Limits on Drug Costs

Medicare Part D plans have different coverage phases throughout the year. During these coverage phases, you pay different amounts for your drugs. In all Part D plans, you enter the catastrophic coverage phase after you reach $8,000 in out-of-pocket costs for covered drugs. This amount comprises what you pay for covered drugs and some costs that others pay.

In 2024, you have $0 cost-sharing during catastrophic coverage. This means you will not be responsible for any of the cost of your Part D-covered drugs once reaching the catastrophic coverage phase. In the past, you owed 5% of the cost of your covered drugs for the remainder of the year once in this coverage phase.

Note that beginning in 2025, your out-of-pocket drug costs will be capped at $2,000.

Extra Help

Extra Help is a federal program that helps pay for most of the out-of-pocket costs of Medicare prescription drug coverage. You are eligible for the program if your income and assets are below federally set limits. Until 2024, you would qualify for either full or partial Extra Help, depending on your income and assets.

In 2024, the Extra Help program is expanding so that all people with Medicare earning less than 150% of the federal poverty level will be eligible for full Extra Help.

The 2024 income limits have not been released yet. Until they are released, you may qualify based on your 2023 income if you also have limited assets.

The 2023 monthly income limit was $1,843 for individuals and $2,485 for couples.

To actively apply or learn more about eligibility, contact your Social Security Administration branch. Find your local branch or call the national line at 800-772-1213.

 In 2024, those with full Extra Help will pay a low or no premium for their drug plan, a $0 deductible, and $4.50 copayments for generic and $11.20 copayments for brand-name drugs—those with Medicaid pay lower copays.

Drug Savings and COVID-19 Coverage

$35 Insulin

Copays for insulin for people with Medicare are limited to $35 per one month’s supply. This applies to all insulin covered by your Part D plan or under Medicare Part B.

No Cost-Sharing for Vaccines

You owe no copays or deductibles for vaccines covered by your Part D plan, including the shingles and RSV vaccines.

COVID-19 Vaccine

Original Medicare Part B covers COVID-19 vaccines and boosters, regardless of whether you have Original Medicare or a Medicare Advantage Plan. You owe no cost-sharing (deductibles, copayments, or coinsurance).

COVID-19 Testing

COVID-19 testing is covered under Medicare Part B. You pay nothing for the test if you have Original Medicare and see a participating provider or if you have a Medicare Advantage Plan and see an in-network provider.

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Published by: AARP

Medicare covers the majority of older Americans’ health care needs, from hospital care and doctor visits to lab tests and prescription drugs. Here are some needs that aren’t part of the program.

1. Opticians and eye exams

While original Medicare covers ophthalmologic expenses such as cataract surgery, it doesn’t cover routine eye exams, glasses or contact lenses. Nor do any Medigap plans, the supplemental insurance that is available from private insurers to augment Medicare coverage. Some Medicare Advantage plans cover routine vision care and glasses. ​​

2. Hearing aids

Medicare covers ear-related medical conditions, but original Medicare and Medigap plans don’t pay for routine hearing tests or hearing aids. ​

3. Dental work

Original Medicare and Medigap policies do not cover dental care such as routine checkups or big-ticket items, including dentures and root canals.

4. Overseas care

Original Medicare and most Medicare Advantage plans offer virtually no coverage for medical costs incurred outside the U.S. ​​

5. Podiatry

Routine medical care for feet, such as callus removal, is not covered. Medicare Part B does cover foot exams or treatment if it is related to nerve damage because of diabetes, or care for foot injuries or ailments, such as hammertoe, bunion deformities and heel spurs.

6. Cosmetic surgery

Medicare doesn’t generally cover elective cosmetic surgery, such as face-lifts or tummy tucks. It will cover plastic surgery in the event of an accidental injury or if needed after another treatment, such as breast reconstruction following a mastectomy.

7. Chiropractic care

Original Medicare does not cover most chiropractic services or the tests that a chiropractor orders, including X-rays. Medicare Part B does pay for one chiropractic service: manual manipulation of the spine by a chiropractor or other qualified provider to correct a vertebral subluxation, which is basically a partial dislocation of a spinal vertebra from its normal position.

8. Massage therapy

​Original Medicare doesn’t cover massage therapy, often used to help reduce chronic pain, although research suggests it may provide short-term, but not long-term, relief. When it comes to pain management, Medicare covers chiropractic care in certain limited circumstances and physical and occupational therapy when prescribed by a doctor. Some Medicare Advantage plans might cover some massage therapy. It’s best to call your plan to find out if it does. ​​

9. Nursing home care

​Medicare pays for limited stays in rehab facilities — for example if you have a hip replacement and need inpatient physical therapy for several weeks. But if you become so frail or sick that you must move to an assisted living facility or nursing home, Medicare won’t cover your custodial costs. (Nursing homes average about $90,000 yearly for a semi-private room and more than $100,000 for a private room. Costs vary based on where you live and what facility you choose.) ​​

10. Concierge care

Some physicians and their practices require a membership fee in order for them to treat you. They advertise that this makes them more responsive and available to their patients. The fees, which can run thousands of dollars a year, vary depending on the concierge or boutique practice. Medicare will not cover these fees. Note that once you’ve paid that fee, if your doctor participates in Medicare he or she must offer all the services Medicare does with the same copays and coinsurance rules applying.

