Review Cost and Coverage

What’s covered:

Overnight hospital stays, including a semi-private room, meals, general nursing, and medications taken as part of your treatment, and some additional services and supplies.⁶  

Costs without insurance:  

Depending on your length of stay, you’ll first pay an inpatient hospital deductible—in <2024>, this totaled <$1,600 >. 

And after day 90, you enter into your bank of “lifetime reserve days,” which is up to 60 reserve days of inpatient hospital coverage that can be used over your lifetime. You’ll pay <$800> per day during your lifetime reserve days. Once you’ve used these up, you’ll be responsible for all costs.⁷  

What’s covered: Skilled nursing facilities provide a high level of medical care such as wound care, IVs, injections, physical therapy, and monitoring of vital signs—this level of care requires trained medical professionals such as a registered nurse or therapist. These facilities may be used for rehabilitation after an injury, stroke, or other condition. They may also be used to treat patients who require constant monitoring and care, but don’t need to be in a hospital.  

Costs without insurance: Original Medicare will cover 100% of the cost for the first 20 days of a qualified stay. If you are admitted for longer, you will pay <$200> per day for days 21 through 100. After 100 days, you will be responsible for all costs.⁸  

What’s covered: Part A covers admittance to inpatient mental health facility or psychiatric hospital for a maximum of 190 days over your lifetime.  

Costs without insurance: The costs for an inpatient mental health stay are the same as inpatient hospital stay costs. For the doctor’s services, you will generally pay 20% of the Medicare-approved amount.⁷  

Coverage: Hospice care focuses on increasing quality of life through pain relief and symptom control, in addition to treatment for mental and emotional health needs. Sometimes referred to as “end of life care,” hospice is typically administered when the diagnosis is deemed terminal or when a cure is not expected. It’s usually received in a patient’s home or other facility where the patient lives, like a nursing home or an assisted nursing facility.  

Costs without insurance: Original Medicare will generally cover 100% of Hospice care costs. A copayment of up to $5 may be charged for each outpatient prescription drug prescribed for pain relief and symptom control. For short-term inpatient respite care, you may be responsible for 5% of the Medicare-approved charges at a Medicare-approved facility.⁹ 

Coverage: Part B will cover visits to your primary care or family doctor and specialists as long as they accept patients covered by Medicare. Specialists are doctors who focus on a specific type of care—like allergists, cardiologists, dermatologists and endocrinologists. You’ll also be covered for visits to covered urgent care facilities if you need treatment for a sudden illness or injury that isn’t a medical emergency.^{10, 11}  

Coverage: Part B will cover a large variety of supplies, equipment, prosthetic devices, and artificial eyes and limbs as long as they are prescribed by your doctor and the supplier of the device is enrolled in Medicare. Suppliers must meet a strict quality standard and offer competitive pricing of the equipment they provide.  

Some of the most common medical supplies and equipment include wheelchairs, scooters, canes and walkers, oxygen equipment and accessories, diabetic monitoring supplies, therapeutic shoes and inserts, slings and braces, CPAP devices, and hospital beds and lifts. Medicare will also cover prosthetic devices and artificial eyes and limbs.^12,13,14  

Coverage: Part B will cover medically necessary therapy. Outpatient therapy is provided outside a hospital or skilled nursing facility. Therapy received in an in-patient setting is generally covered by Original Medicare Part A.  

This includes physical, occupational, and speech therapy as well as cardiac and pulmonary rehabilitation services. Most people think of therapy to regain the use of a particular function after an injury or illness, but in some instances, it can also be used in a preventative measure to manage the progression of a chronic condition.^{15,16,17,18,19}  

Coverage: If you need medically necessary services and traveling via another vehicle could endanger your health, Part B will cover ground ambulance transportation to the nearest hospital, critical access hospital, or skilled nursing facility able to administer the care you need.  

If you need immediate assistance, Original Medicare may cover emergency transportation in an airplane or helicopter. Additionally, Original Medicare may cover non-emergency but medically necessary ambulance transportation if you have a written order from your doctor.²⁰  

For nearly everything covered under Part B, you’ll first be responsible for meeting your yearly deductible, which was <$266> in <2023>. Once you meet your deductible, Original Medicare will typically pay 80% of the Medicare-approved amount, and you’ll generally pay the remaining 20% out of pocket.  

