It’s not uncommon to be unsure of what Medicare does and does not pay for. Typically, people are surprised when they receive bills from their doctor.
Whether you choose original Medicare or Medicare Advantage, they must both cover the same basic services as determined by Medicare Part A and B.
However, here is the key thing to know, even if Medicare covers it, they rarely if ever cover 100% of the cost o the service.
At a high-level Medicare covers the following services:
Part A – Hospital Insurance (This coverage varies from service to service)
- Inpatient care in hospitals
- Skilled nursing facility care
- Hospice
- Home-health
Part B – Medical Insurance (80 percent coverage, after deductible)
- Basic doctor visits
- Many preventative services
- Outpatient Care
Part D – Prescription Drug Coverage (Must have Part A and B to qualify)
- Helps cover the cost to Medicare-approved drug once deductible has been met
Medicare will not cover:
- Cosmetic surgeries or anything that isn’t medically necessary
Additionally, the services they cover will depend on what plan you pick. Original Medicare, which includes Part A and B or Medicare Advantage which includes Part A, B and D.
Let us save you some time, below are the top four services Medicare surprising does or doesn’t cover.
Services Medicare does cover:
- Therapy – While Medicare has always covered physical, occupational and speech therapy, in the past they only covered up to a certain dollar amount. However, just recently Medicare raised the cap on therapy and now they will pay for much more therapy. This is important especially for people will illness, such as Parkinson’s, who need extensive therapy.
- Chemotherapy – Most people don’t know this, but chemotherapy is covered by Medicare Part B. Since chemotherapy must be administered by a health care professional, this care is covered under Medicare Part B, not your prescription plan.
- Preventative Services –There are some preventative services that are part of the Affordable Care Act. You pay nothing for most of these services if you are in line with the rules. Some of these services include:
- Bone mass measurement
- Various types of cancer screenings
- Cardiovascular disease screenings
- Diabetes screening (you may be eligible for up to 2 diabetes screenings each year)
- Glaucoma tests
- Flu shots
- Obesity screening and counseling
- Yearly “Wellness” visit
- Limited Travel outside: Medicare will cover health care while traveling inside the US. The US includes the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Also, Medicare may cover medically necessary ambulance transportation to a foreign hospital only if you need to be admitted for a medically necessary service that is covered by Medicare Part A. So while Medicare may cover a few services outside the US, they don’t cover most services. Please make sure you understand exactly what Medicare covers before you travel overseas
Services Medicare doesn’t cover:
- Chiropractic care: Medicare covers manipulation of the spine if medically necessary to correct your spine if a bone moves out of position. However, you will be responsible for the costs of other services or tests ordered by a chiropractor (including X-rays and massage therapy).
- Too frequent cancer screenings. For example, Medicare covers one clinical breast exam every 24 months. If you are at high risk for cervical or vaginal cancer, Medicare covers these screening tests once every 12 months. Tip: most doctors forget this rule, so when they order you an exam at each of your annual visits, you will be responsible to pay for the extra exams.
- Vision, dental and hearing: Medicare covers medically necessarily vision, dental and hearing services. However, it doesn’t cover non-medically necessary vision, dental and hearing services. Not medically necessary services include annual exams, eye glasses, dental fillings, and hearing aids. You can get coverage for these services through some Medicare Advantage plans or separate vision, dental or hearing insurance plans.
- Services at certain health care providers: While Medicare does cover medically necessary services, you may not be able to get treatment from certain doctors of certain health care providers. For example, we often see people who are signed up for Medicare Advantage plans wanting to get treatment from facilities like M.D. Anderson when they are diagnosed with cancer. This is an issue because while M.D. Anderson currently accepts Original Medicare, it doesn’t accept most Medicare Advantage plans. Many Medicare beneficiaries are shocked to find out they can’t get treatment from certain doctors like this when they face serious health issue.
To get a full list of services Medicare does and doesn’t cover, please look at Medicare’s “Medicare & You” handbook.
It’s critical to your health and financial future that you understand what Medicare does and doesn’t cover. Understanding this ensures that you’re Medicare and supplemental coverage is aligned with your needs and risk.
The Medicare Coach
PS – If you are trying to make your Medicare decision and want help, join our free Medicare workshop “How to Make The Right Medicare Decision Without Wasting Time On Research Or Paperwork.” Once you join the workshop, be sure to ask your questions so we can answer them!
