Medicare & You 2025 PDF

Medicare & You 2025 The official U.S. government Medicare handbook 15 Section 1: Signing up for Medicare Will I get Part A and Part B automatically? If you’re already getting benefits from Social Security or the Railroad Retirement Board (RRB), you’ll automatically get Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B starts the first day of the prior month. If you’re under 65 and have a disability, you’ll get Part A and Part B automatically after getting 24 months of disability benefits, either from Social Security or certain disability benefits from the RRB. If you live in Puerto Rico, you don’t get Part B automatically. You must sign up for it. Go to page 16. If you have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease), you’ll get Part A and Part B automatically the month your Social Security disability benefits begin. If you get Medicare automatically, you’ll get your red, white, and blue Medicare card in the mail 3 months before your 65th birthday or 25th month of disability benefits, and you don’t need to pay a premium for Part A (sometimes called “premium-free Part A”). Most people choose to keep Part B. If you don’t want Part B, let us know before the coverage start date on your Medicare card. If you do nothing, you’ll keep Part B and pay Part B premiums through your Social Security or RRB benefits. If you have other coverage and need help deciding if you should keep Part B, go to page 19. If you choose not to keep Part B but decide you want it later, you may have a delay in getting Medicare Part B coverage because you can only sign up at certain times. You may also have to pay a late enrollment penalty for as long as you have Part B. Go to page 23. Will I have to sign up for Part A and/or Part B? If you’re close to 65, but NOT getting Social Security or RRB benefits, you’ll need to sign up for Medicare. Visit SSA.gov/medicare to apply for Part A and Part B. You can also contact Social Security 3 months before you turn 65 to set up an appointment. If you worked for a railroad, visit RRB.gov, or call the RRB at 1-877-772-5772. TTY users can call 1-312-751-4701. In most cases, if you don’t sign up for Part B when you’re first eligible, you may have a delay in getting Medicare Part B coverage in the future because you can only sign up at certain times. You may also have to pay a late enrollment penalty for as long as you have Part B. Go to page 23. Note: Go to pages 119–122 for definitions of blue words. 16 Section 1: Signing up for Medicare If you have End-Stage Renal Disease (ESRD) and want Medicare, you’ll need to sign up for it. Contact Social Security to find out when and how to sign up for Part A and Part B. For more information, visit Medicare.gov/publications to review the booklet, “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services.” Important! If you live in Puerto Rico and get benefits from Social Security or the Railroad Retirement Board (RRB), you’ll get Part A automatically starting on the first day of the month you turn 65 or after you get disability benefits for 24 months. However, if you want Part B, you’ll need to sign up for it by completing an “Application for Enrollment in Part B Form” (CMS-40B). To get this form in English and Spanish, visit Medicare.gov/basics/forms-publications-mailings/forms/enrollment, or call 1-800-MEDICARE (1-800-633-4227) to have a copy mailed to you. TTY users can call 1-877-486-2048. If you don’t sign up for Part B when you’re first eligible, you may have a delay in getting Part B coverage in the future because you can only sign up at certain times. You may also have to pay a late enrollment penalty for as long as you have Part B. Go to page 23. Where can I get more information? Visit SSA.gov/medicare/sign-up for more information about your Medicare eligibility and to sign up for Part A and/or Part B if you don’t get them automatically. If you worked for a railroad or get RRB benefits, visit RRB.gov or call the RRB at 1-877-772-5772. TTY users can call 1-312-751-4701. You can also get free, personalized, and unbiased health insurance counseling from your State Health Insurance Assistance Program (SHIP). Go to pages 114–117 for the phone number of your local SHIP. After you’ve signed up for Medicare Part A and/or Part B, it’s time to look at your coverage options. People get Medicare coverage in different ways. To get the most out of your coverage, review all of your options and decide what best meets your needs. Go to pages 11–13 for more details. If I didn’t get Part A and Part B automatically, when can I sign up? If you didn’t get premium-free Part A automatically (for example, because you’re still working and not yet getting Social Security or RRB benefits), you can sign up for it any time after you’re first eligible for Medicare. Go to page 22. In this example, your Part A coverage will go back (retroactively) 6 months from when you signed up for Part A or applied for Social Security or RRB benefits, but no earlier than the first month you’re eligible for Medicare. Depending on how you become eligible for Part A, the retroactive period may be different. You can only sign up for Part B during the enrollment periods shown on pages 17–18. Section 1: Signing up for Medicare 17 Important! Remember, in most cases, if you don’t sign up for Part A (if you have to buy it) and Part B when you’re first eligible, your enrollment may be delayed and you may have to pay a late enrollment penalty. Go to pages 22–23. What are the Part A and Part B enrollment periods? You can only sign up for Part B (and/or Part A if you have to buy it) during these enrollment periods. Initial Enrollment Period Generally, you can first sign up for Part A and/or Part B during the 7-month period that begins 3 months before the month you turn 65 and ends 3 months after the month you turn 65. If your birthday is on the first of the month, your 7-month period starts 4 months before the month you turn 65 and ends 2 months after the month you turn 65. Example: If you turn 65 on June 2, your 7-month period would begin in March and end in September. If you turn 65 on June 1, your 7-month period would begin in February and end in August. If you sign up for Part A and/or Part B during the first 3 months of your Initial Enrollment Period, in most cases, your coverage begins the first day of your birthday month. However, if your birthday is on the first day of the month, your coverage starts the first day of the prior month. If you sign up the month you turn 65 or during the last 3 months of your Initial Enrollment Period, your coverage starts the first day of the month after you sign up. Special Enrollment Period After your Initial Enrollment Period is over, you may have a chance to sign up for Medicare during a Special Enrollment Period. For example, if you didn’t sign up for Part B (or Part A if you have to buy it) when you were first eligible because you have group health plan coverage based on current employment (your own, a spouse’s, or a family member’s if you have a disability), you can sign up for Part A and/or Part B: Any time you’re still covered by the group health plan During the 8-month period that begins the month after the employment ends or the coverage ends, whichever happens first Your coverage generally starts the first day of the month after you sign up. If you sign up for Part B while you’re still working, or within the first full month after losing employer coverage, you can request to delay your Part B start date up to 3 months. Usually, you won’t have to pay a late enrollment penalty if you sign up during a Special Enrollment Period. This Special Enrollment Period doesn’t To sign up forapply Part Aif and/or you’re B, eligible for Medicare based on End-Stage Renal visit SSA.gov/medicare/sign-up. Disease (ESRD), or you’re still in your Initial Enrollment Period. 18 Section 1: Signing up for Medicare Important! COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage isn’t considered coverage based on current employment and doesn’t count as employer coverage for a Special Enrollment Period. The same is true for retiree health plans, VA coverage, and individual health insurance coverage (like coverage through the Health Insurance Marketplace®). If you’re considering COBRA, there may be reasons why you should take Part B instead of, or in addition to, COBRA coverage. You have 8 months after your coverage based on current employment ends to sign up for Part B without a penalty, whether or not you choose COBRA. However, if you have COBRA and you’re eligible for Medicare, COBRA may only pay a small portion of your medical costs. You generally aren’t eligible for a Special Enrollment Period to sign up for Medicare when that COBRA coverage ends. Go to page 89 for more information about COBRA coverage. To avoid paying a penalty, make sure you sign up for Medicare when you’re first eligible. If you have retiree coverage, it may not pay for your health services if you don’t have both Part A and Part B. Exceptional situations for a Special Enrollment Period There are other circumstances where you may be able to sign up for Medicare during a Special Enrollment Period. You may be eligible if you miss an enrollment period because of certain exceptional circumstances, like being impacted by a natural disaster or an emergency, incarceration, employer or health plan error, losing Medicaid coverage, or other circumstances outside of your control that Medicare determines to be exceptional. For more information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Important! If you recently lost Medicaid and you now qualify for Medicare, but didn’t sign up for Medicare when you first became eligible, you may be able to sign up for Part A and Part B without paying a late enrollment penalty. If you already have Medicare but lost Medicaid, you also have coverage options. For more information, check out the “Losing Medicaid?” fact sheet at Medicare.gov/media/document/12177-2023-02-508.pdf. General Enrollment Period You can sign up for Part B during the General Enrollment Period (January 1–March 31 