Original Medicare (Parts A and B)

What do we mean by ‘Original’ Medicare?
Medicare Parts A and B, together often colloquially known as Original Medicare or ‘regular’ Medicare, are the direct government insurance most people think of when they think of Medicare. Together they provide hospitalization and medical services coverage, including doctor’s visits, screenings, emergency room care, surgery, medical supplies and equipment, home care, skilled nursing care, hospital inpatient costs and hospice care.

Who is eligible and how much does it cost?
Anyone 65 and older who has 40 coverages of coverage for Social Security Retirement Insurance can receive Medicare Part A (also know as Hospital Insurance) premium-free. Individuals without 40 quarters can receive premium-free coverage if they have a spouse with 40 quarters who is at least 62, or are a widow(er) of a Social Security covered worker. Those not eligible for premium-free Part A can buy-in for $413 (if they have less than 30 quarters), or $227 (if they have 30-39 quarters). Those individuals under age 65 who are disabled and have been on Social Security Disability Insurance for 24 months are also eligible for premium-free Part A.

Individuals eligible for Part A coverage (whether premium-free or paid, and whether based on retirement or disability insurance status) are also eligible to enroll in Part B. If the individual is eligible for premium-free Part A, they must enroll in Part A to be able to enroll in Part B. If the individual is not eligible for premium-free Part A, they can still enroll in Part B at the regular premium amounts.

Part B premiums are variable depending on whether the beneficiary receives Social Security benefits and whether they are considered a high-income earner.

If the individual received Social Security benefits and Medicare Part B premiums were deducted from them in 2016, the amount of their 2017 premium can be no more than the 2016 premium ($104.90) plus the amount of their 2017 cost-of-living adjustment (COLA). The average Part B premium for these individuals is around $109 in 2017. This provision does not apply to premiums with income related adjustments, premiums not deducted from Social Security benefits or paid privately, or those first receiving Social Security benefits in 2017.

For income related adjustments, the most-recently filed tax return available in January of the year is typically used (e.g. for premiums starting January 2017, income will be evaluated based on 2015 filings):

If your yearly income in 2015 (for what you pay in 2017) was You pay each month (in 2017)
File individual tax return File joint tax return File married & separate tax return
$85,000 or less $170,000 or less $85,000 or less $134.00
above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $187.50
above $107,000 up to $160,000 above $214,000 up to $320,000 Not applicable $267.90
above $160,000 up to $214,000 above $320,000 up to $428,000 above $85,000 and up to $129,000 $348.30
above $214,000 above $428,000 above $129,000 $428.60

What is covered?
For hospitalizations in 2017, Part A will pay 100% of inpatient costs for 60 days, after the deductible; 100% of skilled nursing care for 20 days after a 3-day hospital stay, and costs in excess of a $329 daily coinsurance for days 61-90; 100% of hospice care at home, in the hospital or nursing home for terminal patients; will pay for medically necessary home care following a 3-day minimum hospitalization or skilled nursing home stay; up to 3 pints of blood during a hospitalization or nursing home stay. After 90 days, individuals have 60 “lifetime reserve days” where they pay a $658 daily coinsurance. After these 60 reserve days are exhausted, Part A covers no additional costs until the next benefit period/diagnosis.

For doctor’s visits and other medical services, Part B pays 80% of approved charge for:

  • Physician fees
  • Medical equipment and supplies, including oxygen
  • Emergency room services
  • Outpatient surgery
  • Ambulance services
  • Limited podiatry and chiropractic care
  • Eyeglasses (lenses only after cataract surgery)
  • Kidney dialysis services
  • Second surgical opinions
  • Prescription drugs such as injectable cancer drugs
  • Home health care ($1810 each of physical/speech and occupational)
  • Diabetes supplies
  • Prosthetic/orthotic items
  • Smoking cessation counseling (with a smoking related illness)
  • Colorectal screenings (75%)
  • Labs and x-rays (100%)
  • Outpatient mental health services (60%)

Medicare Part B pays 100% of the cost of preventive services.

When to Enroll in Medicare?
The Initial Enrollment Period is a special period three months prior to, the month of your 65th birthday and three months after in which a person should sign up for the various applicable Medicare services and can do so without any penalties. The applicable month is the 24th month of disability for disabled individuals. Most individuals will automatically be enrolled in Medicare during their Initial Enrollment Period if they receive Social Security benefits. Medicare will mail you your Medicare card and you will receive Original Medicare (Parts A and B) by default. If you do not wish to receive Medicare, you must sign the back of your Medicare card and return it to Medicare to disenroll. If you wish to receive your Medicare coverage through a private insurer (Medicare Advantage/Part C), you must sign-up with a plan during your Initial Enrollment Period. If you are not receiving Social Security benefits, you must file an application for either Medicare only, or Medicare and Social Security benefits with the Social Security Administration to receive coverage.

The Special Enrollment Period can be used to enroll in Medicare if an individual initially refused Medicare Part B while still covered by an employment-based group health plan. Individuals who have employment-based group health coverage through their own or a spouse’s current employment (not retiree coverage) can enroll in Medicare within eight months of the end of the employment or insurance coverage without penalty. The Social Security Administration will require evidence of coverage from the plan documenting continuous coverage since age 65. Certain international volunteers (such as Peace Corps Volunteers) are also eligible for a Special Enrollment Period if they dropped coverage when they left the country and are enrolling upon their return to the U.S.

The General Enrollment Period runs every year from January 1 to March 31 and is the time when you can enroll in Medicare if you did not do so during your Initial Enrollment Period or Special Enrollment Period. Coverage will begin effective July 1 of the year of enrollment. Persons will be subject to 10% penalty for each year which they were eligible and did not sign up for Part B after the Initial Enrollment Period. In order to enroll in Medicare, individuals should visit their local Social Security office (you can find yours here), call 1-800-772-1213 or file online.

After enrolling in Medicare, you will receive your Medicare card at the address Social Security has on file in approximately 30 days. Individuals should also sign up for MyMedicare.gov, an online management and record-keeping system about your Medicare enrollment, benefit usage, status of claims and customer service venue.

If individuals need to order a replacement Medicare card, they can do so from MyMedicare.gov or from the Social Security Administration. If individuals have questions about Medicare, they can call 1-800-MEDICARE (1-800-633-42273) for personalized assistance.

  • To find a doctor who accepts Medicare in your area, you can search here.
  • To find and compare information on hospitals accepting Medicare (non-VA), click here.
  • To compare Medicare approved nursing homes, click here.
  • To compare Medicare approved home care agencies, click here
  • To compare Medicare approved dialysis centers, click here
  • To download the current Medicare and You handbook, click here.
  • To talk to a Medicare Counselor for more information or specific questions, please contact our office at 303-333-3482.