Although enrolling in Medicare when you turn 65 is a relatively straightforward process, you might be unclear on exactly what Medicare covered services, procedures, and treatments Medicare covers. It doesn’t help that there are two principal ways to get coverage, which is known as Original Medicare (Part A and Part B) or Part C, also known as the Medicare Advantage Plan. Then there are the additional plans, including Medigap and prescription coverage (Part D).
Each of the Medicare sections cover different treatments, prescriptions, and procedures, although there is some overlap. Furthermore, even though you can visit any doctor or hospital in the United States that accepts Medicare, some coverages are limited in their service area.
What might also be helpful is downloading the Medicare & You 2021 handbook. It is the standard Medicare given to Medicare recipients.
If you are unsure whether Medicare will cover a procedure or treatment (like tattoo removal) after reading this article, then talk with your doctor. If coverage does not extend to a particular treatment or procedure, your doctor may have you sign an Advance Beneficiary Notice of Noncoverage (ABN). An ABN says that you will pay for items that are not covered. You may also use the search option here to check to see if a particular service is included under Medicare.
Original Medicare
The Original Medicare package includes Part A and Part B. It does not cover long-term custodial care, most dental care, dentures, hearing aids or exams for hearing aids, eye exams for prescription glasses, routine foot care, or acupuncture. It does not matter if you want to a hearing aid clinic in Canada or elsewhere, the restrictions are the same. Most coverage implies that you will pay 20% of the total Medicare-approved amount and you must meet the deductible for either Part A or Part B, whichever section will cover the procedures. If the treatment is done as an outpatient, you may also be responsible for paying the facility fee.
Medicare Part A
Medicare Part A is the hospital insurance component. This section covers inpatient care in a hospital or skilled nursing facility, nursing home care, hospice, and home health care.
Inpatient Care
If you are admitted to the hospital as an inpatient because of a doctor’s order and the hospital accepts Medicare, your stay is usually covered in its entirety or partially. You’ll be responsible for the $1,408 deductible charged for every benefit period. A benefit period is the time you spend in the hospital beginning on the day you were admitted and ends the day you have been out of the hospital for 60 days. So if you were hospitalized for 4 days, your benefit period ends 65 days after your admission.
For the first 60 days, you will not need to pay any co-insurance. If your hospital stay extends past that but less than 90 days, there will be a $352 co-insurance charge per day. After 90 days, there is a $704 co-insurance charge per day for each lifetime reserve day. Lifetime reserve days are an extra 60 days of coverage that can be used only once. So if you are hospitalized for 95 days, you’ll still have 55 lifetime reserve days.
Once you’ve used all your lifetime reserve days, you are responsible for all inpatient hospitalization costs. Thus, if your hospital stay is more than 150 days, you will need to pay out-of-pocket starting on day 151, if you don’t have another form of insurance.
Medicare covers a semi-private room, meals, general nursing, medications that are part of your treatment including methadone, and some other services and supplies. Private-duty nursing, a private room (unless medically necessary), personal care items, phone, and TV access are not covered.
Inpatient hospital care can be obtained at acute care and critical access hospitals as well as inpatient rehabilitation and psychiatric facilities. Psychiatric hospital inpatient care is limited to 190 days in a lifetime. Long-term care hospitals and inpatient care as part of a clinical research study are also covered.
If you are admitted inpatient rehabilitation care in an IRF, rehabilitation hospital, or acute care rehabilitation center and your doctor certifies that you have a medical condition that requires this level of care, Medicare Part A will cover part of the expenses. The first 60 days have a deductible of $1,364 unless you were already charged a deductible for a previous hospitalization during the same benefit period. During the COVID-19 pandemic, you may be transferred from an acute-care hospital that is at maximum capacity even if you don’t need rehabilitation.
From 61 to 90 days, you are responsible for $341 coinsurance per day. Over 90 days, the coinsurance is $682 for the lifetime reserve days. After you’ve used all your lifetime reserve days, you must pay for all costs.
Services that are included in the inpatient rehabilitation facility include occupational and physical therapy, speech-language pathology, nursing services, medications, meals, a semi-private room, and other hospital supplies.
Skilled Nursing Facility Care
Medicare Part A will cover skilled nursing facility care if certain conditions are met. You must have days left in your benefit period, you have been admitted as an inpatient to the hospital, and your doctor has determined you need skilled nursing daily. The skilled nursing facility must be certified by Medicare. The skilled services must be related to a medical condition that was treated during a 3-day inpatient hospital stay or a condition that began while you are receiving skilled nursing care.
You pay nothing for the first 20 days of care during each benefit period. If your treatment continues more than 20 days but fewer than 100, there is a $176 co-insurance cost per day. Any care past 100 days is not paid for by Medicare.
Medicare covers a semi-private room, meals, skilled nursing care, physical and occupational therapy, radiation therapy, and chemotherapy. It also covers speech-language pathology services, medical social services, medications, dietary counseling, and medical supplies and equipment used while you are in residence at the facility.
Medicare will also cover the cost of ambulance transportation to a hospital from the skilled nursing facility if you need treatment that isn’t available at the facility. If the skilled nursing facility has an agreement with the Department of Health and Human Services (HHS), Medicare will cover the cost of providing acute hospital care, known as swing bed services.