each year) if you missed your Initial Enrollment Period and don’t qualify for a Special Enrollment Period. You can also buy Part A during this time if you don’t qualify for premium-free Part A and missed your Initial Enrollment Period. You may have to pay a higher Part A and/or Part B premium for late enrollment. Go to pages 22–23. When you sign up during the General Enrollment Period, your coverage starts the first day of the month after you sign up. Not sure if you qualify for an enrollment period? Visit Medicare.gov, or call 1-800-MEDICARE. Section 1: Signing up for Medicare 19 I have other health coverage. Should I get Part B? This information can help you decide if you should get Part B based on the type of health coverage you may have. Employer or union coverage If you or your spouse (or family member if you have a disability) are still working and you have health coverage through that employer or union, go to page 21 to find out how your coverage works with Medicare. You can also contact the employer or union benefits administrator for information. This includes federal or state employment and active-duty military service. It might be to your advantage to delay Part B enrollment while you still have health coverage based on your or your spouse’s current employment. Coverage based on current employment doesn’t include: COBRA (or similar continuation coverage after employment ends) Retiree coverage VA coverage Individual health insurance coverage (like through the Health Insurance Marketplace®) Former employer coverage you get through severance or a layoff TRICARE If you have TRICARE (health care program for active-duty and retired service members and their families), you generally must sign up for Part A and Part B when you’re first eligible to keep your TRICARE coverage. However, if you’re an active-duty service member or an active-duty family member, you don’t have If you toCHAMPVA have sign up forcoverage, Part B to keep your sign you must TRICARE up forcoverage. ForPart Part A and moreB to information, contact your TRICARE contractor. Go to page 90. keep it. Call 1-800-733-8387 for more information about CHAMPVA. Medicaid If you have Medicaid and don’t have Part B, Medicare will pay first for the Part A services Medicare covers. You may also be able to get help from your state to pay for Part A and Part B premiums through a Medicare Savings Program. Go to pages 91–92. To learn more about signing up for Part B, go to page 15. For more information on Medicaid and to find out if you qualify, visit Medicaid.gov/about-us/beneficiary-resources/index.html#statemenu, or call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s Medicaid office. TTY users can call 1-877-486-2048. 20 Section 1: Signing up for Medicare Health Insurance Marketplace® Even if you have Marketplace coverage (or other individual health coverage that isn’t based on current employment), you should sign up for Medicare when you’re first eligible to avoid the risk of a delay in Medicare coverage and the possibility of a Medicare late enrollment penalty. If you have Marketplace coverage: You should end your Marketplace coverage in a timely manner when you become eligible for Medicare to avoid an overlap in coverage. Once you’re considered eligible for premium-free Part A, or already have Part A with a premium, you won’t qualify for help from the Marketplace to pay your Marketplace plan premiums or other medical costs. If you continue to get help paying for your Marketplace plan premiums, you may have to pay back some or all of the help you got when you file your federal income taxes. To find out how to end your Marketplace plan or Marketplace savings when your Medicare coverage begins, visit HealthCare.gov/medicare/changing-from- marketplace-to-medicare. You can also call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325. Health Savings Account (HSA) You aren’t eligible to make contributions to an HSA after you have Medicare. To avoid a tax penalty, you should make your last HSA contribution the month before your Part A coverage begins. Premium-free Part A coverage will go back (retroactively) 6 months from when you sign up for Part A or apply for benefits from Social Security or the Railroad Retirement Board (RRB), but no earlier than the first month you’re eligible for Medicare. Depending on how you become eligible for Part A, the retroactive period may be different. Review the chart below to help decide when it’s best to stop your HSA contributions. If you sign up During your Initial You can avoid a tax penalty for Medicare: Enrollment Period by making your last HSA contribution the month before 2 months after your Initial you turn 65. Enrollment Period ends And your birthday is on Generally, your Medicare the 1st day of the coverage starts the first day month of the month before you turn 65. You can avoid a tax penalty by making your last HSA contribution 2 months before you turn 65. If you wait to Less than 6 months after You can avoid a tax penalty by sign up for you turn 65 stopping HSA contributions the Medicare: month before you turn 65. 6 or more months after You can avoid a tax penalty by you turn 65 stopping HSA contributions 6 months before the month you apply for Note: A Medical Savings Account (MSA) Plan is similar Medicare. to an HSA. Go to page 67. Section 1: Signing up for Medicare 21 How does my other insurance work with Medicare? When you have other insurance (like group health plan, retiree health, or Medicaid coverage) and Medicare, there are rules for whether Medicare or your If youother have coverage payscoverage, retiree health first. like Medicare pays first. insurance from your or your spouse’s former employment… If you’re 65 or older, have group health plan Your group health plan pays coverage based on your or your spouse’s first. current employment, and the employer has 2 0 or more employees… If you’re 65 or older, have group health plan Medicare pays first. coverage based on your or your spouse’s current employment, and the employer has fewer than 2 0 employees… If you’re under 65 and have a disability, have Your group health plan pays group health plan coverage based on your or first. a family member’s current employment, and the employer has 100 or more employees… If you’re under 65 and have a disability, have Medicare pays first. group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees… If you have group health plan coverage based Your group health plan pays on your or a family member’s employment or first for the first 30 months former employment, and you’re eligible for after you become eligible Medicare because of End-Stage Renal Disease for Medicare. Medicare pays (ESRD)... first after this 30-month period. If you have TRICARE... Medicare pays first, unless you’re on active duty, or get items or services from a military hospital or clinic, or other federal health care provider. If you have Medicaid... Medicare pays first. Important! If you’re still working and have employer coverage through work, contact your employer to find out how your employer’s coverage works with Medicare. 22 Section 1: Signing up for Medicare Remember: The insurance that pays first (primary payer) pays up to the limits of its coverage. The insurance that pays second (secondary payer) only pays if there are costs the primary payer didn’t cover. The secondary payer (which may be Medicare) might not pay all of the uncovered costs. If your group health plan or retiree health coverage is the secondary payer, you’ll likely need to sign up for Part B before your insurance will pay. Visit Medicare.gov/publications to review the booklet, “How Medicare Works with Other Insurance” or call 1-800-MEDICARE (1-800-633-4227) to learn more. TTY users can call 1-877-486-2048. Important! If your group health plan coverage ends, call 1-800-MEDICARE to update your record. If you have other changes to your insurance, you can also call Medicare’s Benefits Coordination & Recovery Center at 1-855-798-2627. TTY users can call 1-855-797-2627. If you’re retiring, call 1-800-MEDICARE to make sure your primary insurance information is correct. If you have Part A, you may get a “Health Coverage” form (IRS Form 1095-B) from Medicare. This form verifies that you had health coverage in the past year. Keep the form for your records. Not everyone will get this form. If you don’t get Form 1095-B, don’t worry. Even though you don’t need it to file your taxes, you can request a copy from Medicare. Do I have to pay for Part A? You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working for a certain amount of time. This is sometimes called premium-free Part A. If you aren’t eligible for premium- free Part A, you may be able to buy it. For more information on how to pay your Part A premium, go to page 24. If you buy Part A, you’ll pay a premium of either $278 or up to $505 each month in 2024 depending on how long you or your spouse worked and paid Medicare taxes. If you need help paying your Part A premium, go to pages 91–92. If you have questions about paying for Part A, visit Medicare.gov or call 1-800-MEDICARE. In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. If you choose NOT to buy Part A, you can still buy Part B Medicare.gov Visit if you’re eligible. for 2025 Part A premium amounts. What’s the Part A late enrollment penalty? If you aren’t eligible for premium-free Part A, and you don’t buy it when you’re first eligible, your monthly premium may go up 10%. You’ll have to pay the higher premium for twice the number of years you could have had Part A but didn’t sign up. For example, if you were eligible for Part A for 2 years but didn’t sign up, you’ll have to pay a 10% higher premium for 4 years. Section 1: Signing up for Medicare 23 How much does Part B coverage cost? The standard Part B premium amount in 2024 is $174.70. Most people pay the standard Part B premium amount every month. If your modified adjusted gross income is above a certain amount (in 2024 it’s $103,000 if you file individually or $206,000 if you’re married and file jointly), you may pay