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What does Original Medicare cover?

An older Asian American woman smiling in a park-like setting with a workout towel around her neck asking herself, What Does Medicare Cover?

Original Medicare is the red, white, and blue card that has Part A and 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 across the country who accept Medicare. It is a fee-for-service plan, meaning that the Medicare beneficiary usually pays a fee for each service received. Medicare covers its share of an approved amount up to certain limits, and the individual pays the rest. Below we will detail what Part A covers and what Part B covers as well as a brief explanation of what is not covered under Original Medicare.

Part A (Hospital):

Part A is typically labeled as hospital coverage. Listed below is what’s covered as well as the Medicare beneficiary’s out-of-pocket costs.

Hospital

  • $1,484 deductible for days 1-60 following inpatient hospitalization. 
  • Days 61-90: $371 coinsurance per day
  • Days 91 and beyond: $742 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).

Hospice care

  • $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: $185.50 coinsurance per day of each benefit period.
  • Days 101 and beyond: all costs.

Part B (Doctors):

Part B is typically referred to as doctor coverage. This part of Medicare is responsible for not only doctors, but also: labs, diagnostic tests, imaging, and shots. Listed below is what’s covered under Part B as well as the Medicare beneficiary’s out-of-pocket costs. 

Part B annual deductible:

You pay $203 per year in 2021 for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for the following:

  • Most doctor services 
  • Outpatient therapy
  • Durable medical equipment (DME)
  • Clinical laboratory services: You pay $0 for Medicare-approved services.

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. 

What’s Not Covered By Original Medicare:

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, please refer to our class on “What 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 get coverage for these services you have to pay out-of-pocket, have a long-term health policy, or have Medi-Cal.

Ancillary Services

There are many services 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 lenses
  • Acupuncture

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 refer to our class on “What is Medicare Advantage”.

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 individually or as part of a Medicare Advantage plan. Medicare requires you to have prescription drug coverage or pay a penalty when you do enroll at a later date.

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 examples of Creditable Coverage below, then you are not required to buy a PDP and will not have to pay a penalty.

Examples of Creditable Coverage:

✓ Group/Employer Coverage

✓ VA

✓ TriCare

For questions, support in enrolling into Medicare or any other Medicare related service, please contact one of Local Medicare Agents.

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