BASICS OF ORIGINAL MEDICARE (PART A AND PART B)
The details of Medicare can be complicated, but you can get a good feel for the basics by reviewing the information below. For additional detailed information contact the sources noted throughout the various sections.
There are two ways to get Medicare:
One is Original Medicare (referred to as Parts A and B) and the other is Medicare Advantage (Part C). They cover the same basic services, but they work differently. Original Medicare (Parts A and B) pays fees for your care directly to providers you visit. Medicare Advantage (Part C) plans are operated by private companies approved by Medicare. Medicare pays these companies a fixed fee for your care and then the company handles its own payments to providers.
If you choose to go with Original Medicare Parts A and B then you next have to decide whether or not to buy a Medicare supplement policy, also known as a Medigap policy and then finally whether you want to add a (Part D) stand-alone drug plan.
There are a number of additional important factors that go into making all these decisions and you will ultimately have to do some detailed analysis and comparison to find the plan or plans that suite you best.
Original Medicare Part A and Part B doesn't cover all of the costs
Cost sharing is an important component of most health plans. The basic premise behind it is that if you pay some of the cost of the health care you use, you will use it more carefully and you’ll be encouraged to do things that help keep you healthy and that may reduce your need for medical care.
Original Medicare (Parts A and B) doesn't cover all of the costs of the services you use and your out of pocket costs (also known as cost sharing) can be significant. Understanding how Medicare shares costs is a big part of choosing the right Medicare plan for you. There are essentially four ways that you will pay your share of costs: deductible, copayment, coinsurance and premium. These words have special meanings and understanding how they impact you is vital.
- Deductible — The amount you must pay for health care or prescriptions, before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
- Copayment — An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription a copayment is usually a set amount, rather than a percentage. For example, you might pay a copayment of $15 or $25 for a doctor’s visit or prescription.
- Coinsurance — An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, most services under Medicare (Part B) are paid 80% by Medicare and 20 % by you.)
- Premium — The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.
In these next sections we will look at what Original Medicare pays towards your Part A (Hospital Insurance) and Part B (Medicare Insurance) services and what your share of the costs are. After reviewing those sections it is recommended that you click on the tabs of this site and view information on Medicare Supplements, Medicare Advantage Part (C) and Prescription Drug Plan Coverage Part (D) to round out your basic understanding of how the pieces fit together.
Medicare Part A an Overview
Medicare Part A insurance helps pay for “medically necessary” care (care for an illness or medical condition) that involves an inpatient stay in the hospital. Part A also helps pay for a stay in a skilled nursing facility as a follow-up to a hospital stay, hospice care for the terminally ill and some skilled home health care for the homebound. Part A also helps pay for some blood transfusions.
You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working. This is sometimes called premium-free Part A.
You can choose any qualified provider in the United States who has been accepted by Medicare and who is accepting new patients. Because Part A offers the same benefits throughout the United States, you are not limited to a particular state or region for your care.
Medicare Part A (Hospital Insurance) What’s Covered
Hospital Stays (Inpatient)
Medicare covers semi-private rooms, meals, surgical procedures, lab services, diagnostic services general nursing, and drugs as part of your inpatient treatment, and other hospital services and supplies. This includes care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, inpatient care as part of a qualifying clinical research study, and mental health care.
This doesn’t include private-duty nursing, a television or phone in your room (if there’s a separate charge for these items), or personal care items, like razors or slipper socks. It also doesn’t include a private room, unless medically necessary. If you have Part B, it covers the doctor’s services you get while you’re in a hospital. You costs while in the hospital consist of the following:
- You pay a deductible of $1484.00 (2021) but no co-payment for days 1–60 each benefit period.
- You pay a co-payment of $371.00 (2021) for days 61–90 each benefit period.
- You pay a co-payment of $742.00 (2021) per “lifetime reserve day” after day 90 each benefit period (up to 60 days over your lifetime)
- You pay all costs for each day after the lifetime reserve days.
- Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
A benefit period is the way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. 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 a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.
Important Note: Staying overnight in a hospital doesn’t always mean you’re an inpatient. You’re considered an inpatient the day a doctor formally admits you to a hospital with a doctor’s order. Always ask if you’re an inpatient or an outpatient since it affects what you pay and whether you’ll qualify for Part A coverage in a skilled nursing facility. For more information, visit www.medicare.gov/publications to view the fact sheet “Are You a Hospital Inpatient or Outpatient’. You can also call 1 800 MEDICARE (1 800 633 4227) to find out if a copy can be mailed to you. TTY users should call 1-877-486-2048.
Skilled Nursing Facility Care
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services and supplies after a 3-day minimum medically necessary inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day you’re formally admitted with a doctor’s order and doesn’t include the day you’re discharged. To qualify for care in a skilled nursing facility, your doctor must certify that you need daily skilled care like intravenous injections or physical therapy. Medicare doesn’t cover long-term care or custodial care.
- You pay nothing for the first 20 days each benefit period.
- You pay a co-payment of $185.50 (2021) per day for days 21-100.
