Medicare Part A and Part B, often called Original Medicare, are managed by the federal government. Most individuals who receive Social Security benefits are automatically enrolled in Original Medicare while others need to apply for it as they approach their 65th birthday.
You can use any doctor, health care provider, hospital or other facility that accepts Medicare patients anywhere in the U.S. You will not need to choose a primary care doctor and, in most cases, will not need a referral to see a specialist.
Medicare Part A
Medicare Part A covers inpatient care provided in hospitals or skilled nursing facilities, home health care and hospice care for the terminally ill.
You usually don’t pay a monthly premium for Part A if you or your spouse paid Medicare taxes while working for a specific amount of time. If you aren’t eligible for premium-free Part, you may be able to buy Part A.
Once you meet your Part A deductible, set annually by the federal government, it helps with your covered medical costs.
A copays may apply to specific services, such as extended stays in a hospital or skilled nursing facility. When receiving hospice care, you pay a small copay per prescription for outpatient drugs for pain and symptom management.
Inpatient hospital care lasting between 61 and 90 days for each benefit period.
- Inpatient mental health care lasting between 61 and 90 days for each benefit period.
- Skilled nursing care lasting between 21 and 100 days of each benefit period.
Coinsurance may apply for a limited number of additional days.
Part A coverage and costs are based on benefit periods. A benefit period begins the day you’re admitted to the hospital and ends when you’ve been out for 60 consecutive days. The following coverage restrictions apply to Medicare Part A:
- Inpatient hospital care is limited to 90 days total per benefit period
- Inpatient mental care is limited to 90 days total per benefit period
- Skilled nursing care is limited to 100 days total per benefit period
For each type of care, you can receive coverage for 60 additional days throughout your lifetime – known as “lifetime reserve days.”
Medicare Part B
Medicare Part B covers doctor visits, outpatient care, home health services, durable medical equipment, mental health services, and other medical services. Part B also covers many preventive services like wellness visits, flu shots and mammograms for women.
Medicare Part B has a monthly premium that is based on when you enroll and your annual household income. Part B premiums are typically paid through Social Security withholdings. Penalties for late enrollment may apply.
You must first meet the annual deductible, set by the federal government, before Part B helps with your medical costs.
A copay may apply to specific services, such as those you receive in an outpatient hospital.
You will pay 20% of the Medicare-approved amount for most covered services after you pay the annual deductible, with no annual out-of-pocket maximum.
After you meet your deductible for the year, you typically pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy and durable medical equipment. There is not an out-of-pocket maximum.
Part B premiums, standard deductibles and cost share amounts generally change annually on January 1st. Under Medicare Part B, there are annual limits on services for physical therapy, occupational therapy, and speech language therapy.
Not covered by Original Medicare:
- Dental exams, most dental care, or dentures
- Routine eye exams, eyeglasses, or contacts
- Hearing aids or related exams and services
- Most care while traveling outside the United States
- Help with bathing, dressing, eating, etc. (custodial care)
- Most chiropractic services
- Routine foot care
- Prescription drugs
U.S. citizens or permanent legal residents who have resided in the United States for five continuous years, including the five years prior to applying for Medicare.
You must also meet one of the following:
- Age 65 years and older and eligible to receive Social Security or Railroad Retirement Board benefits
- Under age 65 years, permanently disabled and have received Social Security disability benefits for at least two years
- Any age diagnosed with End-Stage Renal Disease (ESRD) or lateral sclerosis (ALS).
The Initial Enrollment Period (IEP) is a limited window of time when you can enroll in Part A and Part B (Original Medicare) when you are first eligible. You can also enroll in other coverage options such as Medicare Advantage, Medicare Supplement or Medicare Part D (Prescription Drug) if you are already enrolled in Original Medicare.
When you are first eligible, your IEP for Medicare Part A and Part B is a seven-month window starting three months before you turn age 65 and ends three months after the month you turn 65. If you are under age 65 and have an eligible disability, your IEP begins the 22nd month after you began receiving Social Security benefits and continues until the 28th month after you began receiving benefits.
You may be automatically enrolled if you are receiving Social Security or Railroad Retirement Board benefits during your IEP. If you are under 65 with an eligible disability, you will automatically be enrolled. You will receive your Medicare card in the mail three months before your 65th birthday or the 25th month of your eligible disability.
If you’re not automatically enrolled, you need to sign up for Medicare when you first become eligible by contacting the U.S. Social Security Administration.
Penalties may apply for late enrollment, so it is important to know when your personal enrollment windows are. If you miss your Initial Enrollment Period, you will need to manually apply for Medicare Parts A and B.
When you enroll in Medicare Part A and Part B, you can also enroll in a Medicare Prescription Drug (Part D) and a Medicare Supplement plan. Alternatively, you can choose a Medicare Advantage (Part C) plan through a private insurer that covers all Part A and Part B services and typically includes Medicare Prescription Drug coverage.
October 15 through December 7
Provides an annual opportunity to review, and if necessary, make enrollment changes to your Medicare coverage.
During AEP, you might:
- Join a Medicare Advantage (Part C) plan
- Discontinue your Medicare Advantage coverage and return to Original Medicare
- Change from one Medicare Advantage plan to another
- Change your Prescription Drug Coverage (Part D) plan if you are in Original Medicare or have a Medicare Supplement plan
January 1 through March 31
Provides an opportunity to enroll in Medicare Part A and/or Part B. If you enroll in Medicare during GEP, your coverage starts July 1.
During GEP, you might:
- Sign up for Original Medicare if you weren’t automatically enrolled and missed your IEP
- Enroll in Part B if you had opted out of automatic enrollment, didn’t enroll, or dropped your coverage
- Change from a Medicare Advantage plan to another plan or switch back to Original Medicare one time.
Special enrollment periods apply for certain situations when you enroll in Medicare or other Medicare options outside of the IEP or AEP. For example, you are working past age 65 and your coverage through your employer terminates, you may be eligible for an SEP.
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