Understanding What Medicare Does and Does Not Cover

What is Medicare?

When you are planning your healthcare and especially Medicare, it is critical to know what is covered and what is not covered. Due to the many options and plans for Medicare, it can be confusing to know which plan will give you the right coverage. Fortunately, we are going to share with you some information to help make it easier for you.

Medicare is the insurance plan offered by the federal government for people aged 65 and over, as well as people with disabilities, and people who have permanent kidney failure.

Original Medicare includes part A and B. Part D for drug coverage must be included as well through a supplemental plan or another insurance plan, group or individual.

Medicare Part A

Medicare Part A, also called “original Medicare,” is the insurance plan that covers hospital stays and services.

What Medicare Part A costs

Depending on your income, you may have to pay a premium for Part A coverage. You may also have to pay co-payments or a deductible for any services under Medicare Part A. You can apply for assistance or help if you can’t pay. Beginning in 2017, in general, these are the costs for each service:

Hospital services: $1,316 for up to 60 days, $329 per day for 61-90 days, and $658 per day for stays beyond 91 days
Skilled nursing facilities: No charge for the first 20 days, $164.50 per day for 21-100 days, and all costs after 101 days
Hospice care: No charge for hospice care, $5 co-payment for medication, and 5 percent for inpatient respite care (periodic care so your caretaker can rest)

Remember, you have to be approved for these services and you have to make sure you are in an approved facility.

Medicare Part B

Medicare Part B is also a part of “original Medicare” and it covers your doctor services and preventive healthcare, such as yearly doctor visits and tests.
Part B covers a wide range of tests and services, including:

  • screening for cancer, depression, and diabetes
  • ambulance and emergency department services
  • electrocardiograms (ECGs)
  • medical equipment
  • influenza and hepatitis vaccinations
  • some drugs, diabetes supplies, and some prescriptions for eye wear

What Medicare Part B costs

If you have Part A, chances are you will have to also buy Part B coverage as well. For Part B beginning in 2020, most people will have to pay a monthly premium of $144.60 a month.

Some services are covered under Medicare Part B at no additional cost to you if you see a doctor that accepts Medicare. If you need a service outside of what is covered by Medicare, you will have to pay for that service. Services from doctors who do not accept Medicare may cost more and you might have to pay the full amount up-front. If some of the cost is covered, you will get paid back through a claims process.

Medicare Advantage Plans

Medicare Advantage plans, referred to as plan C, also called Medicare Advantage plans, are private insurance Medicare plan options. Most Medicare Advantage plans will include drugs to cover the part D requirement for Medicare coverage. They are private insurance plans approved by Medicare that fill in the gaps in services and hospital care. People with Medicare Part C must already be enrolled with Parts A and B.

Under these plans, you can get prescription drug coverage included with the same payment that is already made for part B.

Medicare Part D

Medicare Part D is the plan that covers prescription drugs not covered by Original Medicare. Part D is required but not automatically given. It can be sold as a supplemental to A and B Medicare or included in a Medicare Advantage plan. There is a penalty for not enrolling initially in Part D when it is first available and wanting to add it on a at a later date.

The cost for Medicare Part D varies depending on what kinds of medications you take, the plan you have, and which pharmacy you choose. You will have a premium to pay and, depending on your income, you may have to pay additional costs. You may also have to make co-payments or pay a deductible.

What’s not covered

While Medicare covers a wide range of care, not everything is covered. Most dental care, eye exams, hearing aids, acupuncture, and any cosmetic surgeries are not covered by Medicare Parts A and B.

Long-term care is also not covered by Medicare. If you think you or a loved one will need long-term care, consider a separate long-term care (LTC) insurance policy.


If you’re getting ready to enroll in Medicare, be sure you select the plan that best fits your healthcare needs. You can talk to the specialists at PM Insurance to get all your questions answered. Request a call today.

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