What Medicare Actually Covers and What You'll Pay Out of Pocket

Medicare covers hospital stays, doctor visits, and some preventive care, but not dental, vision, hearing aids, or long-term care

Medicare has four parts, and each one covers different things. Part A covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services. Part B covers doctor visits, outpatient care, lab tests, and some medical equipment. Part D covers prescription drugs. Part C (Medicare Advantage) is an alternative to Parts A and B offered by private insurance companies, and it bundles coverage differently.

What Medicare does not cover at all: dental work, vision care, hearing aids, long-term custodial care in a nursing home or assisted living, most physical therapy beyond a limited number of visits, and routine foot care. You will pay for these things out of pocket or through a separate private policy.

Even when Medicare does cover something, you typically pay a share. You might pay a deductible before coverage starts, a copay for each visit, or coinsurance (a percentage of the cost). The amounts change every year.

Key Takeaways

• Part A covers hospital stays and some skilled nursing care; Part B covers doctor visits and outpatient services; Part D covers prescription drugs.
• Medicare does not cover dental, vision, hearing aids, or long-term custodial care in a nursing home or assisted living facility.
• You pay deductibles, copays, and coinsurance for most services, and these amounts change each year.
• Supplemental insurance (Medigap) can cover some of the costs Medicare does not, but it is a separate policy you purchase.
• Medicare Advantage (Part C) is a private alternative that may cover some services Original Medicare does not, but usually with different rules and networks.

What Part A covers: Hospital and skilled nursing care

Part A covers inpatient hospital stays, meaning you are admitted and stay overnight. It covers the room, meals, nursing care, and most hospital services. You pay a deductible for each hospital stay (the amount varies by year), and if your stay is longer than 60 days, you start paying coinsurance for each additional day.

Part A also covers up to 100 days in a skilled nursing facility if you are admitted directly from a hospital stay of at least three days. A skilled nursing facility is different from a regular nursing home — it provides medical care and rehabilitation, not just custodial care. After 20 days, you pay coinsurance for days 21 through 100. After day 100, you pay the full cost yourself.

Part A covers some home health services if you are homebound and a doctor orders them. It does not cover help with daily living (like bathing or dressing) unless it is part of a skilled service like physical therapy. It also covers hospice care if you have a terminal illness and choose comfort care instead of curative treatment.

What Part B covers: Doctor visits, outpatient care, and preventive services

Part B covers visits to your doctor, specialist appointments, outpatient surgery, emergency room visits, and lab tests. It covers some medical equipment like wheelchairs, walkers, and oxygen supplies if your doctor prescribes them. It also covers some mental health services, including therapy and psychiatric visits.

Part B includes preventive services at no cost to you: annual wellness visits, screening for cancer, heart disease, diabetes, and osteoporosis, vaccinations, and some other preventive tests. You do not pay a copay or coinsurance for these specific preventive services, though you do pay the Part B deductible once per year before other Part B coverage starts.

Part B does not cover routine eye exams, glasses, or contact lenses. It does not cover hearing exams or hearing aids. It does not cover most dental care, including cleanings, fillings, and extractions. It covers a limited number of physical therapy visits per year (the limit changes), and you pay coinsurance for each visit after you meet your deductible.

What Part D covers: Prescription drugs

Part D is prescription drug coverage offered by private insurance companies approved by Medicare. You choose a plan, and each plan has a different list of covered drugs (called a formulary), different copays, and different pharmacies. Most plans charge a monthly premium on top of your Part B premium.

Part D coverage has stages. You pay a deductible first (usually $505 or more, depending on the plan and year). Then you pay copays or coinsurance for each prescription until you reach a spending threshold. After that, you enter the "coverage gap" and pay a higher percentage of the drug cost until your total out-of-pocket spending reaches a yearly limit. Once you hit that limit, the plan pays most of the cost for the rest of the year.

Not every drug is covered by every plan. If your doctor prescribes a drug that is not on your plan's formulary, you can ask your doctor to prescribe a different drug that is covered, or you can ask the plan for an exception (which sometimes is approved and sometimes is not). You can change your Part D plan once a year during the annual enrollment period in the fall.

What Medicare Advantage (Part C) covers differently

Medicare Advantage is a private insurance alternative to Original Medicare (Parts A and B). You get your Part A and Part B coverage through a private company instead of the government. Most Medicare Advantage plans also include Part D (drug coverage) and may cover some services Original Medicare does not, like dental, vision, or hearing aids — though usually with limits and copays.

