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What Does Medicare Actually Cover? A Complete Guide

Introduction: Understanding Your Medicare Coverage Options

Navigating Medicare coverage can feel overwhelming, especially when you’re trying to understand exactly what services are covered, what you’ll pay out-of-pocket, and how to make the most of your benefits. With Medicare serving over 67 million Americans, understanding your coverage isn’t just important—it’s essential for accessing the preventive care and medical services you need while managing healthcare costs effectively.

“One of the most common questions I hear from patients is simply, ‘What does Medicare actually cover?'” says Dr. Michael Curley, a board-certified Family Medicine physician with over 37 years of experience serving the Inland Empire through PromiseCare Medical Group. “The answer isn’t always straightforward because Medicare has different parts, each covering specific services. But once you understand how these parts work together, you can make informed decisions about your healthcare.”

Medicare coverage extends far beyond basic hospital visits and doctor appointments. From preventive services and diagnostic testing to prescription drugs and skilled nursing care, understanding what Medicare covers—and what it doesn’t—helps you plan for your healthcare needs and avoid unexpected medical bills.

This comprehensive guide breaks down exactly what each part of Medicare covers, explains the costs you’ll encounter, and provides practical guidance from PromiseCare Medical Group physicians who work with Medicare patients every day in Hemet, Murrieta, Temecula, and throughout the Inland Empire.

Understanding the Four Parts of Medicare

Medicare isn’t a single insurance program—it’s divided into four distinct parts, each covering different healthcare services. Think of these parts as building blocks that work together to provide comprehensive health coverage.

Medicare Part A: Hospital Insurance Coverage

Medicare Part A, often called hospital insurance, covers inpatient hospital care and certain other facility-based services. Most people don’t pay a monthly premium for Medicare Part A because they or their spouse paid Medicare taxes for at least 10 years (40 quarters) while working.

What Medicare Part A Covers:

Inpatient Hospital Care: When you’re formally admitted to a hospital, Part A covers your room, meals, nursing care, medications administered during your stay, and other hospital services and supplies. This includes semi-private rooms, intensive care units, and coronary care units.

“Part A is your safety net for serious health events that require hospitalization,” explains Dr. Edivina Gonzales, an Internal Medicine specialist at PromiseCare Medical Group. “It covers the substantial costs associated with hospital stays, which can easily reach tens of thousands of dollars without insurance.”

For 2026, Part A coverage includes:

Skilled Nursing Facility Care: After a qualifying hospital stay of at least three days, Part A covers skilled nursing facility care for rehabilitation services, skilled nursing care, and therapy. This isn’t the same as long-term custodial care or assisted living.

Coverage includes:

Home Health Care: Part A covers medically necessary skilled nursing care and therapy services in your home following a hospital or skilled nursing facility stay. This includes part-time or intermittent skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services.

Hospice Care: For patients with terminal illnesses, Part A covers hospice care including pain relief, symptom management, and support services. This coverage includes drugs for symptom control, medical equipment, counseling services, and short-term respite care.

What Part A Doesn’t Cover:

Part A does not cover custodial care (help with daily activities like bathing and dressing), long-term care, private-duty nursing, or room upgrades to private accommodations unless medically necessary. It also doesn’t cover prescription drugs you take at home—those require Medicare Part D coverage.

Medicare Part B: Medical Insurance Coverage

Medicare Part B covers physician services, outpatient care, preventive services, and durable medical equipment. Unlike Part A, most beneficiaries pay a monthly premium for Part B coverage.

The standard Part B premium for 2026 is $202.90 per month, with an annual deductible of $283. Higher-income beneficiaries may pay more through Income-Related Monthly Adjustment Amounts (IRMAA).

What Medicare Part B Covers:

Physician Services: Part B covers medically necessary doctor visits, including primary care appointments, specialist consultations, and second opinions. This includes office visits, hospital visits while you’re an outpatient, and home visits when medically necessary.

“Part B coverage for physician services is what allows me to provide comprehensive primary care to my Medicare patients,” notes Dr. Curley. “This includes routine check-ups, management of chronic conditions like diabetes and hypertension, and urgent care visits when health concerns arise.”

