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QUESTIONS AND ANSWER
QUESTIONS AND ANSWER
What's Medicare?
What's Medicare?
Medicare
The federal health insurance program for:
People who are 65 or older
Certain younger people with disabilities
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
What are the parts of Medicare
What are the parts of Medicare
The different parts of Medicare help cover specific services:
Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.Medicare Part B (Medical Insurance)
Part B covers doctors' services, outpatient care, medical supplies, and preventive services.Medicare Part D (prescription drug coverage)
It helps cover the cost of prescription drugs (including many recommended shots or vaccines).
What's isn't covered by Part A & B?
What's isn't covered by Part A & B?
Medicare doesn't cover everything. If you need services Part A or Part B doesn't cover, you'll have to pay for them yourself unless:
You have other coverage (including Medicaid) to cover the costs.
You're in a Medicare Advantage Plan or Medicare Cost Plan that covers these services. Medicare Advantage Plans and Medicare Cost Plans may cover some extra benefits, like fitness programs and vision, hearing, and dental services.
Some of the items and services Medicare doesn't cover include:
Long-term care (also called custodial care)
Most dental care
Eye exams (for prescription glasses)
Dentures
Cosmetic surgery
Massage therapy
Routine physical exams
Hearing aids and exams to fit them
Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care)
Covered items or services you get from an opt-out doctor or other provider (except in the case of an emergency or urgent need)
Part A & Part B Premiums
Part A & Part B Premiums
You usually don't pay a monthly premium for Part A if you or your spouse paid Medicare taxes while working for a certain amount of time. This is sometimes called "premium-free Part A."
If you don't qualify for premium-free Part A, you can buy Part A
If you aren't eligible for premium-free Part A, you may be able to buy Part A. You'll pay up to $505 each month in 2024 ($518 in 2025). If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $505 ($518 in 2025). If you paid Medicare taxes for 30–39 quarters, the standard Part A premium is $278 in 2024 ($285 and 2025).
Everyone pays a monthly premium for Part
Most people will pay the standard Part B premium amount. The standard Part B premium in 2024 is $174.70 ($185.00 in 2025). Suppose your modified adjusted gross income, as reported on your IRS tax return two years ago, is above a certain amount. In that case, you'll pay the standard premium and an income-related monthly adjustment (IRMAA). IRMAA is an extra charge added to your premium.
What Part A covers
What Part A covers
What's covered?
What's covered?
Note: If you're in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in specific facilities or for patients with certain conditions.
In general, Part A covers:
In general, Part A covers:
What Part B covers
What Part B covers
If you're in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. But, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in specific facilities or for patients with certain conditions.
What's covered?
What's covered?
INSULIN BENEFIT! Use an insulin pump covered under Part B's durable medical equipment benefit, or you can get your covered insulin through a Medicare Advantage Plan. Your monthly supply of Part B-covered insulin for your pump can't be more than $35. The Part B deductible won't apply. If you get a 3-month supply of Part B-covered insulin, your costs can't be more than $35 for each month's supply. This means you'll generally pay no more than $105 for a 3-month supply of covered insulin. If you have Part B and Medicare Supplement Insurance (Medigap) that delivers your Part B coinsurance, your plan should cover the $35 (or less) cost for insulin.
Part B covers two types of services
Part B covers two types of services
Medically necessary services: Services or supplies needed to diagnose or treat your medical condition that meets accepted medical practice standards.
Preventive services: Health care to prevent illness (like the flu) or detect it early, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a healthcare provider who accepts assignments.
Part B covers things like:
Part B covers things like:
Mental health
Two ways to find out if Medicare covers what you need
Two ways to find out if Medicare covers what you need
Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something usually covered, but your provider thinks Medicare won't. If so, you'll have to read and sign a notice. The notice says you may have to pay for the item, service, or supply.
Medicare coverage is based on three main factors
Medicare coverage is based on three main factors
Federal and state laws.
National coverage decisions made by Medicare about whether something is covered.
Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
How does Medicare work?
How does Medicare work?
With Medicare, you have options in how you get your coverage. Once you enroll, you’ll need to decide how you’ll get your Medicare coverage. There are 2 main ways:
Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You pay for services as you get them. When you get services, you’ll pay a deductible (tooltip) at the start of each year, and you usually pay 20% of the cost of the Medicare-approved service, coinsurance. You can add a separate drug plan (Part D) if you want drug coverage.
Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like copayments, coinsurance, and deductibles. Some Medigap policies also cover services that Original Medicare doesn't cover, like emergency medical care when you travel outside the U.S.
Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare’s coverage rules. The plan must notify you about any changes before the start of the next enrollment year.
Learn about the types of Medicare Advantage Plans.
Each Medicare Advantage Plan can charge different out-of-pocket costs (tooltip). They can also have different rules for how you get services.
Medicare prescription drug coverage (Part D)
Medicare prescription drug coverage (Part D)
Medicare drug coverage helps pay for prescription drugs you need. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage (this includes Medicare drug plans and Medicare Advantage Plans with drug coverage).
Learn more about how to get Medicare drug coverage.
Each plan can vary in cost and the specific drugs covered but must provide at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies.
Learn more about Medicare drug coverage.
Plans have different monthly premiums. You’ll also have other costs in a Medicare drug plan throughout the year. How much you pay for each drug depends on which plan you choose.
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