Long-Term Care
Part A covers care in a long-term care hospital (LTCH) under certain conditions. The coinsurance prices are the same for inpatient care. There is no deductible if you have already paid a deductible for a previous hospitalization during the benefit period.
Long-term care is considered hospital admittance for more than 25 days. Situations, when long-term care might be approved, include extended ventilator use, severe wounds, or head injuries.
Nursing Home Care
Medicare Part A covers inpatient nursing home care that is in a skilled nursing facility not classified as long-term or custodial care. Custodial care includes assistance bathing, dressing, using the bathroom, and eating. If you are in need of skilled nursing care while you are an inpatient in a nursing home, then Medicare will cover that service. An example of this type of service is having surgery sites or wounds dressed by a skilled nurse.
Religious Nonmedical Health Care
If you are receiving care from a religious nonmedical health care institute (RNHCI) and you qualify for skilled nursing or hospital care, Medicare Part A will cover inpatient non-religious items or services. Typically these are items that do not need a doctor’s order or prescriptions including room and board or unmedicated wound dressings. The RNHCI must be certified to take part in Medicare. You also need to have a written statement on file with Medicare stating that your choice of the facility is based on your religious beliefs. Furthermore, you have to agree that if you receive standard medical care, you will revoke your eligibility for RNHCI care for one year after the first change in treatment and five years after the next one.
There is a $1,408 deductible for each benefit period. Up to 60 days, you pay nothing for coinsure. After that, you pay the same coinsurance amounts for inpatient treatment at a medical facility.
Hospice Care
Medicare Part A will cover hospice care under certain conditions. If your life expectancy is less than six months and you agree to palliative rather than medical care, you may receive coverage. You must also sign a waiver to that effect. If you need care longer than six months, then your doctor will need to recertify that you have a terminal illness at a face-to-face meeting to continue receiving coverage.
Medicare will pay for anything needed for pain relief and symptom management including medication and medical equipment. Medical, nursing and social services including spiritual and grief counseling for you and your family are covered as it relates to your end of life plan. You may also qualify for personal aide and homemaker services.
Hospice care can be arranged in a nursing facility or in your own home. If your medication is not covered under Part A, you may need to pay a copayment of $5 for each prescription. If you need inpatient respite care, you may be responsible for 5% of the amount. The respite care must be set up with a Medicare-approved facility. You can stay up to 5 days each time but only occasionally.
The covered services vary depending on your illness and conditions. It may include doctor and nurse care, medical equipment and supplies, and short-term inpatient care. Inpatient care is strictly for pain and symptom management and must be done in a Medicare-approved facility. Physical and occupational therapy, speech-language pathology services, and dietary counseling are covered as they relate to your pain or symptom management care.
Medicare will not cover any treatment or medication intended to cure your terminal illness. It does not cover room and board and will not pay for care from a hospice provider that was not arranged by the hospice medical team. Short-term inpatient or respite care services may be covered or available for a small copayment if arranged through your hospice team. Medicare will also not cover outpatient care, ambulance transportation, or inpatient care unless it is unrelated to your terminal illness or arranged by the hospice team. It’s essential that you check with your hospice team before using any of these services to see if they are covered under the hospice provision.
Home Health Care
Some home health care services are covered by Medicare Part A. If you need part-time or occasional skilled nursing care in your home, then the cost of that is permitted. Physical and occupational therapy as well as speech-language pathology services are covered as long as they are considered medically necessary. These treatments will only be approved if your condition is expected to improve as a result of them or you need a skilled therapist to assist you in therapy that maintains your current condition.
Women who need osteoporosis treatments can also have injections administered at home. Medical supplies and equipment needed to administer home health care, including injectable osteoporosis drugs, are covered.
Medicare will not pay for 24-hour home care, meal deliveries, homemaker services such as cleaning, laundry, and shopping, or personal care including help bathing, dressing or using the bathroom.
To qualify for home health services, you must have a doctor certify you are homebound. This means that you are able to leave the home for occasional non-medical reasons, such as religious services but are not able to get out and about. If you attend adult daycare, you are still eligible for home health care.
Because not all services and items are not covered by Medicare, the home health agency that arranges for your home health care must provide you with an Advance Beneficiary Notice (ABN), which is a written notice of what is not covered by Medicare. If you live in Florida, Illinois, Massachusetts, Michigan, and Texas, you may submit a request to Medicare asking for a review of which of your home health services are included.
Organ Transplants
Part A will cover inpatient services in a Medicare-certified hospital, laboratory tests, and blood for heart, lung, kidney, pancreas, intestine, and liver organ transplant operations. Cornea and stem cell transplants may also be considered under certain conditions and do not have to be performed at a Medicare-approved transplant center.
If you need a kidney transplant, Part A also covers the kidney registry fee, the cost associated with finding a matching kidney, the cost of the kidney donor’s care, and blood that either you or the donor need before, during, or after surgery.
If you have End-Stage Renal Disease (ESRD) and also need a pancreas transplant, Medicare will cover the cost of the second transplant if it is either done at the same time as a kidney transplant or done after a kidney transplant.
Other Covered Services
If you need anesthesia as an inpatient during surgery, you pay 20% of the amount. If you need a blood transfusion, you will receive blood from a blood bank at no charge unless the hospital has to buy their supply. If that is the case, you’ll need to pay for the first three units of blood you receive during a calendar year or have blood donated to replace what you need. Part A will also cover any blood processing and handling fees assessed by the hospital.
