Medicare Coverage Matrix
MEDICARE WHAT IT COVERS WHAT YOU’LL PAY
Part A Inpatient Care Hospital Stays Skilled Nursing Care Qualified Home Care Hospice Care
  • No premium for most people — if owed, up to $458 each month.
  • A deductible per benefit period — This is how much you have to spend before Medicare starts to pay its part.
  • Coinsurance — This is the share of the costs for hospital care you may be required to pay after you’ve met your deductible.
Part B Outpatient Care Doctor Visits Some Preventive Care Diagnostics Tests and Exams Durable Medical Equipment
  • A monthly premium — The standard Medicare Part B monthly premium is $144.60 in 2020, may be higher based on income
  • An annual deductible — The Medicare Part B deductible is $198 in 2020
  • Coinsurance — After meeting the deductible, beneficiaries typically pay 20% of the Medicare approved amount for covered services.
Part C Medicare Advantage All Part A Services All Part B Services Often Fully Covers: Wellness Services Dental Exams Vision Exams Hearing Exams Often Partially Covers: Dental Fillings and Crowns Eye Glasses Hearing Aids Monthly premium:
  • The Part C monthly premium varies by plan.
Deductibles, copayments & coinsurance:
  • The amount you pay for Part C deductibles, copayments, and/or coinsurance varies by plan. Look for specific Part C plan costs, and then call the plans you’re interested in to get more details.
Part D Prescription Drug Coverage Helps with the cost of prescription drugs not covered by Original Medicare. Covers some: Prescription Drugs Monthly premium:
  • The Part D monthly premium varies by plan (higher-income consumers may pay more).
In addition to premiums, you’ll also potentially have to pay:
  • An annual deductible that you must pay before coverage kicks in. The maximum deductible for 2020 is $435, but a plan can put in a smaller deductible if it wants.
  • You’ll also have to pay copays or coinsurance amounts when you purchase prescription drugs. A copay is typically a fixed dollar amount, while coinsurance is a percentage of the total cost.
Medicare Coverage Matrix
MEDICARE Part A WHAT IT COVERS Inpatient Care Hospital Stays Skilled Nursing Care Qualified Home Care Hospice Care WHAT YOU’LL PAY
  • No premium for most people — if owed, up to $458 each month.
  • A deductible per benefit period — This is how much you have to spend before Medicare starts to pay its part.
  • Coinsurance — This is the share of the costs for hospital care you may be required to pay after you’ve met your deductible.
MEDICARE Part B WHAT IT COVERS Outpatient Care Doctor Visits Some Preventive Care Diagnostics Tests and Exams Durable Medical Equipment WHAT YOU’LL PAY
  • A monthly premium — The standard Medicare Part B monthly premium is $144.60 in 2020, may be higher based on income
  • An annual deductible — The Medicare Part B deductible is $198 in 2020
  • Coinsurance — After meeting the deductible, beneficiaries typically pay 20% of the Medicare approved amount for covered services.
MEDICARE Part C WHAT IT COVERS All Part A Services All Part B Services Often Fully Covers: Wellness Services Dental Exams Vision Exams Hearing Exams Often Partially Covers: Dental Fillings and Crowns Eye Glasses Hearing Aids WHAT YOU’LL PAY Monthly premium:
  • The Part C monthly premium varies by plan.
Deductibles, copayments & coinsurance:
  • The amount you pay for Part C deductibles, copayments, and/or coinsurance varies by plan. Look for specific Part C plan costs, and then call the plans you’re interested in to get more details.
MEDICARE Part D WHAT IT COVERS Helps with the cost of prescription drugs not covered by Original Medicare. Covers some: Prescription Drugs WHAT YOU’LL PAY Monthly premium:
  • The Part D monthly premium varies by plan (higher-income consumers may pay more).
In addition to premiums, you’ll also potentially have to pay:
  • An annual deductible that you must pay before coverage kicks in. The maximum deductible for 2020 is $435, but a plan can put in a smaller deductible if it wants.
  • You’ll also have to pay copays or coinsurance amounts when you purchase prescription drugs. A copay is typically a fixed dollar amount, while coinsurance is a percentage of the total cost.

