Original Medicare Coverage Made Simple

Medicare is a combination of many different medical insurance plans provided by the federal government to U.S. citizens who are 65 years and older. Because there are several Medicare plans to choose from, selecting a plan that is right for you can sometimes be confusing.

Original Medicare has four parts and each part addresses a different health care need. The four parts are: A, B, C and D. The vast majority of people enroll in Original Medicare, Parts A and B, because they offer the most services, but you can enroll in as many or as few parts as you choose.

Who is Eligible?

One of the great things about Medicare is that most people are automatically enrolled once they become 65 years old. If you are not automatically enrolled, you can join through your local Social Security office. If you are 65 or older, but not eligible for social security benefits either because you are still working or you don’t qualify, you may have to pay a monthly fee to have Medicare Part A.

You are also eligible for Medicare if you are disabled or have permanent kidney failure. The monthly cost of Medicare is based on income, so premiums vary widely.

What is Medicare Part A?

Medicare Part A is the most widely known plan and is sometimes called the “hospital insurance.” That’s because it covers stays in the hospital and skilled nursing facilities as well as hospice care. However, it will only cover inpatient hospital stays. Inpatients are formally admitted to the hospital by a doctor’s order.

Medicare Part A will cover your stay in a skilled nursing facility if you have three consecutive days in the hospital that is formally ordered by a doctor. It’s important to note that the healthcare services you request have to be approved and must be rendered in an approved facility.

The following coverages are included in Medicare Part A:

• Hospital stays if your doctor formally admits you
• Skilled nursing facility stays after three days in a hospital ordered by your doctor
• Wheelchairs and walkers
• Hospice care
• Home healthcare services if you’re unable to get to a hospital or skilled nursing facility
• The cost of blood for blood transfusions

Cost of Medicare Part A

Your costs for Medicare Part A depend on your income. The good news is that many people don’t have to pay a premium for Part A. Those costs were already paid by you in the form of Medicare tax deductions from your paycheck when you were working.

However, Part A isn’t totally free. You may have to pay a deductible each year before Medicare begins making payments. In many instances, Medicare charges a deductible every time you are admitted into the hospital. 

For Medicare Part A, you pay:

• A deductible each year. This is how much you have to spend before Medicare starts to pay its part.
• Coinsurance. This is the part of the costs for hospital care you may be required to pay after you’ve met your deductible. 
• If you or your spouse receives social security benefits, you don’t have to pay a monthly fee to have Part A and will be automatically enrolled.
• If you or your spouse don’t receive social security benefits, either because you are still working or because you don’t qualify, you will need to join Medicare Part A through your local social security office. You will have to pay a monthly fee to have Part A if you are not eligible for social security benefits.

What is Medicare Part B?

Medicare Part B covers a wide range of services and preventive care such as doctor’s visits, tests and screenings, ambulance transportation, medical equipment and other services. It also covers some medical supplies and drugs, flu and hepatitis vaccinations, diabetes supplies and some eyeglass prescriptions

Cost of Medicare Part B

Since Part B involves a monthly premium, you should consider waiting a while before signing up for Part B if you are still working and have insurance through your job or are covered by your spouse’s health plan. However, it’s important to note that if you don’t have other insurance and don’t sign up for Part B when you first enroll in Medicare, you will probably have to pay a higher monthly premium. You may also have to pay an annual deductible as well as 20 percent of bills for doctor visits and other outpatient services.

If you visit a doctor that accepts Medicare, some healthcare services will be covered under Medicare Part B at no additional cost to you. You will have to pay out of pocket for any services not included in what is covered by Medicare. If you visit a doctor who does not accept Medicare-approved amounts for services, you will pay more for a doctor’s visit and care.

For Medicare Part B, you pay:

• A monthly fee
• A deductible, which is a set amount you pay each year before Medicare starts paying for any of your care
• Twenty percent of the Medicare-approved amount for some types of care. These are doctor’s appointments, physical therapy, diabetes supplies, durable medical equipment like commode chairs, wheelchairs, and other care. You have to meet your deductible first and then pay 20% of the services you receive.

What is Medicare Part C — Medicare Advantage?

Medicare Part C, also known as Medicare Advantage plans, provide additional healthcare services and hospital care coverage for additional costs. The plans are approved by Medicare and fill in the-gaps for those services and care. People with Medicare Part C must already be enrolled in Medicare Part A and Part B.

Under Medicare Advantage plans, prescription drug coverage, dental and vision coverage, and other benefits are provided. You will pay a premium for these plans and the cost will depend on the type of plan you select.

Beginning this year, Medicare Advantage plans will cover things like transportation to a doctor’s appointment for someone with diabetes or a cooking class to improve their diet. For someone with heart disease, the plan could provide fruits and vegetables that are good for the heart. The plan could cover home air cleaners or carpet to remove the irritants that often trigger attacks in asthma sufferers. 

Also beginning this year, Medical Advantage plans may pay for improvements to a member’s home, such as permanent ramps or wider hallways and doors to accommodate wheelchairs.

With the Medicare Advantage plans, you are required to see doctors within a network or copayments, or other fees may apply.

What is a Medicare Supplement? 

Medicare Supplement insurance, also known as Medigap, works with the Original Medicare coverage to help fill in some of the healthcare coverage gaps. The Medicare Supplement plans may pay for certain costs that Original Medicare doesn’t cover including co-payments, deductibles, and emergency overseas health coverage.

You must be 65 and over and be enrolled in Original Medicare Part A and B in order to qualify for Medigap coverage. If you opted for a Medicare Advantage health plan, also known as Part C, you cannot buy a Medigap policy. Although you do have out-of-pocket expenses with Medicare Advantage, they are typically not as great as with Original Medicare.

You can enroll in a Medicare Supplement plan during your Medigap Open Enrollment Period. This is the six-month period that starts on the first day of the month that you are 65 or older and enrolled in Medicare Part B.

What is Medicare Part D?

Medicare Part D is a prescription drug benefit. The insurance companies that offer a Part D plan decide which drugs the plan will cover and what the drugs will cost. Anyone on Medicare with either Part A or Part B is entitled to Part D regardless of income. No physical exam is required, and you cannot be denied for health reasons or because you already use prescription drugs.

To get Medicare Part D, you must enroll in one of the private insurance plans that Medicare has approved to provide a prescription drug benefit.

You must pay a monthly fee to get Medicare Part D prescription drug coverage. This is in addition to the monthly fees you pay for Part B if you have it. If you don’t need any prescription drugs right now, enrolling in the Part D plan with the lowest premium in your area ensures that you have coverage if you suddenly need it, but at the least cost.

To learn more about Medicare, head over to Medicare.gov. To learn about Medicare Advantage, Supplement, and Prescription Drug plans, request a free quote.