Medicare Coverage: What does Medicare Cover?

What Does Medicare Cover?

WebMD Medical Reference

This is a general guide to what Medicare covers. To find out about specific things that Medicare covers, visit the Publications page at www.medicare.gov. Download "Your Medicare Benefits." You can also get a printed booklet by calling (800) MEDICARE (800-633-4227).

Medicare Part A

Most people don't have to pay a fee or premium for Medicare Part A. This is because they or a spouse paid Medicare taxes when they were working. To get Part A free, you or a spouse must have worked for at least 40 "quarters." A quarter means one quarter of a year.

You will not get Part A free if

  • You or your spouse worked less than 40 quarters of Medicaid-covered employment
  • You are disabled and under 65 and lost disability benefits because you were working

If you have to pay for Part A coverage, the fee in 2005 is $393 per month. If you or a spouse worked between 30 to 39 quarters, the cost is reduced to $206 per month.

Hospital Stays

Hospital stays are covered under Medicare Part A. This includes:

  • A semi-private room
  • Meals
  • Nursing
  • Hospital services and supplies
  • Inpatient mental health care (lifetime limit of 190 days)
What You Pay
Days in Hospital You Pay
1-60 Up to $952
61-90 $228 per day
91-150 $456 per day
151 + All costs

Skilled Nursing Facility Care

After a three-day related hospital stay:

Skilled nursing facility care is not the same as long-term nursing home care. Medicare Part A does not cover long-term nursing home care.

What You Pay
Days in Skilled Nursing Facility You Pay
1-20 Nothing
21-100 Up to $114
101 + All costs

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Home Health Care

Home health care benefits include:

  • Part-time or intermittent skilled nursing care
  • Home health aide services
  • Physical and occupational therapy
  • Speech therapy
  • Medical social services
  • Durable medical equipment (wheelchairs, walkers, etc.)
  • Medical supplies
What You Pay
Nothing for Medicare-approved home health care services
20% of the Medicare-approved cost for durable medical equipment

All providers of Part A services must be certified by Medicare. If you go to a provider who is not Medicare certified, Medicare will not pay for the service. All Medicare certified providers accept Medicare and your share of costs as full payment.

Hospice Care

Hospice care is for people with a terminal illness. It covers:

  • Doctors' services
  • Nursing care
  • Durable medical equipment (wheelchairs, walkers, etc.)
  • Medical supplies (bandages, catheters, etc.)
  • Drugs to control symptoms
  • Drugs for pain relief
  • Short-term hospital care
  • Short-term respite care (although this requires a small co-payment)
  • Home health aide services
  • Homemaker services
  • Physical and occupational therapy
  • Speech therapy
  • Social worker services
  • Dietary counseling
  • Grief and loss counseling for you and your family

Hospice care is usually given at home, but Medicare will cover "respite care." Respite care is a short-term stay at a hospice facility. This gives the usual caregiver a chance to rest. Respite care may last up to five days at a time. There is no limit to how many periods of respite care hospice patients may have.

What You Pay
No more than $5 for each prescription drug
5% of what Medicare pays for inpatient respite care per day

Blood

  • Pints of blood you get in the hospital or skilled nursing facility are covered.
What You Pay
You pay for the first three pints of blood.
Unless
You or someone else you know donates three pints of blood.

Medicare Part B

To enroll in Part B, most people pay a premium each month. In 2005, the monthly fee is $78.20. If you sign up late, the cost will be higher.

Medical and Other Services

  • Doctors' services (including office visits, but not routine physical exams)
  • Outpatient medical and surgical services and supplies
  • Diagnostic tests
  • Ambulatory surgery center facility fees for approved procedures
  • Durable medical equipment (such as wheelchairs, walkers, etc.)
  • Second and sometimes third surgical opinions
  • Outpatient mental health care
  • Outpatient occupational and physical therapy
  • Speech therapy
What You Pay
$124 annual deductible in 2005
20% of Medicare-approved amount after the deductible and 100% of charges above the approved amount
50% of most outpatient mental health costs

The Medicare-approved amount is what Medicare has decided it will pay for an item or service. Doctors may charge 15% above the approved amount. In some cases, health care providers and suppliers are required by law to accept the Medicare-approved amount. Any amount over the approved cost is not covered. For example:

After You Reach Your Deductible
Medicare-Approved Cost If You Are Billed You Pay
$100 $100 $20
$100 $150 $70

Laboratory and Radiology Services

Clinical lab services are covered, including:

  • Blood tests
  • Clinical diagnostic tests
  • X-rays, CT scans, MRI scans, and EKG tests
  • Urinalysis
  • Some routine screening tests (see Preventive Services)

What You Pay

You pay nothing for these services.