If you need surgically implanted breast prosthesis after a mastectomy, Part A will cover the procedure as an inpatient. You may be eligible for coverage for the surgery as an inpatient for an implantable automatic defibrillator if you have been diagnosed with heart failure. If you have cancer and are a hospital inpatient, Part A will cover chemotherapy. Although Medicare doesn’t cover dental care, Part A may pay for certain dental services if you are admitted as an inpatient for the procedure.
Medicare Part B
Medicare Part B is the medical insurance component. Part B generally covers about 80% of the cost of doctor’s services you receive as an inpatient in the hospital. It covers most medically necessary services and some preventive services. It also covers ambulance services, clinical research, durable medical equipment, and mental health services. It may cover some outpatient prescription medications. The Part B deductible applies in most cases and you are responsible for 20% of the amount for supplies and treatments unless otherwise stated. If the service is done in an outpatient setting, you have a copayment for the facility.
Acupuncture
Part B will cover 12 acupuncture visits in a 90 day period for chronic low back pain. To qualify, the back pain must have been present longer than 12 weeks, have no known cause, and not as a result of surgery or pregnancy. If acupuncture improves your condition, you may be eligible for another 8 sessions. No more than 20 treatments can be had in a 12 month period. The acupuncturist must have a master’s or doctoral-level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine. The acupuncturist must also have a current license to practice acupuncture in the state you receive the services.
Ambulance Service
Medicare Part B covers ambulance transportation to a skilled nursing facility, critical access hospital, and hospital if being moved in any other type of vehicle will endanger your health. It may also pay for airplane or helicopter ambulance transportation if needed. You can not choose the medical facility that you wish to be taken to. Medicare will only pay for transportation to the nearest facility that can provide the medical care you need.
Medicare sometimes will pay for non-emergency ambulance transportation for medical procedures when authorized by your doctor, such as transportation to the dialysis center in the case of end-stage kidney failure. If the ambulance company has reason to believe that Medicare won’t pay for your ambulance use, you will be given an Advance Beneficiary Notice of Noncoverage (ABN) notice.
If the ambulance service you use is based in New Jersey, Pennsylvania, South Carolina, Maryland, Delaware, District of Columbia, North Carolina, Virginia, or West Virginia you may be subject to a Medicare demonstration program. The ambulance company may send a request for prior authorization if you have scheduled, non-emergency transportation 3 times in 10 days or once a week for 3 weeks or more. If the request is not approved by Medicare for the fourth trip, the ambulance company will bill you.
Ambulatory Surgical Centers
If you received services at an ambulatory surgical center, Part B covers the facility fees for approved surgical procedures. You are responsible for the Part B deductible and 20% of the costs for both the facility and doctor fees. Certain preventive services are covered completely. You can get estimates for ambulatory surgical center outpatient procedures here.
Blood
If the provider you use gets blood from a blood bank free, you will need to pay a copayment for blood processing and handling services as an outpatient and the Part B deductible applies. If your provider must buy blood, you will be responsible for the costs for the first three units of blood per calendar year or get blood donations to replace what you use.
Cardiac Rehabilitation Programs
Part B will cover cardiac rehabilitation programs if you’ve had a heart attack up to 12 months before, had coronary artery bypass surgery, or are experiencing current stable angina. You may also be eligible for coverage if you’ve had a heart valve repaired or replaced, undergone coronary angioplasty, or had a coronary stent inserted.
If you’ve had a heart or heart and lung transplant or are currently diagnosed with stable chronic heart failure, Part B will also cover the rehabilitation program. If your doctor refers you to an intensive cardiac rehabilitation (ICR) program, Part B will typically cover those costs as well. The services must be provided to you as an outpatient.
Chiropractic Services
If you have a subluxation, Part B will cover manual manipulation of the spine by a chiropractor. It will not cover tests or other services offered by a chiropractor including x-rays, massage therapy, or acupuncture.
Chronic Care Management Services
If you have two or more chronic conditions that are expected to last at least a year, Part B may pay for chronic care management services. You are responsible for paying a monthly fee. Part B and coinsurance deductibles apply. Conditions that are considered chronic are arthritis, asthma, diabetes, hypertension, heart disease, osteoporosis, and mental health issues.
Coronavirus Disease 2019 (COVID-19)
Medicare Part B will cover the COVID-19 antibody (serology) and diagnostic tests. You pay nothing if the test is administered in a laboratory, pharmacy, doctor, or hospital. Part B may also cover extra tests for respiratory conditions associated with COVID-19.
Clinical Laboratory Tests
Medically necessary clinical diagnostic laboratory tests are covered by Part B when your doctor orders them. Covered tests include certain blood tests, tests on tissue specimens, urinalysis, and some screening tests. They must be done by a Medicare-approved laboratory.
Clinical Research Studies
Part B will cover some costs if you are participating in clinical research. Clinical trials test the effectiveness of certain types of medical care. They may involve surgical treatment, medicine, or diagnostic tests. If you need hospitalization while undergoing clinical research, Medicare Part A may cover that.
Corrective Lenses and Eye Treatment
If you have had cataract surgery and have an intraocular lens, Part B will pay for one pair of eyeglasses with standard frames or one set of contact lenses. You pay any extra costs for upgraded frames. The supplier must be enrolled in Medicare. If you have age-related macular degeneration (AMD), Part B covers certain diagnostic tests and treatments for this condition.
