Original Medicare

The following information should answer many of your questions about original Medicare.

Also, please call me at (561) 559-7153 if you have any questions.

                           INDEX                                    

A. Medicare Part A
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM

4. INPATIENT HOSPITAL STAY (WHAT YOU PAY IN 2023)
a) Deductible
b) Coinsurance
c) Medicare Covers:
d) Benefit Period for In-Hospital Stay

5. SKILLED NURSING INSURANCE
a) ENROLLMENT

B. Medicare Part B
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM for Part B
4. DEDUCTIBLE
5. COINSURANCE
6. EXCESS CHARGES
7. ENROLLMENT

C. Medicare Part C (Medicare Advantage)
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE
4. PLAN RESTRICTIONS
5. ENROLLMENT

D. Medicare Part D (Medicare Prescription Drug Plan)
1. ELIGIBILITY
2. BENEFITS
3. PREMIUM / DEDUCTIBLE / CO-PAYMENT / COINSURANCE
4. ENROLLMENT
5. PRESCRIPTION DRUG PLAN STAGES

A. Medicare Part A

• Medicare Part A is the Hospital Insurance portion of Original Medicare. Original Medicare allows you to use ANY doctor, specialist, or hospital that accepts Medicare. There are no “networks” of hospitals to which you must adhere; as long as the provider accepts Medicare, you can use that provider or facility.  You do not need a referral.

When are you eligible for Medicare?

• You are 65 years or older, and
• You are a citizen or permanent resident of the United States who has lived in the US for at least five years.
• If you are not yet 65, you might also qualify for coverage if you have a disability or End-Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). You are entitled to Medicare after you get disability benefits from Social Security for 24 months.
• Your age is the main determining factor. You do NOT need to retire or receive Social Security benefits to be eligible for Medicare.
• Some Medicare beneficiaries are dual-eligible, i.e., qualified for both Medicare and Medicaid.

What does Part A cover?

• Inpatient hospital care (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
• Inpatient care in a skilled nursing facility (not custodial or long-term care)
• Hospice care services
• Home health care services

Is there a monthly premium for Part A

• Most people age 65 or older don’t have to pay a monthly payment (called a premium) for Part A because they or their spouses paid Medicare taxes while working 40 or more quarters of Medicare-covered employment.

a) DEDUCTIBLE

$1,676 for each benefit period

b) COINSURANCE

$419 per day for days 61-90 of a hospital stay

$838 per day for days 91 and beyond of a hospital stay up to 60 days over Lifetime Reserve Days

All costs for each day beyond reserve days

c) Medicare covers:

 Up to 90 days of inpatient hospital services in each benefit period

An additional 60 lifetime reserve days

d) Benefit Period for in-hospital stay

A benefit period begins when you are admitted to the hospital and ends when you have been out of the hospital for 60 days or have not received Medicare-covered care in a skilled nursing facility (SNF) or hospital for 60 consecutive days from your day of discharge.

Medicare provides 60 lifetime reserve days of inpatient hospital coverage following a 90-day stay in the hospital. These lifetime reserve days can only be used once. If you use all 60 lifetime days, Medicare will not renew them. Very few people remain in a hospital for 150 consecutive days. In the rare event this does occur, most Medicare Supplement policies would cover additional days

a) ENROLLMENT

• If you already get Social Security Benefits, you’ll be automatically enrolled in Medicare Parts A and B effective the first day of the month you turn 65. Your Medicare Card will be mailed to you about three months before your 65th birthday. Enrollment in Part B is optional. For example, if you work past 65 and have health insurance from your employer, you may not need Medicare Part B.
• If you are under 65 and disabled, you’ll be automatically enrolled after you get disability benefits from Social Security for 24 months. You will get your Medicare card in the mail three months before your 25th month of disability.
• Suppose you still need the Social Security benefits. In that case, you’ll need to apply for Medicare through Social Security three months before you turn 65 – at the start of the Initial Enrollment Period. The Initial Enrollment Period is a 7-month period that begins three months before you turn 65 or, in the case of disability, three months before your 25th month of disability.  You can sign up anytime during the Initial Enrollment Period.  However, waiting until you are 65 or later will delay your Medicare coverage.  Enrollment in Part B is optional.

