We must first understand the basics about Original Medicare: how you qualify, what it actually covers, and if there are services you need that aren’t included.
Original Medicare Monthly Costs
Medicare Part A
- Part A will be free if you have worked and paid Medicare taxes for at least 40 quarters (10 years) in the United States. Most people don’t pay a monthly premium for Part A, due to work history; however, if you don’t automatically qualify you can pay for your Part A with a monthly premium.
Medicare Part B
- Part B premium will cost $135.50 per month and may be deducted from Social Security checks, Railroad Retirement checks or personal check each month. This amount may vary in a few situations. Individuals with income over $85,000, or filing jointly with incomes over $170,000 pay an increased premium, up to $428.60 per month based on the income related monthly adjustment amount (IRMAA). Those with Medi-Cal may have their Part B premium paid by the state.
Part A Deductible and Coinsurance
- $1,364 deductible for days 1-60 following inpatient hospitalization.
- Days 61-90: $341 coinsurance per day
- Days 91 and beyond: $682 coinsurance per day after day 90 for up to 60 days over your lifetime.
- This resets and a new deductible is owed once discharged and the 90 day window has closed.
Home health care
- $0 for medically necessary home health care services.
- 20% of the Medicare-approved amount for durable medical equipment (DME).
- $0 for hospice care.
Mental health inpatient stay
- Mental inpatient hospitalization is treated the same as medical hospitalization.
Skilled nursing facility stay
- Days 1–20: $0 for each benefit period.
- Days 21–100: $170.50 coinsurance per day of each benefit period.
- Days 101 and beyond: all costs.
Part B Deductible and Coinsurance
Part B annual deductible:
You pay $185 per year in 2019 for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for these:
- Most doctor services
- Outpatient therapy
- Durable medical equipment (DME)
- Clinical laboratory services: You pay $0 for Medicare-approved services.
- All services listed below
Outpatient mental health services:
- You pay nothing for your yearly depression screening.
- 20% of the Medicare-approved amount for visits to your doctor or other health care provider to diagnose or treat your condition.
Outpatient hospital services:
- You usually pay 20% of the Medicare-approved amount for the doctor, hospital, or other health care provider’s services. For services that can also be provided in a doctor’s office, you may pay more for outpatient services you receive in a hospital than what you would pay if you received the same care in a doctor’s office. However, the hospital outpatient copayment for the service is capped at the inpatient deductible amount of $1,364.
What Original Medicare Doesn’t Cover
Non-medical Home Health
Original Medicare will not cover any home health services that are not medically necessary. This includes having someone help you with bathing, going to the bathroom, cleaning the house, shopping, or any other service that can fall under assisted living with home health. This would also include any nursing homes or assisted living facilities. To receive coverage for these services you must either pay out of pocket, have a long term health policy, or have Medi-Cal.
There are many services that are considered “extra” that aren’t covered under Original Medicare. These include:
- Most dental care, including dentures, dental procedures or cleanings, fillings, dental plates, tooth extractions, and checkups
- Cosmetic surgery
- Hearing aids
- Routine foot care
- Eye exams for prescription glasses
Medicare Part D
Original Medicare does not include prescription drug coverage. Some medications may be covered when administered within a doctors office. Outside of the doctors office any pharmacy filled medications will require a prescription drug plan (PDP) to be purchased from a private company. Medicare requires you to purchase a PDP, and you may be subject to a penalty if you do not enroll into a PDP when you first receive Medicare benefits.
Any Medicare Beneficiary who does not enroll into a PDP and does not have Creditable Coverage will incur a 1% penalty of the National Drug Premium average for every month the beneficiary is without Creditable Drug Coverage. If you have any of the following below then you are not required to buy a PDP and will not incur a penalty.
Examples of Creditable Coverage:
✓ Group/Employer Coverage