Medicare Part A Guide Medicare Part A is one of two parts of Original Medicare, the federal health care program for people over age 65 and those with certain disabilities. Part A, often referred to as “hospital insurance,” covers inpatient hospital care, home health care, skilled nursing facilities, and other services. Part B, known as “medical insurance,” covers services and supplies that are deemed medically necessary to treat a condition or illness. Most people will be eligible for premium-free coverage once they turn 65. If you are not eligible for premium-free coverage, you can still enroll at age 65, but you’ll pay a monthly premium for coverage.
What Medicare Part A covers Although your coverage will not apply to a simple visit to the doctor (that’s what Part B is for), it will cover your health care costs if you’re admitted to a hospital for at least two nights. Skilled nursing facility care, home health services, and hospice care are also covered under Part A. In general, it covers the following services:
Hospital care: If you are admitted to a hospital for at least two nights, it will cover the costs of a semi-private room, meals, regular nursing services, lab tests, and more related services.
Skilled nursing facility care: If you’ve been in the hospital for at least three days and your doctor certifies that you need follow-up care that you cannot receive at home, it will cover skilled nursing facility care.
Home health services: It covers certain home health services such as skilled nursing care or physical and speech therapy.
Hospice: If you have been diagnosed with a terminal illness and decide that that you want hospice care, it will cover those costs—provided the hospice care focuses on comfort and quality of life, as opposed to a cure.
Medicare Part A eligibility & costs Most people get no-cost coverage based on their work history, or their spouse’s work history. This is called “premium-free Part A.” If you are 65 or older, you are eligible for any of these reasons:
You receive retirement benefits from Social Security or the Railroad Retirement Board.
You are eligible for retirement benefits from Social Security or the Railroad Retirement Board but have not yet received these benefits
You or your spouse paid Medicare taxes while being employed by the government.
If you are younger than 65, you are eligible for premium-free coverage if any of the following applies to you:
You received Social Security or Railroad Retirement Board disability benefits for two years (24 months)
You have End-Stage Renal Disease (ESRD)
If you are not eligible, your premium will be $413 per month in 2017. Even those who get premium-free coverage may still have to pay additional costs, including a yearly inpatient deductible of $1,316. Other costs include the following:
Inpatient days 0 through 60: $0 coinsurance
Inpatient days 61 through 90: $329 coinsurance per day
Lifetime reserve days: $658 coinsurance per day (after 90 days of inpatient stay for up to 60 days)
Skilled nursing facility coinsurance: $164.50 coinsurance per day
These costs can add up, but Medicare Savings Plans may be able to provide financial assistance. These plans vary from state to state.
How and when to sign up for Part A If you live in the United States and have been receiving Social Security or Railroad Retirement Board benefits for at least four months before becoming eligible for Medicare, you will automatically be enrolled in both premium-free Part A and Part B. If you are not getting Social Security or Railroad Retirement Board benefits, you will not be automatically enrolled. To apply, you must contact Social Security. There are three enrollment periods that apply:
Initial Enrollment Period (IEP)
General Enrollment Period (GEP)
Special Enrollment Period (SEP) for the working aged, working disabled, and international volunteers
1. Initial Enrollment Period The Initial Enrollment Period (IEP) is the seven-month period that begins three months prior to your 65th birthday month, includes your birthday month, and ends three months after. If you’re younger than 65 and are eligible based on disability, your IEP begins three months before the 25th month you receive disability benefits, includes the 25th month, and ends three months after.
Your beginning coverage date depends on when you enroll during the IEP. If you enroll in the first three months, your coverage will begin the first month you are eligible for Medicare. If you enroll in any other month of the IEP, your coverage will be delayed. If you have a disability, you will automatically be enrolled in Part A and Part B after you have received disability benefits from Social Security for two years. If you do not buy Part A when you are first eligible, and you do not qualify for premium-free coverage, your monthly premium may go up by 10%. This late enrollment penalty means you’ll have to pay that higher premium for twice the number of years you could have had coverage but didn’t sign up. For example, if you waited two years to enroll, you could pay the 10% penalty for four years.
2. General Enrollment Period The General Enrollment Period (GEP) takes place each year from January 1 to March 31. Part A and Part B coverage begins on July 1 of that same year.
3. Special Enrollment Period Once your IEP ends, you may be able to sign up during a Special Enrollment Period (SEP). If you’re covered under a group health plan based on your current employment, you can sign up for Part A and/or Part B anytime as long as the following situations apply:
You or your spouse is employed
You are covered by a group health plan through the employer or union based on your work
If you or your spouse loses employer-based hospital insurance, or if you were volunteering in a foreign country, you are also eligible to enroll during an SEP. This SEP is an eight-month period with either of these begin dates:
The month after the employment has ended
The month after the group health plan insurance ends
If you qualify for an SEP, you typically do not have to pay the late-enrollment penalty.
Original Medicare assignment Original Medicare pays for health care services through a process called assignment. Assignment means your doctor, health-care provider, or medical product supplier will accept the Medicare-approved amount as full payment for services. Getting services and supplies from a doctor, provider, or supplier who accepts assignment can reduce your out-of-pocket costs. To fully benefit from Original Medicare assignment, you must be aware that:
Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. In some cases, they must accept assignment, for example when they have a participation agreement with Medicare and give you Medicare-covered services.