NOTE: If you didn’t sign up for Medicare Part A or Part B during the Initial Enrollment Period, you may sign up during the next Open Enrollment Period.  This period runs from January 1 through March 31 of each year.  The coverage will start on July 1 of the year you sign up.  If you aren’t eligible for premium-free Part A and didn’t buy Part A when you were first eligible, your monthly premium may go up 10%.  You will have to pay the higher premium for twice how many years you could have had Part A but didn’t join.  You will also have to pay a higher Medicare Part B premium because you could have had Medicare Part B and didn’t take it.  The actual increase is 10% for each entire 12-month period that you were entitled to for Part B, and the penalty is as long as you have Part B.  You may avoid paying a higher premium if you are entitled to a Special Enrollment Period.

B. Medicare Part B

• Medicare Part B is a Medical Insurance portion (as compared to Part A being a Hospital Insurance portion) of Original Medicare and is optional. Original Medicare Part B allows you to use any doctor, specialist, or hospital that accepts Medicare. NOTE: Although most do, not all doctors or hospitals accept Medicare. There is no network of doctors that you have to use, and you never need a referral.  You are paying a separate amount for each service – fee for service.

Qualifications

• You are 65 years or older, and
• You are a citizen or permanent resident of the United States who has lived in the US for at least five years.
• If you are not yet 65, you might also qualify for coverage if you have a disability or End-Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). You are entitled to Medicare after you get disability benefits from Social Security for 24 months.
• Your age is the main determining factor. You do not need to retire or receive Social Security benefits to be eligible for Medicare.
• Many Medicare beneficiaries are dual-eligible, i.e., qualified for both Medicare and Medicaid.

Medicare Part B covers a portion of:

• Doctor and specialist services
• Outpatient hospital care
• Laboratory tests
• Outpatient physical therapy
• Outpatient speech therapy
• Certain home healthcare
• Certain ambulance services
• Specific medical equipment and supplies

Annual Part B Deductible

$257 calendar year 2025

• After you meet the Deductible, you pay 20% of the Medicare-approved amount for doctors’ visits.  There is no limit to your spending.

• For services rendered by non-participating providers, a physician may charge a maximum of 115% of the Medicare-approved amount.  This 15% overcharge is an Excess Charge, which you are responsible for.

• If you already get Social Security Benefits, you will be automatically enrolled in Medicare Part A and B effective the first day of the month you turn 65. Your Medicare Card will be mailed to you about three months before your 65th birthday. Enrollment in Part B is optional.

• If you are under 65 and disabled, you’ll be automatically enrolled after you get disability benefits from Social Security for 24 months. You will get your Medicare card in the mail three months before your 25th month of disability.
• Suppose you still need Social Security benefits. In that case, you will need to apply for Medicare through Social Security beginning three months before you turn 65 at the start of the Initial Enrollment Period.  The Initial Enrollment Period is a 7-month period that begins three months before you turn 65, or, in the case of disability, three months before your 25th month of disability.  You can sign up anytime during the Initial Enrollment Period.  However, your Medicare coverage will be delayed by waiting until you are 65 or later.  Enrollment in Part B is optional.
• If you didn’t sign up for Medicare Part A or Part B during the Initial Enrollment Period, you may sign up during the next General Enrollment Period.  This period runs from January 1 through March 31 of each year.  The coverage will start on July 1 of the year you sign up.  If you aren’t eligible for premium-free Part A and didn’t buy Part A when you were first eligible, your monthly premium may go up 10%. You must pay the higher premium for as many years as you should have had Part A but didn’t join.  You will have to pay a higher Medicare Part B premium because you could have Medicare Part B and didn’t take it.  The actual increase is 10% for each whole 12-month period that you were entitled to for Part B, and the penalty is as long as you have Part B.  You may avoid paying a higher premium if you are entitled to a Special Enrollment Period.