Preventive Services: One of Part B’s most valuable benefits is coverage for preventive services, many of which are covered at no cost to you. These services help detect health problems early when they’re most treatable.

Covered preventive services include:

Outpatient Services: Part B covers a wide range of outpatient services, including emergency department visits, ambulance services, mental health services, and outpatient surgery.

Diagnostic Services: Laboratory tests, X-rays, MRIs, CT scans, and other diagnostic imaging services are covered under Part B. At PromiseCare Medical Group, Dr. Gonzales regularly orders these tests for her patients: “Diagnostic services are essential for accurate diagnosis and treatment planning. Part B coverage means patients can access the imaging and lab work they need without prohibitive costs.”

Durable Medical Equipment (DME): Part B covers medically necessary equipment like wheelchairs, walkers, hospital beds, oxygen equipment, and diabetic supplies including glucose monitors and test strips.

Therapy Services: Outpatient physical therapy, occupational therapy, and speech-language pathology services are covered under Part B, subject to certain limitations and therapy caps in some cases.

Mental Health Services: Part B covers outpatient mental health care, including individual and group therapy, psychiatric evaluations, and medication management for mental health conditions.

After Your Deductible:

After meeting the $283 annual deductible in 2026, you typically pay 20% coinsurance for most Part B services. There’s no yearly limit on what you pay out-of-pocket unless you have supplemental coverage like Medicare Supplement Insurance (Medigap) or Medicare Advantage.

What Part B Doesn’t Cover:

Part B doesn’t cover routine dental care, routine eye exams for eyeglasses, hearing aids, cosmetic surgery, or most prescription drugs (these require Part D coverage). It also doesn’t cover long-term care or custodial care.

Medicare Part C: Medicare Advantage Plans

Medicare Advantage, also called Medicare Part C, offers an alternative way to receive your Medicare benefits. Instead of getting coverage through Original Medicare (Parts A and B), you receive all your Medicare benefits through a private insurance plan approved by Medicare.

How Medicare Advantage Works:

Medicare Advantage plans must cover everything Original Medicare covers, but they can do so with different rules, costs, and coverage restrictions. Most Medicare Advantage plans include prescription drug coverage (Part D), making them an all-in-one option for many beneficiaries.

“Many of my patients at PromiseCare are enrolled in Medicare Advantage plans,” says Dr. Curley. “These plans often include additional benefits like dental, vision, and hearing coverage that aren’t available through Original Medicare, which makes them attractive options for comprehensive care.”

Types of Medicare Advantage Plans:

Medicare Advantage Extra Benefits:

For 2026, 97% or more Medicare Advantage plans offer vision, dental, and hearing benefits beyond Original Medicare. Many plans also include:

PromiseCare Medical Group accepts many Medicare Advantage plans, including those from Aetna, Alignment Healthcare, Anthem BlueCross, Brand New Day, Cigna, Health Net, Humana, SCAN Health Plan, and United Healthcare. The network includes 60+ primary care doctors and 400+ specialists across the Inland Empire.

Medicare Advantage Costs:

For 2026, the average monthly premium for Medicare Advantage plans is expected to be approximately $14.00. However, about 67% of Medicare Advantage plans with prescription drug coverage charge no premium beyond the Part B premium. You’ll still pay the Part B premium even with a Medicare Advantage plan.

The maximum out-of-pocket limit for in-network services decreased to $9,250 in 2026 (down from $9,350 in 2025), though most plans set their limits well below this federal cap.

What to Consider:

Medicare Advantage plans typically have network restrictions, meaning you may need to see specific doctors and hospitals. “Before choosing a Medicare Advantage plan, verify that your preferred doctors and specialists are in the plan’s network,” advises Dr. Gonzales. “Also check if the plan covers the hospitals and urgent care centers you might need to use.”

Medicare Part D: Prescription Drug Coverage

Medicare Part D provides outpatient prescription drug coverage through private insurance companies. You can add Part D coverage to Original Medicare through a standalone prescription drug plan (PDP), or you can choose a Medicare Advantage plan that includes drug coverage.

