The ABCs of Medicare: Who's Covered? What's Covered? What's Not?

When you’re caregiving, you have enough to do without trying to navigate the complexities of insurance, so we put together a simple overview of what’s covered, what’s not, and who can take advantage of Medicare’s most common offerings.

Medicare is a nationwide program managed by the U.S. Government that provides healthcare coverage for those 65 and older. There are four parts to Medicare: Part A provides inpatient/hospital coverage, Part B provides outpatient/medical coverage, Part C provides an alternate way to receive benefits, and Part D provides prescription drug coverage.

Note that Medicare and Medicaid are two entirely different programs. Medicaid is a federal and state program that helps with medical costs for those who are low income. Benefits vary state by state, but you can visit this site to check your eligibility.

Medicare Part A is the most basic form of Medicare, and is used only for inpatient and hospital coverage. For people who are over 65, have worked at least 10 years, and paid Medicare taxes while they worked, Part A doesn’t require any premiums. Keep in mind that Part A still isn’t “free,” as you’re responsible for a deductible in most cases, and a co-pay in others.

Part A covers:

• Inpatient hospital care

• Skilled nursing facility care for those who has a doctor recommended it, or where need was determined during a hospital stay

• Hospice care

• Home healthcare for people under the care of a doctor and homebound. These services must be:

  • Medical social services

  • Occupational therapy

  • Speech-language pathology services

  • Part-time skilled nursing care

  • Part-time home health aide services

Part B is medical insurance that covers non-hospital expenses like blood tests, doctor’s visits, and x-rays. Since it’s medical insurance, you need to pay monthly premiums and meet a deductible before the benefits kick in.

Part B covers:

• Doctors’ appointments. a.k.a. “wellness checks”

• Preventive services like screenings

• Ambulance services

• Durable medical equipment (DME) if prescribed by a doctor, including walkers, blood sugar monitors, commode strips, and crutches. You’ll need to purchase these through a vendor that accepts DME prescriptions. Keep in mind that for DMEs, you’re often responsible for a 20% co-pay.

• Mental health services (inpatient and outpatient treatments as well as partial hospitalization)

• Yearly depression screenings

• Clinical research studies to compare different treatments or study how well new treatments are working

• Some prescription drug coverage

Part C, commonly called “Medicare Advantage,” bundles up the other types of Medicare into one package. It’s completely optional, but you must also have Part A and Part B in order to enroll.

Medicare Advantage includes all the benefits that Part A and Part B include, and may cover some additional services like eye exams, hearing aids, and dental care. Unlike Parts A and B, Part C is offered through private insurance companies, so what is and isn’t covered depends on your specific plan.

Medicare Part D, which is also referred to as the Medicare prescription drug benefit, is an optional program designed to help Medicare enrollees pay for self-administered prescription drugs (the cost of most professionally-administered prescriptions is covered under Part B of United States Medicare).

Part D is offered three ways: through private insurers as a standalone plan, for people enrolled in Medicare A, or as a set of benefits included with Medicare Advantage Plans.

With the exception of Medicare Part C, or “Medicare Advantage,” there are a number of services that Medicare plans do not cover.

If you’re a recipient of Medicare Part A and/or Part B, your plan will not cover:

• Homemaker services (shopping, cleaning, laundry)

• Custodial or personal care (bathing, dressing, using the bathroom)

• Acupuncture

• Long-term care

• Most dental care

• Eye exams related to prescribing glasses

• Dentures

• Cosmetic surgery

• Hearing aids and exams for fitting them

• Routine foot care

• Adult diapers and other absorbent incontinence products

For the most up-to-date information on coverage, bookmark the official Medicare website.