C. Medicare Part C (Medicare Advantage)

• Instead of enrolling or using the Original Medicare, you may enroll in a Medicare Part C – Medicare Advantage Plan. Private insurance companies offer these plans, and Medicare must approve them.  It is not a ‘fee for service’ as is Original Medicare.  Instead, Medicare pays a fixed monthly amount to insurance companies for the enrolled members regardless of whether or not members used the services.

When are you eligible for Medicare Part C?

• You have both Part A and Part B
• You live in the service area of the plan

What are the Medicare Advantage Plans Benefits

• Plans must enroll anyone eligible. The minimum benefits are offered to all members, regardless of age or health status.  Consequently, pre-existing health conditions cannot be considered, enrollment cannot be denied, and the premium cannot be increased because of the health conditions.
• It covers all services that Original Medicare covers (Part A and Part B), except hospice care. (Original Medicare covers hospice care even if you are in a Medicare Advantage Plan).
• May offer extra coverage, such as vision, hearing, dental, and health and wellness programs
• Can come with or without Prescription Drug Coverage (MA-PD)
• There are several types of plans available: HMO, PPO, PFFS, MSA, and SNP
• Plans have different rules for how you get services.  For some plans, you must stay “in-network” and get referrals from your primary care physician.  Emergencies are exceptions as no referrals are necessary, and services are available anywhere in the U.S.
• You are still a part of the Medicare system.  With a Medicare Advantage plan, private insurance administers the program and pays for your services.  If the private insurance company fails, you are guaranteed acceptance back into Original Medicare.

What are the Advantages?

Many Advantage Plans have zero premium. However, some plans charge a monthly premium in addition to the Part B premium (although others pay the Part B premium). There are additional charges for Prescription Drug Coverage (if applicable), and for Extra coverage (if applicable). The total cost may be higher or lower than you’ll pay under Original Medicare.

• Each plan can charge different out-of-pocket costs.  You usually pay co-payments for each visit or service.  The plan may also charge you a yearly deductible or any additional deductibles.
• Most Medicare Advantage Plans will offer a maximum out-of-pocket (a yearly limit to your health care covered expenses).

Restrictions?

• Medicare restricts when you can enter or leave a plan, i.e., for another Medicare Advantage Plan.  These restrictions change yearly, and changes can be made during Annual Enrollment Periods.

You can join, switch, or drop a Medicare Advantage Plan during:

• Initial Enrollment Period – a 7-month period that begins three months before you turn 65 or 3 months before your 25th month of disability.  The period includes the three months before, the month of, and the three months after the triggering event, such as ‘turning 65’.
• Annual Enrollment Period – between October 15 and December 7.  Your coverage will begin on January 1 of the following year.  You have the option of switching to another plan:
  •  Between Medicare Advantage plans,
  • From a Medicare Advantage plan to Original Medicare, or
  • From Original Medicare to Medicare Advantage plan.

Be careful when changing plans, as your Prescription Plan may be affected. It’s important when making any change that you are careful that the change is best for you as to coverage and cost.  This is where you should contact the MyHealthcareSeach@gmail.com agent for assistance.

• Medicare Advantage Disenrollment Period – between January 1 and March 31.  You can dis-enroll from your current Medicare Advantage plan but only return to Original Medicare.  You can also select a Part D Prescription Drug Coverage.
• Particular Election Period (SEP) – In certain situations, you may be eligible for a Special Election that allows you to change your coverage outside the enrollment periods described above. Examples of SEP are – you’ve moved out of the service area, you are qualified for Extra Help, you have both Medicare and Medicaid, etc.
• People who either have Medicare and Medicaid or qualify for Extra Help can switch plans every month.
• Typically, enrollment is on a calendar year basis, starting when your coverage begins.

Also, note that Part C plans have a contract with Medicare that governs minimum provisions.

D. Medicare Part D (Medicare Prescription Drug Plan)

There are two types of Medicare Part D plans.