How Part D Works in 2026:

Thanks to the Inflation Reduction Act, Part D underwent significant improvements in 2025 that continue in 2026. The most important change is the $2,000 annual out-of-pocket spending cap, which protects beneficiaries from catastrophic prescription drug costs.

“The $2,000 cap has been life-changing for many of my patients with expensive medications,” notes Dr. Curley. “Patients who were struggling to afford their prescriptions now have predictable costs and better medication adherence.”

Part D Coverage Phases in 2026:

  1. Deductible Phase: You pay 100% of drug costs until you meet the deductible (varies by plan, maximum $590 in 2026)
  2. Initial Coverage Phase: You pay copays or coinsurance for covered drugs until your total out-of-pocket costs reach $2,000
  3. Catastrophic Phase: Once you reach $2,000 in out-of-pocket costs, you pay $0 for covered drugs for the rest of the year

Prescription Payment Plan:

Starting in 2025, Medicare offers a prescription payment plan allowing beneficiaries to spread their out-of-pocket costs across the year rather than paying large amounts upfront. This optional program helps manage cash flow for expensive medications.

Part D Formularies:

Each Part D plan has a formulary—a list of covered drugs organized into cost tiers. Drugs in lower tiers have lower copays than drugs in higher tiers. Plans must cover at least two drugs in each category and class, but the specific drugs covered vary by plan.

Part D Costs for 2026:

The average standalone Part D premium is projected to be approximately $34.50 per month in 2026. For Medicare Advantage plans with drug coverage, the average Part D premium after rebates is projected to be about $11.50 per month.

Higher-income beneficiaries pay Income-Related Monthly Adjustment Amounts in addition to their plan premium. The late enrollment penalty applies if you don’t maintain creditable drug coverage when first eligible.

What Part D Doesn’t Cover:

Part D doesn’t cover drugs administered during hospital stays (those are covered under Part A) or certain medications covered under Part B (such as chemotherapy and certain injected drugs). It also doesn’t cover medications prescribed for off-label uses not approved by the FDA.

Original Medicare vs. Medicare Advantage: Understanding Your Options

Choosing between Original Medicare and Medicare Advantage is one of the most important decisions you’ll make regarding your healthcare coverage. Each option has distinct advantages depending on your health needs, budget, and preferences.

Original Medicare (Parts A & B)

How It Works:

With Original Medicare, you can see any doctor or hospital that accepts Medicare anywhere in the United States. There are no network restrictions, and you don’t need referrals to see specialists.

Costs to Consider:

Adding Coverage:

Most people with Original Medicare add:

“Original Medicare offers tremendous flexibility,” explains Dr. Gonzales. “My patients with Original Medicare can see me at PromiseCare and also travel to see specialists at major medical centers across the country without network restrictions or referrals.”

Medicare Advantage (Part C)

How It Works:

Medicare Advantage plans bundle Parts A, B, and usually D into one plan offered by private insurance companies. Most plans have network restrictions and may require referrals.

What’s Included:

Network Considerations:

“The main trade-off with Medicare Advantage is the network limitation,” notes Dr. Curley. “You’ll typically need to use doctors and hospitals within the plan’s network, and HMO plans require referrals for specialist care. However, many patients find the extra benefits and out-of-pocket protection worth these restrictions.”

PromiseCare Medical Group’s extensive network of primary care physicians and specialists means Medicare Advantage patients can access coordinated care across multiple specialties within one network. With 18 urgent care centers, members also have convenient access to after-hours care.

Which Option Is Right for You?

Choose Original Medicare if you:

Choose Medicare Advantage if you:

Understanding Medicare Costs: Premiums, Deductibles, and Out-of-Pocket Expenses

Medicare coverage comes with various costs that can significantly impact your healthcare budget. Understanding these expenses helps you plan financially and avoid surprises.