Diagnostic Laboratory and Non-Laboratory Tests
If your doctor determines that a test is medically necessary, whether it is a clinical diagnostic laboratory test or a non-laboratory test, then Part B covers these in full or part. If your doctor orders hearing or balance exams, then Medicare Part B will cover them as non-laboratory tests (CT scans, MRIs, EKGs, X-rays, and PET scans).
Dialysis, Kidney Disease Education, and Transplants
If you have Stage IV or chronic kidney disease, Part B will cover up to six sessions of kidney disease education. These sessions will help you make informed decisions about your dialysis or transplant treatment.
If you have End-Stage Renal Disease (ESRD), you must have Medicare Part B to have full coverage for your dialysis treatment. Medicare will cover inpatient, outpatient, and home dialysis treatments.
For home dialysis, the equipment and supplies are covered as well as training on how to use the equipment. You may need to pay 20% of any fees associated with home training. Part B does not cover the cost of having a dialysis aide come to help you with home dialysis or lost wages during home dialysis training. Medicare does not pay for blood or packed red blood cells for home dialysis unless it is included as part of a doctor’s service
You may also qualify for some home support services including monthly check-ups or emergency help. Most injectable, IV, and oral medications are covered for outpatient and home dialysis. If your child needs dialysis, the amount you pay will vary based on the type and age of the child. The 20% coinsurance rate is also based on the pediatric dialysis rate.
If you are traveling in the United States and need dialysis, you can go to a Medicare-certified facility for treatment. Medicare does not pay for transportation to the dialysis facility unless your doctor determines it to be medically necessary for you to be transported by ambulance. Medicare Part A will cover inpatient dialysis.
If you have a kidney transplant, Part B covers doctors’ services before, during, and after surgery, including your hospital stay. It will also cover immunosuppressive drugs for 36 months after you leave the hospital. Part B will continue your transplant medication coverage indefinitely if you were eligible for Medicare before you got ESRD.
Diabetes Care
A variety of services are covered by Part B if you have diabetes. If you’ve been diagnosed with diabetes, Part B will cover up to 10 hours of initial outpatient diabetes self-management training (DSMT). These 10 hours include one hour of individual training as well as nine hours of group training. Two hours of follow-up training can be had each year beginning the year after the initial training. You might be eligible to receive medical nutrition therapy training if you have a written referral from your doctor.
Blood sugar monitors, test strips, and lancet devices with lancets for diabetes are included. You are eligible for one eye exam for diabetic retinopathy each year done by an eye doctor license to do the test in your state.
If you need to use an insulin pump, the pump and insulin may be considered a DME. Otherwise, insulin is not covered. Glucose control solution used in conjunction with an insulin pump is covered. If your diabetes requires frequent insulin dosage change, Part B will cover a therapeutic continuous glucose monitor (CGM) and the related supplies.
Part B also covers one foot exam per year if you have diabetes-related lower leg nerve damage. The exam might also include treatment for ulcers and calluses and toenail management.
If you have diabetes or severe diabetic foot disease, Part B covers the fitting of one pair of custom-molded shoes and inserts or one pair of extra-depth shoes. You may also be eligible for 2 more custom-molded shoes or 3 pairs of inserts for extra-depth shoes each year. If you prefer shoe modifications instead of inserts, that too is covered. Your primary doctor must certify that you need therapeutic shoes or inserts. The shoes or inserts must be prescribed by a podiatrist.
Defibrillators
If you have been diagnosed with heart failure and have outpatient surgery for an implantable automatic defibrillator, you pay 20% of the total cost and a facility copayment.
Durable Medical Equipment
Part B covers durable medical equipment (DME) that is medically necessary prescribed by your doctor for home use. Depending on the type of DME needed, you may be expected to rent or buy it from Medicare-approved suppliers. Equipment covered by Medicare must be durable, used for a medical reason, not useful to someone who is not sick or injured, used in your home, and have an expected lifetime of three years.
Crutches, canes, walkers, wheelchairs, and scooters are considered DMEs and qualify for coverage. Accommodations such as commode chairs, hospital beds, patient lifts, traction equipment, and pressure-reducing support surfaces. You may need to get prior approval for some types of pressure-reducing support surfaces including certain beds, such as air-fluidized beds, mattresses, and mattress overlays.
Continuous passive motion devices are covered for 21 after having knee replacement surgery. If you’ve been diagnosed with obstructive sleep apnea, Medicare will provide a 3-month trial with a Continuous Positive Airway Pressure (CPAP) device. If, after three months, your doctor determines you should continue using a CPAP, Medicare may continue its coverage. If you had a CPAP before you enrolled in Medicare, you may be eligible for a replacement rental or accessories under certain conditions.
Other DME that might be considered medically necessary include infusion pumps with supplies, nebulizers with nebulizer medications, oxygen equipment, as well as suction pumps. Arm, leg, back, and neck braces are accepted claims when they are considered medically necessary.
Humidifiers are considered DME when used in conjunction with CPAP, respiratory assist devices, or oxygen equipment. You pay 20% of the rental or purchase of a humidifier used with CPAP for respiratory assist devices. The cost of the humidifier is included in the monthly oxygen equipment fee.
