
What Is Medicare In The United States (US)?
Medicare is a federal health insurance program in the United States (US) that primarily provides coverage for individuals aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions. Understanding what Medicare covers in the United States (US) is essential for beneficiaries to maximize their healthcare benefits.
Medicare consists of different parts, including Medicare Part A, Medicare Part B, Medicare Part C (Medicare Advantage), and Medicare Part D, each covering various healthcare services. Knowing what Medicare covers in the United States (US) helps individuals make informed decisions about their medical care and avoid unexpected costs.
The Medicare program in the United States (US) is administered by the Centers for Medicare & Medicaid Services (CMS) and provides essential healthcare services, including hospital care, doctor visits, preventive services, prescription drug coverage, and more. Below, we break down what Medicare covers in the United States (US) by exploring each part in detail.
What Does Medicare Part A Cover In The United States (US)?
Hospital Stays And Inpatient Care
Medicare Part A covers inpatient hospital stays in the United States (US), including semi-private rooms, meals, general nursing, and necessary hospital services. Beneficiaries must meet a deductible before coverage begins, and coverage is typically limited to a specific number of days per benefit period.
Skilled Nursing Facility (SNF) Care
Medicare Part A also covers skilled nursing facility (SNF) care for eligible individuals who require short-term rehabilitation or specialized nursing care following a hospital stay of at least three consecutive days. The coverage includes skilled nursing services, therapy, and necessary medical supplies.
Hospice Care
Medicare Part A provides hospice care coverage for terminally ill patients in the United States (US) who have a life expectancy of six months or less. This coverage includes palliative care, pain management, respite care, and counseling services.
Home Health Care
Eligible Medicare beneficiaries can receive home health care services under Part A, including intermittent skilled nursing care, physical therapy, and speech-language pathology services. However, personal or custodial care is generally not covered.
What Does Medicare Part B Cover In The United States (US)?
Doctor Visits And Outpatient Services
Medicare Part B covers doctor visits, outpatient medical services, and preventive care in the United States (US). This includes primary care physician visits, specialist appointments, lab tests, and diagnostic services such as X-rays and MRIs.
Preventive Care And Screenings
Medicare Part B provides preventive care services, including screenings for conditions like cancer, diabetes, and heart disease. Beneficiaries can also receive vaccinations, such as flu and pneumonia shots, at no additional cost.
Durable Medical Equipment (DME)
Medicare Part B covers durable medical equipment (DME), such as wheelchairs, oxygen equipment, and prosthetic devices, when prescribed by a doctor. This helps beneficiaries manage chronic conditions and disabilities.
Mental Health Services
Mental health care is an essential part of Medicare Part B coverage in the United States (US). Beneficiaries have access to outpatient therapy, counseling, psychiatric evaluations, and medication management services.
What Does Medicare Part C (Medicare Advantage) Cover In The United States (US)?
Comprehensive Coverage Through Private Plans
Medicare Part C, also known as Medicare Advantage, offers an alternative way to receive Medicare benefits through private insurance companies. These plans combine Medicare Part A, Part B, and often Part D coverage into a single plan.
Additional Benefits Not Covered By Original Medicare
Many Medicare Advantage plans in the United States (US) provide additional benefits that Original Medicare does not cover, such as vision, dental, hearing, and wellness programs. Some plans also include gym memberships and telehealth services.
Network-Based Coverage And Costs
Medicare Advantage plans often use network-based healthcare models, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which may require referrals for specialists and limit coverage to specific providers.
What Does Medicare Part D Cover In The United States (US)?
Prescription Drug Coverage
Medicare Part D helps beneficiaries pay for prescription medications. Each plan has a formulary (list of covered drugs), which includes both generic and brand-name medications.
The Medicare Part D Donut Hole
Medicare Part D has a coverage gap, known as the “donut hole,” which temporarily increases out-of-pocket costs after reaching a spending threshold. However, beneficiaries receive discounts on covered drugs during this period.
Catastrophic Coverage
Once beneficiaries exceed a certain out-of-pocket spending limit, they enter catastrophic coverage, where they pay only a small percentage of prescription drug costs for the remainder of the year.
What Does Medicare Not Cover In The United States (US)?