Medicare Part A Costs (2026)

Premium:

Deductible & Coinsurance:

Medicare Part B Costs (2026)

Standard Premium: $202.90/month

Income-Related Monthly Adjustment Amount (IRMAA):

Higher-income beneficiaries pay additional premiums based on income from two years prior. For 2026, these are based on 2024 tax returns:

Individual Income Married Filing Jointly Monthly Part B Premium
≤$106,000 ≤$212,000 $202.90
$106,001-$133,000 $212,001-$266,000 $288.90
$133,001-$167,000 $266,001-$334,000 $403.90
$167,001-$200,000 $334,001-$400,000 $518.90
$200,001-$500,000 $400,001-$750,000 $633.90
>$500,000 >$750,000 $748.90

Deductible: $283 per year

Coinsurance: 20% for most Part B services after deductible

“Many patients are surprised by IRMAA,” observes Dr. Gonzales. “It’s important to understand that even if you’re retired, income from investments, pensions, or part-time work can trigger higher Medicare premiums.”

Medicare Advantage Costs (2026)

Average Premium: $14.00/month (many plans charge $0 beyond Part B premium)

Out-of-Pocket Maximum: Up to $9,250 for in-network services (most plans set lower limits)

Additional Costs: Copays and coinsurance vary by plan and service

Medicare Part D Costs (2026)

Average Premium: $34.50/month for standalone plans; $11.50/month for MA-PD plans

Deductible: Varies by plan (maximum $590)

Out-of-Pocket Cap: $2,000 annually

IRMAA for Part D: Higher-income beneficiaries pay $13.70 to $87.30 in additional monthly premiums

Strategies to Manage Medicare Costs

1. Take Advantage of Preventive Services

“Medicare covers many preventive services at no cost,” emphasizes Dr. Curley. “Annual wellness visits, cancer screenings, cardiovascular screenings, and vaccinations are all covered without copays or deductibles under Part B. These services help catch health problems early when they’re most treatable and less expensive.”

2. Review Plans Annually

Medicare plans can change their costs, coverage, and networks each year. During the Annual Enrollment Period (October 15-December 7), compare plans to ensure you have the best coverage for your needs.

3. Consider Supplemental Coverage

Medicare Supplement Insurance (Medigap) can help cover out-of-pocket costs associated with Original Medicare, providing more predictable expenses.

4. Explore Financial Assistance Programs

Low-income beneficiaries may qualify for Medicare Savings Programs through their state, which help pay Medicare premiums, deductibles, and coinsurance. The Extra Help program assists with Part D prescription drug costs.

5. Use Network Providers

If you have Medicare Advantage, staying within your plan’s network helps minimize out-of-pocket costs. PromiseCare Medical Group participates in multiple Medicare Advantage networks, providing accessible care for members across the Inland Empire.

Preventive Care Coverage: Your Most Valuable Medicare Benefit

One of Medicare’s most important benefits is comprehensive coverage for preventive services—most of which are available at no cost to you. These services focus on keeping you healthy and detecting potential health problems early.

Annual Wellness Visits

Medicare covers one annual wellness visit each year at no cost. This isn’t the same as a physical exam; it’s a comprehensive review of your health risks and a personalized prevention plan.

“The annual wellness visit is an opportunity to review your medications, discuss any health concerns, update your medical history, and create a personalized prevention plan,” explains Dr. Curley. “We assess cognitive function, evaluate fall risks, screen for depression, and review your vaccination status. It’s comprehensive preventive care focused on keeping you healthy.”

What’s Included:

First-Time Visit:

Your “Welcome to Medicare” preventive visit must occur within the first 12 months of Part B coverage. After that, you’re eligible for an annual wellness visit every 12 months.

Cancer Screenings

Medicare provides extensive coverage for cancer screening tests that can detect cancer early when treatment is most effective:

Mammograms: Covered once every 12 months for women 40 and older; baseline mammogram for women 35-39

Colorectal Cancer Screening: Multiple options covered including colonoscopy every 10 years (or 2 years if high-risk), flexible sigmoidoscopy every 4 years, fecal occult blood test annually, CT colonography every 5 years

Prostate Cancer Screening: Digital rectal exam and PSA test covered once every 12 months for men 50 and older

Cervical and Vaginal Cancer Screening: Pap smears and pelvic exams covered every 24 months (every 12 months if high-risk)

Lung Cancer Screening: Annual low-dose CT scan for those who meet specific criteria related to smoking history

Dr. Gonzales emphasizes the importance of screening: “Cancer caught early is often more treatable and less costly to manage. Medicare’s coverage of these screenings removes financial barriers to potentially life-saving early detection.”