Medicare Part A Covers

Medicare Part A is hospital coverage. It covers care you receive while an inpatient in a hospital or skilled nursing facility. Medicare manages Part A coverage and costs based on a benefit period. The Part A deductible, for example, is charged for each benefit period.

Medicare Part B Covers

Medicare Part B is medical coverage. It covers doctor visits, clinic services and care you receive as an outpatient.

What Part A & Part B (Original Medicare) Doesn’t Cover

Original Medicare (Parts A and B) covers many medical and hospital services, but it doesn’t cover everything. Many people are surprised to learn that prescription drugs aren’t covered. Prescription drug coverage can be purchased through Medicare Part D, but it’s not provided by Part A or Part B. You may have to pay for these services yourself unless you have other insurance that covers them. Some Medicare Advantage (Part C) plans may help with certain services not covered by Original Medicare. Here are some other services that are not covered by Original Medicare:
  • Dental exams, most dental care or dentures
  • Routine eye exams, eyeglasses or contacts
  • Hearing aids or related exams or services
  • Most care while traveling outside the United States
  • Help with bathing, dressing, eating, etc. (custodial care)
  • Comfort items such as a hospital phone, TV or private room
  • Long-term care
  • Cosmetic surgery
  • Most chiropractic services
  • Acupuncture or other alternative treatments
  • Routine foot care

Medicare Advantage (Part C) Covers

Medicare Part C is also called Medicare Advantage. These plans combine the coverage of Parts A and B into one plan. They often include prescription drug coverage and other services such as dental, vision and hearing care, as well.

Medicare Part D Covers

Medicare Part D is prescription drug coverage. It helps pay for medications your doctor prescribes. You can get a standalone Part D plan or get a Medicare Advantage plan that includes drug coverage.

Medicare Supplement Insurance: Medigap

Medicare Supplement Insurance, also known as Medigap, helps pay some out-of-pocket costs that come with Original Medicare. There are 10 Medicare supplement insurance plans standardized by the federal government. Each is labeled with a letter. Every plan with the same letter offers the same benefits, no matter what state it’s offered in or by which insurance company. Massachusetts, Minnesota and Wisconsin have different plans. The level of coverage varies. There are standardized plans that cover all Medicare deductibles, copayments and coinsurance, while others leave some costs for you to pay on your own. Medicare supplement plans provide nationwide coverage.   You may enroll in a Medicare supplement plan at any time, but you may be denied coverage or charged more based on your health history if you enroll after your Medicare Supplement Open Enrollment Period.

Medicare Coverage Combinations:

Additional coverage can be added to Original Medicare or you can choose a Medicare Advantage plan that has all the coverage you need. You may add a standalone Part D plan, a Medicare supplement plan or both to Original Medicare (Parts A & B).
1
[Part A/Part B]Original Medicare (Parts A & B) or just Part A or just Part B
2
[Part A/Part B + Part D]Original Medicare (Parts A & B) plus a standalone Part D plan
3
[Part A/Part B + Part D + Medicare Supplement]Original Medicare (Parts A & B) plus a standalone Part D plan plus a Medicare Supplement plan
4
[Part A/Part B + Medicare Supplement]Original Medicare (Parts A & B) plus a Medicare Supplement plan
5
[Part C + Part D]A Medicare Advantage (Part C) plan with built-in drug coverage
6
[Part C]A Medicare Advantage (Part C) plan without drug coverage
7
[Part C + Part D]A Medicare Advantage (Part C) plan without drug coverage plus a standalone Part D plan, only works with certain Medicare Advantage plan types
Note: Combination 7 is only available if you choose a Private Fee-For-Service (PFFS) Medicare Advantage plan without drug coverage or a Medicare Savings Account (MSA) plan. These are the only types of Medicare Advantage plans that can be combined with a standalone Medicare Prescription Drug plan.