• If you use Original Medicare (or Medicare Advantage Plan of PFFS/ MSA types), you may use a stand-alone Medicare Prescription Drug Plan (PDP). Using a prescription drug plan is optional. Private insurance companies approved by Medicare operate these prescription drug plans.
• Alternatively, if you are enrolled in a Medicare Advantage Plan that does not have prescription coverage, you may enroll in a Medicare Advantage Prescription Drug Plan (MA-PD).

You are eligible for a Medicare Prescription Drug Plan if enrolled in Medicare Part A and/or Part B.

Covers most types of prescription drugs (generic and brand names) with few exceptions.

• Part D adds drug coverage to Original Medicare as a separate insurance policy and is included in some Advantage Plans, i.e., HMO and PPO Plans, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
• Unlike Original Medicare, the Part D coverage is not standardized.  All plans must provide at least a standard level of coverage set by Medicare, but each plan can vary in cost and drugs covered.  Insurance companies decide which drugs they cover, at what level (tier), and whether or not to cover some.

Each plan can vary in cost and drugs covered.  The cost includes monthly premiums, yearly deductibles, and copayments or coinsurance.

• Most Medicare Drug plans have a coverage gap (sometimes called the ‘donut hole’). It means that after you and your plan spend a certain amount on prescriptions, you’ll need to pay higher out-of-pocket costs for all drug costs up to a specified limit. After reaching this limit, you will enter the catastrophic coverage you will have zero cost for covered prescriptions. Each year, the prescription plans start over.

When can you join, switch, or drop a Medicare Prescription Drug Plan (PDP):

• Initial Enrollment Period – a 7-month period that begins three months before you turn 65 or 3 months before your 25th month of disability.  The period includes the three months before, the month of, and the three months after the triggering event, such as ‘turning 65’.
• At Annual Enrollment Period – between October 15 and December 7.  Your coverage will begin on January 1 of the following year.
• In certain situations, you may be eligible for a Special Election Period (SEP) that allows you to change your coverage outside of the regular enrollment periods described above. Examples of SEP are – you’ve moved out of the service area, enrolled into the PACE plan, lost creditable prescription coverage, have both Medicare and Medicaid, etc.   SEP length is dependent on the event that triggered it.   For example, people who qualify for Extra Help have continuous SEP – they can change plans once a month.
• You don’t need to cancel the old plan when switching to a PDP. It will end automatically when the new plan begins.
• Typically, enrollment is on a calendar year basis. Starting January 1 when your coverage begins.
• Suppose you didn’t enroll in a Prescription Drug Plan when you were first eligible, and you go without Creditable Prescription Drug Coverage for 63 continuous days or more. In that case, you may have to pay a penalty if you decide to join later.  The penalty is 1% for each month you could have been enrolled but were not assuming you didn’t have the creditable coverage.  (Creditable Prescription Drug Coverage is prescription drug coverage that is at least ‘as good’ as standard Medicare Prescription Drug Coverage).
• Each PDP plan must provide its members the Annual Notice of Change every year.  Changes may include changes in drug tier structure as well as cost sharing.

There are four stages in PDP.  Coverage varies significantly among various carriers.  

• Yearly Deductible – some plans have a deductible that you pay before the plan starts to pay.
• Copayment/Coinsurance – For each covered prescription, you may have to pay an amount (co-payment) to receive the prescription.
• Coverage Gap (donut hole) – As of 2025, the Coverage Gap no longer exists. Once your out-of-pocket cost reaches $2,000, you’re in the Catastropic Coverage.
• Catastrophic Coverage – After reaching $2,000 out-of-pocket with covered prescriptions, your prescription costs for the remainder of the year will be zero cost.

Premiums for Part D coverage

• Monthly premium: The Part D monthly premium varies by plan (higher-income consumers may pay more).

Part D premiums by income

The chart below shows your estimated prescription drug plan monthly premium based on your income as reported on your IRS tax return. If your income is above a specific limit, you’ll pay an income-related monthly adjustment amount in addition to your plan premium. 

Income bracket premium adjustments for 2024 Medicare Part D IRMAA

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