What Part A covers

What’s covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

In general, Part A covers:

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors 

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

What Part B covers

What’s covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers 2 types of services

  • Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Part B covers things like:

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

What drug plans cover

Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost.

A drug in a lower tier will generally cost you less than a drug in a higher tier. Sometimes, if your prescriber thinks you need a drug that’s on a higher tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:

  • Provide written notice to you at least 60 days prior to the date the change becomes effective.
  • At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.