Review Cost and Coverage

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When choosing a Medicare plan, two most essential questions are "What’s covered?" and "How much will it cost?" Let’s start with what’s covered—Medicare comes in four parts, each serving a different role in helping cover your healthcare needs.¹

Government Sponsored Medicare Program

Also known as Original Medicare, Parts A and B come standard for most Americans who turn 65 years old or qualify due to an eligible disability —they cover the more basic healthcare services.

Private Insurance Plans

Parts C and D can be purchased separately—they’re designed to fill coverage gaps that Original Medicare doesn’t account for, which we’ll discuss in more depth later in the guide.

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Part A

Medicare Part A helps cover hospital expenses such as room, board and other inpatient services, limited stay in a skilled nursing facility, and helps cover hospice care and home-health care. ²

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Ambulance Services
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Inpacient Hospital & Services
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Skilled Nursing Facility Care
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Home Health Care & Hospice
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Part B

Medicare Part B helps cover medical expenses, such as doctor's services, outpatient services and other medical supplies. It also helps cover some occupational and physical therapy services and some home-health care. It also covers some preventive services. Typically, the monthly premium you pay for Medicare Part B is deducted from your Social Security benefits. ³

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Outpatient Services
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Medical & Lab Services
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Doctor Visits & Preventive Care
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Durable Medical Equipment & Supplies
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Part C

Known as Medicare Advantage, Medicare Part C plans cover all of your Medicare Parts A and B benefits plus they may also include Medicare Part D prescription drug coverage. With a Medicare Advantage plan that includes prescription drug coverage, you simply choose to receive your benefits through a private health insurance company, giving you the convenience of an all-in-one plan. ⁴

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Prescription Drug Coverage
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Basic Dental Services
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Vision
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Hearing
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Part D

One of the major gaps in Original Medicare is prescription drug coverage. For help managing the costs of your prescription medications, you generally will need to add on a Medicare Part D plan, also known as prescription drug coverage.⁵
Prescription drug coverage is in many Medicare Advantage Plans (Part C), but there are also Medicare Advantage plans available without prescription drug coverage.

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Breaking down Original Medicare Parts A and B

Learn the ins and outs of Original Medicare—what it covers, what it doesn’t, and how much you may expect to pay.

What is Part A?

Part A helps cover a variety of costs including inpatient stays, inpatient mental health, skilled nursing, and hospice care.²

Dig into the details

What’s covered

Overnight hospital stays, including a semi-private room, meals, general nursing, and medications taken as part of your treatment, and some additional services and supplies.⁶

Costs without insurance

Depending on your length of stay, you’ll first pay an inpatient hospital deductible—in <2022>, this totaled <$1,556>.

After paying that, Medicare will cover 100% of the cost of your stay for the first 60 days. For days 61-90, in <2022> you would’ve paid <$389> per day.

And after day 90, you enter into your bank of “lifetime reserve days,” which is up to 60 reserve days of inpatient hospital coverage that can be used over your lifetime. You’ll pay <$778> per day during your lifetime reserve days. Once you’ve used these up, you’ll be responsible for all costs.⁷

What’s covered

Skilled nursing facilities provide a high level of medical care such as wound care, IVs, injections, physical therapy, and monitoring of vital signs—this level of care requires trained medical professionals such as a registered nurse or therapist. These facilities may be used for rehabilitation after an injury, stroke, or other condition. They may also be used to treat patients who require constant monitoring and care, but don’t need to be in a hospital.

Costs without insurance

Original Medicare will cover 100% of the cost for the first 20 days of a qualified stay. If you are admitted for longer, you will pay <$194.50> per day for days 21 through 100. After 100 days, you will be responsible for all costs.8

What’s covered

Part A covers admittance to inpatient mental health facility or psychiatric hospital for a maximum of 190 days over your lifetime.

Costs without insurance

The costs for an inpatient mental health stay are the same as inpatient hospital stay costs. For the doctor’s services, you will generally pay 20% of the Medicare-approved amount.7

Coverage

Hospice care focuses on increasing quality of life through pain relief and symptom control, in addition to treatment for mental and emotional health needs. Sometimes referred to as “end of life care,” hospice is typically administered when the diagnosis is deemed terminal or when a cure is not expected. It’s usually received in a patient’s home or other facility where the patient lives, like a nursing home or an assisted nursing facility. 

