When you first become eligible for Medicare, the different parts can feel confusing. The foundation of Medicare is called Original Medicare, and it includes Part A and Part B.
Part A generally helps pay for hospital-related care. Part B generally helps pay for doctor visits, outpatient care, and medical services. Together, they can provide important coverage, but they do not pay for every health care expense.
Understanding what each part covers may help you decide whether you also want other coverage, such as a Medicare Supplement plan, a Part D prescription drug plan, or another Medicare option.
What is Medicare Part A?
Medicare Part A is often called hospital insurance. It may help cover care when you are formally admitted to a hospital or need certain types of facility-based care.
Many people do not pay a monthly premium for Part A because they or their spouse paid Medicare taxes while working. This is often called premium-free Part A. However, not everyone qualifies for premium-free Part A, and other out-of-pocket costs can still apply.
Part A may help cover:
- Inpatient hospital stays
- Limited care in a skilled nursing facility after a qualifying hospital stay
- Hospice care for people who meet Medicare’s requirements
- Some home health care services
It is important to understand that Part A does not simply pay all hospital bills. You may have a deductible when you are admitted to the hospital. You may also have daily copayments if a hospital stay lasts beyond Medicare’s covered period.
Medicare measures hospital benefits in benefit periods, rather than using one deductible for the entire calendar year. That can be surprising for people who are new to Medicare. A new benefit period may begin after you have been out of the hospital or skilled nursing facility for a certain amount of time.
What does Medicare Part A not usually cover?
Part A has limits. For example, it generally does not cover long-term custodial care in a nursing home. Custodial care means help with daily activities, such as bathing, dressing, eating, or moving around, when that is the main type of care needed.
Part A also does not generally cover a private hospital room unless it is medically necessary. It may not cover personal items, such as television or telephone charges, either.
Skilled nursing facility coverage can also be misunderstood. Medicare may cover a limited stay when you need skilled care, such as physical therapy or nursing services, after a qualifying hospital stay. It does not generally pay for an ongoing nursing home stay when only personal care is needed.
What is Medicare Part B?
Medicare Part B is often called medical insurance. It helps cover many of the health care services you may use outside the hospital.
Unlike Part A, most people pay a monthly premium for Part B. The premium can vary based on income and may change from year to year. You may also have a yearly deductible and usually pay a share of the Medicare-approved cost for many covered services.
Part B may help cover:
- Doctor and specialist visits
- Outpatient hospital services
- Lab tests, X-rays, and diagnostic screenings
- Emergency room care when you are not admitted as an inpatient
- Ambulance services when medically necessary
- Durable medical equipment, such as walkers, wheelchairs, or oxygen equipment
- Physical therapy, occupational therapy, and speech therapy when covered requirements are met
- Preventive services, such as certain screenings, vaccines, and wellness visits
Part B can be especially valuable for preventive care. Medicare may cover many preventive services with little or no cost to you when you meet the coverage rules and use a provider who accepts Medicare. Still, costs can vary depending on the service, the provider, and whether additional testing is needed.
Does Part B cover doctor visits and outpatient surgery?
Yes, Part B generally helps cover doctor visits, specialist appointments, outpatient surgery, and care received at an outpatient hospital department. In many cases, you remain responsible for a portion of the approved cost after meeting your Part B deductible.
This is one reason many people take a close look at their options for helping with out-of-pocket costs. Original Medicare does not have a general annual out-of-pocket maximum for Part A and Part B services.
With Original Medicare alone, your share of costs may continue as you receive covered services. A Medicare Supplement insurance policy, also called Medigap, may help pay certain deductibles, copayments, and coinsurance left by Original Medicare. Benefits and premiums can vary by plan, insurance carrier, and state.
What does Original Medicare usually not cover?
Original Medicare provides broad medical and hospital coverage, but it has important gaps. Part A and Part B generally do not cover most routine services in these areas:
- Most prescription drugs you take at home
- Routine dental care, dentures, and most dental procedures
- Routine eye exams for glasses and most eyeglasses
- Most routine hearing exams and hearing aids
- Routine foot care, except in certain medical situations
- Care received outside the United States, except in limited circumstances
- Long-term custodial care
For prescription drugs, many people consider enrolling in a standalone Medicare Part D plan. Part D plans have their own covered drug lists, pharmacies, premiums, deductibles, and rules. Comparing plans based on your specific medications can be helpful.
How can you manage Medicare’s coverage gaps?
There is no one Medicare choice that fits everyone. Your health needs, budget, travel habits, preferred doctors, and comfort with provider networks can all matter.
Some people choose Original Medicare and add a Medicare Supplement plan plus a separate Part D plan. This approach may offer the flexibility to see any doctor or hospital that accepts Medicare, without a network in most cases. A Medigap policy may also help make certain out-of-pocket costs more predictable.
Others choose a Medicare Advantage plan, which is another way to receive Medicare-covered benefits through a private insurance company. These plans often include additional benefits and may include prescription drug coverage. They commonly use provider networks and may have different rules for referrals, prior authorization, and out-of-network care.
It can be useful to compare the full picture rather than focusing on one feature. Consider your doctors, medications, expected health care use, travel plans, and the costs you may pay when you receive care.
Knowing the basics can make Medicare easier
Medicare Part A and Part B are the starting point for many people. Part A may help with inpatient hospital care, while Part B may help with doctors, outpatient services, and preventive care. But both parts include deductibles, coinsurance, and services they may not cover.
Eric can help you understand how Original Medicare works and discuss Medicare Supplement options in your area. Reach out for free, no-pressure help as you sort through your Medicare choices.