If you have severe lung disease, your arterial blood gas level has fallen and other types of treatment have failed, Part B will cover oxygen equipment and accessories rental. This coverage includes oxygen supply systems, oxygen storage containers, and tubing or related accessories for oxygen delivery. If you qualify, you will be able to rent oxygen equipment for 36 months. Maintenance, servicing, and repairs are covered by your monthly payments. If you own the equipment, Part B will help pay for refills and replacements.
Emergency Department and Urgent Care Services
When you have an injury, sudden illness, or an illness that takes a turn for the worse, Part B will usually cover treatment in the emergency room or urgent care facility. You are also responsible for making a copayment for each visit and hospital service. If you are admitted to the hospital within 3 days of your emergency room visit for the same or related issue, there is no copayment fee because it will be considered part of your inpatient stay.
Foot Care
If you have had a foot injury or a condition like bunion deformities, hammer toe, or heel spurs, Part B will cover a visit to a podiatrist. If you need orthopedic shoes as a necessary part of a leg brace, Medicare will cover the cost.
Hyperbaric Oxygen Therapy (HBO)
If you have certain conditions, Part B will cover hyperbaric oxygen (HBO) therapy if it is administered in a chamber. These conditions include acute carbon monoxide intoxication, acute traumatic peripheral ischemia, or acute peripheral arterial insufficiency. If you’ve had a gas embolism or have gas gangrene or progressive necrotizing infections, then you may be eligible for the treatment.
If you are experiencing decompression illness, cyanide poisoning, or have suffered crushing injuries and suturing of severed limbs, then HBO therapy is in order. If you will be having skin grafts and the treatment is needed to prepare and preserve compromised areas, Part B allows HBO therapy. If you have Type 1 or Type 2 diabetes and have a lower extremity wound as a result that is classified as Wagner grade III or higher and standard wound therapy has not been successful, Medicare may allow HBO treatment.
Other conditions that may permit HBO therapy after conventional treatment has failed or in conjunction with conventional treatment include chronic refractory osteomyelitis, actinomycosis, osteoradionecrosis, and soft tissue radionecrosis.
Medication
Medicare Part B covers some prescriptions in certain conditions. Usually, these are not self-administered. Medication may be covered if you are taking them as part of hospital outpatient services.
Drugs that are used in conjunction with durable medical equipment (DME) like a nebulizer or infusion pump and injectable osteoporosis medication are types of prescriptions covered under Part B. A doctor must certify that you are unable to administer the treatment yourself. Some antigens prepared by your doctor and erythropoietin by injection for End-Stage Renal Disease (ESRD) are covered. Some oral End-Stage Renal Disease (ESRD) medication may be covered if the same drug is available as an injection.
If you have hemophilia, Medicare will pay for blood clotting factors. Most injectable and infused medications are allowable when administered by a licensed medical provider. Parental and enteral nutrition given intravenously or through tube feeding is covered. If you have been diagnosed with primary immune deficiency disease, the Intravenous Immune Globulin (IVIG) is covered but not for services or items needed to administer IVIG at home.
Hepatitis B shots are covered if you have hemophilia, End-Stage Renal Disease (ESRD), or diabetes. These shots are also covered if you live with someone with Hepatitis B or you are a health care worker that has frequent contact with blood or other bodily fluids.
Medicare will cover one flu shot per flu season if the doctor or health care provider agrees to accept the amount Medicare covers and not charge you additional costs. Medicare will cover two pneumococcal shots as long as they are at least one year apart. Medicare may also pay for other vaccines if you need them as part of your treatment for an illness or injury.
Medicare Part B will cover transplant drug therapy only if you had Medicare coverage for the organ transplant. If you are eligible for Medicare because of ESRD and you receive a transplant, your coverage ends 36 months after the transplant. Part B will cover transplant drug therapy for a pancreas transplant for 36 months if you have the procedure done after a kidney transplant.
Medicare Part B provides coverage for oral cancer drugs only if the same drug is available in injectable form. Oral anti-nausea medication is covered if they are given within 48 hours of chemotherapy or used as a replacement for intravenous anti-nausea drugs.
If the prescription is given in a doctor’s office or pharmacy, you pay 20% of the amount plus the Part B deductible. If the medication is prescribed to you as an outpatient, you have a copayment of 20% as well.
Mental Health
Part B will cover one depression screening each year if it is done in a doctor’s office or clinic that can provide referrals and follow-up care. If you need individual or group psychotherapy, family counseling, or a psychiatric evaluation, Medicare will provide coverage. Your mental health services can be provided by a Medicare-approved psychiatrist, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, doctor, or a physician assistant.
You may also be eligible for testing to see if the treatment you are receiving is beneficial and/or diagnostic tests. Certain prescription drugs are covered under Part B as well as medication management services.
You are allowed a one-time preventative visit to review your risk factors for depression and a yearly wellness visit with your doctor. Outpatient mental health services designed for the treatment of alcohol or drug abuse may also be allowed under certain conditions. You may be responsible for additional copayments if your services are conducted at a hospital outpatient clinic or department.
If your provider offers Psychiatric Collaborative Care, Medicare may cover behavioral health integration services for depression, anxiety, or other mental health concerns. You are responsible for a monthly fee.
