What Do Medicare Parts A and B Cover? - dummies

What Do Medicare Parts A and B Cover?

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Part A and Part B form the core of Medicare. They provide the coverage that you have if you enroll in the traditional or original Medicare program that has been around since 1966, although many more services have been added since then.

Parts A and B are also the basis of your coverage if you’re in a Medicare Advantage health plan, because all those plans must by law cover the same services as the traditional program, although the plans can provide extra benefits if they want to.

These two parts of Medicare cover entirely different services. But sometimes Parts A and B work in tandem. For example, if you need to go into the hospital, in most cases Part A covers the cost of your room, meals, and nursing care after you’ve met the deductible.

But Part B covers the cost of your medical treatment — services provided by surgeons, other doctors, and anesthetists. This division of coverage also applies to staying in a skilled nursing facility for continuing care after leaving the hospital, using home health services, and receiving hospice care.

Necessary medical care

In essence, Medicare covers services that are reasonable or necessary to save life and maintain or improve health. That includes really big-ticket items — such as transplants of the heart and other organs, delicate surgery to repair severe injuries, cancer treatments, and many others — that cost Medicare tens of thousands, and in some cases hundreds of thousands, of dollars.

The program also, of course, covers more-routine and less-expensive services, from allergy shots to X-rays.

Sometimes people who’ve used a lot of services, or a few really expensive ones, and are scared to death that their Medicare coverage is going to “run out.” This isn’t something to worry about. In general, no limit caps the amount of coverage you can get from Medicare for necessary services — except for a few specific situations.

Preventive care

Being able to treat a medical problem is good, but dodging it altogether is better! These days, that seems an obvious truth. Yet Medicare has only fairly recently expanded coverage for services that help prevent or stave off some of the diseases that make people very ill and — not coincidentally — cost Medicare mountains of money.

Even better: Many of these preventive tests, screenings, and counseling sessions now come free (no co-pays or deductibles) thanks to the 2010 Affordable Care Act. More than 50 million people with Medicare took advantage of these services, at no cost to themselves, during the first 30 months after they became free on January 1, 2011, according to government reports.

But to get these services for free, know that you need to see a doctor who accepts assignment — meaning that she has agreed to accept the Medicare-approved amount as full payment for any service provided to a Medicare patient. Otherwise, you have to pony up a co-pay or, in some circumstances, even the full cost.

Now take a look at this table, which shows the range of preventive tests, screenings, and counseling sessions that Medicare covers under Part B and whether they cost you anything. It’s a pretty impressive list!

Preventive Care Services Medicare Covers
Service Frequency Covered Cost to You
“Welcome to Medicare” checkup. Once only, during first 12 months in Part B. Free, but any other tests the doctor refers you for may require
a co-pay.
Wellness checkup. Once every 12 months, after you’ve had Part B for one
Free as long as you ask for a wellness visit and not a
Alcohol abuse counseling. One screening and up to 4 counseling sessions a year. Free.
Bone mass measurement. Once a year if you’re at risk for broken bones; more if
medically necessary.
Breast cancer: mammograms. Once a year for women age 40 or older. Free.
Cardiovascular tests to detect conditions leading to heart
attack or stroke.
Once every five years. Free for the tests, but a co-pay is usually required for the
doctor visit.
Cardiovascular counseling to help lower risk of heart attack or
Once a year with your primary care doctor. Free.
Cervical/vaginal cancer screening — Pap tests and pelvic
Once every 24 months, or every 12 months if you’re at
high risk.
Colorectal cancer — fecal occult blood test. Once every 12 months if you’re 50 or older. Free.
Colorectal cancer — flexible sigmoidoscopy. Once every 48 months if you’re 50 or older. Free.
Colorectal cancer — colonoscopy. Once every 120 months, or every 24 months if at high risk. Free for the test, but a co-pay is required if a polyp is found
and removed during the test.
Colorectal cancer — barium enema (when used instead of
the preceding two procedures).
Once every 48 months, or every 24 months if at high risk. A co-pay is required.
Depression screening. Once a year in a primary care setting. Free screening, but a co-pay is required for doctor visit and
follow-up care.
Diabetes screening. Up to two screenings a year if you’re at risk of
developing diabetes.
Flu shots. Once a year in flu season. Free.
Glaucoma (eye disease) tests. Once every 12 months if you’re at high risk. A co-pay is required, and your Part B deductible applies.
Hepatitis B shots. Whenever doctor orders them if you’re at risk. Free.
HIV screening. Once every 12 months or up to 3 times during pregnancy. Free.
Laboratory services. Blood tests and urinalysis, as ordered by doctor anytime. Free.
Obesity counseling sessions. Up to 20 sessions in one year as long as your body mass index
(BMI) is 30 or higher.
Pneumonia shot. Needed once after age 65. Free.
Prostate cancer PSA test. Once every 12 months for men over 50. Free.
Prostate cancer digital rectal exam. Once every 12 months for men over 50. A co-pay is required, and the Part B deductible applies.
Sexually-transmitted infections screening and counseling. Tests once every 12 months or more often if pregnant. Up to 2
counseling sessions with a primary care provider.
Free if tests are ordered by a doctor and performed in a
Medicare-approved laboratory.
Stop-smoking counseling. Up to 8 sessions in any 12 month period. Free.
X-rays, MRIs, CT scans, EKGs, and so on. As ordered for diagnosis by a doctor. A co-pay is required, and your Part B deductible applies.

Source: Centers for Medicare & Medicaid Services

Note: Services labeled “free” (meaning no co-pay or deductible required) assume that you go to a doctor who accepts Medicare’s payment in full.

Specialized Care

Medicare A also covers certain specialized forms of nursing care, such as care in a skilled nursing facility, home health care services, hospice care, and pregnancy and childbirth.