What does Medicare cover?
Benefits are health care services covered under your plan, whether it is Original Medicare, a Medicare Advantage plan or a Medicare Supplement Insurance plan. These can be preventive services, medical treatments, prescription drugs and more.
Most plan benefits are a set amount or a percentage of total cost, and may depend how long you receive care. Here’s an example:
Suppose you have Original Medicare Part A in 2026 and need a hospital stay. Your Part A deductible is $1,736. Once that is paid, Medicare will cover the cost for up to 60 days. The benefit is 100% of the total cost. After 60 days, though, you become responsible for a copayment of $434 per day. The benefit becomes the difference between your copay and the total cost. After 90 days, the copayment goes up to $868 per day, up to 60 lifetime reserve days. Same benefit type, different amounts.
What does Original Medicare cover?
Original Medicare has two parts: Part A hospital insurance and Part B medical insurance.
Medicare Part A covers hospital stays and most of the services you receive as an inpatient in a hospital or skilled nursing facility.
Medicare Part B helps pay for outpatient services in a clinic or hospital.
What does a Medicare Advantage plan cover?
Medicare Advantage (Part C) plans are offered by private insurance companies. They offer all the benefits of Original Medicare (Part A and Part B), and many plans have extras like dental, vision, and hearing benefits. Most include prescription drug coverage.
Medicare Advantage plans may also have $0 copays for items like physical exams, lab tests, preventive care, virtual medical and mental health visits. Benefits vary by plan and area, so check the details and compare plans before you choose.
What are the coverage differences between Original Medicare and a Medicare Advantage plan?
Original Medicare only covers some types of care if they are required as part of another medical condition. Medicare Advantage plans generally offer more coverage.
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| Dental exams | Doesn’t cover most dental care unless it is considered “medically necessary.” |
Many cover preventive services like oral exams and routine cleanings. Some also cover comprehensive services like fillings, crowns, bridges and dentures. |
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| Hearing aids | Part B will cover diagnostic hearing and balance exams if medically necessary. Won’t cover hearing aids. |
Some plans cover hearing aids. Many pay for routine hearing-related exams and services. |
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| Vision care | Only covers medically necessary vision care, such as for diabetes, cataract surgery or macular degeneration. |
Many plans include one routine annual eye exam. Some plans offer an allowance for glasses frames or contact lenses. |
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| Chiropractic | Only to correct a subluxation (dislocated spine). |
Many plans offer a set number of routine visits each year and charge a copay. |
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| Accupuncture | Only offers coverage for chronic low back pain, up to 12 visits in 90 days. |
Some plans cover acupuncture for broader conditions beyond back pain. |
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| Assisted living | Does not pay for custodial care (room and board) in assisted living facilities. |
Some Special Needs plans and long-term care plans offer minor support services. |
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| Home health care | Covers skilled nursing, physical therapy, occupational therapy or speech-language pathology services for homebound patients. |
Plans provide the same coverage for home health care services as Original Medicare. |
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| Hospice | Part A covers comprehensive care for terminal illness, including drugs prescribed for symptom control. |
Medicare Advantage members usually transition to Original Medicare for hospice benefits. |
What does a Special Needs plan cover?
Special Needs plans (SNPs) are Medicare Advantage plans designed for people with certain health care or financial needs. They cover the same health care services as Medicare Part A and Part B. Some may also cover extra services tailored to the specific group they're designed to serve. All Special Needs plans provide prescription drug coverage.
There are three kinds of Special Needs plans:
- A Chronic Special Needs plan (C-SNP) is for people living with specific chronic or disabling long-term health conditions.
- A Dual Special Needs plan (D-SNP) includes care coordination and additional benefits for people who qualify for both Medicare and Medicaid.
- An Institutional Special Needs plan (I-SNP) is for people who live in a long-term care setting, such as a skilled nursing facility. An Institutional-Equivalent Special Needs plan (IE-SNP) is for someone who receives skilled nursing care at home or in assisted living.
Availability of plans will depend on where you live.
What does a Medicare Part D plan cover?
Medicare Part D prescription drug plans are available as standalone plans called PDP or as part of Medicare Advantage plans known as MAPD.
Part D plans cover drugs on the plan’s drug list (formulary) and most adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). (Some vaccines are covered by Medicare Part B.)
Your prescription drug costs will vary depending what tier a drug is in, what coverage stage you are in and if you use a preferred network pharmacy.
- You pay the full cost of a prescription in the Deductible stage if your plan has one
- In the Initial Coverage stage, you pay a copay or coinsurance
- In the Catastrophic Coverage stage, the plan pays the full amount for Medicare covered Part D drugs
What does a Medicare Supplement plan cover?
Original Medicare (Part A and Part B) generally pays about 80% of covered expenses. You’re responsible for paying the rest. A Medicare Supplement Insurance (Medigap) plan helps pay your share.
When you receive covered care services, your provider will bill Original Medicare first. After receiving the share Medicare pays, the provider will bill the plan, which will pay for some or all of the rest after you meet your Part B deductible.
In general, Original Medicare and Medicare Supplement plans don’t cover long-term care, such as custodial care in a nursing home, or private-duty nursing services. Some Medicare Supplement plans offer discounts and additional services to help with these costs.
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