an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium. ToVisit determine if you’llfor Medicare.gov pay the IRMAA, 2025 Medicareamount Part B premium uses the modified and income adjusted limits. gross income reported on your IRS tax return from 2 years ago. Visit Medicare.gov Note: You mayto learn also paymore about an extra IRMAA.for your Medicare drug coverage amount (Part D) premium if your modified adjusted gross income is above a certain amount. Go to page 82. If you have to pay an extra amount and you disagree (for example, your income is lower due to a life event), visit SSA.gov/medicare/lower-irmaa. What’s the Part B late enrollment penalty? Important! If you don’t sign up for Part B when you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Part B. Your monthly Part B premium may go up 10% for each full 12 months in the period that you could’ve had Part B, but didn’t sign up. If you’re allowed to sign up for Part B during a Special Enrollment Period, you usually don’t pay a late enrollment penalty. Go to pages 17–18. Example: Mr. Smith’s Initial Enrollment Period ended December 2020. He waited until March 2023 (during the General Enrollment Period) to sign up for Part B. His Part B premium penalty is 20%, and he’ll have to pay this penalty in addition to his standard Part B premium for as long as he has Part B. (Even though Mr. Smith didn’t have Part B for 27 months, this included only 2 full 12-month periods.) Cost & coverage: To learn how to get help with Medicare costs, go to page 91. How can I pay my Part B premium? If you get Social Security or Railroad Retirement Board (RRB) benefits, your Part B premium will be deducted from your monthly benefit payment. Note: If you get a bill from the RRB, mail your premium payments to: RRB Medicare Premium Payments PO Box 979024 St. Louis, MO 63197-9000 If you have questions about bills you get from the RRB, call 1-877-772- 5772. TTY users can call 1-312-751-4701. 24 Section 1: Signing up for Medicare If you’re a federal retiree with an annuity from the Office of Personnel Management and you aren't entitled to Social Security or RRB benefits, you can ask to have your Part B premiums deducted from your annuity. Call 1-800-MEDICARE (1-800-633-4227) to make your request. TTY users can call 1-877-486-2048. If you don’t get Social Security or RRB benefit payments, you’ll get a bill for your Part B premium. Typically, Part B premiums are billed quarterly (every 3 months). If you also pay for Part A or Part D IRMAA, or use Medicare Easy Pay to pay your premiums, you’ll get a monthly bill (pages 22 and 82). There are 4 ways to pay your premium bill: 1. Pay online by credit card, debit card, Health Savings Account (HSA) card, savings or checking account. To do this, log into (or create) your secure Medicare account at Medicare.gov. Paying online is a faster and more secure way to pay without sending personal information in the mail. You’ll get a confirmation number when you make your payment. 2. Pay directly from your savings or checking account through your bank’s online bill payment services. Ask if your bank offers this service. Some may charge a fee. Your bank will need this information: Your Medicare Number: It’s important to use the exact number on your red, white, and blue Medicare card, but without the dashes. Payee name: CMS Medicare Insurance Payee address: Medicare Premium Collection Center PO Box 790355 St. Louis, MO 63179-0355 3. Sign up for Medicare Easy Pay. This free service deducts your payment from your savings or checking account automatically each month. Visit Medicare.gov/basics/costs/pay-premiums/medicare-easy-pay, or call 1-800-MEDICARE to find out how to sign up. 4. Mail your payment to Medicare. You can pay by check, money order, credit card, debit card, or Health Savings Account (HSA) card. Write your Medicare Number on your payment, and fill out your payment coupon. Mail your payment and coupon to: Medicare Premium Collection Center PO Box 790355 St. Louis, MO 63179-0355 If you have questions about your premiums, call 1-800-MEDICARE or visit Medicare.gov. If you need to change your address on your bill, visit SSA.gov/mycontact. You may be able to get help from your state to pay your Part A and Part B premiums through a Medicare Savings Program. Go to pages 91–92. 25 Section 2: Find out what Medicare covers What services does Medicare cover? In this section, you’ll find information about the items, tests, and services that Original Medicare (Part A and Part B) covers in hospitals, doctors’ offices, and other health care facilities. You may be eligible for the Medicare-covered services in this section if you have both Part A and Part B. If you have Original Medicare, you’ll use your red, white, and blue Medicare card to get your Medicare-covered services. Your Medicare card shows whether you have Part A (listed as HOSPITAL), Part B (listed as MEDICAL), or both, and the date your coverage begins. Important! If you join a Medicare Advantage Plan or other Medicare health plan, make sure to share your plan’s card with your provider to get Medicare-covered services. Note: If you’re not lawfully present in the U.S., Medicare won’t pay your Part A and Part B claims, and you can’t join a Medicare Advantage Plan or a Medicare drug plan. What does Part A cover? Part A (Hospital Insurance) helps cover: Inpatient care in a hospital Skilled nursing facility care Hospice care Home health care Pages 26–29 list common services Part A covers and general descriptions. For more information on Part A-covered services, visit Medicare.gov/coverage. Note: Go to pages 119–122 for definitions of blue words. 26 Section 2: Find out what Medicare covers What do I pay for Part A-covered services? Copayments, coinsurance, or deductibles may apply for each service listed on the following pages. If you’re in a Medicare Advantage Plan or have other insurance (like Medigap, Medicaid, employer, retiree, or union coverage), your out-of-pocket costs like copayments, coinsurance, or deductibles may be diff erent. For more information about costs, contact your plan. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Part A-covered services Blood If the hospital gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year, or you or someone else can donate the blood. Home health services Part A and/or Part B covers home health benefits. Go to page 43. Hospice care To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. When you agree to hospice care, you’re agreeing to comfort care (palliative care) instead of care to cure your terminal illness. You also must sign a statement choosing hospice care instead of other Medicare- covered treatments for your terminal illness and related conditions. Coverage includes: All items and services you need for pain relief and symptom management Medical, nursing, and social services Drugs for pain and symptom management Durable medical equipment for pain relief and symptom management Aide and homemaker services Other covered services you need to manage your pain and other symptoms, as well as spiritual and grief counseling for you and your family Medicare-certified hospice care is usually given in your home or other facility where you live, like a nursing home. Original Medicare will still pay for covered benefits for any health problems that aren’t part of your terminal illness and related conditions, but hospice should cover most of your care. Medicare won’t pay room and board for your care in a facility, unless the hospice medical team decides you need short-term inpatient care to manage pain and other symptoms. This care must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility that contracts with the hospice provider. Section 2: Find out what Medicare covers 27 Caregiver relief and support Medicare also covers inpatient respite care, which is care you get in a Medicare-approved facility so your caregiver (family member or friend) can rest. You can stay for up to 5 days each time you get respite care. Your hospice provider will arrange this for you. After 6 months, you can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies (at a face-to-face meeting) that you’re still terminally ill. You pay: Nothing for hospice care. A copayment of up to $5 per prescription for outpatient drugs for pain and symptom management. Five percent of the Medicare-approved amount for inpatient respite care. Original Medicare will be billed for your hospice care, even if you’re in a Medicare Advantage Plan. When you get hospice care, your Medicare Advantage Plan can still cover services that aren’t part of your terminal illness or any conditions related to your terminal illness. For more on hospice care and to find Medicare-approved providers, contact your plan or visit Medicare.gov/care-compare. Inpatient hospital care Medicare covers semi-private rooms, meals, general nursing, drugs (including methadone to treat an Opioid Use Disorder), and other hospital services and supplies as part of your inpatient treatment. This includes care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, psychiatric care in inpatient psychiatric facilities, and inpatient care for a qualifying clinical research study. This doesn’t include private-duty nursing, a television or phone in your room (if there’s a separate charge for these items), personal care items (like razors or slipper socks), or a private room, unless medically necessary. If you also have Part B, it generally covers 80% of the Medicare-approved amount for doctors’ services you get while you’re in a hospital. In 2024, you pay: Days 1–60 (of each benefit period): $0 after you meet your Part A deductible. Days 61–90 (of each benefit period): $408 each day. After day 9 0 (of each benefit period): $816 each day for each lifetime reserve day (up to 60 days over your lifetime). After you use all of your lifetime reserve days, you pay all costs. Part A only pays for up to 190 days of inpatient psychiatric hospital care you get in a freestanding psychiatric hospital during your lifetime. Visit Medicare.gov for 2025 amounts. 