There are 4 Different Parts to Medicare. The confusion for most people is how they work and all tie together.

4 Parts of Medicare

 

We can break this down to make it simpler for you to understand. Medicare itself has parts (not plans), below are the breakdown of each part of Medicare.

Part A 

Part A of Medicare is your hospital insurance.

In General, Part A covers:

Part A Covers Your Hospital Stay & Care

  • Inpatient care in a hospital
  • Skilled nursing facility care
  • Inpatient care in a skilled nursing facility (not custodial or long-term care)
  • Hospice care
  • Home health care
  • Blood transfusions requiring more than 3 pints of blood.

Think of Part A as your room and board in the hospital. This part of Medicare provides you a place to stay, with meals, while you receive medical services.

We’ve had consumers ask us, particularly healthy people, if they may need only Part A. Maybe they don’t use many medical services yet and so they wonder if they can get away with Part A alone.

However, there are many things that happen in a hospital that can fall under Part B, so it’s important that you enroll in both A & B unless you have other coverage coordinating with Medicare.

 

Part A Cost

You usually don’t pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes during your working years. Part A is free for most people as long as they have worked at least 10 years in the U.S.

The cost of Part A for most people at age 65 is $0

 

What’s not covered by Part A & Part B?

Medicare doesn’t cover everything. If you need certain services Medicare doesn’t cover, you’ll have to pay for them yourself unless:

  • You have other insurance that covers them
  • You have a Medicare health plan that covers them

Even if Medicare covers a service or item, you generally have to pay your  deductiblecoinsurance, and copayment.

Some of the items and services that Medicare doesn’t cover include:

  • Long-term care (also called custodial care )
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and exams for fitting them
  • Routine foot care

Part B

The Part of Medicare that covers doctor visits is Part B as well as your outpatient services that are deemed medically necessary. Medicare Part B includes coverage for services like lab testing, diagnostic imaging, preventive care, surgeries, ambulance rides, chemotherapy and radiation, and even extensive dialysis care for people with renal failure. Many of these procedures may occur in a hospital. However, they fall under Part B because physicians provide them, so it’s not always easy to determine what is inpatient vs outpatient care.

Covers Your Doctors & Outpatient Services

Part B also covers things like:

  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
    • Inpatient
    • Outpatient
    • Partial hospitalization
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs
  • Cancer therapy and kidney dialysis.

Keep in mind: If you’re in a Medicare Advantage Plan or other Medicare plan, you 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 certain settings or for patients with certain conditions.

 

Part B Costs

You pay a monthly premium for Part B. Your Part B monthly premium will be automatically deducted from your benefit payment if you get benefits from one of these:

  • Social Security
  • Railroad Retirement Board
  • Office of Personnel Management

If you don’t get these benefit payments, you’ll get a bill.

Most people will pay the standard monthly premium amount. If your income earnings is above a certain amount, you may pay what Medicare calls Income Related Monthly Adjustment Amount also known as (IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago. This is the most recent tax return information provided to Social Security by the IRS.

The standard Part B premium amount in 2021 is $148.50. Most people will pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your monthly premium.

 

If your yearly income in 2019 (for what you pay in 2021) was  

 

You pay each month (in 2021)

File individual tax return File joint tax return File married & separate tax return
$88,000 or less $176,000 or less $88,000 or less $148.50
above $88,000 up to $111,000 above $176,000 up to $222,000 Not applicable $207.90
above $111,000 up to $138,000 above $222,000 up to $276,000 Not applicable $297.00
above $138,000 up to $165,000 above $276,000 up to $330,000 Not applicable $386.10
above $165,000 and less than $500,000 above $330,000 and less than $750,000 above $88,000 and less than $412,000 $475.20
$500,000 or above $750,000 and above $412,000 and above $504.90

 

Part B  Deductible & Coinsurance

The deductible you pay is $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 these:

  • Most doctor services (including most doctor services while you’re a hospital inpatient)
  • Outpatient therapy
  • Durable medical equipment (DME)

 

What’s not covered by Part A & Part B?

