Understanding your Medicare coverage will help you plan for the expected and unexpected.
Original Medicare (made up of Part A and Part B) is a federally funded healthcare program that typically covers seniors age 65 or older and people on disability. While Medicare can cover a number of your healthcare expenses, it does not cover everything you might need for the rest of your life.
In fact, you will probably need to purchase at least one or two additional plans to protect you from high healthcare-related expenses. Or, you may decide to switch from Original Medicare to Medicare Advantage.
Here are some examples of the medical expenses that are NOT covered by Original Medicare.
- Most prescription drugs
- Co-pays, co-insurance and deductibles
- Medical coverage when you are traveling outside the US
- Dental exams, most dental care or dentures
- Routine eye exams, prescription eyeglasses or contacts
- Hearing exams, hearing aids or hearing-related services
- Routine foot care
- Wellness programs/gym memberships
- Custodial/personal care
- Long-term care
- Cosmetic surgery
- Most chiropractic services
- Acupuncture or other alternative treatments
Most people require some form of prescription drug coverage, which Medicare-eligible people can get through a Medicare Part D, Prescription Drug Plan (which is not included in Original Medicare) or by switching from Original Medicare to a Medicare Advantage Plan that also includes prescription drug coverage.
Expenses like co-pays, co-insurance, deductibles and protection when traveling outside the US can be covered through certain Medicare Supplement Plans/Medigap Plans, which can be purchased from private insurance companies.
Additionally, most people need some Dental, Vision and Hearing Coverage to cover the costs of items like exams, hearing aids, eyeglasses, dentures and more. You can purchase stand-alone coverage for these benefits, or consider switching to a Medicare Advantage policy that includes this type of coverage.
What Does Original Medicare Cover?
Medicare Part A covers inpatient hospital stays, certain home health services, hospice care, skilled nursing facility care and some transplants. Examples of what Part A may cover include:
Inpatient Hospital Stays
- Semi-private (shared) room
- Inpatient care at acute care hospitals
- Prescription drugs as part of your inpatient treatment
- Care at inpatient rehabilitation facilities, long-term care hospitals and critical access hospitals
- Inpatient care as part of a qualifying clinical research study
- Mental health care
- Certain organ and stem cell transplants at Medicare-approved facilities
Home Health Services
- Medically necessary part-time or intermittent skilled nursing care
- Physical therapy, speech therapy and a continuing need for occupational therapy
- Medical social services
- Part-time or intermittent home health aide services
Hospice Care (for those expected to live 6 months or less)
- Prescription drugs for pain relief and symptom management (in some cases, you may need to make a co-payment)
- Medical, nursing and social services
- Short-term inpatient care
- Homemaker services
- Physical, occupational and speech therapy
- Short-term inpatient stays for pain and symptom management (in a Medicare-approved facility)
- Respite care (a temporary stay in a Medicare-approved facility while your usual caregiver is unavailable or needs a break)
- Certain health problems that aren’t related to your terminal illness
- Grief counseling
Skilled Nursing Facility Care (after a three-day minimum hospital stay)
- A semi-private room
- Skilled nursing and rehab services
Medicare Part B helps cover preventive services (like medical checkups and screenings) and medically necessary services, such as supplies or services you need to treat a medical condition. Examples of what Part B may cover includes:
- Ambulance Services
- Cardiac rehab
- Diabetes self-management and supplies
- Some medical equipment like walkers, wheelchairs or oxygen
- Emergency room service
- Kidney dialysis
- Outpatient mental health care
- Occupational therapy
- Some approved services, such as X-rays, casts and stitches
- Routine physical or wellness exams
- Physical therapy
- Prosthetic and orthotic devices
- Pulmonary rehab
- Preventative screenings
- Urgent Care
Overall, Medicare is a helpful service that can save you thousands of dollars in medical expenses, but most people will need additional coverage to protect themselves. Talk to a licensed insurance agent about what specific coverage and policies are best for your individual needs.