Partial hospitalization might be covered by Part B if your doctor says you would otherwise need to be admitted to a hospital and you meet certain requirements. With partial hospitalization, you will receive structured outpatient psychiatric services. Medicare will help cover this treatment when it is provided in a community mental health center or hospital outpatient department. It may cover occupational therapy and individual patient training and education. You are responsible for a percentage of each service you receive in a partial hospitalization treatment setting besides the Part B deductible.
Medicare does not cover meals, transportation, support groups, and job skill training or testing as part of partial hospitalization services.
Nutrition Therapy Services
Part B might cover any medical nutrition therapy (MNT) services you need if you have diabetes, kidney disease, or had a kidney transplant less than 36 months before. Services that are covered include an initial nutrition assessment, group or individual nutritional therapy sessions, and follow-up care. Your doctor must make a referral for you to receive MNT services unless you receive dialysis. In that case, MNT considered part of your dialysis care. Services may also be provided through telehealth.
Opioid Use Disorder Treatment
Part B covers opioid use disorder treatment services that are provided by Medicare-enrolled opioid treatment programs (OTPs). You may receive counseling over the phone, online, or in-person.
Ostomy Supplies
If you need ostomy supplies after a colostomy, ileostomy, or urinary ostomy, Part B will cover the supplies your doctor says that you need.
Outpatient Services and Supplies
If you have a procedure done as an outpatient, Part B typically covers most expenses including supplies. This coverage may extend to overnight stays for observation and same-day-surgeries. There is often a copayment both to the doctor and to the hospital in addition to the Part B deductible. If the services you receive are in a critical access hospital (CAH), you may have a higher copayment. During the COVID-19 pandemic, some services may be covered even if they are offered in parking lot tents, hotels being used as medical facilities, or in your home when it has been classified as a hospital visit.
Medically necessary outpatient physical therapy, chemotherapy, radiation therapy, speech-language pathology services may also be covered by Part B under certain circumstances. Outpatient primary care and preventative care provided by a rural health clinic (RHC) are covered by Part B.
Preventive and Screening Services
Part B covers a host of preventive and screening services. Unless otherwise noted, you pay nothing for these services if your doctor accepts assignment, agrees to the amount Medicare authorizes to pay, and does not charge more for the service.
Initial Screening
You are eligible for a one-time “Welcome to Medicare” preventive visit within the first 12 months after enrolling in Medicare Part B. You may need to pay coinsurance and the Part B deductible apply if your doctor performs tests or provides other medical services during the Welcome visit and these tests or services are not covered under Medicare’s preventive benefits.
The approved services for the Welcome visit include flu and pneumococcal shots, body mass index calculation index, a simple vision test, and height, weight, and blood pressure measurements. Your doctor may also talk to you about your risk for depression, creating advance directives, and provide a written plan with a list of screenings, shorts, and other preventative services you may need in the future.
Alcohol and Drug Screening
One abdominal aortic aneurysm screening ultrasound is covered if you have a family history of abdominal aortic aneurysms, you are a man between 65-75, or you have smoked at least 100 cigarettes over your lifetime. You need a referral from your doctor.
Under certain conditions, Medicare Part B will pay for yearly alcohol misuse screenings and counseling. To qualify, you must be an adult that drinks alcohol but does not meet the medical criteria for alcohol dependency and your doctor believes you are abusing alcohol. You’ll be eligible for four in-person counseling sessions per year if you are not under the influence during the sessions. Counseling must be done by a primary care practitioner in a primary care setting, not a rehabilitation center.
If you chew tobacco or smoke, Part B will cover up to eight visits for tobacco use cessation counseling every 12 months to help you quit. The counseling must be done by a qualified doctor.
Cardiovascular Disease Screenings
Cardiovascular disease screenings are provided under Part B once every five years. Cardiovascular disease (behavioral therapy) is covered once a year when conducted by a primary care practitioner in a primary care setting.
Cancer Screenings
Cervical and vaginal cancer screening includes Pap tests, pelvic exams, and clinical breast exams. Part B will cover these exams once every 24 months. If you are at-risk, then you are eligible to have the screening tests done every 12 months. The Human Papillomavirus (HPV) test can be done once every five years if you are a woman between the ages of 30 and 65.
You can receive yearly lung cancer screening with Low Dose Computed Tomography (LDCT) if you are between the ages of 55 and 77, are asymptomatic, are a smoker or quit smoking fewer than 15 years ago, have smoked one pack per day for 30 years, and your doctor gives you a written order.
Part B covers screening mammograms. You can receive a baseline mammogram if you are a woman between the ages of 35 and 39. Then you are eligible for one screening mammogram every 12 months after the age of 40. If you need a diagnostic mammogram, it can be scheduled more frequently.
A yearly prostate cancer screening including a digital rectal exam and prostate-specific antigen (PSA) blood test is covered under Part B preventive services for men over the age of 50.
The multi-target stool DNA test can be administered once every three years under certain conditions. If you are between the ages of 50 and 85 and have no lower gastrointestinal pain, blood in your stool, or had a positive fecal immunochemical or guaiac fecal occult blood test. You also must not have any personal or family history of adenomatous polyps, colorectal cancers, inflammatory bowel disease, Crohn’s Disease, ulcerative colitis, or hereditary nonpolyposis colorectal cancer.
