Medicare 101: What Does Medicare A & B Cover?
So, what does, and doesn’t, Medicare cover? For those with original, fee-for-service Medicare, the following lists offer the highlights.
Services Medicare Part A (“Hospital Insurance”) DOES cover:
Inpatient hospital care
Inpatient care in a skilled nursing facility for a limited number of days, following a qualifying 3-day minimum inpatient hospital stay for a related illness or injury
Home health services as ordered by a doctor (or other health care provider), including nursing care; physical, speech or occupational therapy; medical social services; home health aide services and medical supplies for use at home
Hospice care if you have a terminal illness with a life expectancy of 6 months or less, as certified by a doctor, at home or facility where you reside. Limited coverage for stays in a hospice facility, hospital or skilled nursing facility for pain or symptom management
Services Medicare Part A does NOT cover include:
Custodial care or long-term care in a skilled nursing facility or nursing home. Custodial care includes non-skilled personal care, like help with bathing, dressing, eating, getting in and out of a bed or chair, or toileting
Private duty nursing
Confusion often exists about Medicare coverage and nursing homes. Medicare does NOT pay for room and board costs or non-skilled personal (custodial) care in a nursing home, or long term care or assisted living facility. It does cover Medicare-approved medical care and services, ordered and rendered by a Medicare-enrolled health care provider, such as a doctor or physical therapist, to the beneficiary who is a resident.
Services Medicare Part B (“Medical Insurance”) DOES cover:
Doctors’ visits, services and tests; outpatient care and services; some home health services not covered under Part A; Medicare-covered durable medical equipment (DME), prosthetics, orthotics and supplies
Medicare-covered services provided by non-physician health care providers, such as nurse practitioners, physician assistants, social workers, psychologists, physical therapists, and others
Many preventive services and tests
Outpatient mental health care
Kidney dialysis services and supplies
Ambulance transport for medically-necessary services (limited)
Chiropractic services (limited)
Eyeglasses (limited to after-cataract surgery that implants an intraocular lens)
Some prescription drugs (i.e. injections in doctor’s office, certain oral cancer drugs)
Transplants and immunosuppressive drugs
Things that are NOT covered by Medicare, under either Parts A or B, include: routine dental care, dentures, hearing aids and exams for fitting hearing aids, cosmetic surgery, and acupuncture.
For those who get coverage through a Medicare Advantage Plan (Medicare Part C), the story is somewhat different. Medicare Advantage Plans are offered by Medicare-approved private insurers, and must cover all the services covered under original Medicare, except hospice care, which continues to be covered by original fee-for-service Medicare even when a person is enrolled in a Medicare Advantage Plan. These plans, which may charge a premium, deductible and co-insurance, may include extra benefits and services NOT covered under original fee-for-service Medicare, such as dental and vision care, glasses, hearing aids and health and/or wellness programs. Most plans also include prescription drug coverage, available to those in original Medicare under Part D.
Information about what Medicare does and doesn’t cover is available in the “Medicare & You” handbook, updated and mailed annually to every beneficiary in October, and also available at the Medicare website www.medicare.gov. This Medicare website is also a great source of information, as is 1-800-MEDICARE (633-4227)-TTY users call 1-877-486-2048-where trained customer service representatives can help. In addition, APPRISE, the Pennsylvania State Health Insurance Program, can provide personalized help in your community-call 1-800-783-7067 to get the help you need.