When you turn 65, navigating the complexities of healthcare coverage becomes a major concern. Fortunately, Medicare, the federal health insurance program, is designed to support older adults and individuals with specific disabilities. However, understanding what Medicare covers, and just as importantly, what it doesn’t, can be tricky. In this guide, we’ll break down the different parts of Medicare and help you make sense of the options available.

What is Medicare?

Medicare is the government health insurance program primarily for people 65 or older, though younger individuals with certain disabilities or medical conditions (like End-Stage Renal Disease) may also qualify. The program is divided into several parts, each designed to cover different healthcare needs. For a complete overview, visit the Medicare.gov page on getting started with Medicare.

The Four Parts of Medicare

1. Medicare Part A (Hospital Insurance) 

Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services. For most people, Part A is premium-free, as long as you or your spouse paid Medicare taxes while working.

What’s Covered Under Part A?

  • Inpatient hospital stays (up to a certain limit)
  • Limited stays in a skilled nursing facility after a hospital stay
  • Hospice care for those with terminal illnesses
  • Some home healthcare services

What’s Not Covered?

  • Long-term care (beyond skilled nursing or rehab)
  • Personal care, like assistance with bathing, dressing, or eating

2. Medicare Part B (Medical Insurance) 

Part B is your coverage for outpatient care, including doctor visits, preventive services, and medical supplies. Unlike Part A, Part B requires a monthly premium.

What’s Covered Under Part B?

  • Doctor visits and outpatient services
  • Preventive services, such as flu shots and cancer screenings
  • Durable medical equipment like walkers and wheelchairs
  • Mental health services

What’s Not Covered?

  • Routine dental, vision, or hearing care
  • Cosmetic surgery
  • Prescription drugs (those are covered by Part D)

3. Medicare Part C (Medicare Advantage) 

Medicare Advantage plans are an alternative to Original Medicare (Parts A and B). These are offered by private insurance companies approved by Medicare and often bundle Part A, Part B, and sometimes Part D (prescription drug coverage) into one plan. They may offer extra benefits like vision, dental, and hearing coverage.

What’s Covered Under Part C?

  • Everything covered under Parts A and B
  • Additional benefits like dental, vision, and hearing (depending on the plan)
  • Prescription drugs (if your Medicare Advantage plan includes Part D coverage)

What’s Not Covered?

  • Coverage limits and out-of-pocket costs can vary significantly by plan, so review the details carefully before enrolling.

4. Medicare Part D (Prescription Drug Coverage) 

This is the part of Medicare that helps cover the cost of prescription drugs. You can purchase a standalone Part D plan if you have Original Medicare, or get prescription drug coverage as part of a Medicare Advantage plan.

What’s Covered Under Part D?

  • A range of prescription drugs, which vary by plan
  • Drugs that are essential for treating common conditions, such as diabetes or heart disease

What’s Not Covered?

  • Over-the-counter medications
  • Some high-cost specialty drugs may have limited coverage or higher out-of-pocket costs. Learn more about the different parts of Medicare to understand which coverage options are best for you.

Medicare Supplement Insurance (Medigap)

Medigap is not part of Medicare. It is a separate option that helps fill in the gaps not covered by Original Medicare (Parts A and B). Medigap plans are sold by private insurance companies and can help with expenses like copayments, coinsurance, and deductibles.

What’s Not Covered by Medicare?

While Medicare offers extensive coverage, there are notable gaps, including:

  • Long-term care (nursing home or in-home assistance beyond short-term skilled care)
  • Routine dental, vision, and hearing care
  • Cosmetic procedures
  • Most care received outside of the U.S.

Making Medicare Work for You

Understanding Medicare is the first step toward getting the best coverage for your health needs. Whether you choose Original Medicare with a supplemental Medigap plan or a Medicare Advantage plan that covers more services in one package, take time to assess your healthcare priorities. Consider your current medical needs, prescription drug costs, and whether you may need dental, vision, or hearing services in the future.

If Medicare sounds overwhelming, you’re not alone. You can learn more by joining one of GetSetUp’s Medicare classes, where Guides will help you understand the best options for your situation.

Reviewed By: Keith Gilbert