Screening barium enemas are covered once every 48 months if you are over the age of 50. If you are at high risk for developing colorectal cancer, you can have the exam done once every 24 months. If you are having the test as an outpatient, you are also responsible for the copayment since Part B deductible won’t apply.
You can get a screening colonoscopy once every 24 months if you are in the high-risk category. If you are not at high risk for this type of cancer, you can get a test once every 120 months. You can also get a colonoscopy 48 months after a flexible sigmoidoscopy procedure. Medicare will cover colonoscopies. However, if during the procedure, a polyp is found and removed, you are responsible for 20% of the cost. The Part B deductible doesn’t apply in this case.
Part B will cover a screening fecal occult blood test once every 12 months if you are older than 50 and your doctor has given you a referral. Every 48 months, you can receive a screening flexible sigmoidoscopy if you over the age of 50. If you aren’t in the high-risk category, you can get a sigmoidoscopy every 120 after a previous screening colonoscopy. If a biopsy is done or a lesion removed during the procedure, you may have to pay a copayment. Part B deductible doesn’t apply in this case.
Depression Screenings
One depression screening per year is covered by Part B if it is done in a primary care setting.
Diabetes Screenings
If you are at risk for developing diabetes or have already been diagnosed with pre-diabetes, you may be eligible to get two diabetes screenings each year. You may also qualify for two screenings if you have hypertension, dyslipidemia, obesity, or a history of high blood sugar. If you have a family history of diabetes, have had gestational diabetes, are overweight, or over the age of 65, you may also be eligible for two screenings per year.
Glaucoma Screening
If you are at high risk for glaucoma, Part B will cover a glaucoma test once every 12 months. High-risk individuals include those with diabetes, with a family history of glaucoma, African-Americans over the age of 50, and Hispanics over the age of 65. If it is done in an outpatient procedure, you are responsible for a copayment as well.
Infectious Disease Screenings
Hepatitis B Virus (HBV) infection screening is covered by Part B if you are at high risk for contracting Hepatitis B or if you are pregnant and your doctor orders the screening. High-risk individuals can get the HBV infection screening once a year if you continue to be at high risk but don’t get a Hepatitis B shot. If you are pregnant, you can receive the HBV infection screening at the first prenatal visit, and when you deliver your baby.
A yearly hgepatitis C screening test is covered by Part B if your doctor orders one and you are at high risk because you have used illicit injection drugs, had a blood transfusion before 1992, or were born between 1945 and 1965.
Part B covers a once per year HIV (Human Immunodeficiency Virus) screening if you are between the ages of 15 and 65. If you are younger or older than that age group, you may qualify if you have an increased risk of contracting HIV. You can get the screening three times during pregnancy.
Part B covers sexually transmitted infections (STI) screenings and counseling for chlamydia, gonorrhea, and syphilis if you’re pregnant or at increased risk for an STI. These tests are available once every 12 months, or if you are pregnant, at certain stages of the pregnancy.
Two individual sessions of high-intensity behavioral counseling sessions per year may be provided if you are a sexually active person at increased risk for contracting an STI. You will need a doctor’s referral for the tests and counseling. Counseling must be done in a primary care clinic and provided by a doctor.
Obesity Screening
If you have a body mass index (BMI) over 30, Part B will cover both obesity screenings and behavioral counseling. The counseling must be done by a primary care practitioner in a primary care setting. If you are considered morbidly obese, Medicare may cover gastric bypass, laparoscopic banding, or another bariatric surgery.
Osteoporosis Screening
Part B will cover bone mass measurements (bone density) tests once every 24 months if you are a woman and your doctor determines you are at risk for osteoporosis or estrogen-deficient. This must be demonstrated through x-rays that show vertebral fractures, osteoporosis, or osteopenia. You must already be on prednisone or another steroid drug or about to begin this treatment. If you have primary hyperparathyroidism, you also qualify for coverage.
Wellness Visits
If you have been enrolled in Part B for more than 12 months, you are eligible for a yearly “Wellness” visit. This is to create or update your personal prevention plan based on your current health. It may also include a cognitive impairment assessment and advance care planning.
The Part B deductible does not apply for the Wellness visit under most circumstances. You may need to pay coinsurance and the Part B deductible would apply if your doctor performs tests or provides other medical services during the Wellness visit and these tests or services are not covered under Medicare’s preventive benefits.
Prosthetic Breasts, Devices, Eyes, and Limbs
Enteral nutrition supplies and equipment, otherwise known as a feeding pump, is classified as a prosthetic device. After a mastectomy, Part B covers some external breast prostheses which include a post-surgical bra. If your doctor determines you need artificial eyes or limbs, you pay 20% and the Part B deductible applies.
Pulmonary Rehabilitation Programs
If you have moderate to very severe chronic obstructive pulmonary disease (COPD), Part B will provide coverage for a comprehensive pulmonary rehabilitation program. If you receive treatment in a doctor’s office, you pay 20% of the amount. If treatment occurs in a hospital outpatient setting, you pay a copayment to the facility each session.
Sleep Studies
If you have symptoms of sleep apnea, Part B will cover Type I, II, III, and IV sleep tests and related devices if your doctor orders them. Type I tests are only covered if they are done in a sleep lab facility.
Surgery, Second Opinions, and Surgical Supplies
The exact cost of surgery and the supplies needed are sometimes difficult to determine in advance. Medicare covers many surgeries, both inpatient (covered by Part A) and outpatient (covered by Part B).