Cardiovascular Disease Screening

Medicare covers cardiovascular disease screening blood tests once every 5 years, including cholesterol, lipid, and triglyceride levels. For those with specific risk factors, more frequent testing may be covered.

“Cardiovascular disease remains the leading cause of death in the United States,” notes Dr. Curley. “Regular screening allows us to identify risk factors early and implement preventive strategies through lifestyle modifications or medication before serious cardiovascular events occur.”

Diabetes Screening and Management

Medicare covers diabetes screening tests twice per year if you have pre-diabetes or certain risk factors. For diagnosed diabetics, Medicare covers:

Bone Density Testing

Medicare covers bone mass measurements once every 24 months (more frequently if medically necessary) for those at risk of osteoporosis. This simple test can identify bone loss before fractures occur.

Vaccinations

Medicare covers several important vaccines at no cost:

Part B Coverage: Flu shots (once per flu season), pneumococcal vaccines, hepatitis B vaccines (for those at medium to high risk), COVID-19 vaccines

Part D Coverage: Shingles vaccine, tetanus/diphtheria/pertussis (Tdap)

“Vaccinations are essential preventive care, especially for older adults whose immune systems may be more vulnerable,” emphasizes Dr. Gonzales. “We encourage all our Medicare patients to stay current with recommended vaccinations.”

Depression and Mental Health Screening

Medicare covers one annual depression screening and separate screenings for alcohol misuse. Mental health services, including diagnostic assessments and treatment, are also covered under Part B.

Obesity Counseling

If you have a body mass index of 30 or higher, Medicare covers intensive behavioral therapy for obesity, including one face-to-face visit per week for the first month.

Making the Most of Preventive Services

“Many patients aren’t aware of all the preventive services Medicare covers,” observes Dr. Curley. “At PromiseCare, we proactively discuss these services with patients and help them stay on track with recommended screenings and preventive care. This proactive approach is fundamental to maintaining health as we age.”

What Medicare Doesn’t Cover: Important Gaps to Know

While Medicare provides comprehensive coverage for many healthcare services, there are important gaps in coverage that beneficiaries should understand and plan for.

Dental Care

Not Covered by Original Medicare:

Exception: Medicare Part A covers dental services received as part of a covered inpatient stay (for example, jaw reconstruction following an accident).

Coverage Options: Many Medicare Advantage plans include dental benefits. Alternatively, you can purchase standalone dental insurance.

Vision Care

Not Covered by Original Medicare:

Covered: Medicare Part B covers eye exams to diagnose and treat diseases and conditions like glaucoma, macular degeneration, and cataracts. It also covers one pair of eyeglasses or contact lenses after cataract surgery.

Coverage Options: Medicare Advantage plans frequently include vision benefits covering routine exams and eyewear allowances.

Hearing Services

Not Covered by Original Medicare:

Covered: Medicare Part B covers diagnostic hearing and balance exams if your doctor orders them to determine if you need medical treatment.

Coverage Options: Many Medicare Advantage plans now include hearing aid coverage, a benefit not available through Original Medicare.

Long-Term Care

Medicare does not cover long-term custodial care—assistance with activities of daily living like bathing, dressing, and eating—whether in a nursing home or at home.

“This is one of the most significant Medicare coverage gaps,” explains Dr. Gonzales. “Medicare covers skilled nursing care after a qualifying hospital stay, but only for up to 100 days and only when you need skilled services like physical therapy or wound care. Long-term custodial care requires either private payment, long-term care insurance, or Medicaid eligibility.”

What Medicare Does Cover: Skilled nursing facility care following a qualifying hospital stay, hospice care for terminal illness, and limited home health care for medically necessary skilled services.

International Travel

With rare exceptions for emergency care near the Canadian or Mexican border, Medicare doesn’t cover healthcare services outside the United States. Some Medicare Supplement (Medigap) policies offer limited coverage for foreign travel emergencies.