- You pay all costs for each day after day 100 in a benefit period.
Religious Non-Medical Health Care Institution (Inpatient Care)
Medicare will only cover the non medical, non-religious health care items and services (like room and board) in this type of facility if you qualify for hospital or skilled nursing facility care, but medical care isn’t in agreement with your religious beliefs. Only non medical items and services that don’t require a doctor’s order or prescription, like un-medicated wound dressings or use of a simple walker during your stay, are available. Medicare doesn’t cover the religious portion of care.
To qualify for hospice care, your doctor must certify that you’re terminally ill and expected to live 6 months or less. If you’re already getting hospice care, a hospice doctor or nurse practitioner will need to see you about 6 months after you enter hospice to certify that you’re still terminally ill. Coverage includes drugs for pain relief and symptom management; medical, nursing, and social services; certain durable medical equipment; and other covered services, as well as services Medicare usually doesn’t cover, like spiritual and grief counseling. A Medicare-approved hospice usually gives hospice care in your home or other facility where you live, like a nursing home.
Hospice care doesn’t pay for your stay in a facility (room and board) unless the hospice medical team determines that you need short term inpatient stays for pain and symptom management that can’t be addressed at home. These stays must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility which contracts with the hospice. Medicare also covers inpatient respite care which is care you get in a Medicare-approved facility so that your usual caregiver can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness. You can continue to get hospice care as long as the hospice medical director or hospice doctor re-certifies that you’re terminally ill.
- You pay nothing for hospice care
- You pay a co-payment of up to $5 per prescription for outpatient prescription drugs (2021) for pain symptom management
- You pay 5% (2021) of the Medicare-approved amount for inpatient respite care.
Home Health Services
Medicare covers medically-necessary part-time or intermittent skilled nursing care, and/ or physical therapy, speech-language pathology services, and/or services for people with a continuing need for occupational therapy. A doctor enrolled in Medicare, or certain health care providers who work with the doctor, must see you face-to-face before the doctor can certify that you need home health services. That doctor must order your care and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part time or intermittent home health aide services, and medical supplies for use at home. You must be home-bound, which means leaving home is a major effort.
- You pay nothing for covered home health care services
- You pay 20% (2021) of the Medicare-approved amount for durable medical equipment (DME).
If the hospital gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.
Medicare Part B Overview
Medicare Part B insurance helps pay for a variety of medically necessary care—that is, care for an illness or medical condition. This includes services like doctor’s office visits, care in hospitals and clinics when you are not admitted for an inpatient stay, durable medical equipment, laboratory tests and some diagnostic screenings, and some skilled nursing care at home, if you’re home-bound.
Part B also covers most doctor services you receive as a hospital inpatient, although other hospital services are covered by Part A. Part B is voluntary, but most people sign up when they first become eligible. In 2021, Medicare Part B is making it easier to get preventive care. It will now cover an annual wellness exam plus additional preventive screenings at no cost to you.
Most people must pay a Part B premium each month and most people will pay the standard premium amount which is $148.50 (2021). However, if you’re modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain amount, you may pay more. Your modified adjusted gross income is your adjusted gross income. Some people with limited incomes may pay less. In addition Medicare Part B has an annual deductible of $203 (2021). You must pay this deductible before Medicare Part B starts to pay its share of your costs.
For some people the Medicare premiums, deductibles and coinsurance costs can be reduced or waived if they qualify for one of the four Medicare Savings Programs available in New York. These four Medicare Savings Programs include:
- Qualified Medicare Beneficiary (QMB) Program- pays your Part A&B premiums, deductibles nd coinsurance
- Specified Low-Income Medicare Beneficiary (SLIMB) Program- pays your Part B premium
- Qualifying Individual (QI) Program- pays your Part B premium
- Qualified Disabled and Working Individuals (QDWI) Program – pays your Part A premium
It is also very important to note that if you qualify for a QMB, SLMB, or QI program, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage. Extra Help is a Federal Government program that can significantly reduce your prescription drug costs. These combined programs can provide you with significant savings on your Medicare costs, so be sure to investigate whether or not you qualify for any of these programs.
By Clicking on the hyperlinks on this page you can get an Application for the Medicare Savings Program, the phone numbers and addresses of your local Department of Social Services and get information on how whether or not you qualify for the Medicare Savings Program.
The contact information for people living in Nassau and Suffolk Counties is given below:
Medicare Part B Covered Services
Nassau County DSS, 60 Charles Lindbergh Blvd., Uniondale, New York 11553-3656, (516) 227-7474 or (516) 227-8519
Suffolk County DSS, 3085 Veterans Memorial Highway, Ronkonkoma, New York 11779-8900, (631) 854-9700, Deer Park (631) 854-6600, Hauppauge (631) 853-8714
What’s covered and what you pay for Medicare Part B Services
Most doctors agree to take Medicare’s payment of the Medicare-approved amount as full payment. This is called “accepting assignment.” If your doctor accepts assignment, your share is limited to 20% of the Medicare-approved amount.
