Original Medicare is the red, white, and blue card that Part A and/or Part B. Original Medicare is managed by the federal government and provides Medicare eligible individuals with coverage for and access to doctors, hospitals, or other health care providers who accepts Medicare (which is most providers). It is a fee-for-service plan, meaning that the person with Medicare usually pays a fee for each service. Medicare pays its share of an approved amount up to certain limits, and the person with Medicare pays the rest. Below we will detail what Part A covers, what Part B covers, and briefly what Medicare doesn’t cover.
Part A (Hospital):
Part A is typically labeled as hospital coverage and covers everything listed below.
- $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 one 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 (Doctors):
Part B is typically referred to as doctors coverage. This is only half true because it is the part of Medicare responsible for not only doctors but also, labs, diagnostic tests, imaging, and shots. Part Be covers what’s listed below.
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 (Emergency Room):
- 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 get in a hospital than you’ll pay for the same care in a doctor’s office. However, the hospital outpatient co-payment for the service is capped at the inpatient deductible amount of $1,364.
What’s Not Covered:
There are a lot of things not covered by Original Medicare. Here I am only going over the most popular things that come up. for a full list and explanation of what’s not covered, please (Click Here).
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 get coverage for these services you have to 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
- Hearing aids
- Routine foot care
- Eye exams for prescription glasses and glasses
Coverage for these services can often be covered through a form of Medicare insurance called Medicare Advantage plans. Your doctor will often accept one in your area that has a low to no premium and as long you have both Part A and Part B you will qualify. For more information on these kinds of plans please (Click Here).
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 individually or as part of a Medicare Advantage plan from a private company. Medicare requires you to have a PDP or pay a penalty when you do enroll into a PDP later.
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 without creditable Drug Coverage. If you have any of the following below then you are not required to buy a PDP.
Examples of creditable Coverage:
✓ Group/Employer Coverage
For questions or support in either enrolling into Medicare, a Prescription Drug Plan, Medicare Advantage plan, or any other Medicare related service please contact us at the option that best suits you below.