Before you visit a doctor, schedule a procedure, or purchase supplies, it’s important to ask if they participate in Original Medicare—because if they don’t, you’ll likely have to pay more.²¹ 

Coverage: Services deemed medically necessary including certain blood tests, urinalysis, tests on tissue specimens, and certain screenings are all fully covered. These must be ordered by your doctor and administered in a Medicare-approved laboratory.²²  

Coverage: Dozens of preventive screenings and services including diabetes screenings, depression screenings, mammograms, colonoscopies, glaucoma tests, and various cancer screenings are fully covered. For a full list of covered preventive screenings and programs, check Medicare.gov.²³  

Coverage: Once you’ve had Original Medicare Part B coverage for over 12 months, Original Medicare covers an annual “wellness” visit, so you can receive care and advice based on your current mental and physical health. You’ll fill out a Health Risk Assessment questionnaire and your doctor will help you create, update, and maintain a personalized prevention plan and routine screening schedule to help you stay healthy.²⁴

Coverage: Depending on your physical health, Part B may cover shots and vaccines including pneumococcal shots, Hepatitis B shots, and flu shots.  

Costs without insurance: Part B covers these certain shots and vaccines at 100%, if your doctor accepts assignment. However, if your doctor recommends additional tests or services, they may not be covered.²⁵  

Coverage: With few exceptions, Original Medicare Parts A and B do not cover prescription drug costs. But Medicare participants must obtain prescription drug coverage as soon as they’re eligible for Medicare, unless they have creditable drug coverage somewhere else, such as a spouse’s employer-sponsored health coverage. If you enroll later, you may be subject to a late penalty.  

There are two options for Prescription Drug coverage, also known as Part D. The first is a stand-alone Part D Prescription Drug plan, which  can only be added to  Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. Or you can enroll in a Medicare Advantage Prescription Drug plan, which combines all the benefits of Part A and Part B coverage with Prescription Drug coverage (Part D), effectively replacing Original Medicare. Without this additional coverage, you could be responsible for paying 100% of the cost of your prescriptions. 

Coverage: Original Medicare does not cover most dental care, but Medicare participants can obtain separate dental coverage from a private insurance company such as Reliance Medicare.  

There are two options for dental coverage. You can either add a stand-alone dental insurance plan to your Original Medicare or enroll in a Medicare Advantage plan, also known as Part C, that may include some routine dental coverage. Medicare Advantage is a more robust offering that replaces Original Medicare. If you choose not to purchase dental coverage you could be responsible for paying 100% of the cost of your dental care.^26,27  

Coverage: Part B covers a simple vision test as part of the “Welcome to Medicare” preventive visit, but it’s only offered once during your first year of Part B coverage. Part B also covers a yearly eye exam for those living with diabetes and diabetic retinopathy, as long as it’s performed by an eye doctor who is legally permitted to do testing in the state where you live.  

Eye exams for diagnostic purposes, such as testing for glaucoma or macular degeneration, may also be covered. If treatment may improve a chronic eye condition and is viewed as medically necessary by a physician participating in Medicare, Part B may cover it—you’ll need to check with your doctor to see if your condition is deemed medically necessary.  

Most routine vision care like routine eye-exams, eyeglasses, contacts, and corrective procedures won’t be covered by Original Medicare—but adding a stand-alone vision insurance plan to your Original Medicare or enrolling in a Medicare Advantage plan with some routine vision coverage, may replace your Original Medicare with a more robust coverage offering. If you choose not to purchase vision coverage, you could be responsible for paying 100% of the cost of your vision care^28,29,30  

Coverage: Part B covers diagnostic hearing and balance exams if ordered to determine whether medical treatment is needed. However, Original Medicare does not cover hearing exams, hearing aids or fittings—that’s where Medicare Advantage plans with routine hearing coverage, can help, since they may include some coverage for routine hearing care in addition to the benefits that come with Parts A and B. If you choose not to purchase hearing coverage, you could be responsible for paying 100% of the cost of your hearing care.³¹  

Coverage: Original Medicare covers certain in-home health services, including skilled nursing care, physical therapy, speech pathology, and occupational therapy. Original Medicare will not pay for 24-hour in-home care or meals delivered to you at home. If your in-home care needs exceed what can be classified as part-time or intermittent skilled nursing care, they will not be eligible for coverage.  

If you choose to purchase a Medicare Advantage plan with an in-home health benefit, you may have access to additional in-home health programs at no additional cost.³²  

You may be responsible for paying 100% of the cost of your prescriptions, dental, vision, hearing, and in-home care.  

This is not a full summary of Original Medicare coverage, benefits, and costs. For a full list of covered services use the “Is my test, item or service covered?” search tool on Medicare.gov.³³