Long-Term Care
Medicare does not cover long-term care, also known as custodial care, in nursing homes or assisted living facilities unless it is medically necessary following a hospital stay.
Dental, Vision, And Hearing Services
Original Medicare does not cover routine dental care, vision exams, or hearing aids. However, some Medicare Advantage plans offer these benefits.
Cosmetic Surgery And Alternative Therapies
Medicare does not cover cosmetic procedures or elective surgeries. Additionally, alternative therapies such as acupuncture (except for chronic low back pain) and naturopathy are generally not covered.
How To Enroll In Medicare In The United States (US)?
Automatic Enrollment And Initial Enrollment Period
Most individuals are automatically enrolled in Medicare Part A and Part B when they turn 65 if they receive Social Security benefits. Others must enroll manually during the Initial Enrollment Period (IEP), which begins three months before turning 65 and lasts for seven months.
Special Enrollment Period (SEP)
Individuals who delay Medicare enrollment due to employer-sponsored health coverage can sign up later through a Special Enrollment Period (SEP) without facing penalties.
Late Enrollment Penalties
Failing to enroll in Medicare Part B or Part D on time may result in late enrollment penalties, increasing monthly premiums for the rest of the beneficiary’s life.
Conclusion
Understanding what Medicare covers in the United States (US) is essential for making informed healthcare decisions. Medicare provides hospital coverage, outpatient services, preventive care, prescription drugs, and additional benefits through Medicare Advantage. However, long-term care, dental, vision, and hearing services are not covered under Original Medicare. Enrolling at the right time helps beneficiaries avoid penalties and ensure access to the healthcare services they need.
Frequently Asked Questions
1. What Does Medicare Cover In The United States (US)?
Medicare covers a wide range of healthcare services for eligible individuals in the United States (US). It consists of four parts: Medicare Part A (hospital insurance), Medicare Part B (medical insurance), Medicare Part C (Medicare Advantage), and Medicare Part D (prescription drug coverage). Medicare Part A covers hospital stays, skilled nursing facility (SNF) care, hospice care, and some home health services. Medicare Part B covers doctor visits, outpatient care, preventive screenings, mental health services, and durable medical equipment (DME). Medicare Part C (Medicare Advantage) includes everything in Parts A and B but may also offer dental, vision, and hearing coverage. Medicare Part D helps cover prescription medications. However, Medicare does not cover long-term care, most dental care, hearing aids, or cosmetic procedures.
2. What Does Medicare Part A Cover In The United States (US)?
Medicare Part A provides hospital insurance for eligible individuals in the United States (US). It primarily covers inpatient hospital stays, which include semi-private rooms, meals, nursing care, and necessary hospital services. Part A also covers skilled nursing facility (SNF) care, but only for short-term rehabilitation after a hospital stay of at least three days. Hospice care is included for terminally ill patients who opt for comfort-focused care instead of curative treatment. Part A also covers limited home health services, such as skilled nursing care and therapy, if prescribed by a doctor. However, it does not cover long-term care in nursing homes or custodial care. Beneficiaries usually do not pay a premium for Part A if they have worked and paid Medicare taxes for at least ten years.
3. What Does Medicare Part B Cover In The United States (US)?
Medicare Part B provides medical insurance for outpatient services in the United States (US). It covers doctor visits, specialist appointments, outpatient hospital care, and preventive screenings like mammograms, colonoscopies, and flu shots. Diagnostic tests, including blood work, X-rays, MRIs, and CT scans, are also covered. Part B helps pay for mental health services, including therapy and counseling. It covers durable medical equipment (DME), such as wheelchairs, oxygen tanks, and prosthetic devices. Some home health services, like physical therapy and intermittent skilled nursing care, are included. However, Medicare Part B does not cover dental, vision, or hearing care. Beneficiaries pay a monthly premium, an annual deductible, and typically 20% of the cost of most covered services after meeting the deductible.