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Your health is important and needs to be protected. If you are 65 or older or have certain disabilities, or End-Stage Renal Disease, you can get health care coverage through the Medicare program. You’ll get access to health care services you need to achieve and maintain good health.

It’s important to review your Medicare coverage options and find an affordable option that meets your healthcare needs.

Medicare coverage options

There are two types of Medicare coverage:

• Traditional or Original Medicare.
• Medicare Advantage.

Original Medicare helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. It also covers:

• Services from doctors and other health care providers.
• Outpatient care.
• Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment).
• Preventive services (like screenings, certain vaccines, and annual wellness visits).

Original Medicare is often referred to as Part A and Part B. You can go to any doctor or hospital, anywhere in the United States, that accepts Medicare. If you have Original Medicare, you can also buy a Medicare Supplement Insurance (Medigap) policy from a private insurance company. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medigap policy can help pay some of the remaining health care costs, such as copayments, coinsurance, and deductibles.

Medicare Advantage bundles your Original Medicare – and usually Medicare prescription drug coverage – into one health insurance plan. If you select Medicare Advantage coverage, you join a plan offered by Medicare-approved private companies.

Each plan can have different rules for how you get services – like referrals to see a specialist. All plans must cover emergency and urgent care, as well as all medically necessary services covered by Original Medicare.

In many cases, you can only use doctors and other providers who are in your plan’s network and service area. Costs for monthly premiums and services vary depending on which plan you join. Some plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

Whether you choose Original Medicare or Medicare Advantage, be sure you have prescription drug coverage. You can join a Medicare Prescription Drug Plan (called a PDP) in addition to Original Medicare. You can also get it by joining a Medicare Advantage plan with Medicare prescription drug coverage.

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The Centers for Medicare & Medicaid Services (CMS) announced this week that it will cover seat elevation technology in Medicare-covered power wheelchairs as durable medical equipment (DME). Effective immediately, both Original Medicare and Medicare Advantage will cover seat elevation for those who need it to perform activities of daily living in the home. This landmark decision meaningfully expands Medicare coverage and appropriately prioritizes enrollee independence and quality of life.

Despite the clear need many power wheelchair users have for technology that helps them safely transfer to and from the wheelchair and to better reach items and surfaces without joint or muscle strain, Medicare generally considered seat elevation in power wheelchairs to be a “mere accessory.” This categorization prevented coverage and downplayed the importance of features that help people maintain well-being, physical health, and community living.

Last year, CMS announced that it was considering updating this policy. The agency proposed allowing Medicare to cover seat elevation for some power wheelchair users as DME. This began a series of comment opportunities where beneficiaries and advocates, including Medicare Rights, applauded this proposal, explained the need for seat elevation, and urged CMS to cover seat elevation for all power wheelchair users, not just the proposed subset.

In the final policy, CMS agreed to expand coverage to additional groups, citing the thousands of public comments from wheelchair users, advocates, and other stakeholders. The new coverage will apply when the individual has a specialty evaluation confirming they can use the equipment safely and when they need it for one of three conditions: (1) to perform weight-bearing transfers with or without caregiver assistance and/or the use of assistive equipment; (2) to perform the non-weight bearing transfer to or from the power wheelchair in the home; or (3) to complete one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home.

Other individuals, including those who do not use complex rehabilitative power-driven wheelchairs, may be able to gain coverage on a case-by-case basis. Future reforms could further improve access—CMS has indicated that it is also considering covering power wheelchair standing systems as DME.

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Medicare Part A and Part B cover a variety of services, including inpatient hospital care, skilled nursing care, preventive services, home health care, and ambulance transportation. Additional services such as vision and dental care may be available through a Medicare Advantage plan.

What Services Are Covered by Medicare?

People enrolled in Original Medicare have access to a range of inpatient and outpatient services.

For example, Medicare Part A covers inpatient care in a hospital, home health care, skilled nursing facility care, and hospice services.

Medicare Part B covers two main types of services: Medically necessary services or supplies and preventive services such as flu shots and cancer screenings. Clinical research, mental health services, durable medical equipment, and ambulance transportation are all covered by Medicare Part B.

All Medicare Advantage plans are required to offer the same services as Original Medicare but offer additional services such as dental and vision care.