Other Services Not Covered

Planning for Coverage Gaps

“Understanding what Medicare doesn’t cover is just as important as knowing what it does cover,” advises Dr. Curley. “Patients should consider their individual health needs and budget when deciding whether to add supplemental coverage through Medigap policies, Medicare Advantage plans with extra benefits, or specialized insurance like dental or long-term care coverage.”

At PromiseCare Medical Group, physicians work with patients to maximize their Medicare benefits while helping them understand and plan for services that require additional coverage or out-of-pocket payment.

Enrollment Periods: When You Can Sign Up or Change Coverage

Understanding Medicare enrollment periods is crucial because missing deadlines can result in late enrollment penalties, coverage gaps, or limited plan options.

Initial Enrollment Period (IEP)

Your Initial Enrollment Period is a 7-month window surrounding your 65th birthday:

If you’re already receiving Social Security benefits at 65, you’ll be automatically enrolled in Medicare Parts A and B. If you’re not receiving Social Security, you must actively enroll during your IEP.

Exception: If you’re still working and have employer coverage, you may delay Part B enrollment without penalty. However, you should still enroll in Part A if it’s premium-free.

General Enrollment Period (GEP)

If you miss your Initial Enrollment Period, you can enroll in Medicare during the General Enrollment Period from January 1 to March 31 each year. Coverage begins July 1.

Late Enrollment Penalty: Enrolling late may result in permanent premium increases for Part B (10% per full 12-month period you were eligible but not enrolled) and Part D (calculated based on months without coverage).

Annual Enrollment Period (AEP)

The Annual Enrollment Period runs from October 15 to December 7 each year. During this time, you can:

Changes made during AEP take effect January 1 of the following year.

“Every year during the Annual Enrollment Period, I encourage my patients to review their Medicare coverage,” says Dr. Curley. “Plans change their costs, covered drugs, and networks annually. What worked well last year might not be your best option this year, especially if your health needs or medications have changed.”

Medicare Advantage Open Enrollment Period

From January 1 to March 31, if you’re already in a Medicare Advantage plan, you can:

You can only make one change during this period.

Special Enrollment Periods (SEP)

Special circumstances may trigger a Special Enrollment Period allowing you to enroll outside regular enrollment periods:

Special Enrollment Periods have specific timeframes and documentation requirements. Contact Medicare or a licensed insurance agent for guidance on SEP eligibility.

Coordinating with PromiseCare Medical Group

“If you’re considering changing your Medicare coverage, check that your preferred doctors and specialists are in the new plan’s network before enrolling,” advises Dr. Gonzales. “PromiseCare accepts many Medicare Advantage plans, but it’s always best to verify network participation for your specific plan. Our staff can help confirm whether we accept a particular plan you’re considering.”

Working with Your Primary Care Provider: Maximizing Your Medicare Benefits

Having a trusted primary care provider is one of the most effective ways to maximize your Medicare benefits and maintain optimal health.

The Role of Your Primary Care Physician

Your primary care physician serves as your health advocate, coordinating your care across specialists, managing chronic conditions, and focusing on preventive services.

“As a primary care physician, I’m the quarterback of my patients’ healthcare teams,” explains Dr. Curley. “I coordinate with specialists, review all medications, track health trends over time, and ensure patients receive appropriate preventive care. This comprehensive approach helps avoid duplicate tests, medication interactions, and fragmented care.”

Continuity of Care at PromiseCare Medical Group

PromiseCare Medical Group’s network of 60+ primary care doctors and 400+ specialists allows for seamless care coordination within one system. This integrated approach means:

Shared Medical Records: Providers across PromiseCare can access your medical history, test results, and treatment plans, reducing redundant testing and improving care coordination.

Specialized Expertise: When you need specialist care, your primary care physician can refer you to PromiseCare specialists who are already familiar with the network’s care standards and have established relationships with primary care providers.

Comprehensive Care Management: For patients with complex chronic conditions, PromiseCare offers care management programs that coordinate services across multiple providers.