Costs without insurance

Original Medicare will generally cover 100% of Hospice care costs. A copayment of up to $5 may be charged for each outpatient prescription drug prescribed for pain relief and symptom control. For short-term inpatient respite care, you may be responsible for 5% of the Medicare-approved charges at a Medicare-approved facility.9

What is Original Medicare Part B?

Part B, also known as medical insurance, helps cover doctors' visits, urgent care, outpatient care, home health services, durable medical equipment, and many preventive services.³

Benefits of Part B

Coverage

Part B will cover visits to your primary care or family doctor and specialists as long as they accept patients covered by Medicare. Specialists are doctors who focus on a specific type of care—like allergists, cardiologists, dermatologists and endocrinologists. You’ll also be covered for visits to covered urgent care facilities if you need treatment for a sudden illness or injury that isn’t a medical emergency.10, 11

Coverage

Part B will cover a large variety of supplies, equipment, prosthetic devices, and artificial eyes and limbs as long as they are prescribed by your doctor and the supplier of the device is enrolled in Medicare. Suppliers must meet a strict quality standard and offer competitive pricing of the equipment they provide.

Some of the most common medical supplies and equipment include wheelchairs, scooters, canes and walkers, oxygen equipment and accessories, diabetic monitoring supplies, therapeutic shoes and inserts, slings and braces, CPAP devices, and hospital beds and lifts. Medicare will also cover prosthetic devices and artificial eyes and limbs.12,13,14

Coverage

Part B will cover medically necessary therapy. Outpatient therapy is provided outside a hospital or skilled nursing facility. Therapy received in an in-patient setting is generally covered by Original Medicare Part A.

This includes physical, occupational, and speech therapy as well as cardiac and pulmonary rehabilitation services. Most people think of therapy to regain the use of a particular function after an injury or illness, but in some instances, it can also be used in a preventative measure to manage the progression of a chronic condition.15,16,17,18,19

Coverage

If you need medically necessary services and traveling via another vehicle could endanger your health, Part B will cover ground ambulance transportation to the nearest hospital, critical access hospital, or skilled nursing facility able to administer the care you need.

If you need immediate assistance, Original Medicare may cover emergency transportation in an airplane or helicopter. Additionally, Original Medicare may cover non-emergency but medically necessary ambulance transportation if you have a written order from your doctor.20

For nearly everything covered under Part B, you’ll first be responsible for meeting your yearly deductible, which was <$203> in 2021. Once you meet your deductible, Original Medicare will typically pay 80% of the Medicare-approved amount, and you’ll generally pay the remaining 20% out of pocket.

Before you visit a doctor, schedule a procedure, or purchase supplies, it’s important to ask if they participate in Original Medicare—because if they don’t, you’ll likely have to pay more.21

What’s 100% covered

Original Medicare covers the  cost of some preventive services such as various preventive screenings, shots and vaccines.

Coverage

Services deemed medically necessary including certain blood tests, urinalysis, tests on tissue specimens, and certain screenings are all fully covered. These must be ordered by your doctor and administered in a Medicare-approved laboratory.22

Coverage

Dozens of preventive screenings and services including diabetes screenings, depression screenings, mammograms, colonoscopies, glaucoma tests, and various cancer screenings are fully covered. For a full list of covered preventive screenings and programs, check Medicare.gov.23

Coverage

Once you’ve had Original Medicare Part B coverage for over 12 months, Original Medicare covers an annual “wellness” visit, so you can receive care and advice based on your current mental and physical health. You’ll fill out a Health Risk Assessment questionnaire and your doctor will help you create, update, and maintain a personalized prevention plan and routine screening schedule to help you stay healthy.24

Coverage

Depending on your physical health, Part B may cover shots and vaccines including pneumococcal shots, Hepatitis B shots, and flu shots.

