B Coverage
Medicare Part B provides medical coverage. There are two main types of services: medically necessary outpatient services
(needed to treat a disease or condition) and preventive services. Medicare Part B differs from Part A because it offers
coverage for things needed on an outpatient basis.
Examples of medically necessary outpatient and preventive services that may be covered by Part B include:
- Doctor office visits
- Flu and pneumonia shots
- Clinical laboratory tests (blood tests, urinalysis, etc.)
- Emergency room services
- Ambulance services
- Getting a second opinion before surgery
- Clinical research
- Some diagnostic screenings (colorectal screenings, mammograms, etc.)
- Mental healthcare as an outpatient
Similar to Part A, there are certain items not covered by Medicare Part B. These include custodial care
(help with dressing, bathing, eating, etc.) and most cases of dental, vision or hearing care.
Medicare Part C Coverage
Medicare Part C is called Medicare Advantage, a way to combine coverage from Part A and Part B.
Medicare Advantage plans must provide – at minimum – the same coverage offered by Medicare Parts A and B.
Examples of the services covered by Medicare Part C include:
- Hospital inpatient stays
- Skilled nursing services
- Home health services
- Medically necessary outpatient services
- Doctor office visits
- Medically necessary preventive services (shots and screenings)
- Laboratory tests
Medicare Part C may also include Part D coverage, which is then called a Medicare Advantage Prescription Drug Plan (MA-PD).
Medicare Part D Coverage
Individuals who select prescription drug coverage have two options: they can either
enroll in a stand-alone Prescription Drug Plan (PDP), or choose a Medicare Advantage Prescription Drug Plan (MA-PD).
Medicare Part D covers the most commonly prescribed drugs.However, the specific drugs covered might vary depending on the PDP.
The covered drugs are included in the plan’s formulary, or list of drugs.