Medicare Preventive Services

Most Medicare beneficiaries are 65 and older. It’s important for this age group to stay on top of their health care, including taking measures to prevent illness or detect diseases at an early stage when treatment is more effective.

Medicare Part B offers preventive services to help you stay healthy in retirement. Many of these tests or screenings are fully covered by Medicare while others require cost-sharing for the beneficiary such as a copayment, coinsurance, and a deductible.

Once you enroll in Medicare Part B, you have 12 months to receive a free “Welcome to Medicare” physical exam, according to AARP.

After you’ve been enrolled in Medicare Part B for a year, you are eligible for an annual wellness visit to build or update your prevention plan based on your current health and risk factors.

Medicare preventive services include:

• Flu shots and vaccines
• Lab tests and screenings
• Cancer screenings, including mammograms and prostate exams
• Diabetes screenings and self-management training
• Bone mass measurements
• Health monitoring, counseling, and education
• Nutrition therapy services
• Welcome to Medicare preventive visit and yearly wellness visit

Preventive Vaccine Coverage

Vaccines are included under Medicare’s preventive services. Beneficiaries are covered by several preventive vaccines, including an annual flu shot. Medicare typically pays for the entire cost of the vaccine if it’s under coverage.

While Medicare does not cover all vaccines, some can be received if they are related to the treatment of a condition. Other vaccines are available through Part D prescription drug plans.

Durable Medical Equipment Under Medicare

Medicare does cover durable medical equipment (DME). DME is typically a non-disposable item or type of equipment that assists with a medical condition. Examples include wheelchairs, canes, or walkers, all of which Medicare can cover.

Medicare typically will not cover any disposable, temporary items or equipment that’s more substantial, like a hospital bed.

Common Types of Durable Medical Equipment

• Wheelchairs
• Canes
• Walkers
• Hospital beds
• Crutches

As with other items covered by Medicare, DME must be considered medically necessary for you to use for it to be covered.

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Some policymakers are attempting to add bureaucratic barriers to Medicaid that would put health coverage for millions of people at risk. On April 26, the Republican-led House of Representatives advanced legislation linking a debt limit increase to harmful funding cuts and policies, including adding complex work requirements to Medicaid starting in 2024.

The evidence is clear that such requirements do not further the Medicaid program’s objectives, and instead create barriers to care and put coverage at risk. For example, a recent Kaiser Family Foundation (KFF) analysis shows that Medicaid work and reporting requirements are confusing to enrollees and can result in substantial coverage loss, even if they meet the underlying requirements. In an earlier report, KFF found that if all states implemented work requirements, most disenrollment would be among individuals who would lose coverage due to the new administrative burdens, rather than due to noncompliance with the actual work requirements. Many of these adults would become uninsured and pay more for health care.

Adding Medicaid work requirements nationally could affect millions of enrollees. In assessing the current proposals, the Congressional Budget Office (CBO) estimates that around 15 million people would be subject to work requirements and in danger of losing coverage. HHS estimates that number would be closer to 21 million. The likely administrative burdens would be significant, partially because many adults with Medicaid do not use computers, the internet, or email, which could be a barrier in finding a job or complying with policies to report work or exemption status. Adults over 50 face particular challenges in complying, and the health consequences, if they lose Medicaid coverage, are likely to be especially severe. Research has shown that for people with serious health needs, coverage interruptions lead to increased emergency room visits and hospitalizations, admissions to mental health facilities, and health care costs.

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Medicare does not cover all healthcare services. Services excluded from Medicare coverage include but are not limited to:

• Alternative medicine, including experimental procedures and treatments, acupuncture, and chiropractic services, except when manipulation of the spine is medically necessary to fix a subluxation of the spine (when one or more of the bones of the spine move out of position)
• Most care received outside of the United States
• Cosmetic surgery, unless needed to improve the function of a malformed part of the body
• Most dental care
• Hearing aids, including examinations for prescribing or fitting hearing aids—though in some cases implants to treat severe hearing loss are covered
• Personal care, including help with bathing, dressing, and eating, when it is the only care you need
• Custodial care (homemaker services), including light housekeeping, laundry, and meal preparation, when it is the only care you need
• Nursing home care (long-term care), including medical care, therapy, 24-hour care, and personal care, except during a Medicare-covered skilled nursing facility (SNF) stay
• Non-medical services, including a private hospital room, hospital television and telephone, canceled or missed appointments, and copies of x-rays
• Most non-emergency transportation, including ambulette services
• Certain preventive services, including routine foot care
• Most vision care, including eyeglasses (except following cataract surgery) and examinations for prescribing or fitting eyeglasses

You are responsible for the full cost of care if you receive a service that Medicare does not cover. If you have a Medicare Advantage Plan, your plan may cover some of these services. Ask your plan if it covers any additional services.

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