4. What Does Medicare Part C (Medicare Advantage) Cover In The United States (US)?
Medicare Part C, also called Medicare Advantage, is an alternative to Original Medicare in the United States (US). These plans are offered by private insurance companies and cover everything included in Medicare Part A and Part B. Many Medicare Advantage plans also provide additional benefits that Original Medicare does not cover, such as dental, vision, hearing, and wellness programs. Some plans include transportation services, gym memberships, and telehealth visits. Most Medicare Advantage plans also incorporate Medicare Part D prescription drug coverage. These plans may require members to use a network of healthcare providers, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Costs vary by plan, and beneficiaries typically pay different premiums, copayments, and deductibles than with Original Medicare.
5. What Does Medicare Part D Cover In The United States (US)?
Medicare Part D provides prescription drug coverage for Medicare beneficiaries in the United States (US). These plans are offered by private insurance companies approved by Medicare. Each plan has a formulary, which is a list of covered drugs that typically includes both generic and brand-name medications. Beneficiaries pay a monthly premium, a yearly deductible, and a share of prescription costs based on their plan’s tier system. Part D also includes a coverage gap (the “donut hole”), during which beneficiaries temporarily pay more for drugs until they reach catastrophic coverage, where costs decrease significantly. Medicare Part D helps cover medications for chronic conditions, short-term treatments, and vaccines not covered under Medicare Part B. However, over-the-counter drugs and some specialty medications may not be covered.
6. What Does Medicare Not Cover In The United States (US)?
Medicare does not cover certain medical services and expenses in the United States (US). Long-term care (custodial care) in nursing homes or assisted living facilities is not covered. Routine dental, vision, and hearing services—including dentures, eye exams, and hearing aids—are also excluded. Medicare does not pay for cosmetic surgery, except in cases of reconstructive surgery after an accident or illness. Alternative therapies, such as acupuncture (except for chronic low back pain), chiropractic care beyond spinal adjustments, and naturopathy, are not covered. Additionally, most prescription drugs are not covered under Original Medicare (Parts A and B), requiring beneficiaries to enroll in Medicare Part D for medication coverage. Medicare also does not cover medical expenses outside the United States (US), except in very limited situations.
7. What Does Medicare Cover For Seniors In The United States (US)?
Medicare provides health insurance coverage for seniors aged 65 and older in the United States (US). It includes hospital stays (Part A), doctor visits and outpatient care (Part B), and prescription drugs (Part D). Many seniors choose Medicare Advantage (Part C) for additional benefits like dental, vision, and hearing coverage. Medicare covers preventive services, such as screenings for cancer, diabetes, and heart disease, as well as flu shots and vaccinations. Seniors needing rehabilitation services, skilled nursing care, or home health care may qualify under Medicare guidelines. However, Medicare does not cover long-term nursing home care, requiring seniors to consider other financial options, such as Medicaid or private long-term care insurance.
8. What Does Medicare Cover For Disabled Individuals In The United States (US)?
Medicare covers disabled individuals under age 65 in the United States (US) if they receive Social Security Disability Insurance (SSDI) benefits for at least 24 months. Coverage includes Medicare Part A (hospital stays, skilled nursing facility care, hospice, and home health services) and Medicare Part B (doctor visits, outpatient care, preventive screenings, and medical equipment). Disabled individuals can also enroll in Medicare Part C (Medicare Advantage) and Medicare Part D (prescription drug coverage) for additional benefits. Some disabled individuals qualify for Medicare Savings Programs (MSPs) or Medicaid to help cover out-of-pocket costs. Individuals with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) qualify for Medicare without the 24-month waiting period. However, Medicare does not cover long-term care, routine dental, vision, or hearing services.
9. What Does Medicare Cover For Hospital Stays In The United States (US)?
Medicare Part A covers hospital stays and inpatient care in the United States (US). It includes semi-private rooms, meals, general nursing, and hospital services necessary for treatment. Beneficiaries must pay a deductible per benefit period, and coverage is limited to a certain number of days. Medicare pays in full for the first 60 days, after which copayments apply. If a hospital stay extends beyond 90 days, a patient must use lifetime reserve days or pay the full cost. Part A also covers intensive care unit (ICU) stays, rehabilitation hospitals, and mental health inpatient services. However, it does not cover private rooms, personal items, or long-term custodial care. Outpatient hospital services, including emergency room visits, are covered under Medicare Part B.
