Every Medicare beneficiary will begin their Medicare journey with “Original Medicare.” Original Medicare comprises of Medicare Part A and Medicare Part B. Part A provides hospital coverage.
There are a few ways to enroll. If you receive Social Security or Railroad Retirement benefits, you will be automatically enrolled on the first day of the month that you turn 65. You will receive a red, white, and blue Medicare card about three months before your birthday.
If you do not receive Railroad or Social Security benefits, you will need to enroll during your Initial Enrollment Period (IEP). Your IEP starts three months before your 65th birthday and ends three months after. If you miss this period, not only will you be charged a late enrollment penalty fee, but you won’t be able to enroll until the General Enrollment Period from January 1 through March 31.
To enroll for the first time, visit your local Social Security office, call Social Security (800-772-1213), or apply online. If you would rather enroll in a Medicare Advantage plan that covers more than Part A and Part B (and can sometimes be cheaper), you can enroll by contacting Medicare Plan Finder.
If you or your spouse paid Medicare taxes while working for over 39 quarters, or if you are eligible for retirement benefits from either Social Security or the Railroad Retirement Board, you will not have to pay a premium for Medicare Part A.
If you worked for 30 to 39 quarters of your life and paid Medicare taxes, your premium will be $240 per month in 2019. If you worked and paid Medicare taxes for less than 30 quarters of your life (or did not work at all), your premium will be $437 per month in 2019.*
Most beneficiaries will be responsible for a deductible and coinsurance for hospital and skilled nursing facility stays as well. See the charts below for what your other costs may be.
*If you do not enroll when you first become eligible, you will face up to a 10% premium increase for enrolling late.
In most cases, a doctor, pharmacist, or specialist will have to prescribe a certain treatment or service and provide proof that it is medically necessary before Medicare will cover it. Part A covers:
Part A hospital benefits are broken into 60-day periods. Everyone will start by paying the deductible, which is $1,364 in 2019. Once you've spent $1,364 on hospital services, your first 60 days in the hospital are completely covered. If you have to stay in the hospital for more than 60 days in a row, you will be responsible for coinsurance ($341 per day in 2019) for days 61-90. If you have to stay even longer, you will be responsible for coinsurance of $682 per day (2019) for days 91 through 150. Your Part A coverage will end after day 150.
Once you have been out of the hospital for 60 days, your “day count” will reset to 0. The next time you are admitted to a hospital, you will have 60 days of coverage once again.
Medicare also covers up to 190 days per lifetime for inpatient psychiatric hospital care. If you are already hospitalized when you enroll in Medicare, you can be reimbursed for up to 150 hospital days.
Your hospital coverage includes a semi-private room, hospital meals, nursing services, intensive care, drugs and medical supplies used during your stay, lab tests and x-rays, operating and recovery services, some blood transfusions, rehabilitation, and symptom management. It does NOT include non-medically necessary amenities like completely private hospital rooms, private nurses, and personal care items that hospitals may provide (shower supplies, TV, etc.).
In some cases, an overnight hospital stay does not automatically make you an inpatient. It is easy to assume that you are an “admitted” patient if you are brought to a private or semi-private room, but that may not be the case. If you’re getting emergency care, same-day surgery, x-rays, or lab tests, you may be considered an outpatient even if you stay overnight. For inpatient classification, a doctor has to purposely keep you there overnight and then formally admit you as such.
A doctor may keep you for several hours under observation before deciding to admit you. During those hours, you are considered an outpatient and will be covered under your Part B. Medicare Part A covers inpatient hospital stays, but Part B covers outpatient stays. If you need more care after leaving the hospital, you must have been an inpatient for at least three days for Medicare to cover a skilled nursing facility.
Medicare covers 100 days of skilled nursing care related to a hospital stay. Days 1-20 are covered completely, but days 21 through 100 require coinsurance of $170.50 per day (2019).
If you are hospitalized for any reason, you have 30 days from your hospitalization to enter a nursing facility (for the same condition) to have that care covered. You must require a level of care that cannot be provided at home or from your outpatient doctor. The nursing care must be ordered by a doctor and must be administered daily by a professional nurse or therapist. If your nursing facility determines that you no longer need care, your Medicare coverage for that service will end. Like hospital stays, benefit periods last for 60 days. If you leave the facility and are back home for at least 60 days, the next time you enter a facility your “day count” will reset to 0.
Nursing homes are required to keep up with your condition and your coverage and to report to Medicare whether or not you require Medicare-covered care. If you are denied Medicare coverage for your skilled nursing care and would like to appeal, you can file an appeal. The appeals process can take up to a year. If you need to file an appeal, be sure to gather all care-related information you have: your doctor’s information, and prescriptions you had, hospital and nursing facility filings, etc.
If you require long-term care in a nursing home, know that Original Medicare (Part A and Part B) does not cover “custodial” care. Custodial care refers to daily activities like bathing, dressing, eating, etc. Part A only covers skilled nursing. You may be able to find a Medicare Advantage plan that covers long-term nursing home care.
Part A hospice care is for people who are terminally ill and require counseling, prescriptions, medical equipment, and other supplies for comfortable living. Hospice care often takes place in the home with a family caregiver or private nurse. If you are terminally ill and qualify for hospice care, you and your caregiver or family member will work with a doctor to establish a care plan.
When you begin hospice care, you sign off that you are accepting palliative care instead of other Medicare-covered treatments. This means that you have been given six months or less to live and you are waiving treatment** attempts in favor of assistance to live comfortably for the next six months. Your coverage includes some doctor and nursing services, medical equipment, prescription drugs for pain and discomfort, homemaker services, some therapy services, counseling, etc. Hospice coverage does not include any further treatment to cure your illness or conditions and does not include room and board. You also cannot select a different doctor or service halfway through - you select a hospice care team in the beginning, and that’s what’s covered.*
There is no deductible for hospice care, but you will have to continue to pay your Part A and B premiums that you paid before. You may also be responsible for up to a $5 copay for any pain medications and for up to 5% of the Medicare-approved amount for inpatient respite care (for your caregivers). Your coverage will come in 90-day periods. After 90 days, your doctor will have to re-certify that you are terminally ill and that you still require hospice care.
*You are required to select your team of doctors and professionals from the beginning. You will have the opportunity to change doctors after your 90-day period ends.
**If you enter recovery during your hospice care and would like to switch from hospice back to regular treatments, you can do that at any time without losing coverage.
A combination of Medicare Part A and Part B can cover your home health costs if you are housebound and/or a doctor orders home health care for you. Medicare will not cover personal care services like bathing, dressing, and using the toilet, but it will cover home therapy services, certain home medical supplies and equipment, and skilled nursing services such as tube feedings, catheter changes, injections, etc. Medicare usually pays 100% for nursing and therapy services and 80% for medical equipment (leaving you responsible for 20% of the cost).
While Parts A and B are both parts of what is called “Original” or “Traditional” Medicare, they each operate a bit differently. Part A mainly covers hospital services and hospice, while Part B is your more comprehensive medical coverage. Part B covers your doctor services, lab tests and x-rays that your primary physician calls for, emergency transportation, durable medical equipment, etc. Additionally, while everyone will pay a premium for Part B, most people will receive premium-free Part A.
To get started on your enrollment process, give us a call! We can answer your questions and help you sort through your options. Set up a free appointment with one of our licensed and experienced agents in your area by calling 1-844-431-1832 or completing this form.
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