“Having all your providers within one network streamlines communication and care coordination,” notes Dr. Gonzales. “When I refer a patient to our cardiologist or endocrinologist, I know they’ll receive excellent care, and I’ll get timely updates on the consultation and treatment plan.”

Choosing Your Primary Care Physician

When selecting a primary care physician under Medicare, consider:

Training and Experience: Look for board-certified physicians with experience in geriatric care or family medicine.

Communication Style: Choose a doctor who listens, explains things clearly, and involves you in decision-making.

Accessibility: Consider office location, hours, and how the practice handles urgent concerns and after-hours needs.

Network Participation: Verify the physician accepts your Medicare plan (Original Medicare or your specific Medicare Advantage plan).

Hospital Affiliations: Check which hospitals your physician has privileges at, ensuring they’re convenient and meet your preferences.

At PromiseCare Medical Group, physicians like Dr. Curley (37+ years of experience in Family Medicine and Geriatric Medicine) and Dr. Gonzales (Internal Medicine specialist) provide patient-centered care with deep expertise in managing the health concerns of Medicare beneficiaries.

Medicare Annual Wellness Visits

Medicare beneficiaries should schedule their annual wellness visit each year at no cost. These visits provide an opportunity to:

“The annual wellness visit is different from a sick visit or physical exam,” clarifies Dr. Curley. “It’s specifically designed to be preventive and forward-looking. We talk about keeping you healthy and developing strategies to prevent future health problems.”

After-Hours Care and Urgent Needs

PromiseCare Medical Group maintains relationships with 18 urgent care centers across the Inland Empire, providing Medicare patients with convenient access to care outside regular office hours.

“If something urgent comes up after hours or on weekends, patients can visit one of our network urgent care centers and receive coordinated care,” explains Dr. Gonzales. “The urgent care visit records integrate with our electronic medical records, so I’m aware of the visit and can follow up appropriately.”

Frequently Asked Questions About Medicare Coverage

Q: Does Medicare cover prescription drugs?

A: Original Medicare (Parts A and B) does not include prescription drug coverage. You need to enroll in Medicare Part D or a Medicare Advantage plan that includes drug coverage to get prescription drug benefits. Medicare Part A covers medications you receive during a hospital stay, and Part B covers certain injected drugs and chemotherapy, but regular prescriptions require Part D coverage.

Q: Can I use any doctor with Medicare?

A: With Original Medicare, you can see any doctor or hospital that accepts Medicare assignment anywhere in the United States—no referrals needed. With Medicare Advantage plans, you typically need to use network providers and may need referrals for specialists. PromiseCare Medical Group accepts many Medicare Advantage plans in addition to Original Medicare.

Q: What happens if I don’t enroll in Medicare Part B when I turn 65?

A: If you don’t have creditable coverage from an employer, delaying Part B enrollment results in a late enrollment penalty of 10% of the monthly premium for each full 12-month period you were eligible but not enrolled. This penalty continues for as long as you have Part B. If you have employer coverage, you may be able to delay without penalty, but you should verify this is creditable coverage and enroll within 8 months of leaving the employer plan.

Q: Does Medicare cover dental work, eyeglasses, or hearing aids?

A: Original Medicare does not cover routine dental care, eyeglasses (except after cataract surgery), or hearing aids. Many Medicare Advantage plans include these benefits as supplemental coverage. Alternatively, you can purchase separate insurance for these services.

Q: How much will I pay out-of-pocket with Medicare?

A: Out-of-pocket costs vary significantly based on whether you have Original Medicare or Medicare Advantage, whether you add supplemental coverage, and your health needs. Original Medicare has no out-of-pocket maximum—you pay 20% coinsurance after deductibles for Part B services. Medicare Advantage plans have out-of-pocket maximums (capped at $9,250 for in-network services in 2026, though most plans set lower limits). Medigap policies can help cover Original Medicare’s cost-sharing.

Q: Does Medicare cover long-term nursing home care?

A: Medicare covers skilled nursing facility care for up to 100 days following a qualifying hospital stay when you need skilled services like physical therapy or wound care. Medicare does not cover long-term custodial care (assistance with daily living activities). Long-term care requires private payment, long-term care insurance, or Medicaid eligibility.

