No, Medicare benefits don't inherently "run out" for life, but your coverage can be lost if you stop paying premiums, move, or no longer qualify; and specific benefits (like Advantage plan extras or hospital trust funds) have limits, rules, or future funding concerns, though Medicare itself continues to pay for services as long as you're enrolled and eligible. Original Medicare is a lifetime benefit if you maintain it, but Medicare Advantage plans have yearly changes, and hospital trust funds face long-term solvency questions, meaning benefits might shift, but not stop entirely.
Original Medicare doesn't have an out-of-pocket maximum. Medicare Advantage plans do. And the out-of-pocket maximum is different between plans. If you're shopping for a Medicare Advantage plan, be sure you choose one with an out-of-pocket maximum that fits your budget.
Once your out-of-pocket expenses reach the threshold in a calendar year, Medicare will cover up to 80% of any further out-of-pocket expenses you have for out-of-hospital medical services that are subsidised under the MBS. A number of out-of-hospital services have a cap on how much Medicare will pay.
This means that Medicare benefits are not payable for any service where the service was rendered more than 1 year earlier than the date the claim was made with Medicare. For services rendered prior to 5 September 2025, this timeframe is up to 2 years from the date of service.
Once you meet your deductible, Part A will pay for days 1–60 that you are in the hospital. For days 61–90, you will pay a coinsurance for each day. If you need to stay in the hospital for longer than 90 days, you can use up to 60 lifetime reserve days. These are extra days of Medicare coverage for long hospital stays.
While there may not be lifetime caps on coverage, Medicare does have out-of-pocket costs and maximums. These costs can include deductibles, co-payments, and co-insurance. Understanding these costs and maximums can help you plan your healthcare expenses.
Under a Care Plan, you are entitled to a total of five Medicare-rebatable allied health visits per calendar year. These five visits can be used with one provider or shared among several, depending on your GP's recommendations. Care Plans can be set up at any time and remain active until you use all allocated visits.
There are some things Original Medicare won't cover. Generally, most vision, dental and hearing services are not covered by Medicare Parts A and B. Other services not covered by Medicare Parts A and B include: Routine physical exams.
Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided unless an exception applies.
A benefit period begins the day you're admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or SNF after one benefit period has ended, a new one begins.
To avoid the Medicare Levy Surcharge (MLS) in Australia, the primary method for high-income earners is to take out an appropriate private hospital insurance policy that covers you for the entire financial year (July 1 to June 30). This policy must have a low excess (under $750 for singles, $1500 for couples/families), not just 'extras' cover, and be in place before the financial year starts to avoid liability for any gaps, say Nanak Accountants and Qantas Insurance. Alternatively, you might be exempt if your income is below the threshold or you qualify for other specific Medicare levy exemptions, according to the ATO.
Plans have a yearly limit on what you pay for covered Medicare services (which may include different limits for in-network and out-of-network services). Once you reach your plan's limit, you'll pay nothing for covered services for the rest of the year.
Medicare does not cover the costs of:
Medicare Advantage plans are difficult to budget, and most plans have high out-of-pocket costs. This is the biggest reason they are bad for some people. With Original Medicare and supplemental Medicare insurance, you pay the bulk of your major medical costs upfront through monthly insurance premiums.
Starting in 2025, all Part D and Medicare Advantage plans will have a $2,000 annual cap on out-of-pocket prescription drug costs (this cap was previously $8,000). Once you hit this threshold, your costs for covered prescriptions will be $0 for the rest of the year.
Reaching a Medicare Safety Net threshold
Once you've reached the threshold, we'll pay the higher Medicare benefit for the rest of the calendar year. If you're a registered family or couple, you'll need to confirm who's in your registered Medicare Safety Net family before you can get the higher Medicare benefits.
All you have to do is provide proof that you pay Medicare Part B premiums. Each eligible active or retired member on a contract with Medicare Part A and Part B, including covered spouses, can get their own $800 reimbursement. Download our Medicare Reimbursement Account QuickStart Guide to learn more.
If Medicare denies payment: You're responsible for paying. However, since a claim was submitted, you can appeal to Medicare. If Medicare does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).
We'll need your bank account details to pay your Medicare benefit. Find out more about how to update your bank account details. We can't accept online claims for services over 2 years old.
Eliquis (generic name: Apixaban) alone racked up $18.3 billion in Medicare spending in 2023, nearly double the next drug, Ozempic. Alongside Xarelto, anticoagulants accounted for over $24 billion in 2023.
Drugs that promote fertility (i.e., Clomid, Gonal-f, Ovidrel®, Follistim®, etc.) Drugs for cosmetic purposes or hair growth (i.e., Propecia®, Renova®, Vaniqa®, etc.) Drugs for the relief of cough and cold symptoms (i.e., Phenergan w/Codeine, Robitussin® AC, Tanafed, Tessalon® Perle, etc.)
No, Medicare in the United States generally does not cover routine dental care (exams, cleanings, fillings, dentures, etc.) for adults, but it does cover certain dental services if they are part of a medically necessary hospital procedure, like jaw reconstruction, or for children under specific state programs like the Child Dental Benefits Schedule (CDBS) in Australia (which isn't US Medicare). For most adults, dental coverage in the U.S. comes from private insurance, dental-specific plans, or state programs for low-income individuals, while Medicare primarily handles medical care, not dental.
A GP Mental Health Care Plan does not expire.
It is an ongoing document. You don't need a new Care Plan just because it is a new calendar year or 12 months since the Care Plan was prepared.
Yes, Medicare covers physiotherapy for eligible Australians with chronic conditions or complex needs via a GP referral under the Chronic Disease Management (CDM) plan, offering rebates for up to 5 allied health sessions per year, but it's usually not completely free, requiring a gap payment for the physio's full fee, though the rebate significantly reduces costs. You need a GP to assess eligibility, create a care plan, and provide a referral for these subsidised sessions.
After 90 days, when Medicare Part A stops paying, you can use up to 60 lifetime reserve days, but you'll pay a steep copay. In 2026, it's $868 per day. If you have a Medicare Supplement plan and your hospital stay lasts longer than the 90 days covered by Medicare Part A, your supplement plan may kick in.