What does Medicare cover?

If you’re evaluating Medicare, reviewing your Medicare options, or considering enrolling in Medicare for the first time, it can be an overwhelming process trying to understand Medicare and what Medicare covers.

For those turning 65, there is much to consider before making a decision about what is the right Medicare health plan for you. Doing thorough research and seeking Medicare help from professionals who know what is covered by each Medicare health plan are the keys to evaluating the best Medicare choices for you.

Contact us for free one-on-one assistance from an experienced Licensed Insurance Agent ready guide you through your Medicare options.

What is Medicare?

Medicare is federal health care coverage for qualifying individuals age 65 and older. Some younger individuals with disabilities may also qualify for Medicare health insurance prior to age 65, primarily those who have been receiving Social Security Disability Insurance (SSDI) benefits for two years (24 months). Medicare coverage is divided into several parts, each addressing different aspects of healthcare, and individuals considering enrolling in Medicare can select the parts that best meet their healthcare and financial needs.

Original Medicare – Part A & Part B

Medicare health plans are comprised of multiple parts. Original Medicare includes Part A and Part B.

Medicare Part A is known as Hospital Insurance. Part A covers services provided at a hospital or inpatient facility such as:

• Inpatient Hospital Care: Covers hospital stays for the first 60 days, including semi-private rooms, meals, general nursing, and other hospital services and supplies.
• Skilled Nursing Facility (SNF) Care: Benefits include care in a skilled nursing facility for a limited time after a hospital stay (up to the first 20 days are covered at full cost) with coinsurance kicking in for days 21 – 100 at $204/day in 2024.
• Hospice Care: Covers services for individuals with a terminal illness, focused on providing comfort and support.

Medicare Part B is known as Medical Insurance. Part B covers medical services provided outside of a hospital or medical care facility, and certain doctor services. This includes:

• Outpatient Care: Covers doctor visits, preventive services such as wellness visits, vaccinations and screenings, and outpatient procedures.
• Home Health Care: Includes medically necessary services at home, including part-time skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services.
• Durable Medical Equipment (DME): Covers equipment and supplies such as walkers, wheelchairs, and oxygen equipment.
• Diagnostic Hearing and Balance Exams: Covers diagnostic hearing and balance exams if your doctor or other health care provider orders them to determine if you need medical treatment. This may also include a visit to an audiologist every 12 months without an order from your doctor, if it is for non-acute hearing conditions or diagnostic services related to hearing loss that is treated with surgically implanted hearing devices.

In addition to Original Medicare, there are two other parts – Medicare Part C (Medicare Advantage) and Medicare Part D (prescription drug coverage).

What is covered by Medicare Advantage (Part C)?

For those looking to lower out-of-pocket costs with Original Medicare, Medicare Part C, or Medicare Advantage, is a private health insurance plan endorsed by Medicare that combines the coverage of Part A and Part B and can include additional benefits not featured in Original Medicare such as vision, dental, and fitness programs. Medicare Advantage plans also typically include prescription drug coverage (Part D).

What is covered by Medicare Part D?

Medicare Part D offers prescription drug coverage. The covered drugs are classified by tiers, and each tier has a different cost. Each Medicare Part D plan has its own list of covered drugs, which is called a “formulary.”

Medicare Part D covers a wide variety of prescription drugs and other medical supplies, and coverage options consist of four tiers – Tiers 1, 2, 3 and a Specialty Tier. The drugs in Tier 1 typically have the lowest copayment and tend to be generic drugs. Tiers 2 and 3 include brand name drugs, with Tier 2 offering preferred and Tier 3 featuring non-preferred drugs. The Specialty Tier offers those drugs that are most expensive, and therefore have the highest copayments associated with them.

What is covered by Medicare Supplement (Medigap) Plans?

Medigap is private insurance that individuals can purchase to lower out-of-pockets costs of Original Medicare, including Part A coinsurance and hospital fees, as well as hospice copayments, Part B coinsurance or copayments, blood transfusion costs (up to the first 3 pints), and deductibles. Medigap (Medicare Supplement) also covers some services while traveling abroad that Original Medicare does not cover.

What is not covered by Medicare?

It’s important to note that while Medicare health plans cover a wide range of healthcare services, no one plan covers everything. For example, certain services like long-term care, most dental care, and vision care are generally not covered by Original Medicare.

Original Medicare coverage specifics vary based on the type of health plan you choose and any additional coverage you may have, such as Medigap or Medicare Advantage. For a more comprehensive overview of what Medicare does not cover, call Aevo to discuss the specific types of care you are looking for.

Does Medicare cover eye exams?

Original Medicare health insurance does not cover eye exams, however, many Medicare Advantage plans do offer vision coverage, including eye exams.

Is dental covered under Medicare?

In general, dental services are not covered by Medicare. However, certain dental services qualify for Medicare coverage if you’re receiving them as a hospital inpatient. This may happen if you have an underlying medical condition or if the severity of the procedure warrants hospitalization. Also, specific inpatient or outpatient dental services where they are related to the success of a medical treatment you are receiving may also qualify. Additionally, many Medicare Advantage plans do provide dental coverage.

Does Medicare cover hearing aids?

Original Medicare does not include coverage for hearing aids or exams for fitting hearing aids. However, many Medicare Advantage plans offer hearing coverage benefits.

Is the RSV vaccine covered by Medicare?

Yes, most vaccinations (those recommended by the Advisory Committee on Immunization Practices), including the RSV vaccine, are covered by Medicare Part D.

How can you find out what is and isn’t covered under Medicare?

To determine whether a specific health service or medical treatment is covered by Medicare, you can contact your treating provider to see if they think Medicare will cover it.

You can also contact Aevo anytime to ask one of our licensed agents your Medicare questions, in addition to utilizing Medicare’s website or your Medicare handbook (if you are currently enrolled in Medicare).