Understanding Medicare: What It Covers & What It Doesn’t

I. Introduction: Why Medicare Confuses So Many People

Many people assume that once they turn 65, Medicare will cover all their medical needs. Then the first hospital bill or prescription receipt arrives and the confusion begins. Medicare can feel like a maze of rules, coverage limits, and exceptions that few people truly understand.

Even for those who have been managing their own insurance for years, Medicare feels different. There are several parts, each with its own costs and requirements. Some services are fully covered, others only partly, and some not at all. It’s no wonder so many families are caught off guard by unexpected bills or insurance denials.

At Haven Healthcare Advocates, we often hear from clients who thought a hospital stay, rehab service, or medication would be covered, only to find out later that it wasn’t. Our RN-led team steps in to explain coverage, file appeals, and help patients make sense of what went wrong.

This article breaks down the basics of Medicare coverage. Learn what’s included, what isn’t, and how to avoid surprises. Whether you’re preparing to enroll or already using Medicare, understanding these details can help you make smarter healthcare choices and avoid unnecessary stress.

Key Takeaways

1. Medicare is complex, and understanding what each part covers prevents costly surprises.

2. Original Medicare includes Part A (hospital) and Part B (medical); optional plans cover prescriptions (Part D) or combine services (Medicare Advantage).

3. Medicare does not cover long-term care, routine dental or vision, or 24-hour home support.

4. Many denials happen because of misunderstandings about coverage, not errors.

5. RN advocates and medical billing experts can review claims, appeal denials, and help you understand your plan.

6. Haven Healthcare Advocates provides health insurance consulting and medical billing advocacy services to clients in Florida and across the country.

Table of Contents

II. The Basics: What Medicare Is and Who It’s For

Medicare is the federal health insurance program for people aged 65 and older, and for certain younger individuals with disabilities or specific health conditions. It’s meant to make healthcare more affordable in retirement, but the way it’s structured can be hard to follow.

There are two main paths: Original Medicare and Medicare Advantage.
Original Medicare includes Part A and Part B, which are managed by the federal government. Medicare Advantage, also known as Part C, is offered by private insurance companies approved by Medicare. These plans combine hospital, medical, and often prescription coverage, but they come with their own costs, rules, and provider networks.

Understanding the difference between Medicare Parts A, B, and C , and what each one covers, is the first step toward avoiding unexpected bills and coverage gaps.

III. What Medicare Covers

Here is what original Medicare covers:

Part A (Hospital Insurance) covers inpatient care in hospitals, short stays in skilled nursing facilities, limited home health services, and hospice care. Most people don’t pay a premium for Part A if they paid Medicare taxes during their working years.

Part B (Medical Insurance) covers doctor visits, outpatient care, preventive screenings, lab work, and some medical equipment. Part B does require a monthly premium, and there’s also an annual deductible and coinsurance for most services.

Part D (Prescription Drug Coverage) helps pay for medications. These plans are offered by private insurers, and coverage depends on the specific plan’s drug list, known as a formulary. Costs can vary depending on the medications you take.

Medicare Advantage (Part C) plans are managed by private insurers and bundle together Parts A and B, often with Part D included. These plans may offer extras like dental, vision, and hearing coverage. However, they usually have provider networks, meaning you’ll need to see doctors and hospitals within that plan’s system.

IV. What Medicare Doesn’t Cover

One of the biggest misunderstandings about Medicare is assuming it covers everything. It doesn’t. There are clear gaps that often take people by surprise.

Medicare does not cover long-term or custodial care, such as extended stays in nursing homes or 24-hour in-home care. It also doesn’t pay for routine dental, hearing, or vision care. Most prescription drugs aren’t covered unless you have a Part D plan. And while short-term rehabilitation after a hospital stay might be included, ongoing assistance with daily activities is not.

Another common source of confusion involves home health services. Medicare will cover certain types of skilled home health care, such as nursing visits, physical therapy, or wound care, if a doctor certifies that the patient is homebound and the care is medically necessary. 

What it doesn’t cover are non-medical home care services, such as help with meals, bathing, or companionship. Those fall outside Medicare’s rules and are usually paid out of pocket or arranged through private agencies.

At Haven Healthcare Advocates, we often help families bridge this gap. Through our care management services in Tampa, we guide clients in coordinating Medicare-covered home health with private elder care and community resources to make sure every need is addressed.

Many families first realize these limits after a hospital discharge, when Medicare stops paying for rehab earlier than expected or denies coverage for extended care. That’s when our team often steps in to review the situation, explain the reason for the insurance denial, and help families file an appeal when appropriate.

V. Where Gaps Lead to Denials or Out-of-Pocket Costs

Most insurance denials under Medicare happen not because of errors, but because patients or families misunderstood what’s covered. For example, someone may expect Medicare to pay for home health services after a hospital stay, only to find that the care isn’t considered “skilled” and therefore isn’t eligible.

Our nurse advocates see this often. Sometimes the issue is a missed authorization, a provider billing mistake, or a claim coded incorrectly. Other times, it’s simply that the service falls outside Medicare’s coverage rules. That’s where medical billing advocacy makes a difference.

By reviewing the bill, communicating with the insurance company, and filing timely appeals, advocates help patients recover funds or avoid paying for something that should have been covered. More importantly, they help families understand what to expect in the future, reducing stress and confusion with each new claim.

VI. When to Ask for Help

You don’t need to wait for a denial letter to ask for help understanding your Medicare coverage. A health insurance consultant or RN advocate can review your current plan and explain how it applies to your specific needs.

It’s especially helpful to reach out when:

• You’re comparing Medicare Advantage and Original Medicare and need help choosing the right fit.

• You’ve received a bill or denial that doesn’t make sense.

• You’re being discharged from a hospital or rehab facility sooner than expected.

• You’re managing care for an aging parent and need guidance on coverage limits or referrals.

At Haven Healthcare Advocates, we help clients nationwide with Medicare questions, denials, and appeals. Our RN-led team brings both medical and insurance insight, something most billing specialists can’t offer.

Frequently Asked Questions

• Does Medicare cover long-term care?

  No. Medicare covers short-term skilled nursing care after a hospital stay, but not long-term or custodial care in a nursing home.

• What’s the difference between Original Medicare and Medicare Advantage?

  Original Medicare is run by the federal government and lets you see any doctor who accepts Medicare. Advantage plans are run by private insurers, often with limited provider networks and different rules.

• What happens if Medicare denies my claim?

  You can appeal. A medical billing advocate or RN advocate can review the denial, explain the reason, and help file an appeal with proper documentation.

• Does Medicare cover home health care?

  Only if it’s considered “skilled care,” such as nursing or physical therapy after a hospital stay. Personal or custodial care isn’t covered.

• How can Haven Healthcare Advocates help?

  Our nurses understand both the clinical and financial sides of healthcare. We review coverage, explain benefits, correct billing errors, and handle appeals so you don’t have to manage it alone.

Final Thoughts

Medicare can be confusing, but understanding its parts, and its limits, can save you time, money, and frustration. Whether you’re facing an unexpected bill or planning for future care, the right guidance makes all the difference. At Haven Healthcare Advocates, our RN-led team helps clients make sense of Medicare and take control of their healthcare decisions with confidence.