The trade-off is that Medicare Advantage plans typically have networks. You must see doctors in the plan's network (except in emergencies), and you usually need a referral to see a specialist. If you see an out-of-network doctor, you pay more or the plan does not cover it at all. Some plans require prior approval before you have certain procedures.

Medicare Advantage plans have maximum out-of-pocket limits, meaning once you spend a certain amount in copays and coinsurance in a year, the plan covers the rest. Original Medicare does not have this limit. You can switch to Original Medicare or a different Medicare Advantage plan during the annual enrollment period.

What supplemental insurance (Medigap) covers

Medigap is a private insurance policy that covers some of the costs Medicare does not — like deductibles, copays, and coinsurance. It is separate from Medicare itself; you buy it from a private insurance company. Medigap does not cover services Medicare does not cover (like dental or vision), but it reduces what you pay for services Medicare does cover.

There are ten standardized Medigap plans (labeled A through N), and each one covers a different combination of costs. For example, Plan G covers the Part B deductible and coinsurance, but Plan A does not. You can compare plans and choose the one that fits your budget and health needs. Medigap plans have monthly premiums, and the cost varies by plan, your age, and your location.

You cannot have both Medigap and Medicare Advantage at the same time. If you have Original Medicare (Parts A and B), you can add Medigap. If you have Medicare Advantage, you do not need Medigap because Medicare Advantage already includes Part A and Part B coverage.

Services with limits or restrictions

Medicare covers some services but limits how much or how often. Physical therapy, occupational therapy, and speech therapy are covered, but Medicare sets an annual limit on how many visits you can have (the limit is currently 60 visits per service per year, though this can change). Mental health services are covered, but outpatient therapy visits may have copays and annual limits depending on your plan.

Durable medical equipment like wheelchairs, oxygen, and CPAP machines are covered if your doctor prescribes them, but you pay 20 percent coinsurance after your Part B deductible. Some equipment requires prior approval from Medicare before you order it. Chiropractic care is not covered except for manual manipulation of the spine, and that is limited to 20 visits per year.

Home health services are covered only if you are homebound and a doctor orders skilled care (like nursing or therapy). Help with bathing, dressing, or meals is not covered unless it is part of a skilled service. If you need ongoing help with daily living, that is long-term custodial care, which Medicare does not cover.

What you pay: Deductibles, copays, and coinsurance

Original Medicare has separate deductibles for Part A and Part B. You pay the Part A deductible once per hospital stay (not once per year). You pay the Part B deductible once per year, and after you meet it, you typically pay 20 percent coinsurance for most services. Part D has its own deductible and copay structure that varies by plan.

The exact amounts change every year. For 2024, the Part A deductible is $1,632 per hospital stay, and the Part B deductible is $240 per year. Part D deductibles range from $0 to $505 depending on the plan. These numbers are set by Medicare and announced in the fall for the following year.

If you have a Medigap policy, it pays some or all of these costs depending on which plan you chose. If you have Medicare Advantage, you pay copays and coinsurance according to that plan's rules, and there is a yearly out-of-pocket maximum you cannot exceed.

Frequently Asked Questions

Does Medicare cover dental work or dentures?

No. Medicare does not cover routine dental care, cleanings, fillings, extractions, root canals, or dentures. You pay for dental work out of pocket or through a separate dental insurance policy. Some dental discount plans are available, but they are not insurance — they offer reduced rates at participating dentists.

Will Medicare pay for glasses or hearing aids?

Original Medicare does not cover routine eye exams, glasses, contact lenses, or hearing aids. Some Medicare Advantage plans include vision and hearing coverage, but usually with limits and copays. You can also purchase standalone vision and hearing insurance policies, or pay out of pocket.

What happens if I need to stay in a nursing home long-term?

Medicare covers up to 100 days in a skilled nursing facility after a hospital stay, but only if you need medical care and rehabilitation. Long-term custodial care in a nursing home is not covered. You pay for it out of pocket or through Medicaid if you meet income and asset limits. Long-term care insurance is a separate policy some people purchase before they need care.

Can I see any doctor I want with Original Medicare?

Yes. Original Medicare has no network restrictions, so you can see any doctor who accepts Medicare. With Medicare Advantage, you usually must see doctors in the plan's network, and you may need a referral to see a specialist. Check your plan's provider directory before choosing a plan.

What if my doctor prescribes a drug that is not on my Part D plan's list?

You can ask your doctor to prescribe a different drug that is covered by your plan. You can also request an exception from your Part D plan, which sometimes is approved if your doctor explains why the covered alternatives would not work for you. If the exception is denied, you can appeal or switch to a different Part D plan during the annual enrollment period.