Learn About Medicare Covered Services Guide

Understanding Medicare Coverage Basics

Medicare is a federal health insurance program primarily designed for people age 65 and older, though some younger individuals with specific conditions may participate. The program began in 1965 and now serves over 66 million people in the United States. Medicare is divided into different parts, each covering different types of services and costs. Understanding what each part covers helps you know what medical expenses Medicare may help pay for and what costs you might cover yourself.

Original Medicare consists of Part A and Part B. Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services. Part B covers outpatient services like doctor visits, preventive care, medical equipment, and laboratory tests. When you receive services covered under Original Medicare, you typically pay a deductible first, then Medicare pays its share and you pay coinsurance or copayments for the remaining costs.

In 2024, the Part A hospital deductible is $1,632 per benefit period, and the Part B deductible is $240 per year. After meeting these deductibles, you generally pay 20% of approved amounts for most Part B services. These costs can vary by year as Medicare adjusts amounts annually based on inflation and other factors.

Medicare also includes Part D, which covers prescription medications, and Part C (Medicare Advantage), which is an alternative way to receive your Part A and Part B coverage through private insurance companies. Many people also purchase supplemental insurance, called Medigap, to help cover costs that Original Medicare doesn't pay.

Practical Takeaway: Before exploring specific services, understanding these basic parts of Medicare helps you recognize which program section might cover different types of medical care you receive.

Hospital and Inpatient Services Covered by Medicare Part A

Medicare Part A primarily covers inpatient hospital stays. When you're admitted to a hospital as an inpatient (meaning you stay overnight and receive care in the hospital), Part A covers your room, meals, nursing care, medications administered in the hospital, and other hospital services. In 2024, after you pay the $1,632 deductible, Medicare covers all approved costs for days 1-60 of a hospital stay during each benefit period. A benefit period begins when you're admitted to the hospital and ends when you haven't received inpatient hospital or skilled nursing facility care for 60 days in a row.

For days 61-90, you pay a coinsurance amount of $408 per day (in 2024), and Medicare covers the rest. If your hospital stay extends beyond 90 days, you can use lifetime reserve days, though these are limited to 60 days total for your entire lifetime, and you pay $816 per day coinsurance for these days.

Part A also covers skilled nursing facility (SNF) care. This is different from regular nursing home care. Skilled nursing care means you need daily care from nurses or other medical professionals who have special training, such as wound care, physical therapy, or intravenous medication administration. To be covered, you generally must have a qualifying hospital stay of at least three days, and your doctor must determine that you need skilled care. Medicare covers the first 20 days entirely, and days 21-100 require a daily coinsurance payment of $204 (in 2024).

Home health services are another Part A coverage area. If your doctor determines you're homebound and need skilled nursing care or therapy services, Part A may cover those services provided by a Medicare-certified home health agency. This includes skilled nursing visits, physical therapy, occupational therapy, and speech therapy. You typically don't pay for Part A-covered home health services, though you may pay 20% coinsurance for medical equipment like wheelchairs or walkers.

Practical Takeaway: Knowing the difference between inpatient hospital stays, skilled nursing care, and home health services helps you understand what costs to expect and how long coverage continues for each type of care.

Doctor Visits and Outpatient Services Covered by Medicare Part B

Medicare Part B covers most outpatient medical services, including doctor visits whether they occur in an office, hospital outpatient department, or other setting. This includes visits with your primary care doctor, specialists, and other healthcare providers. Part B covers the cost of these visits after you meet your annual deductible ($240 in 2024) and then covers 80% of the approved amount while you typically pay 20% coinsurance.

Preventive services are fully covered by Part B with no coinsurance or copayment required, even before you meet your deductible. This includes annual wellness visits with your doctor, screenings for conditions like cancer and diabetes, vaccinations such as flu shots and pneumonia vaccines, and cardiovascular screening tests. For example, colorectal cancer screening is covered for people age 50 and older, and mammograms for breast cancer screening are covered annually for women age 40 and older. Depression screening is also a covered preventive service for all adults.

Part B covers diagnostic tests and lab work ordered by your doctor. Blood tests, urinalysis, imaging studies like X-rays and ultrasounds, and EKG tests are generally covered. When these tests occur in a hospital outpatient setting or independent lab facility, you pay your coinsurance after meeting your deductible. Some labs and imaging centers may bill you differently, so it's important to understand whether a facility is participating with Medicare.

Medical equipment and supplies are covered under Part B when prescribed by your doctor. This includes items such as wheelchairs, walkers, canes, diabetic supplies like test strips and lancets, oxygen equipment, and orthopedic braces. For durable medical equipment (items expected to last three years or more), you pay 20% coinsurance after meeting your deductible. The equipment must be from a Medicare-approved supplier for coverage.

Mental health services including therapy and counseling are covered by Part B. You can receive these services in a doctor's office, hospital outpatient department, community mental health center, or clinic. After meeting your Part B deductible, you typically pay 20% coinsurance for these visits, though this may vary depending on the type of provider and setting.

Practical Takeaway: Part B's coverage of preventive services means you should take advantage of free annual screenings and wellness visits, which can help catch health conditions early.

Prescription Medication Coverage Under Medicare Part D

Medicare Part D is prescription drug coverage offered by insurance companies approved by Medicare. If you have Original Medicare (Part A and B), you can purchase Part D coverage from a private insurance company. If you have Medicare Advantage (Part C), prescription drug coverage may be included in your plan or offered separately. Most people should have Part D coverage or other creditable prescription drug coverage to avoid potential penalties.

Part D coverage includes both brand-name and generic prescription medications. The coverage structure typically includes a deductible (which can be up to $545 in 2024), an initial coverage period where you and your plan share costs, a coverage gap sometimes called "the donut hole," and catastrophic coverage for very high costs. Understanding this structure helps you predict your medication expenses throughout the year.

During the initial coverage phase in 2024, after paying your deductible, you typically pay a copayment (a fixed amount like $5, $10, or $15) or coinsurance (a percentage of the drug cost) for each prescription. The amount depends on which tier the medication is placed on—generic drugs are usually cheaper than brand-name drugs. Once you and your plan have spent $5,850 total on covered drugs, you enter the coverage gap.

In the coverage gap, you pay a higher percentage of prescription costs, though manufacturers' discounts and your coinsurance contributions both count toward getting you out of this gap. Once your out-of-pocket costs reach $8,550 (in 2024), you enter catastrophic coverage where Medicare pays most of the cost and you pay only a small coinsurance or copayment amount.

Part D plans vary significantly in which medications they cover, what tier each medication is on, and what pharmacies you can use. You can view the specific formulary (list of covered drugs) for any plan you're considering. If your regular medication isn't on a plan's formulary, you may be able to request an exception from the insurance company, or you might need to consider a different plan.

Generic medications are generally significantly less expensive than brand-name drugs and are required to have the same active