Medicare Costs

Medicare helps pay for many health care items and services, but you will pay a share of the cost, as well. Your Medicare costs include:
  • Premiums
  • Deductibles
  • Co-payments
  • Co-insurance
Premiums are payed outright. Deductibles, co-payments (co-pays) and co-insurance are ways that Medicare shares the cost of your care with you (cost sharing). Premium A premium is a fixed amount that you pay. Depending on your coverage, you may pay a premium to Medicare, to a private insurance company or to both. Most premiums are charged monthly and can change from year to year. Deductible A deductible is a set amount that you pay out of pocket for covered services before your plan begins to pay. Co-payment A co-payment, or co-pay, is a fixed amount you pay at the time you receive a covered service. For example, you might pay $12 when you fill a prescription or $20 each time you go to the doctor. Co-insurance Co-insurance is when you and your plan split the cost of a covered service. For example, your plan might pay 80% and you would pay 20% of the allowed amount.

How do I choose a Medicare plan?

Think about your needs so you can see how different coverage options might work for you. Answering the following questions can help you get started. How is your health?
  • How often do you go to the doctor?
  • What health problems do you have?
  • What medications do you take regularly?
What are your preferences?
  • Which doctors, hospitals and pharmacies do you like to go to?
  • How important is it for you to have access to health care while traveling?
  • What other coverage do you have, such as an employer or retiree plan?
What is your budget?
  • What are you able to pay each month in premiums?
  • How comfortable are you covering co-pays or co-insurance for health services?
  • What is your risk tolerance of high out-of-pocket costs?

Enrolling in a Medicare Plan

Initial Enrollment Period
The Initial Enrollment Period (IEP) is 7 months long. It includes your 65th birthday month plus the 3 months before and the 3 months after. It begins and ends 1 month earlier if your birthday is on the first. You may enroll in Original Medicare – Part A, Part B or both. You can also choose to join a Medicare Advantage plan (Part C) or a prescription drug plan (Part D). You will receive your Medicare Benefits card approximately a few months before your 65th birthday. Have this card ready when you call or begin online enrollment.




General Enrollment Period
The GEP happens every year from January 1 to March 31. You may use the General Enrollment Period (GEP) to enroll in Original Medicare – Part A, Part B or both if you miss your IEP. You can also choose to join a Medicare Advantage plan (Part C) or a prescription drug plan (Part D) from April 1 to June 30 the same year.

Medicare Supplement Open Enrollment Period
The Medicare supplement open enrollment is 6 months long. It begins the month you are 65 or older and are enrolled in Medicare Part B. You cannot be denied coverage or charged more based on your health history if you enroll during your open enrollment. Some states may allow for additional Open Enrollment Periods.

Special Enrollment Period: Working past 65
You may qualify for a Special Enrollment Period (SEP) to enroll in Original Medicare – Part A, Part B or both without penalty for up to 8 months after the month your (or your spouse’s) employment or employer coverage ends, whichever comes first. You can also join a Medicare Advantage plan (Part C) or prescription drug plan (Part D) up to 2 full months after the same event, if you are eligible.

Other FAQs About Medicare Coverage

Many people enroll in just Part A when they turn 65 and have employer coverage. Part A is premium free if you or your spouse worked and paid Medicare taxes for at least 10 years. If your employer provides creditable coverage, you may be able to delay enrolling in Part B without penalty.

Here’s what you need to about turning 65 and enrolling in Medicare:
  • You must be 65 to enroll in Medicare — your spouse’s age doesn’t count.
  • You can enroll in Medicare even if you work past age 65 and have employer coverage, or you are 65 and have coverage through your spouse’s employer.
  • If you’re not collecting Social Security yet you can still enroll in Medicare.