10. What Does Medicare Cover For Outpatient Services In The United States (US)?
Medicare Part B covers outpatient services, including doctor visits, emergency room visits, diagnostic tests, X-rays, MRIs, CT scans, and lab work in the United States (US). It also covers preventive screenings, mental health services, and physical therapy. Outpatient surgeries and procedures performed in hospital outpatient departments or ambulatory surgical centers are included. Additionally, Part B covers urgent care, chemotherapy, and dialysis. Some home health services, such as skilled nursing and therapy, are also covered. However, Medicare does not cover routine dental, vision, hearing exams, or cosmetic procedures under outpatient services. Beneficiaries must pay an annual deductible and 20% coinsurance after the deductible is met. Some services may require prior authorization.
11. What Does Medicare Cover For Prescription Drugs In The United States (US)?
Medicare covers prescription drugs through Medicare Part D in the United States (US). Part D plans are provided by private insurance companies and cover generic and brand-name medications. Coverage includes medications for chronic conditions, antibiotics, pain management, and vaccines (such as shingles and tetanus shots). Each plan has a formulary, a list of covered drugs categorized into tiers, affecting out-of-pocket costs. Beneficiaries pay a monthly premium, deductible, and copayments or coinsurance. There is also a coverage gap (donut hole) where drug costs temporarily increase before catastrophic coverage kicks in. Medicare Part B covers certain outpatient drugs, such as chemotherapy and infusion medications. However, over-the-counter medications and some specialty drugs are not covered.
12. What Does Medicare Cover For Mental Health Services In The United States (US)?
Medicare covers mental health services under Medicare Part A and Part B in the United States (US). Part A covers inpatient mental health care in a general hospital or psychiatric facility, up to 190 days in a lifetime. Part B covers outpatient mental health services, including psychotherapy, counseling, psychiatric evaluations, and medication management. Telehealth mental health services are also covered. Medicare pays for substance use disorder treatment, such as counseling and detox programs. However, long-term residential treatment and alternative therapies (such as holistic treatments) are not covered. Beneficiaries typically pay 20% coinsurance after meeting the Part B deductible. Medicare Advantage plans may offer additional mental health benefits, such as wellness programs and care coordination.
13. What Does Medicare Cover For Preventive Care In The United States (US)?
Medicare Part B covers preventive care services to help beneficiaries stay healthy and detect conditions early in the United States (US). Covered preventive services include cancer screenings (breast, cervical, prostate, and colorectal), cardiovascular disease screenings, diabetes screenings, and bone density tests. Medicare also covers flu shots, pneumonia vaccines, and COVID-19 vaccines at no cost. Beneficiaries receive a “Welcome to Medicare” visit and annual wellness visits to create a preventive care plan. Smoking cessation programs, depression screenings, and obesity counseling are included. Some preventive services require a doctor’s order, and certain tests may have frequency limits. Original Medicare does not cover comprehensive physical exams, though some Medicare Advantage plans may offer them.
14. What Does Medicare Cover For Skilled Nursing Facility (SNF) Care In The United States (US)?
Medicare Part A covers skilled nursing facility (SNF) care in the United States (US) for beneficiaries who need short-term rehabilitation or skilled medical care after a hospital stay of at least three days. Covered services include skilled nursing care, physical therapy, occupational therapy, speech-language pathology, and medical supplies. Medicare pays in full for the first 20 days of SNF care per benefit period, with a daily copayment required for days 21-100. After 100 days, Medicare stops coverage, and beneficiaries must pay all costs. Medicare does not cover long-term nursing home stays, custodial care, or personal care services. Some Medicare Advantage plans may offer expanded SNF benefits.
15. What Does Medicare Cover For Home Health Care In The United States (US)?
Medicare covers home health care for eligible beneficiaries in the United States (US) under Medicare Part A and Part B. Covered services include skilled nursing care, physical therapy, occupational therapy, speech therapy, and medical social services. To qualify, a doctor must certify that the patient is homebound and needs intermittent skilled care. Medicare does not cover 24-hour home care, meal delivery, or personal care (such as bathing and dressing) unless part of skilled care. Durable medical equipment (DME) may be covered under Part B. Home health care services are usually fully covered by Medicare with no copayments, but some medical equipment may require coinsurance.
