How to Understand What Medicare Actually Covers

A clear guide to Medicare coverage basics to help families navigate healthcare benefits for aging parents. HowTo: Family Edition: family how-tos that actually help.

1. Know the Four Parts of Medicare. Medicare has four main parts that cover different things. Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health services - most people get this automatically at 65. Part B covers doctor visits, outpatient care, medical equipment, and preventive services like annual wellness visits and screenings. Part C, also called Medicare Advantage, is an alternative that combines Parts A and B through private insurance companies, often including prescription drug coverage. Part D covers prescription medications and is available as a separate plan or included in Medicare Advantage plans.
2. Understand What's Covered vs. What You Pay. Medicare covers many essential services, but it doesn't cover everything. Hospital stays are covered under Part A after you meet the deductible, but you'll pay coinsurance for longer stays. Doctor visits and outpatient services under Part B typically require you to pay 20% of the cost after meeting the annual deductible. Medicare covers preventive care like mammograms, colonoscopies, and annual wellness visits at no cost to you. However, Medicare doesn't cover long-term custodial care, most dental care, eye exams for glasses, hearing aids, or care outside the United States.
3. Learn About Prescription Drug Coverage. Medicare Part D covers prescription medications, but each plan has its own list of covered drugs called a formulary. Plans organize drugs into tiers, with generic medications typically costing less than brand-name drugs. There's often a coverage gap called the 'donut hole' where you pay more out-of-pocket until you reach catastrophic coverage. You can enroll in a standalone Part D plan if you have Original Medicare, or choose a Medicare Advantage plan that includes drug coverage.
4. Know Your Rights and Appeals Process. If Medicare denies coverage for something your doctor says you need, you have the right to appeal. Start by asking your healthcare provider to submit additional information or resubmit the claim with more details. You can file a formal appeal through Medicare's process, which has multiple levels if your initial appeal is denied. Keep detailed records of all communications, and don't hesitate to ask for help from Medicare customer service or a Medicare counselor in your area.