Q: Can I switch from Medicare Advantage back to Original Medicare?

A: Yes, you can switch from Medicare Advantage to Original Medicare during the Annual Enrollment Period (October 15-December 7) or the Medicare Advantage Open Enrollment Period (January 1-March 31). You may want to enroll in a Medigap policy and Part D plan when returning to Original Medicare. Note that Medigap enrollment may require medical underwriting unless you qualify for guaranteed issue rights.

Q: What is the Medicare Part D donut hole?

A: As of 2025, the Part D “donut hole” (coverage gap) has been eliminated as part of the Inflation Reduction Act reforms. Beneficiaries now have a $2,000 annual out-of-pocket cap. Once you spend $2,000 out-of-pocket on covered drugs, you pay nothing for the rest of the year. This is a significant improvement from the previous system.

Q: Does Medicare cover preventive services?

A: Yes, Medicare Part B covers many preventive services at no cost to you, including annual wellness visits, cancer screenings (mammograms, colonoscopies, prostate exams), cardiovascular screenings, diabetes screenings, bone density tests, and vaccinations (flu, pneumonia, COVID-19). These services have no copay or deductible when provided by a participating provider.

Q: How does Medicare work if I’m still working past 65?

A: If you have employer health coverage through your own or your spouse’s current employment, you can delay Medicare Part B enrollment without penalty as long as you enroll within 8 months of leaving the employer plan. You should still enroll in Part A if it’s premium-free. Work with your employer’s benefits department to understand how Medicare coordinates with your employer coverage.

Q: What should I bring to my first Medicare doctor visit?

A: Bring your Medicare card (red, white, and blue card or Medicare Advantage plan card), a list of current medications including dosages, a list of other providers you see, your medical history including surgeries and major illnesses, and any relevant medical records from previous providers. If this is your “Welcome to Medicare” visit, your doctor will conduct a comprehensive health assessment and create a personalized prevention plan.

Conclusion: Making Medicare Work for Your Health

Understanding what Medicare covers is the foundation for accessing the healthcare you need while managing costs effectively. From hospital care and physician services to preventive screenings and prescription drugs, Medicare provides comprehensive coverage designed to protect your health and financial security.

“Medicare is a valuable benefit, but it’s most effective when you understand how to use it,” concludes Dr. Curley. “Know what preventive services you’re entitled to at no cost, choose providers who accept your coverage, and don’t hesitate to ask questions about costs before receiving services.”

At PromiseCare Medical Group, serving the Inland Empire with 60+ primary care doctors and 400+ specialists, our physicians are committed to helping Medicare beneficiaries maximize their coverage and maintain optimal health. Whether you have Original Medicare, Medicare Advantage, or are transitioning to Medicare for the first time, PromiseCare provides accessible, coordinated, patient-centered care.

Key Takeaways:

For more information about Medicare coverage or to schedule an appointment with a PromiseCare Medical Group physician, call (951) 390-2840. During the Medicare Annual Enrollment Period (October 15-December 7), our team can help you understand which Medicare plans include PromiseCare in their networks.

Remember: Your health deserves a check-in. Take advantage of Medicare’s comprehensive coverage, stay current with preventive services, and partner with your healthcare providers to maintain your health and well-being for years to come.

About PromiseCare Medical Group

PromiseCare Medical Group is the Inland Empire’s largest Independent Physician Association, serving Medicare beneficiaries across Riverside County with 60+ primary care physicians, 400+ specialists, and 18 urgent care centers. Our physicians accept Medicare Advantage plans from Aetna, Alignment Healthcare, Anthem BlueCross, Brand New Day, Cigna, Health Net, Humana, SCAN Health Plan, United Healthcare, and Original Medicare.

Medical Disclaimer: This article is for informational purposes only and should not replace professional medical advice. Medicare coverage, benefits, and costs are subject to change annually. Always verify coverage details with Medicare.gov or your specific plan before making healthcare decisions. Consult with your physician regarding individual health concerns and treatment options.