Medicare supplement insurance is also known as Medigap. It’s private insurance you can buy to help pay some costs not paid by Original Medicare (Parts A & B). Medicare Advantage plans (Part C) are an alternative to Original Medicare plans (Parts A & B). It’s a different way to get your Medicare benefits.

Medicare’s dental coverage is limited. If you have Original Medicare (Part A and Part B), you won’t be covered for most dental services and supplies, including:
  • Dental exams
  • Routine cleanings
  • Fillings
  • Tooth extractions
  • Dentures and dental implants

No. Original Medicare does not cover dentures. It may cover the cost of teeth extraction before an inpatient procedure but will not cover the cost of dentures after the procedure. In general, Medicare does not cover any routine dental care, including cleanings or check-ups, and never pays for dentures.

Part A – Medicare Part A covers vision care only when the vision condition is considered a medical problem — as in a medical emergency or traumatic injury when the beneficiary must be admitted to the hospital. Medicare Part A does not cover routine vision exams and eye refractions. Beneficiaries must pay 100% of the cost unless they have other vision coverage.   Part B – Medicare Part B covers some vision care, but not routine vision exams. You are not covered for vision correction such as eyeglasses or contact lenses under Medicare Part B unless you need vision correction after cataract surgery.   Part C – Medicare Advantage plans (Part C) offers an alternative way to receive your Original Medicare benefits. Medicare Advantage plans are offered by private, Medicare-approved insurers. All private insurers must offer at least the same benefits as Original Medicare (except hospice care, which Medicare Part A covers), but they may include other benefits, such as routine vision. When routine vision benefits are available through a Medicare Advantage plan, your premiums could be higher than those charged by Medicare Advantage plans that do not offer routine vision benefits.   Part D – A Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan may cover certain products related to vision care, like eye drops or other vision medications prescribed by a doctor.

Medicare covers a colonoscopy every 120 months (10 years) for most people, and once every 24 months if you have a high risk of developing colon cancer. Key risk factors include a history of inflammatory bowel disease or having had polyps removed in the past.

While Medicare Part D covers your prescription drugs in most cases, there are circumstances where your drugs are covered under either Part A or Part B of Original Medicare. Part A covers the drugs you need during a Medicare-covered stay in a hospital or skilled nursing facility (SNF). Part B covers some medications administered in a clinical setting, such as chemotherapy.

While Original Medicare (Parts A & B) doesn’t provide vision coverage for routine eye care, it does help pay for cataract surgery. Surgery may be needed when a cataract causes vision loss that affects daily activities like reading or driving.

Services covered by Medicare’s home health benefit include intermittent skilled nursing care, therapy, and care provided by a home health aide. Depending on the circumstances, home health care will be covered by either Part A or Part B. Medicare doesn’t pay for:
  • 24-hour-a-day care at home
  • Meals delivered to your home
  • Homemaker services
  • Custodial or personal care

If you have Medicare Part A (Hospital Insurance) and meet all these conditions, you can get hospice care:
  • Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (with a life expectancy of 6 months or less).
  • You accept palliative care (for comfort) instead of care to cure your illness.
  • You sign a statement choosing hospice care instead of other Medicare-covered benefits to treat your terminal illness and related conditions.

Medicare does not cover any type of long-term care, whether in nursing homes, assisted living facilities or people’s own homes. You pay 100% for non-covered services, including most long-term care.

Medicare does not cover any type of long-term care, whether in nursing homes, assisted living facilities or people’s own homes. You pay 100% for non-covered services, including most long-term care.

Medicare Part B may cover dermatology care if it’s deemed medically necessary to evaluate, diagnose or treat a specific medical condition. Medicare does not cover routine dermatology care, however, such as the treatment of non-cancerous acne.   Medicare Advantage plans include the same benefits as Medicare Part A and Part B, and many plans may include coverage for dermatology, as well as for prescription drugs, dental, vision, wellness programs and other benefits.   Medicare only offers limited coverage of cosmetic procedures, so if you are seeing a dermatologist for the treatment of wrinkles, for example, you may not be covered.