16. What Does Medicare Cover For Hospice Care In The United States (US)?
Medicare Part A covers hospice care for beneficiaries in the United States (US) who are terminally ill with a life expectancy of six months or less. To qualify, a doctor must certify that the patient is choosing comfort care (palliative care) instead of curative treatments. Covered services include pain management, symptom control, nursing care, social services, spiritual counseling, and bereavement support for families. Medicare also covers medications for symptom relief, medical equipment (such as wheelchairs and hospital beds), and short-term inpatient or respite care. However, hospice care does not cover treatments aimed at curing the illness, room and board at a hospice facility, or non-medical services like daily personal care unless part of the hospice plan. Hospice services are fully covered, with minimal out-of-pocket costs for medications.
17. What Does Medicare Cover For Medical Equipment In The United States (US)?
Medicare Part B covers durable medical equipment (DME) in the United States (US) when it is medically necessary and prescribed by a doctor. Covered DME includes wheelchairs, walkers, hospital beds, oxygen equipment, prosthetic limbs, blood sugar monitors, and CPAP machines. Medicare rents or purchases equipment depending on the type of device. Beneficiaries typically pay 20% of the Medicare-approved amount after meeting their Part B deductible. Medicare does not cover items for personal convenience, such as bathroom safety rails, hearing aids, or over-the-counter braces. Some Medicare Advantage (Part C) plans offer additional coverage for DME, including extra supplies or lower costs for specific items.
18. What Does Medicare Cover For Vision, Dental, And Hearing In The United States (US)?
Original Medicare does not cover routine vision, dental, or hearing services in the United States (US). Medicare Part A may cover vision, dental, or hearing services only if related to a covered hospital stay (e.g., jaw surgery or treatment for an eye injury). Medicare Part B covers eye exams for people with diabetes, glaucoma screenings, and cataract surgery (including one pair of eyeglasses after surgery). It also covers cochlear implants for severe hearing loss. However, Medicare does not cover routine eye exams, hearing aids, or dental cleanings, fillings, dentures, and extractions. Many Medicare Advantage (Part C) plans include coverage for dental, vision, and hearing, offering benefits not available under Original Medicare.
19. What Does Medicare Cover For Emergency And Urgent Care In The United States (US)?
Medicare Part B covers emergency and urgent care services in the United States (US). Emergency room (ER) visits are covered anywhere in the U.S., but beneficiaries must pay a copayment and coinsurance. Medicare Part A covers hospital inpatient care if the patient is admitted after the ER visit. Urgent care centers are covered under Medicare Part B for conditions that require immediate attention but are not life-threatening. Medicare Advantage (Part C) plans often provide additional emergency coverage, including international emergency care in some cases. However, Original Medicare generally does not cover medical expenses outside the U.S., except in limited situations, such as when a foreign hospital is closer than a U.S. facility.
20. What Does Medicare Cover Compared To Medicaid In The United States (US)?
Medicare and Medicaid are different government health programs in the United States (US). Medicare is a federal program for people aged 65 and older and certain disabled individuals, covering hospital care (Part A), medical services (Part B), prescription drugs (Part D), and Medicare Advantage plans (Part C). Medicaid is a state and federal program that provides healthcare for low-income individuals of any age. Medicaid covers many services Medicare does not, such as long-term nursing home care and personal care services. Some people qualify for both Medicare and Medicaid (dual eligibility), allowing Medicaid to help pay Medicare premiums, deductibles, and copayments. Medicaid eligibility and benefits vary by state, while Medicare benefits are the same nationwide.
Further Reading
- What Are The Eligibility Requirements For Patients To Have Medicare In The United States (US)?
- Are Medicare And Medicaid The Same In The United States (US)?
- How Do I Qualify For Both Medicare And Medicaid In The United States (US)?
- Who Is Eligible For Both Medicare And Medicaid In The United States (US)?
- How Do I Qualify For Medicare In The United States (US)?
- How Do I Qualify For Medicare Advantage In The United States (US)?
- Who Is Eligible For Medicare Advantage In The United States (US)?
- How To Apply For Medicare Advantage Plans In The United States (US)
- What Are The Advantages And Disadvantages Of Medicare Advantage Plans In The United States (US)?
- Can I Switch Medicare Advantage Plans In The United States (US)?