28 Section 2: Find out what Medicare covers Note: Hospitals are now required to share the standard charges for all of their items and services (including the standard charges negotiated by Medicare Advantage Plans) on a public website to help you make more informed decisions about your care. Am I an inpatient or outpatient? Whether you’re an inpatient or an outpatient affects how much you pay for hospital services and if you qualify for Part A skilled nursing facility care. You’re an inpatient when the hospital formally admits you with a doctor’s order. You’re an outpatient if you’re getting emergency or observation services (which may include an overnight stay in the hospital or services in an outpatient clinic), lab tests, or X-rays, without a formal inpatient admission (even if you spend the night in the hospital). Each day you have to stay, you or your caregiver should ask the hospital and/or your doctor, a hospital social worker, or a patient advocate if you’re an inpatient or outpatient. Important! Sometimes doctors will keep you as an outpatient for observation services while they decide whether to admit you as an inpatient or release (discharge) you. If you’re under observation more than 24 hours, the hospital must give you a “Medicare Outpatient Observation Notice” (also called “MOON”). This notice tells you why you’re an outpatient (in a hospital or critical access hospital) getting observation services, and how it affects what you pay in the hospital and for care after you leave. Religious non-medical health care institution (inpatient care) If you qualify for inpatient hospital or skilled nursing facility care in these facilities, Medicare will only cover inpatient, non-religious, non-medical items and services, like room and board, and items or services that don’t need a doctor’s order or prescription (like unmedicated wound dressings or use of a simple walker). Medicare doesn’t cover the religious portion of this type of care. Skilled nursing facility care Medicare covers skilled nursing facility care after a 3- day minimum medically necessary inpatient hospital stay (not including the day you leave the hospital) for an illness or injury related to the hospital stay. Medicare covers semi-private rooms, meals, skilled nursing and therapy services, and other medically necessary services and supplies in a skilled nursing facility. To qualify for skilled nursing facility care, your doctor must certify that you need daily skilled care (like intravenous fluids/medications or physical therapy) which, as a practical matter, you can only get as a skilled nursing facility inpatient. Medicare doesn’t cover non-medical long-term care. Go to page 56. You may get skilled nursing care or therapy if it’s necessary to improve or maintain your current condition. If you disagree with your discharge, you can appeal. For example, if you’re discharged only because you aren’t improving, but still need skilled nursing care or therapy to keep your condition from getting worse, you can appeal. Go to page 100. Section 2: Find out what Medicare covers 29 In each benefit period (2024), you pay: Days 1–20: Nothing. Note: If you’re in a Medicare Advantage Plan, you may be charged copayments during the first 20 days. Days 21–100: $204 each day. Days 101 and beyond: All costs. Note: You may not need a 3-day minimum inpatient hospital stay if your doctor participates in an Accountable Care Organization (ACO), or your provider is approved for a Skilled Nursing Facility 3-Day Rule Waiver. If your provider participates in an ACO (pages 110–111), ask about benefits that may be available. Medicare Advantage Plans may also waive the 3-day minimum. Contact your plan for more information. What does Part B cover? Medicare Part B (Medical Insurance) helps cover medically necessary doctor’s services, outpatient care, home health services, durable medical equipment, mental health services, limited outpatient prescription drugs, and other medical services. Part B also covers many preventive services. Go to pages 30–55 for a list of common Part B-covered services. Medicare may cover some services and tests more often than the timeframes listed if needed to diagnose or treat a condition. Medicare.gov/coverage Find out if Medicare covers a service that isn’t on this list: Or, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. What do I pay for services Part B covers? The list of covered services is in alphabetical order on the following pages. It gives general information about what you pay if you have Original Medicare and use doctors or other health care providers who accept assignment (pages 59–60). You’ll pay more if you use doctors or providers who don’t accept assignment. If you’re in a Medicare Advantage Plan or have other insurance (like Medigap, Medicaid, employer, retiree, or union coverage), your out-of-pocket costs like copayments, coinsurance, or deductibles may be diff erent. Contact your plan for more information. Under Original Medicare, if the Part B deductible applies, you must pay all costs (up to the Medicare-approved amount) until you meet the yearly Part B deductible. After you meet your deductible, Medicare will pay its share and you typically pay 20% of the Medicare-approved amount (if the doctor or other health care provider accepts assignment). There’s no yearly limit on what you pay out of pocket if you have Original Medicare. There may be limits on what you pay if you have supplemental coverage like Medigap, Medicaid, employer, retiree, or union coverage. You pay nothing for most covered preventive services if you get the services from a doctor or other qualified health care provider who accepts assignment. However, for some preventive services, you may have to pay a deductible, coinsurance, or both. These costs may also apply if you get a preventive service in the same visit as a non-preventive service. 30 Section 2: Find out what Medicare covers Part B-covered services This apple is next to the preventive services on pages 30– 55. Preventive service Abdominal aortic aneurysm screenings Medicare covers an abdominal aortic aneurysm screening ultrasound once if you’re at risk (only with a referral from your doctor or other qualified health care provider). You’re considered at risk if you have a family history of abdominal aortic aneurysms, or you’re a man 65–75 and have smoked at least 100 cigarettes in your lifetime. You pay nothing for the screening if your doctor or other qualified health care provider accepts assignment. Acupuncture Medicare only covers acupuncture (including dry needling) for chronic low back pain. Medicare covers up to 12 acupuncture visits in 90 days for chronic low back pain defined as: Lasting 12 weeks or longer Not having an identifiable cause (for example, not an identifiable disease like cancer that has spread, or an infectious or inflammatory disease) Pain that isn’t associated with surgery or pregnancy Medicare covers an additional 8 sessions if you show improvement. You can get a maximum of 20 acupuncture treatments in a 12-month period. The Part B deductible and coinsurance apply. If you aren’t showing improvement, Medicare won’t cover the 8 additional treatments. Not all providers can give acupuncture, and Medicare can’t pay licensed acupuncturists directly for their services. Advance care planning Medicare covers voluntary advance care planning as part of your yearly “Wellness” visit (pages 54–55). This is planning for care you would get when you need help making decisions for yourself. As part of advance care planning, you may choose to complete an advance directive. This important legal document records your wishes about medical treatment in the future, if you aren’t able to make decisions about your care. You can talk about an advance directive with your health care provider, and they can help you fill out the forms, if you prefer. Consider carefully who you want to speak for you and what directions you want to give. You have the right to carry out your plans as you choose without discrimination based on your age or disability. You can update your advance directive at any time. You pay nothing if it’s given as part of the yearly “Wellness” visit, and your doctor or other qualified health care provider accepts assignment. Medicare may also cover this service as part of your medical treatment. When advance care planning isn’t part of your yearly “Wellness” visit, the Part B deductible and coinsurance apply. Section 2: Find out what Medicare covers 31 Need help with your advance directive? Visit the Eldercare Locator at eldercare.acl.gov to find help in your community. Preventive service Alcohol misuse screenings & counseling Medicare covers an alcohol misuse screening for adults (including pregnant individuals) who use alcohol, but don’t meet the medical criteria for alcohol dependency. If your primary care doctor or other health care provider determines you’re misusing alcohol, you can get up to 4 brief, face-to-face counseling sessions per year (if you’re competent and alert during counseling). You must get counseling in a primary care setting, like a doctor’s office. You pay nothing if your primary care doctor or other health care provider accepts assignment. Ambulance services Medicare covers ground ambulance transportation to a hospital, critical access hospital, rural emergency hospital, or skilled nursing facility for medically necessary services when traveling in any other vehicle could endanger your health. Medicare may pay for emergency ambulance transportation in an airplane or helicopter if you need immediate and rapid ambulance transport that ground transportation can’t provide. In some cases, Medicare may pay for medically necessary, non-emergency ambulance transportation if you have a written order from your doctor stating that ambulance transportation is medically necessary. For example, a patient discharged from the hospital may need a medically necessary ambulance transport to a skilled nursing facility. Medicare will only cover ambulance transportation to the nearest appropriate medical facility that’s able to give you the care you need. You pay 20% of the Medicare-approved