Medicare can be confusing, especially when you’re trying to figure out what services are covered and what you’ll have to pay for yourself. Whether you’re getting ready to enroll in Medicare or helping a loved one understand their coverage, knowing the basics can help you avoid unexpected medical bills.
What Is Medicare?
Medicare is a federal health insurance program primarily for adults age 65 and older. Some younger people with certain disabilities or medical conditions may also qualify.
Medicare is different from Medicaid, which is a joint federal and state program that helps people with limited income and resources pay for healthcare.
Medicare has four parts, and each covers different healthcare needs.
Part A: Hospital Insurance
Part A helps cover care you receive in a hospital or certain healthcare facilities. This can include:
- Inpatient hospital stays
- Short-term skilled nursing facility care if you qualify
- Hospice care
- Certain home healthcare services
One important thing to know is that Medicare does not automatically pay for your entire hospital stay. Depending on your situation, you may still have deductibles or other out-of-pocket costs.
Part B: Medical Insurance
Part B helps pay for many of the healthcare services you receive outside of a hospital, including:
- Doctor visits and outpatient appointments
- Medical equipment such as walkers and wheelchairs
- Preventive screenings and vaccinations
- Physical, occupational, and speech therapy
- Other medically necessary services
Most people pay a monthly premium for Part B, and there may be additional costs depending on the services received.
Part C: Medicare Advantage
Medicare Advantage is another way to receive your Medicare benefits. These plans are offered by private insurance companies approved by Medicare.
Medicare Advantage plans provide the services covered by Parts A and B, and many offer additional benefits such as:
- Prescription drug coverage
- Dental care
- Vision care
- Hearing services
Not all Medicare Advantage plans are the same. Costs, benefits, and which doctors or hospitals you can use may be different depending on the plan you choose.
Part D: Prescription Drug Coverage
Part D helps pay for prescription medications.
You can receive Part D coverage through a separate prescription drug plan or through many Medicare Advantage plans.
Each plan has its own list of covered medications. This means a prescription that costs one amount under one plan could cost something different under another.
It’s a good idea to check that your medications are covered before choosing a plan.
What Doesn’t Medicare Usually Cover?
This is where many families get surprised. While Medicare covers a wide range of medical services, there are some important things that Original Medicare generally does not pay for.
These include:
- Routine dental care, such as cleanings, fillings, and dentures
- Routine eye exams for glasses or contact lenses
- Hearing aids and exams for fitting them
- Long-term care in assisted living, nursing homes, or memory care communities when the care is primarily personal assistance
- Ongoing help at home with everyday activities such as bathing, dressing, and eating
- Routine physical exams
- Most healthcare received outside the United States
There are exceptions to some of these rules. For example, Medicare may cover certain dental services when they are directly connected to another covered medical procedure. Some Medicare Advantage plans also offer additional dental, vision, or hearing benefits.
One important distinction is the difference between skilled nursing care and long-term personal care. Medicare may cover a short stay in a skilled nursing facility when certain requirements are met. However, it generally does not pay for someone to live long-term in a nursing home or assisted living community simply because they need help with daily activities.
This is especially important for families who are beginning to look into senior living or in-home care options.
Why Is Understanding Medicare Important?
One of the biggest misconceptions about Medicare is that once you turn 65, all your healthcare expenses will be covered.
Unfortunately, that’s not the case.
Medicare can still involve monthly premiums, deductibles, copayments, and services that aren’t covered at all.
Some people purchase additional insurance, called Medigap, to help pay certain out-of-pocket costs that Original Medicare doesn’t cover.
The type of coverage you choose can make a big difference in what you pay and which healthcare providers you can see.
A Little Planning Can Help Avoid Surprises
Medicare provides valuable health coverage, but it doesn’t cover everything. Before scheduling a medical procedure, arranging home care, or moving into a senior living community, it’s important to understand what your specific plan will pay for.
If you’re unsure, contact Medicare or your insurance provider and ask questions before receiving services.
Taking a little time to understand your coverage now can help you make better decisions and avoid unexpected expenses later.
For additional information about Medicare and what it covers, visit www.medicare.gov.
