What’s not covered under Medicare Part A and Part B?
This article was updated on: 07/25/2017
If you’re a new Medicare enrollee or about to become eligible, you may have questions about what’s included in your benefits—and more importantly, what’s not. Here’s a look at your coverage under the Medicare program.
What do I get with Original Medicare?
Original Medicare refers to coverage under Part A, or hospital insurance, and Part B, the medical insurance portion. Most people are automatically enrolled in Original Medicare if they’re already receiving Social Security benefits when they become eligible for Medicare.
If you are hospitalized as an inpatient, Part A generally covers:
- A semi-private hospital room, unless your doctor orders a private room for medical reasons
- Hospital meals
- General nursing
- Medically necessary prescription drugs, supplies, and equipment you receive while you are in the hospital
- Skilled nursing facility care
- Hospice care
- Some home health care (for a limited time, as medically necessary)
Part A does NOT generally cover:
- Nursing homes for custodial care only
- Private-duty nursing
- Care outside the United States in most cases
- Hospital stays related to cosmetic surgery or stays that are not “medically necessary”
- Prescription drugs, unless they’re given to you as a hospital inpatient as part of your treatment.
Sometimes your Medicare Part A and Part B benefits cover different parts of a hospital stay. For example, while you’re a hospital inpatient, Part A covers many services (such as those listed above), but Part B may cover things like lab tests and your stay in a recovery room.
Part B may cover:
- Doctor visits
- Outpatient medical care
- Certain vaccinations, such as the flu shot
- Some preventive exams, tests, and screenings
- Behavioral therapy
- Physical, occupational, respiratory, and speech therapy
- Limited and usually temporary home health care (but not for custodial care, such as assistance with eating, bathing, dressing, and toileting)
- Medically necessary ambulance transportation
- Durable medical equipment and supplies
- Annual physical exam
- Mental health services
Part B does NOT generally cover:
- Prescription drugs except in limited circumstances (those administered by a medical professional, such as IV medications, for example)
- Routine foot care and podiatry services
- Routine hearing care and hearing aids
- Routine eye exams and prescription eyewear
- Routine dental care, including exams, fillings, extractions, and dentures
- Fitness or wellness programs
These items represent a partial list; your doctor or health-care provider may be able to help you understand specific coverage related to your treatment. It’s also important to remember that you may have to pay a copayment or coinsurance for any services covered by Medicare, and there are no limits on the out-of-pocket expenses you are responsible for each year. In some cases, you may also be required to use providers contracted with Medicare in order to receive coverage.
How can I get help paying for things Part A and Part B don’t cover?
For prescription drug coverage, you can sign up for a stand-alone Medicare Part D Prescription Drug Plan to work alongside your Medicare Part A and Part B coverage. Another way you can get this coverage is through certain Medicare Advantage plans, described below.
According to the Kaiser Family Foundation, one in three Medicare beneficiaries choose to receive their Medicare benefits through the Medicare Part C program, or Medicare Advantage. In fact, enrollment in Medicare Advantage has grown by 50% since health-care reform passed in 2009. This may be because Medicare Advantage plans often include coverage for many of the services not covered under Original Medicare. For example, Medicare Advantage plans may cover:
- Prescription drugs (subject to the plan’s formulary, or list of approved medications); some may include discounts on certain over-the-counter medications, as well.
- Routine eye exams, prescription eyewear, and/or contact lenses.
- Hearing exams; some may include an annual benefit toward hearing aids.
- Routine dental exams and non-surgical restorations.
- Immunizations and vaccinations.
- Wellness and fitness programs (some even include discounted gym memberships).
Basically, many Medicare Advantage plans combine your Part A and Part B coverage with prescription drug coverage and other benefits in one convenient plan. All Medicare Advantage plans must provide at least the same level of coverage as Original Medicare (except for hospice care, which is still provided under Part A), but they may include additional benefits.
Some things to keep in mind about the Medicare Advantage program:
- Medicare Advantage plans are offered by private insurance companies contracted with Medicare. Plan benefits may vary depending on where you live, and not all plans may be available in every location.
- You must continue to pay your Part B premium each month; depending on your plan, you may also pay an additional monthly premium. Premiums may also vary depending on where you live and which insurance company you chose.
- Some plans may require you to use a network of health-care providers, unless you need emergency care.
- If you enroll in a Medicare Advantage plan, you can no longer use your Original Medicare benefits while you are enrolled in the plan. Medicare Advantage replaces Original Medicare, it does not supplement it.
- Medicare Advantage plans cannot be combined with Medicare Supplement plans (Medigap) or (in most cases) with stand-alone Medicare Part D Prescription Drug Plans.
Would you like more information about how to get coverage for services you need that aren’t available under Original Medicare? I’d be happy to discuss your options, including Medicare Advantage plans. If you prefer, you can request an email with information prepared for you, or schedule a telephone call, by clicking one of the buttons below. To view a list of plans in your area you may qualify for, click the “Compare Plans” button. To get help right away, please call me or another eHealth licensed insurance agent at 1-844-847-2660 (TTY users can call 711) Monday through Friday, 8AM to 8PM ET.