Some doctors, though, do not agree to take the Medicare-approved amount as full payment. In these instances Medicare reduces the Medicare-approved amount for these doctors by 5%, but allows these doctors to charge you up to an additional 15% of the reduced Medicare-approved amount. (This ceiling is less than 15% in some states, and some states prohibit additional charges completely.) This is called “balance billing” or “excess charges”.
Under Original Medicare, if the Part B deductible applies you must pay all costs until you meet the yearly Part B deductible before Medicare begins to pay its share. Then, after your deductible is met, you typically pay 20% of the Medicare-approved amount of the service, if the doctor or other health care provider accepts assignment. There’s no yearly limit for what you pay out-of-pocket for Part B services.
You pay nothing for most preventive services if you get the services from a doctor or other qualified health care provider who accepts assignment. However, for some preventive services, you may have to pay coinsurance for the office visit or other copay's or deductibles when you get these services. Please note that Preventive Services on the list below are identified with the word –Preventive Services next to the benefit.
To find out if Medicare covers a Part B service not on the list below, visit www.medicare.gov/coverage or call 1 800 MEDICARE (1 800 633 4227). TTY users should call 1 877 486 2048. For more details about whether you are covered for Medicare Part B covered services, visit www.medicare.gov/publications to view the booklet “Your Medicare Benefits.” Call 1 800 MEDICARE to find out if a copy can be mailed to you.
Medicare Part B (Medical Insurance) Quick Reference List of Services
- Abdominal Aortic Aneurysm Screening – Preventive Service
- Alcohol Misuse Counseling - Preventive Service
- Ambulance Services
- Ambulatory Surgical Centers
- Bone Mass Measurement (bone density) - Preventive Service
- Breast Cancer Screening (mammograms) - Preventive Service
- Cardiac Rehabilitation
- Cardiovascular Disease (behavioral therapy) - Preventive Service
- Cardiovascular Screenings - Preventive Service
- Cervical and Vaginal Cancer Screening - Preventive Service
- Chiropractic Services (limited)
- Clinical Research Studies
- Colorectal Cancer Screenings - Preventive Service
- Defibrillator (implantable automatic)
- Depression Screening - Preventive Service
- Diabetes Screenings - Preventive Service
- Diabetes Self-Management Training - Preventive Service
- Diabetes Supplies
- Doctor and other Health Care Provider Services
- Durable Medical Equipment (DME) (like walkers)
- EKG (electrocardiogram) Screening
- Emergency Department Services
- Eyeglasses (limited)
- Federally-Qualified Health Center Services
- Flu Shots- Preventive Service
- Foot Exams and Treatment
- Glaucoma Tests - Preventive Service.
- Hearing and Balance Exams
- Hepatitis B Shots - Preventive Service
- HIV Screening - Preventive Screening
- Home Health Services
- Kidney Dialysis Services and Supplies
- Kidney Disease Education Services
- Laboratory Services
- Medical Nutrition Therapy Services - Preventive Screening
- Mental Health Care (outpatient)
- Obesity Screening and Counseling - Preventive Screening
- Occupational Therapy
- Outpatient Hospital Services
- Outpatient Medical and Surgical Services and Supplies
- Physical Therapy
- Pneumococcal Shot - Preventive Screening
- Prescription Drugs (limited)
- Prostate Cancer Screenings - Preventive Screening
- Prosthetic/Orthotic items
- Pulmonary Rehabilitation
- Rural Health Clinic Services
- Second Surgical Opinions
- Sexually Transmitted Infections Screening and Counseling - Preventive Screening
- Speech-Language Pathology Services
- Surgical Dressing Services
- Tests (other than lab tests)
- Tobacco Use Cessation Counseling - Preventive Screening
- Transplants and Immunosuppressive Drugs
- Travel (Health care needed when traveling outside the United States)
- Urgently-Needed Care
- Welcome to Medicare” Preventive Visit - Preventive Screening
- Yearly “Wellness” Visit- Preventive Screening
For more details about Medicare Part B covered services view the booklet Your Medicare Benefits or visit www.medicare.gov/publications.
To find out if Medicare covers a Part B service not on the list above, please visit http://www.medicare.gov/coverage, or call 1 800 MEDICARE (1 800 633 4227). TTY users should call 1 877 486 2048.
What’s NOT covered by Part A & Part B?
Medicare doesn’t cover everything. If you need certain services that Medicare doesn’t cover, you’ll have to pay for them yourself unless:
- You have other insurance (or Medicaid) to cover the costs.
- You’re in a Medicare health plan that covers these services.
Some of the items and services that Medicare doesn’t cover include:
- Long-term care (also called custodial care).
- Routine dental or eye care.
- Cosmetic surgery.
- Hearing aids and exams for fitting them.
- Most care when travelling outside the United States
If you have Original Medicare, visit www.medicare.gov/coverage, or call 1 800 MEDICARE (1 800 633 4227) to find out if Medicare covers a service you need. TTY users should call 1 877 486 2048. If you’re in a Medicare health plan, contact your plan.