amount. The Part B deductible applies. Ambulatory surgical centers Medicare covers the facility service fees related to approved surgical procedures done in an ambulatory surgical center (outpatient facility that performs surgical procedures), and the patient is expected to be released within 24 hours. Except for certain preventive services (for which you pay nothing if your doctor or other health care provider accepts assignment), you pay 20% of the Medicare-approved amount to both the ambulatory surgical center and the doctor who treats you. The Part B deductible applies. You pay all of the facility service fees for procedures Medicare doesn’t cover in ambulatory surgical centers. Cost & coverage: Get cost estimates for ambulatory surgical center outpatient procedures: Medicare.gov/procedure-price-lookup 32 Section 2: Find out what Medicare covers Bariatric surgery Medicare covers some bariatric surgical procedures, like gastric bypass surgery and laparoscopic banding surgery, when you meet certain conditions related to morbid obesity. For cost information, visit Medicare.gov/coverage/bariatric-surgery. Behavioral health integration services If you have a behavioral health condition (like depression, anxiety, or another mental health condition), Medicare may pay your provider to help manage that condition. Some providers that manage behavioral health conditions may offer integrated care services, like the Psychiatric Collaborative Care Model. This model is a set of integrated behavioral health services, including care management support that may include: Care planning for behavioral health condition(s) Ongoing assessment of your condition Medication support Counseling Other treatment your provider recommends Your health care provider will ask you to sign an agreement for you to get these services on a monthly basis. Your Part B deductible and coinsurance will apply to the monthly service fee. Blood If the provider gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. However, you’ll pay a copayment for the blood processing and handling services for each unit of blood you get. The Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year, or you or someone else can donate the blood. Preventive service Bone mass measurements This test helps to see if you’re at risk for broken bones. Medicare covers it once every 24 months (more often if medically necessary) for people who have certain medical conditions (like possible osteoporosis) or meet certain criteria. You pay nothing for this test if your doctor or other qualified health care provider accepts assignment. Cardiac rehabilitation Medicare covers comprehensive programs that include exercise, education, and counseling if you’ve had at least one of these conditions: A heart attack in the last 12 months Coronary artery bypass surgery Current stable angina pectoris (chest pain) A heart valve repair or replacement A coronary angioplasty (a medical procedure used to open a blocked artery) or coronary stenting (a procedure used to keep an artery open) Section 2: Find out what Medicare covers 33 A heart or heart-lung transplant Stable chronic heart failure Medicare covers regular and intensive cardiac rehabilitation programs. Medicare covers services in a doctor’s office or hospital outpatient setting. You pay 20% of the Medicare-approved amount if you get the services in a doctor’s office, and a copayment in a hospital outpatient setting. The Part B deductible applies. Preventive service Cardiovascular behavioral therapy Medicare covers a cardiovascular behavioral therapy visit one time each year with your primary care doctor or other qualified primary care provider in a primary care setting (like a doctor’s office) to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips on eating well. You pay nothing if your primary care doctor or other health care provider accepts assignment. Preventive service Cardiovascular disease screenings These screenings include blood tests for cholesterol, lipid, and triglyceride levels that help detect conditions that may lead to a heart attack or stroke. Medicare covers these screening blood tests once every 5 years. You pay nothing for the tests if the doctor or other qualified health care provider accepts assignment. New! Caregiver training resources Medicare now covers training that helps your caregiver learn and develop skills to care for you (like giving medications, personalized care, and more) as part of your treatment plan. If your health care provider determines that caregiver training is appropriate for your treatment plan, your caregiver can get individual or group training sessions from your provider without requiring you to be present. Training must focus on your health goals, and your treatment must require a caregiver’s help to succeed. You pay 20% of the Medicare-approved amount. The Part B deductible applies. Preventive service Cervical & vaginal cancer screenings Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the pelvic exam, Medicare also covers a clinical breast exam to check for breast cancer. Medicare covers these screening tests once every 24 months in most cases. Medicare covers these screening tests once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal Pap test in the past 36 months. Medicare also covers Human Papillomavirus (HPV) tests (as part of a Pap test) once every 5 years if you’re 30–65 without HPV symptoms. You pay nothing for the lab Pap test, the lab HPV with the Pap test, the Pap test specimen collection, and pelvic and breast exams if your doctor or other qualified health care provider accepts assignment. 34 Section 2: Find out what Medicare covers Chemotherapy Medicare covers chemotherapy in a doctor’s office, freestanding clinic, or hospital outpatient setting if you have cancer. You pay a copayment for chemotherapy in a hospital outpatient setting. You pay 20% of the Medicare-approved amount for chemotherapy in a doctor’s office or freestanding clinic. The Part B deductible applies. For Part A-covered chemotherapy in an inpatient hospital setting, go to inpatient hospital care on pages 27–28. Chiropractic services Medicare only covers manipulation of the spine to correct a subluxation (when the spinal joints fail to move properly but the contact between the joints remains intact). You pay 20% of the Medicare-approved amount. The Part B deductible applies. Chronic care management services If you have 2 or more serious chronic conditions (like arthritis and diabetes) that you expect to last at least a year, Medicare may pay for a health care provider’s help to manage those conditions. This includes a comprehensive care plan that lists your health problems and goals, other providers, medications, community services you have and need, and other health information. It also explains the care you need and how it will be coordinated. If you agree to get this service, your provider will prepare the care plan for you or your caregiver, help you with medication management, provide 24/7 access for urgent care management needs, give you support when you go from one health care setting to another, and help you with other chronic care needs. You pay a monthly fee, and the Part B deductible and coinsurance apply. If you have supplemental insurance, including Medicaid, it may help cover the monthly fee. Chronic pain management and treatment services Medicare covers monthly services for people living with chronic pain (persistent or recurring pain lasting longer than 3 months). Services may include pain assessment, medication management, and care coordination and planning. The Part B deductible and coinsurance apply. Clinical research studies Clinical research studies test how well different types of medical care work and if they’re safe, like how well a cancer drug works. For certain clinical research studies, Medicare covers some costs, like office visits and tests. You may pay 20% of the Medicare-approved amount, depending on the treatment you get. The Part B deductible may apply. Note: If you’re in a Medicare Advantage Plan, Original Medicare may cover some costs along with your Medicare Advantage Plan. Contact your plan for details about coverage for clinical research studies. Section 2: Find out what Medicare covers 35 Cognitive assessment & care plan services When you visit your provider (including your yearly “Wellness” visit), they may perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, or making decisions. Conditions like depression, anxiety, and delirium can also cause confusion, so it’s important to understand why you may be having symptoms. Medicare covers a separate visit with a doctor or health care provider to do a full review of your cognitive function, establish or confirm a diagnosis like dementia or Alzheimer’s disease, and develop a care plan. You can bring someone with you, like a spouse, friend, or caregiver, to help provide information and answer questions. During this visit, the doctor or health care provider may: Perform an exam, talk with you about your medical history, and review your medications. Identify your social supports including care that your usual caregiver can provide. Create a care plan to help address and manage your symptoms. Help you develop or update your advance care plan. Go to pages 30–31. Refer you to a specialist, if needed. Help you understand more about community resources, like rehabilitation services, adult day health programs, and support groups. The Part B deductible and coinsurance apply. New! Some people living with dementia and their family and unpaid caregivers may be able to get additional support through the Guiding an Improved Dementia Experience Model pilot program. Talk to your provider for more information and to find out if they’re participating. Preventive service Colorectal cancer screenings Medicare covers these screenings to help find precancerous growths or find cancer early, when treatment is most effective. Medicare may cover one or more of these screening tests: Barium enema: Medicare covers this test once every 48 months if you’re 45 or older (or every 