Outpatient Hospital Services

  • Medicare Part B covers services and supplies you get while being treated as an outpatient in a hospital.

What You Pay

You pay a co-payment. The amount varies depending on the type of service or supply.

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Blood

  • Pints of blood you get for transfusions are covered.
What You Pay
You pay for the first three pints of blood you get.
20% of the approved cost for more than three pints
Unless
You or someone you know donates blood to replace what you used.

Preventive Services

Medicare covers the following preventive services:

Service How Often Who Can Get It
Bone mass measurements (to look for bone thinning osteoporosis) Once every two years (or more if needed) People at risk of osteoporosis
Cardiovascular Screening Blood Tests (including tests of cholesterol, lipids, triglycerides, and other markers of cardiovascular disease) Every 5 years. Ask your doctor
Colorectal Cancer Screening (includes one or more of the following tests: colonoscopy, fecal occult blood test, flexible sigmoidoscopy, and/or a barium enema. Depends on your risk. Ask your doctor. People who age 50 or older or who are at high risk of colorectal cancer.
Diabetes Screening Tests (tests of blood glucose levels) Ask your doctor. You may be eligible for up to two screenings each year. Certain people who are at risk for diabetes
Digital rectal exam (a prostate cancer screening test) Once a year Men aged 50 and older
Flu shot (vaccination) Once a year in fall or winter Everyone
Glaucoma testing (a vision-robbing condition) Once a year People who are at high risk of glaucoma.
Hepatitis B shot (vaccination) N/A Certain people at risk for Hepatitis B
Mammogram Once a year All women aged 40 and older
Pap test and pelvic exam, includes breast exam Once every two years; or once a year if you are at high risk All women
Pneumonia shot (vaccination) Ask your doctor Everyone
Prostate Cancer Screening (digital rectal exam and PSA test) Once a year Men aged 50 and older
"Welcome to Medicare" Physical Examination (includes measurements of height, weight, blood pressure, an EKG, education and counseling.) One time only Everyone whose Part B coverage began after January 1, 2005

For some of these services, you might have to pay a deductible, coinsurance, or co-payment. The costs will vary depending on the services you need and the type of Medicare plan you have.

Not Covered by Medicare A or B

With a few exceptions, these things are not covered by Medicare Parts A or B:

  • Prescription drugs (Medicare Part D will cover drugs starting in 2006)
  • Long-term nursing home care, if you only need help with daily activities
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and hearing exams
  • Eyeglasses and eye exams
  • Foot care
  • Diabetic insulin and syringes - will be covered under Part D
  • Health care outside the United States
  • Dental care and dentures
  • Routine or yearly physical exams (If your Part B coverage begins on or after January 1, 2005, Medicare will cover a one-time only physical exam within the first 6 months of coverage.)
  • Custodial care (help with bathing, dressing, eating, and using the bathroom)
  • Orthopedic shoes

Medicare Advantage (formerly called Medicare + Choice)

Medicare Advantage plans are health insurance policies you can buy from private companies. A Medicare Advantage plan replaces your traditional Medicare plan. They must offer all the services that traditional Medicare does. Medicare Advantage plans may also offer:

  • Prescription drug benefits
  • Dental Services
  • Hearing examinations and hearing aides
  • Eye examinations and glasses
  • Additional preventive services

To find and compare Medicare Advantage plans offered in your area, use Medicare's Personal Plan Finder.

New Drug Benefit

Prescription drugs will be covered by Medicare starting in 2006. Until then, you can save money on prescriptions by buying a drug discount card.

  • Discount cards are intended to save 10% to 25% on prescription drugs.

To find out about buying a discount card, use Medicare's Drug Discount Card tool, or call (800) MEDICARE ((800) 633-4227).

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You may also qualify for a credit to pay for prescriptions. Single people who make $12,919 a year or less, and married couples with an annual income of $17,320 or less are eligible.


Reviewed by Cynthia Haines, MD, August 2005.

SOURCES: Centers for Medicare and Medicaid Services. Medicare.gov web site. National Council on the Aging web site.


For additional Medicare information, please read the following articles:


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Reviewed on 12/9/2005

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