If you would like a second opinion about a medically necessary surgery that is not an emergency, Part B will pay for that. If the first and second opinions are different, Medicare will pay for a third opinion. Part B provides coverage for tests and analysis the doctor may request.
If you need treatment for a surgery wound, Part B covers this service and the necessary supplies needed to dress the wound. If the surgery wound is treated in a hospital outpatient setting, you may have a copayment to the facility.
Transitional Care Management Services
If you are returning home after a hospital or a skilled nursing facility, you may be eligible for coverage of certain services to help you manage your transition for the first 30 days. You may also be able to have an in-person office visit within two weeks of your return.
Telehealth
Certain telehealth services are covered under Part B such as office visits, psychotherapy, consultations, virtual check-ins, and E-visits. Virtual check-ins allow you to talk to health care professionals via phone, video, or email. This type of communication can be used for COVID-19 treatment from anywhere. To be eligible for coverage, the virtual check-in must not be related to a doctor’s visit that you had within the past seven days and can not result in a medical visit.
Telehealth services are available at renal dialysis facilities and at your home. If you are experiencing a stroke, you can access telehealth services no matter your location.
Travel Coverage
Medicare Part B will cover some services if you receive them on board a ship that is in the territorial waters surrounding the U.S. If the ship is more than 6 hours from a U.S. port, Medicare will not cover your treatment. Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are considered part of the United States and have Medicare coverage at select facilities.
If you are in the U.S. when a medical emergency occurs and a foreign hospital is closer than a U.S. hospital, Medicare may pay for inpatient hospital, doctor, ambulance services, or dialysis. If you are in Canada, traveling between Alaska and another state, you may be covered for treatment in a Canadian hospital.
If you meet the above conditions, you are responsible for 20% of the total cost and the Part B deductible applies. If you do not meet the conditions, you are responsible for 100% of the costs. Medications purchased outside the U.S. are not covered. Foreign hospitals are not required to file claims. You will need to submit an itemized bill for any services you received.
Medicare Part C
Medicare Part C is a bundled plan often called Medicare Advantage Plan. Medicare pays a certain amount to the companies that offer Medicare Advantage Plans. Because Medicare Advantage Plans include Part A and Part B, all the services that the Original Medicare contains are covered. Hospice Care and some clinical research costs are still covered by Original Medicare.
There are services available through this plan that are not covered by Part A and B. Some plans cover vision, hearing, dental, and even fitness programs.
The downside is, most of the services must be obtained by a private provider within a specific service area network. If your service area does cover a particular procedure, you’ll need to pay out-of-pocket expenses which can vary. If you need a treatment or service that your plan says is not necessary, you can appeal the decision.
The amount of your out-of-pocket expenses depends on whether the plan has a monthly premium, whether it includes the cost of all or part of the Part B premium, and whether there are deductibles. The copayment or coinsurance that you are responsible for paying may vary for each visit or service. The frequency and type of services vary by plan and can influence your out-of-pocket costs. The plan’s out-of-pocket limit and whether you have Medicaid can also change how much you pay.
Your individual coverage plan may also determine whether you need a referral to visit a specialist or where you go for non-emergency care. The rules governing the Medicare Advantage Plan change every September.
You will receive two notices from your plan each fall, “Evidence of Coverage” (EOC), and “Annual Notice of Change” (ANOC). The EOC provides details about what your plan covers and how much you pay for services. The ANOC will highlight changes in costs, coverage, or service area effective in January of the following year.
You will lose coverage under the Medicare Advantage Plan and be returned to the Original Medicare program if you are in a Medicare Advantage HMO or PPO and you join the Medicare Prescription Drug Plan (Part D) that is not part of the bundled Medicare Advantage Plan.
Medigap policies are not compatible with Medicare Advantage Plans. Medigap will not cover premiums, copayments, or deductibles associated with Medicare Advantage Plan.
Medicare Part D
Medicare Part D is one of the newest Medicare covered services, which is the prescription drug plan component. It is often bundled up in the Medicare Advantage Plan. Beginning in 2021, some seniors will be able to get insulin at a reduced price. Insulin will cost $35 for a 30-day supply if you are enrolled in Part D or Medicare Advantage Plan and the provider participates in the insulin savings model. To check availability for your area, you can search here.
Each plan has its own list (formulary) of drugs it covers. At least two varieties of the most commonly prescribed medications are included. Your doctor might prescribe you something that is not on your plan’s formulary. If your doctor agrees, a similar drug can be substituted. If your doctor feels you must have that specific medication, you can request an exception.
The plan can change the list and prices during the year. If they do, and it affects a medication you are taking, you will be given 30 days’ written notice. When you go for your next refill, the pharmacy will provide you with a month’s supply of the current medication when you present the notice under the terms you were given up until the change.
Typically, the medications are classified into tiers. Generic drugs would be in a lower tier and cost you less out-of-pocket than name-brand medications. To find out if your current prescriptions are covered in a Medicare Part D plan, you can search here. You should also know about the Medicare “donut hole.”
Medicare Covered Services Conclusion
Services, medications, and medical equipment covered by Medicare change regularly. If you are still unsure whether the specific treatment you need is covered, use the search option here at the official Medicare website for more information.