24 months if you’re high risk) when your doctor uses it instead of a flexible sigmoidoscopy or screening colonoscopy. You pay 20% of the Medicare-approved amount for your doctors’ services. In a hospital outpatient setting, you also pay the hospital a copayment. The Part B deductible doesn’t apply. Visit Medicare.gov/coverage/barium-enemas for more information. Screening Colonoscopies: Medicare covers this screening test once every 120 months (or every 24 months if you’re high risk) or 48 months after a previous flexible sigmoidoscopy. There’s no minimum age requirement. If you initially have a non-invasive stool-based screening test (fecal occult blood tests or multi-target stool DNA test) and receive a positive result, Medicare also covers a follow-up colonoscopy as a screening test. You pay nothing for 36 Section 2: Find out what Medicare covers Flexible sigmoidoscopies: Medicare covers this test once every 48 months if you’re 45 or older, or 120 months after a previous screening colonoscopy if you aren’t at high risk. You pay nothing for the test if your doctor or other qualified health care provider accepts assignment. If your doctor finds and removes a polyp or other tissue during the colonoscopy or flexible sigmoidoscopy, you pay 15% of the Medicare-approved amount for your doctors’ services. In a hospital outpatient setting, you also pay the hospital a 15% coinsurance. The Part B deductible doesn’t apply. Fecal occult blood tests: Medicare covers this screening test once every 12 months if you’re 45 or older. You pay nothing for the test if your doctor or other qualified health care provider accepts assignment. Multi-target stool DNA & blood-based biomarker tests: Medicare covers these screening tests once every 3 years if you meet all of these conditions: You’re between 45–85. You show no symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, a positive guaiac fecal occult blood test or fecal immunochemical test. You’re at average risk for developing colorectal cancer, meaning: You have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis. You have no family history of colorectal cancer or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer. Multi-target stool DNA tests are at-home lab tests. Blood-based biomarker tests are conducted in a lab. You pay nothing for these tests if your doctor or other qualified health care provider accepts assignment. Continuous Positive Airway Pressure (CPAP) devices & accessories Medicare may cover a 3-month trial of CPAP devices and accessories if you’ve been diagnosed with obstructive sleep apnea. After the trial period, Medicare may continue to cover CPAP devices and accessories if you meet with your doctor in person, and your doctor documents in your medical record that you meet certain conditions and the CPAP is helping you. You pay 20% of the Medicare-approved amount for the machine rental and purchase of related supplies (like masks and tubing). The Part B deductible applies. Medicare pays the supplier to rent the machine for 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you’ll own it. Note: Medicare may cover a rental or replacement CPAP machine and/or CPAP accessories if you had a CPAP machine before you got Medicare, and you meet certain requirements. Section 2: Find out what Medicare covers 37 Preventive service Counseling to prevent tobacco use & tobacco-caused disease Medicare covers up to 8 face-to-face visits in a 12-month period if you use tobacco. You pay nothing for the counseling sessions if your doctor or other qualified health provider accepts assignment. COVID-19 (Coronavirus disease 2019) Many people with Medicare are at higher risk for serious COVID-19 illness, so it’s important to take the necessary steps to keep yourself and others safe. Medicare covers several tests, items, and services related to COVID-19. Talk with your doctor or health care provider to find out which are right for you. Preventive service COVID-19 Vaccines: FDA-approved and FDA-authorized vaccines help reduce the risk of illness from COVID-19 by working with the body’s natural defenses to safely develop immunity (protection) against the virus. You pay nothing for the COVID-19 vaccine if your doctor or other qualified health care provider accepts assignment for giving you the shot. Be sure to bring your red, white, and blue Medicare card with you when you get the vaccine so your health care provider or pharmacy can bill Medicare. If you’re in a Medicare Advantage Plan, you must use the card from your plan to get your Medicare-covered services. You pay nothing when you get the vaccine from an in-network provider. Check with your plan for more information. Diagnostic laboratory tests: These tests check to see if you have COVID-19. You pay nothing when a health care provider orders this test and you get it from a laboratory, pharmacy, doctor, or hospital that takes Medicare. If you're in a Medicare Advantage Plan, check with your plan to find out if you have any out-of-pocket costs. Monoclonal antibody treatments and products: These FDA-authorized or approved treatments can help fight the disease and keep you out of the hospital. You must test positive for COVID-19, have mild to moderate symptoms, and be at high risk for progressing to severe COVID-19, and/or needing hospitalization. Original Medicare will cover monoclonal antibody treatments if you have COVID-19 symptoms. You pay nothing for these treatments when you get them from a Medicare provider or supplier. You must meet certain conditions to qualify. If you're in a Medicare Advantage Plan, check with your plan about your coverage and costs. Note: Certain FDA authorized or approved monoclonal antibody products can protect you before you’re exposed to COVID-19. If you have Part B and your doctor decides this type of product could work for you (like if you have a weakened immune system), you pay nothing for the product when you get it from a Medicare provider or supplier. 38 Section 2: Find out what Medicare covers Get more information Learn more about these covered services at Medicare.gov/medicare- coronavirus. For more on COVID-19, visit CDC.gov/coronavirus. Defibrillators Medicare may cover an implantable cardioverter defibrillator if you’ve been diagnosed with heart failure. If the surgery takes place in an outpatient setting, you pay 20% of the Medicare-approved amount for your doctors’ services. You also pay a copayment. In most cases, the copayment can’t be more than the Part A hospital stay deductible. The Part B deductible applies. Part A covers surgeries to implant defibrillators in an inpatient hospital setting. Go to inpatient hospital care on pages 27–28. Preventive service Depression screening Medicare covers one depression screening per year. The screening must be done in a primary care setting (like a doctor’s office) that can provide follow-up treatment and/or referrals. You pay nothing for this screening if your doctor accepts assignment. If you or someone you know is struggling or in crisis and would like to talk to a trained crisis counselor, call or text 988, the free and confidential Suicide & Crisis Lifeline. You can also connect with a counselor through web chat at 988lifeline.org. Diabetes equipment, supplies, & therapeutic shoes Medicare covers meters and continuous glucose monitors used to estimate your blood glucose (blood sugar level) and related supplies, including test strips, lancets, lancet holders, sensors, and control solutions. Medicare also covers tubing, insertion sets, and insulin for patients using insulin pumps, and sensors, transmitters, and receivers for patients using continuous glucose monitors. In addition, Medicare covers one pair of extra-depth or custom shoes and inserts per year for people with specific diabetes-related foot problems. You pay 20% of the Medicare-approved amount if your supplier accepts assignment. The Part B deductible applies. Important! Medicare drug coverage (Part D) may cover insulin you inject yourself, certain medical supplies used to inject insulin (like syringes), disposable pumps, and some oral diabetes drugs. Check with your plan for more information. The cost of a one-month supply of each covered insulin product is capped at $35. Go to page 88. Similar caps on costs apply for traditional insulin used in Part B-covered insulin pumps. Preventive service Diabetes screenings Medicare covers up to 2 blood glucose (blood sugar) laboratory test screenings (fasting or non-fasting) each year if your doctor determines you’re at risk for developing diabetes. You pay nothing for the test if your doctor or other qualified health care provider accepts assignment. Section 2: Find out what Medicare covers 39 Preventive service Diabetes self-management training Medicare covers diabetes outpatient self-management training to teach you to cope with and manage your diabetes. The program may include tips for eating healthy, being active, monitoring blood glucose (blood sugar), taking prescription drugs, and reducing risks. You must have been diagnosed with diabetes and have a written order from your doctor or other health care provider. Some patients may also be eligible for medical nutrition therapy services (page 45). You pay 20% of the Medicare- approved amount. The Part B deductible applies. Note: You may be able to get diabetes self-management training from a doctor or other health care provider who’s located elsewhere using audio and video communication technology, like your phone or a computer. Visit adces.org/program-finder to find certified programs near you. Doctor & other health care provider services Medicare covers medically necessary doctor services (including outpatient services and some inpatient hospital doctor services) and most preventive services. Medicare also covers services you get from other health care providers, like physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, physical therapists, occupational therapists, speech-language pathologists, and clinical psychologists. Except for certain preventive services (for which you may pay nothing if your doctor or other provider accepts assignment), you pay 20% of the Medicare-approved amount for most services. The Part B deductible applies. Important! If you haven’t received services from your doctor or group practice in the last 3 years, they may consider you a new patient. Check with the doctor or group practice to find out if they’re accepting new patients. Drugs Part B covers a limited number of outpatient prescription drugs, like: Most injectable and infused drugs when a licensed medical provider gives them Certain oral anti-cancer drugs Drugs used with some types of durable medical equipment (like a nebulizer or external infusion pump) Intravenous Immune Globulin for use in the home Certain drugs you get in a hospital outpatient setting (under very limited circumstances) Most renal dialysis drugs and biological products (page 44) Note: Other than the examples above, you pay 100% for most drugs, unless you have Medicare drug coverage (Part D) or other drug coverage. Go to pages 79–90 for more information about Medicare drug coverage. 