If a doctor, provider, or supplier accepts assignment, they agree to only charge you the Medicare deductible or coinsurance amount and will wait for Medicare to pay its share.
All doctors, providers, and suppliers that give you Medicare-covered services have to submit your claim to Medicare directly. They can't charge you for submitting the claim.
Medicare Part B Guide
Medicare Part B is one of the two parts of Original Medicare, the federal government-managed health care program for people over age 65 and those with certain disabilities. Part B, often referred to as “medical insurance,” covers services and supplies that are considered medically necessary to treat a condition or disease. This coverage contrasts with Part A “hospital insurance,” which covers hospital services, home health care, skilled nursing facilities, and certain other services. You’ll need to enroll in Medicare Part B coverage when you are initially eligible—the three months before and the three months after your 65th birthday—or you’ll have to pay a penalty to enroll later. There are exceptions for people who are still working; they can wait to enroll once their employer-based coverage ends. People who have certain disabilities will be automatically enrolled after receiving 24 months of Social Security benefits.
What Medicare Part B covers
Part B covers two general categories of care: medically necessary services and preventive care. Medically necessary services generally require you to pay a copay or coinsurance, but you get preventive services at no cost.
The government defines medically necessary services as “services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.” Essentially, they’re the things that help you recover from being sick or injured. These services include a variety of benefits, from wheelchairs to help you after knee surgery to a doctor’s office visit for the flu. Common medically necessary services include the following:
Doctor’s office visits
Durable medical equipment
Mental health and chemical dependency care
Outpatient (same-day) hospital stays
Home health care not associated with a hospital stay
Some services require prior authorization to be covered. Check with your health care provider to find out if prior authorization is required. Preventive care includes services that are designed to help you be well or keep you from getting sick. Medicare defines preventive services as “health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.” Here are some common preventive services covered by Part B Medicare:
Annual wellness visits
Cancer screening tests
HIV and STD screening and counseling
Tobacco cessation counseling
How much Medicare Part B costs
Medicare Part B has three cost types: premiums, deductibles, and coinsurance. These are the costs for 2017:
The standard Part B premium is $134 per month (or more, depending on income).
The Part B deductible is $183 per year.
The Part B coinsurance is 20 percent (of the amount Medicare approves)
How to get Medicare Part B
Your first—and most important—chance to enroll in Medicare Part B is just before you turn 65. You have the three months before and after your birthday month to enroll.
If you want Part B coverage, it’s important that you enroll during this initial period because if you don’t, you’ll have to wait until the next enrollment period, which is January through March. If you enroll at that time, your Part B coverage won’t begin until July 1. If you miss both of those initial Part B enrollment periods and wait more than a year, you may have to pay a penalty for signing up later. This penalty is permanently applied to your Part B premium. According to Herald & Review, penalties raised Part B premiums by 29 percent on average.
How to Enroll
You have a few options to sign up for Medicare Part B. Some people are automatically enrolled, like those already getting Social Security benefits, but many have to sign up themselves. You’ll be enrolled automatically and get your Medicare card three months before your 65th birthday if you meet one of these requirements:
You currently get Social Security benefits.
You are disabled and get disability benefits.
You have Amyotrophic Lateral Sclerosis (ALS).
You need to sign up for Part B coverage yourself if you fall under these conditions:
You don’t receive Social Security benefits.
You have End-Stage Renal Disease (ESRD).
You live in Puerto Rico.
If you need to sign up for Part B coverage, you can do so by one of these methods:
Online. Apply online on the Social Security Administration’s website.
In person. Apply in person at a Social Security office.
By phone. Call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778).
These are the costs for new plans purchased in 2017. If you have been receiving Medicare before 2017 and pay your premiums through Social Security benefits, you may pay less ($109 on average).
Medicare Part B premium
Unlike Part A coverage, which has no premium, Part B requires you to pay a monthly premium. This premium is deducted from your Social Security benefits, or, if you don’t receive Social Security, you will get a bill. The federal government sets the standard Part B premium each year, but how much you actually pay depends on your income. Many Part B enrollees don’t pay the standard premium amount; they pay an Income Related Monthly Adjusted Amount (IRMAA) instead. If you have Medicaid in addition to Medicare, your state Medicaid program will pay your Medicare Part B premium.
Medicare Part B deductible
A deductible is the amount you must pay for medically necessary services before Medicare begins paying. Each year, you must satisfy the Part B deductible. Once you’ve met the deductible, you’ll begin paying the Part B coinsurance.
Part B coinsurance
Coinsurance splits the cost of covered services between you and Medicare. For Part B coverage, you’ll pay 20 percent of the amount that Medicare approves once you meet the deductible. For example, if Medicare approves $50 per month for a wheelchair rental, you’ll pay $10 (20 percent) and Medicare will pay $40 (80 percent).
To find doctors and suppliers who accept assignment, visit Medicare.gov and select "Find a Doctor" or "Find Suppliers of Medical Equipment in Your Area." You can also call 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048), 24 hours a day, seven days a week.