Common Questions about Original Medicare
What is Original Medicare?
Medicare is the federal health insurance program for:
- People 65 years of age and older.
- Some people under age 65 who have disabilities.
- People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
Medicare has several parts, including:
- Part A (Hospital Insurance)
- Part B (Medical Insurance)
- Part D (Prescription Drug Coverage)
Who is eligible for Medicare?
To be eligible for Medicare Part A and Part B, you must be a U.S. citizen or a permanent legal resident for at least five continuous years and have worked and paid Medicare taxes for at least 10 years. You must also meet at least one of the following criteria for Medicare eligibility:
- Be age 65 or older and eligible for Social Security
- Be permanently disabled and receive disability benefits for at least two years
- Have end-stage renal disease (ESRD) (permanent kidney failure that requires dialysis treatment or a kidney transplant)
- Have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS)
What does Medicare Part A cover?
Medicare Part A helps pay for:
- Care in hospitals as an inpatient
- Critical access hospitals (small facilities that give limited outpatient and inpatient services to people in rural areas)
- Skilled nursing facilities
- Hospice care
- Some home health care
What does Medicare Part B cover?
Medicare Part B (Medical Insurance) helps pay for:
- Doctors’ services
- Outpatient hospital care
- Certain medically necessary services, such as physical and occupational therapists and some home health care
Where can I find out if Medicare covers a service or supply I need?
Answers about what Medicare covers can be found in the “Find Out What Medicare Covers” section on the Medicare website: English | Español. This section of the website provides information about your health care benefits in the Original Medicare plan (sometimes referred to as “fee-for-service”). By searching this database, you will find:
- Some of the services and supplies the Original Medicare plan covers;
- The conditions that must be met for some services or supplies to be covered;
- How often services or supplies are covered (limits);
- How much you pay;
- Who you can contact if you have additional questions;
- Some of the services and supplies the Original Medicare plan does not currently cover.
Please note that some services and supplies are statutorily excluded from Medicare coverage. Congress would need to change Medicare in order for current excluded services and supplies to be covered.
What is the difference between Medicare and Medicaid?
Medicare is an insurance program. Medical bills are paid from trust funds that Medicare beneficiaries have paid into. Medicare primarily serves people over age 65, whatever their income. It also serves younger disabled people and individuals with End-Stage Renal Disease. Patients pay part of costs through deductibles for hospital and other costs. Monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services (CMS), an agency of the federal government.
Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. Medicaid serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines.
What will Medicare cost me?
Premium Amounts (for 2020, may change for 2021):
Depending on your eligibility, there are three possible premiums for Medicare Part A Hospital Insurance.
- Most people do not pay a monthly Part A premium because they or a spouse have 40 or more quarters of Medicare-covered employment.
- The Part A premium is $252 per month for people having 30 – 39 quarters of Medicare-covered employment.
- The Part A premium is $458 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
Part B: (Medical Insurance) Premium:
- $144.60 per month
Medicare Deductible and Co-insurance Amounts:
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible during the first 60 days and co-insurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay:
- $1,408 deductible
- A total of $0 for a hospital stay of 1 – 60 days.
- $352 per day for days 61 – 90 of a hospital stay.
- $704 per day for days 91 – 150 of a hospital stay (Lifetime Reserve Days).
- All costs for each day beyond 150 days.
Skilled Nursing Facility Co-insurance
- A total of $0 for a hospital stay of 1 – 20 days.
- $176 per day for days 21 – 100 each benefit period.
- Days 101 and beyond you pay all costs.
Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)
- $198 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $198 deductible).
What are my options for additional coverage?
If you have both Medicare Part A and Part B, you can sign up for Medigap insurance or a Medicare Advantage plan from a private provider. These options may offer coverage beyond what Medicare covers. While there are several options to consider, one place to begin a search would be with the Medicare Options Compare on the Medicare website: English | Español. Or, call 1-800-MEDICARE (1-800-633-4227). TTY users can call TTY, 24 hours a day, 7 days a week.
What is Medicare Advantage?
A Medicare Advantage plan serves as an alternative to Original Medicare (Part A Hospital Insurance and Part B Medical Insurance).
When you enroll in a Medicare Advantage plan (also called Medicare Part C), you receive your Part A and Part B benefits through a single plan sold by a private insurance company, like Elderplan.
Medicare Advantage plans usually have lower out-of-pocket costs and offer additional benefits that aren’t covered by Original Medicare, such as prescription drug coverage, hearing, dental, vision, wellness benefits, over-the-counter (OTC) coverage, transportation and much more!
Medicare Advantage plans have limits on how much you will pay every year for medical costs.
In most cases, you’ll need to use doctors who are in the plan’s network.
What is the difference between Medicare and Medicare Advantage?
People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage plan like Elderplan. Here’s a look at the differences between these two options.
Original Medicare is the traditional program offered directly through the federal government.
You receive a red, white, and blue card to show to your providers when receiving care and includes Part A (inpatient/hospital coverage) and Part B (outpatient/medical coverage). But it doesn’t provide certain benefits that you may need, like prescription drug coverage, long-term care, dental and eye exams and more.
Medicare Advantage plans usually have lower out-of- pocket costs and offer additional benefits that aren’t covered by Original Medicare, such as prescription drug coverage, hearing, dental, vision, wellness benefits, over-the-counter (OTC) coverage, transportation and much more!
Medicare Advantage plans have limits on how much you will pay every year for medical costs. In most cases, you’ll need to use doctors who are in the plan’s network.
How do I sign up for Original Medicare?
If you decide to enroll in Medicare during your Initial Enrollment Period, you can sign up for Parts A and/or B by:
- Visiting your local Social Security office
- Calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) – make sure to ask for a written receipt
- Mailing a signed and dated letter to Social Security that includes your name, Social Security number, and the date you would like to be enrolled in Medicare- make sure to use certified mail and request receipt
- Or, by applying online at ssa.gov – make sure to save your confirmation page
- If you are eligible for Railroad Retirement benefits, enroll in Medicare by calling the Railroad Retirement Board (RRB) or contacting your local RRB field office.
When can I sign up for Original Medicare?
You can enroll in Original Medicare when you age into Medicare at 65 years old, beginning three months prior to your 65th birthday, extending to three months after. You can also enroll during the Annual Enrollment Period which begins every year on October 15th and ends December 7th. Additionally, during Open Enrollment Period, January 1st – March 31st, you can disenroll from your current plan and switch to a different Medicare Advantage plan or return to original Medicare and purchase a Medicare supplement plan.
Outside of those times, there are special circumstances when certain life events occur that make you eligible to enroll. These chances to enroll are called Special Enrollment Periods and may include the following:
- You move to a new address
- You change jobs
- You lose your current coverage
- You qualify for extra help from the government
- Your current plan changes its contract with Medicare
- And others