40 Section 2: Find out what Medicare covers For some drugs used with an external infusion pump, and for Intravenous Immune Globulin for use in the home, Medicare may also cover services (like nursing visits) under the home infusion therapy benefit and the Intravenous Immune Globulin benefit (page 44). Part B also covers some injectable or implantable drugs to treat substance use disorder when a provider administers them in a doctor’s office or in an outpatient hospital setting. You pay 20% of the Medicare-approved amount for these drugs. The Part B deductible applies. You won’t have to pay any copayments for these services if you get them from a Medicare-enrolled Opioid Treatment Program (page 47). Doctors and pharmacies must accept assignment for Part B-covered drugs, so you should never be asked to pay more than the coinsurance or copayment for the Part B drug itself. Important! Your coinsurance can change depending on your prescription drug’s price. You might pay a lower coinsurance for certain Part B-covered drugs and biologicals when you get them in a doctor’s office or pharmacy, or in a hospital outpatient setting, if their prices have increased higher than the rate of inflation. The specific drugs and potential savings change every quarter. If the Part B-covered drugs you get in a hospital outpatient setting are part of your outpatient services, you pay a copayment for the services. Part B doesn’t cover “self-administered drugs” in a hospital outpatient setting. “Self-administered drugs” are drugs you’d normally take on your own. What you pay for self-administered drugs in a hospital outpatient setting depends on whether you have Medicare drug coverage (Part D) or other drug coverage, and if the hospital’s pharmacy is in your drug plan’s network. If you have other drug coverage, your drug plan may cover drugs that Part B may not cover. Contact your drug plan to find out what you pay when Part B doesn’t cover the drugs you get in a hospital outpatient setting. Durable medical equipment (DME) Medicare covers medically necessary items like oxygen and oxygen equipment, walkers, and hospital beds when a Medicare-enrolled doctor or other health care provider orders them for use in the home. You must rent most items, but you can also buy them. Some items become your property after you’ve made a number of rental payments. You pay 20% of the Medicare-approved amount. The Part B deductible applies. Make sure your doctors and DME suppliers are enrolled in Medicare. It’s important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment (which means they can charge you only the coinsurance and Part B deductible for the Medicare-approved amount). If DME suppliers aren’t participating and don’t accept assignment, you may have to pay for the full cost of the DME. Section 2: Find out what Medicare covers 41 Electrocardiogram (EKG or ECG) screenings Medicare covers a routine EKG/ECG screening if you get a referral from your doctor or other health care provider during your one-time “Welcome to Medicare” visit (page 54). After you meet the Part B deductible, you pay 20% of the Medicare-approved amount. Medicare also covers EKGs or ECGs as diagnostic tests (page 52). You also pay a copayment if you have the test at a hospital or a hospital-owned clinic. Emergency department services Medicare covers these services when you have an injury, a sudden illness, or an illness that quickly gets much worse. You pay a copayment for each emergency department visit and 20% of the Medicare-approved amount for doctors’ services. The Part B deductible applies. If your doctor admits you to the same hospital as an inpatient, your costs may be different. E-visits Medicare covers E-visits to allow you to talk with your provider using an online patient portal without going to the provider’s office. Providers who can give these services include doctors, nurse practitioners, clinical nurse specialists, physician assistants, physical therapists, occupational therapists, speech-language pathologists, and when they are for mental health care, licensed clinical social workers, clinical psychologists, marriage and family therapists, and mental health counselors. To get an E-visit, you must request one with your doctor or other provider. You pay 20% of the Medicare-approved amount for your doctor’s or other provider's services. The Part B deductible applies. Eyeglasses Medicare covers one pair of eyeglasses with standard frames (or one set of contact lenses) after each cataract surgery that implants an intraocular lens. Medicare will only pay for contact lenses or eyeglasses from a supplier enrolled in Medicare, whether you or your provider submits the claim. After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for corrective lenses after cataract surgery with an intraocular lens. Federally Qualified Health Center services Federally Qualified Health Centers provide many outpatient primary care and preventive health services. There’s no deductible, and you usually pay 20% of the charges or the Medicare-approved amount. You pay nothing for most preventive services. Federally Qualified Health Centers may offer discounts if your income is limited. Visit findahealthcenter.hrsa.gov to find a health center near you. Preventive service Flu shots Medicare covers the seasonal flu shot (or vaccine). You pay nothing for the flu shot if your doctor or other health care provider accepts assignment for giving you the shot. 42 Section 2: Find out what Medicare covers Foot care Medicare covers yearly foot exams or treatment if you have diabetes-related lower leg nerve damage that can increase the risk of limb loss, or if you need medically necessary treatment for foot injuries or diseases, like hammer toe, bunion deformities, and heel spurs. You pay 20% of the Medicare-approved amount for medically necessary treatment your doctor approves. The Part B deductible applies. You also pay a copayment for medically necessary treatment in a hospital outpatient setting. Preventive service Glaucoma screenings Medicare covers this screening once every 12 months if you’re at high risk for the eye disease glaucoma. You’re at high risk if you have diabetes, a family history of glaucoma, are African American and 50 or older, or are Hispanic and 65 or older. An eye doctor who’s legally allowed to do glaucoma screenings in your state must do or supervise the screening. You pay 20% of the Medicare-approved amount. The Part B deductible applies. You also pay a copayment in a hospital outpatient setting. Hearing & balance exams Medicare covers these diagnostic exams if your doctor or health care provider orders them to see if you need medical treatment. You can visit an audiologist once every 12 months without an order from a doctor or other health care provider, but only for non-acute hearing conditions (like hearing loss that occurs over many years) and for diagnostic services related to hearing loss that’s treated with surgically implanted hearing devices. You pay 20% of the Medicare-approved amount. The Part B deductible applies. You also pay a copayment in a hospital outpatient setting. Note: Medicare doesn’t cover hearing aids or exams for fitting hearing aids. Preventive service Hepatitis B shots Medicare covers these shots (or vaccines) if you’re at medium or high risk for Hepatitis B Virus. Some risk factors include hemophilia, End-Stage Renal Disease (ESRD), diabetes, living with someone who has Hepatitis B, or employment as a health care worker who has frequent contact with blood or body fluids. Check with your doctor to find out if you’re at medium or high risk for Hepatitis B. You pay nothing for the shot if your doctor or other health care provider accepts assignment for giving you the shots. Preventive service Hepatitis B Virus infection screenings Medicare covers Hepatitis B Virus infection screening tests if your doctor orders it. Medicare also covers the screening tests: Yearly, only if you’re at continued high risk and don’t get a Hepatitis B shot. Section 2: Find out what Medicare covers 43 If you’re pregnant: At the first prenatal visit for each pregnancy At the time of delivery for those with new or continued risk factors At the first prenatal visit for future pregnancies, even if you previously got the Hepatitis B shot or had negative Hepatitis B screening results You pay nothing for the screening test if the doctor or health care provider accepts assignment. Preventive service Hepatitis C Virus infection screenings Medicare covers one Hepatitis C screening test if you meet one of these conditions: You’re at high risk because you use or have used illicit injection drugs. You had a blood transfusion before 1992. You were born between 1945–1965. Medicare also covers yearly repeat screening tests if you’re at high risk. Medicare will only cover a Hepatitis C screening test if your health care provider orders one. You pay nothing for the screening test if your primary care doctor or other qualified health care provider accepts assignment. Preventive service HIV (Human Immunodeficiency Virus) screenings Medicare covers HIV screening tests once per year if you’re: Between 15–65. Younger than 15 or older than 65, and at increased risk. Medicare also covers this screening test up to 3 times during a pregnancy. You pay nothing for the HIV screening test if your doctor or other qualified health care provider accepts assignment. Home health services Medicare covers home health services under Part A and/or Part B. Medicare covers medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy services. Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. “Part-time or intermittent” means you may be able to get skilled nursing care and home health aide services if they’re provided less than 8 hours each day or less than 28 hours each week (or up to 35 hours a week in some limited situations). A doctor or other health care provider (like a nurse practitioner) must assess you face-to-face before certifying that you need home health services. A doctor or other health care provider must order your care, and a Medicare-certified home health agency must provide it. 44 Section 2: Find out what Medicare covers Medicare covers home health services as long as you need part-time or intermittent skilled services and as long as you’re “homebound,” which means: You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury. Leaving your home isn’t recommended because of your condition. You’re normally unable to leave your home because it’s a major effort. You pay nothing for covered home health services. However, for Medicare-covered durable medical equipment, you pay 20% of the Medicare-approved amount. The Part B deductible applies. Home infusion therapy services, equipment & supplies Medicare covers equipment and supplies (like pumps, IV poles, tubing, and catheters) for home infusion therapy to administer certain IV infusion drugs, like Intravenous Immune Globulin, at home. Medicare covers certain equipment and supplies (like the infusion pump) and the infusion drug under durable medical equipment (page 40). Medicare also covers services (like nursing visits), training for caregivers, and patient monitoring. You pay 20% of the Medicare-approved amount for these services and for the equipment and supplies you use in your home. Kidney (renal) dialysis services & supplies Generally, Medicare covers 3 dialysis treatments (or equivalent continuous ambulatory peritoneal dialysis) per week if you have End-Stage Renal Disease (ESRD). This includes renal dialysis drugs and biological products, laboratory tests, home dialysis training, support services, equipment, and supplies. The dialysis facility is responsible for coordinating your dialysis services (at home or in a facility). You pay 20% of the Medicare-approved amount. The Part B deductible applies. Kidney disease education Medicare covers up to 6 sessions of kidney disease education services if you have Stage 4 chronic kidney disease that will usually require dialysis or a kidney transplant, and your doctor or other qualified health care provider refers you for the service. You pay 20% of the Medicare-approved amount per session if you get the service from a doctor or provider. The Part B deductible applies. Laboratory tests Medicare covers medically necessary clinical diagnostic laboratory tests when your doctor or provider orders them. These tests may include certain blood tests, urinalysis, certain tests on tissue specimens, and some screening tests. You generally pay nothing for these tests. Section 2: Find out what Medicare covers 45 Preventive service Lung cancer screenings Medicare covers lung cancer screening tests with low dose computed tomography once per year if you meet these conditions: You’re 50–77. You don’t have signs or symptoms of lung cancer (you’re asymptomatic). You’re either a current smoker or you quit smoking within the last 15 years. You have a tobacco smoking history of at least 20 “pack years” (an average of one pack—20 cigarettes—per day for 20 years). You get an order from your doctor. You pay nothing for this screening test if your doctor accepts assignment. Before your first lung cancer screening, you’ll need to schedule an appointment with a health care provider to discuss the benefits and risks of lung cancer screening to decide if the screening is right for you. Lymphedema compression treatment items If you’ve been diagnosed with lymphedema, Medicare may cover your prescribed gradient compression garments (standard and custom fitted). You pay 20% of the Medicare-approved amount. The Part B deductible applies. Preventive service Mammograms Medicare covers a mammogram screening to check for breast cancer once every 12 months if you’re a woman 40 or older. Medicare covers one baseline mammogram if you’re a woman between 35–39. You pay nothing for the test if the doctor or other qualified health care provider accepts assignment. Part B also covers diagnostic mammograms more frequently than once a year when medically necessary. You pay 20% of the Medicare-approved amount for diagnostic mammograms. The Part B deductible applies. Note: Medicare covers medically necessary breast ultrasounds only when your doctor or provider orders them. Preventive service Medical nutrition therapy services Medicare covers medical nutrition therapy services if you have diabetes or kidney disease, or if you’ve had a kidney transplant in the last 36 months and a doctor refers you for services. Only a Registered Dietitian or nutrition professional who meets certain requirements can provide medical nutrition therapy services. If you have diabetes, you may also be eligible for diabetes self-management training (page 39). You pay nothing for medical nutrition therapy preventive services because the deductible and coinsurance don’t apply. 46 Section 2: Find out what Medicare covers Preventive service Medicare Diabetes Prevention Program If you have prediabetes and meet other eligibility requirements, Medicare covers a once-per-lifetime health behavior change program to help you prevent type 2 diabetes. The program begins with 16 weekly core sessions led by coaches in a group setting over a 6-month period. Once you complete the core sessions, you’ll get 6 monthly follow-up sessions to help you maintain healthy habits. You can attend sessions in-person, virtually, or both. You can get these services from an approved Medicare Diabetes Prevention Program supplier. These suppliers may be traditional health care providers or organizations like community centers or faith-based organizations. To find a supplier or learn more about the program, visit Medicare.gov/coverage/ medicare-diabetes-prevention-program. If you’re in a Medicare Advantage Plan, contact your plan to find out where to get these services. Mental health care (outpatient) Medicare covers mental health care services to help with conditions like depression and anxiety. These visits are often called counseling or psychotherapy, and can be done individually, in group psychotherapy or family settings, and in crisis situations. Coverage includes services generally provided in an outpatient setting (like a doctor’s or other health care provider’s office, hospital outpatient department, or by telehealth), including visits with a psychiatrist or other doctor, clinical psychologist, clinical nurse specialist, clinical social worker, nurse practitioner, or physician assistant. Medicare-covered mental health care includes: Services provided by marriage & family therapists and mental health counselors. Partial hospitalization services that are given by a Community Mental Health Center or by a hospital to outpatients. This structured day program offers outpatient psychiatric services as an alternative to inpatient psychiatric care. Intensive outpatient program services that include intensive psychiatric care, counseling, and therapy. These services may be given in hospitals, Community Mental Health Centers, Federally Qualified Health Centers, Rural Health Clinics, and Opioid Treatment Programs (when services are for the treatment of Opioid Use Disorder). Partial hospitalization and intensive outpatient services are for more hours a day than care you’d get in a doctor’s or therapist’s office. To learn more, visit Medicare.gov/coverage/mental-health-care-partial-hospitalization. Generally, you pay 20% of the Medicare-approved amount and the Part B deductible applies for mental health care services. Part A covers inpatient mental health care services you get in a hospital (page 27). Section 2: Find out what Medicare covers 47 Preventive service Obesity behavioral therapy If you have a body mass index (BMI) of 30 or more, Medicare covers obesity screenings and behavioral counseling to help you lose weight by focusing on diet and exercise. Medicare covers this counseling if your primary care doctor or other primary care provider gives the counseling in a primary care setting (like a doctor’s office), where they can coordinate your personalized plan with your other care. You pay nothing for this service if your primary care doctor or other provider accepts assignment. Occupational therapy services Medicare covers medically necessary therapy to help you perform activities of daily living (like dressing or bathing). This therapy helps to improve or maintain current capabilities or slow decline when your doctor or other health care provider certifies you need it. You pay 20% of the Medicare-approved amount. The Part B deductible applies. Opioid Use Disorder treatment services Medicare covers Opioid Use Disorder treatment services in Opioid Treatment Programs. The services include medication (like methadone, buprenorphine, naltrexone, and naloxone), dispensing and administration of such medications, substance use counseling, drug testing, individual and group therapy, intake activities, periodic assessments, and intensive outpatient services. Medicare covers counseling, therapy services, and periodic assessments both in-person and, in certain circumstances, virtually (using audio and video communication technology like your ph

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