 

Costs without insurance

Part B covers these certain shots and vaccines at 100%, if your doctor accepts assignment. However, if your doctor recommends additional tests or services, they may not be covered.25

What’s not fully covered?

Certain services and procedures are not 100% covered, such as dental, vision, prescription drugs and more.

Benefits of items not fully covered by Parts A and B

Coverage

With few exceptions, Original Medicare Parts A and B do not cover prescription drug costs. But Medicare participants must obtain prescription drug coverage as soon as they’re eligible for Medicare, unless they have creditable drug coverage somewhere else, such as a spouse’s employer-sponsored health coverage. If you enroll later, you may be subject to a late penalty. 

There are two options for Prescription Drug coverage, also known as Part D. The first is a stand-alone Part D Prescription Drug plan, which  can only be added to  Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. Or you can enroll in a Medicare Advantage Prescription Drug plan, which combines all the benefits of Part A and Part B coverage with Prescription Drug coverage (Part D), effectively replacing Original Medicare. Without this additional coverage, you could be responsible for paying 100% of the cost of your medications.

Coverage

Original Medicare does not cover most dental care, but Medicare participants can obtain separate dental coverage from a private insurance company such as Humana. 

There are two options for dental coverage. You can either add a stand-alone dental insurance plan to your Original Medicare or enroll in a Medicare Advantage plan, also known as Part C, that may include routine dental coverage. Medicare Advantage  is a more robust offering that replaces Original Medicare. If you choose not to purchase  dental coverage you could be responsible for paying 100% of the cost of your dental care.26,27 

Coverage

Part B covers a simple vision test as part of the “Welcome to Medicare” preventive visit, but it’s only offered once during your first year of Part B coverage. Part B also covers a yearly eye exam for those living with diabetes and diabetic retinopathy, as long as it’s performed by an eye doctor who is legally permitted to do testing in the state where you live. 

Eye exams for diagnostic purposes, such as testing for glaucoma or macular degeneration, may also be covered. If treatment may improve a chronic eye condition and is viewed as medically necessary by a physician participating in Medicare, Part B may cover it—you’ll need to check with your doctor to see if your condition is deemed medically necessary. 

Most routine vision care like routine eye-exams, eyeglasses, contacts, and corrective procedures won’t be covered—but there are other two ways to cover them. Either add a stand-alone vision insurance plan to your Original Medicare or enroll in a Medicare Advantage plan with routine vision coverage, to replace your Original Medicare with a more robust coverage offering. If you choose not to purchase vision coverage , you could be responsible for paying 100% of the cost of your vision care.28,29,30 

Coverage

Part B covers diagnostic hearing and balance exams if ordered to determine whether medical treatment is needed. However, Original Medicare does not cover hearing exams, hearing aids or fittings—that’s where Medicare Advantage plans with routine hearing coverage, , can help, since they may include coverage for routine hearing care in addition to the benefits that come with Parts A and B. If you choose not to purchase hearing coverage, you could be responsible for paying 100% of the cost of your hearing care.31

Coverage

Original Medicare covers certain in-home health services, including skilled nursing care, physical therapy, speech pathology, and occupational therapy. Original Medicare will not pay for 24-hour in-home care or meals delivered to you at home. If your in-home care needs exceed what can be classified as part-time or intermittent skilled nursing care, they will not be eligible for coverage. 

If you choose to purchase a Medicare Advantage plan with an in-home health benefit, you may have access to additional in-home health programs at no additional cost.32

You may be responsible for paying 100% of the cost of your prescriptions, dental, vision, hearing, and in-home care.

This is not a full summary of Original Medicare coverage, benefits, and costs. For a full list of covered services use the “Is my test, item or service covered?” search tool on Medicare.gov.33


5 ways you may get help paying

Read up on the programs that may help  paying for Medicare costs a little bit easier for those who qualify.

Dual-eligible 

Dual-eligible is the term used to describe people who are enrolled in both Medicare and Medicaid. Dual-eligible beneficiaries are individuals who are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and/or assistance with Medicare premiums. They receive cost sharing through state-run Medicare Savings Programs (MSP), which provide help for premiums, deductibles, coinsurance and copayments, depending on the participant's income level and the specific MSP.5

Some private insurance companies, like Humana, have plans that are specifically designed for Dual-eligible consumers. Medicare Advantage Dual-Eligible Special Needs Plans often combine all the benefits of Medicaid and Medicare, and may also include coverage for routine dental, vision and hearing care; nonemergency transportation to and from medical care; fitness programs; an over-the-counter medication allowance and more.

Think you may be dual-eligible? Find out and learn about the benefits of these plans

Check my Eligibility

Plans not available in all areas.  Costs, coverage, and benefits vary by location. 

“Extra Help” with Prescription Drug Costs - Low Income Subsidy (LIS) 

The federal government helps many Medicare beneficiaries pay their prescription drug costs through the Low Income Subsidy (LIS), also known as “Extra Help” program. Those who qualify for the Medicare Extra Help program get free or reduced drug coverage premiums and reduced out-of-pocket costs like deductibles and coinsurance. 

Some people qualify for prescription drug help automatically, while others need to apply. In order to qualify for this assistance you must be receiving Medicare, live in the U.S. and meet certain resource and income requirements. 

It’s important to note, applying for Extra Help is not the same as joining a prescription drug plan. Whether you qualify for extra help or not, you must also enroll in a plan to get prescription drug coverage. If you do qualify for extra help, and choose to get your part d prescription drug coverage through Humana, we will send you a Low Income Subsidy (LIS) rider telling you how much help you’ll get next year towards your drug plan premium, deductible, and copayments. 

For more information, contact your local Social Security office or visit the social security website to see if you qualify, and apply.34

Medicare Savings Programs (MSP) 

Under this program, your state Medicaid program helps you pay your Medicare premium, and in some cases, your deductibles and coinsurance, if you meet certain conditions. Keep in mind, these programs have different names in different states.5

For more information, contact your State Medicaid Program or visit Medicare.gov

Programs of All-inclusive Care for the Elderly (PACE) 

This program offers a combination of medical, social, and long-term-care services. It is available only in states that choose to offer it under Medicaid, and eligibility requirements vary from state to state.35

For more information, contact your State Medicaid Program or visit Medicaid.gov

Supplemental Security Income (SSI) benefits 

This is help for people who are disabled, over age 65, and have limited financial resources. It’s important to also note that SSI is not the same as Social Security benefits.

For more information, contact your local Social Security office or visit the social security website. You can also use their Benefits Eligibility Screening Tool (BEST) to find out if you're eligible.36,37


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Test your knowledge

See how well you know Original Medicare costs and coverages by matching the terms to their correct definitions.

 


Frequently Asked Questions about Cost and Coverage

Offered by the federal government, it includes Part A (hospital insurance) and Part B (medical insurance) benefits. Original Medicare helps cover hospital and doctor visits.

In most cases, you usually don't pay a monthly premium for Medicare Part A (hospital) coverage if you or your spouse paid Medicare taxes for a certain amount of time while working.

You do need to pay a premium for Part B coverage. In <2022>, the Medicare Part B premium is <$170.10> or higher depending on your income.

Yes. Most people will pay a deductible for parts A and B. The <2022> Part A deductible for inpatient hospital coverage is <$1,556.00>. The <2022> annual deductible for Part B medical coverage is <$230.00>.

Original Medicare does not include prescription drug coverage. You may choose to purchase a stand-alone prescription drug plan or a Medicare Advantage Prescription Drug Plan from a private company.

Yes. If you are enrolled in Original Medicare, you can go to any doctor or hospital in the U.S. that accepts Medicare. If you have Medicare coverage through a private insurance company, you may save money by staying in your plan’s network.

You can enroll or change plans two times a year. First during the annual enrollment period from Oct 1 – Dec 7 and then again during Open Enrollment from Jan 1 – March 31. From April 1 – Oct 1 you will need a special enrollment period to switch plans. If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare.

Yes. Preexisting conditions, also known as previous health conditions, do not affect your Medicare eligibility and coverage. Original Medicare (Part A and Part B) is available to any individual age 65 or older, younger than 65 with a disability, or any age with end-stage kidney disease (ESKD).1

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