Medicare doesn’t cover everything. If you need certain services Medicare doesn’t cover, you’ll have to pay for them yourself unless:

  • You have other insurance that covers them
  • You have a Medicare health plan that covers them

Even if Medicare covers a service or item, you generally have to pay your  deductiblecoinsurance, and copayment.

Some of the items and services that Medicare doesn’t cover include:

  • Long-term care (also called custodial care )
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and exams for fitting them
  • Routine foot care

 

Parts A and B together – make up what we call Original Medicare. They are the only 2 parts in Medicare that you will ever sign up for at the Social Security office or Railroad Retirement Board.

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare.  If you join a Medicare Advantage Plan, you still have Medicare.  These “Bundled” plans include  Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare prescription drug (Part D).

Medicare Advantage also called Part C

To enroll in a Part C plan, you must be enrolled in both Parts A and B.

You must live in the plan service area.

The most important element of  Medicare Advantage or Part C is that it is not Original Medicare. It is an alternative to Original Medicare and is managed by private insurers. This means that once you enroll, your Medicare coverage will come from the Advantage plan itself, and no longer from the government.

 

There are 2 ways to get medicare:

  1. Original Medicare (Government) 80% + Medicare Supplement (Private) 20% + Prescription Drug Plan (Private)
  2. Medicare Advantage (some includes Prescription Durg Plan, Dental, Vision, Hearing and Wellness Benefits)

This is a choice whether you wish to join a Medicare Advantage Plan or just stay with your original Medicare A & B and enrolling in Medigap / Medicare Supplement Plan. Call us and we can help you determine the best path that will work for you.

 

Who provides coverage?

Private insurance companies approved by Medicare like UnitedHealthCare, Humana, Anthem, Aetna, etc.

 

How come I do not enroll in it at Social Security like A & B?

Because Part C is voluntary. Some people prefer to get their Medicare coverage from Original Medicare and traditional Medicare Supplement plans. Others do not mind being in a network and like having just one plan that includes all of the services provided by Original Medicare, Prescription Drug Plan, Dental, Vision and other Wellness benefits all wrapped into one plan with one monthly premium.

 

How do you choose your providers?

We can help you determine the best plans in your area and personalize it to your needs. You choose the one the works best for you.

 

How much does it cost?

  • You usually pay a low and sometimes no monthly premium for your MA Plan (in addition to your monthly Part B premium).
  • You may pay a co-payment or coinsurance for covered services. Many MA plans offer vision, hearing, and dental coverage. Costs, extra coverage, and rules vary by plan.
  • Plans have a yearly limit on your out-of-pocket costs. Once you reach a certain limit, you’ll pay nothing for covered services for the rest of the year.
  • Your out-of-pocket costs may be lower in an MA plan.

 

Medicare Advantage Plans cover all Medicare services

Medicare Advantage Plans must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgently needed care.

The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare. If you’re not sure whether a service is covered, check with your provider before you get the service.

Most Medicare Advantage Plans offer coverage for things that aren’t covered by Original Medicare, like vision, hearing, dental, and wellness programs (like gym memberships). Plans can also cover more extra benefits including services like transportation to doctor visits, over-the-counter drugs, adult day-care services, meal plans, and other health-related services that promote your health and wellness.

Plans can also tailor their benefit packages to offer these new benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat those conditions. Check in with us to see what benefits are offered on every plan available in Nevada.

Most include Medicare prescription drug coverage (Part D).

 

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D).

You may be able to join a stand-alone prescription drug plan if you enroll in a plan that does have prescription drug plan:

  • Can’t offer drug coverage (like Medicare Medical Savings Account plans)
  • Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these occur:

  • You move out of the plan’s service area.
  • You join a separate Medicare Prescription Drug Plan.

Covers Your Retail Prescription Drugs

Part D is a federally created program to help you lower the cost of your retail prescription drugs. Unlike Medicare Part A & B, you will not enroll in Part D through the Social Security office. Instead, you will select one of the Part D plans available in your county from private insurance carriers. By signing up for that plan, you will have enrolled in Part D.

Medicare drug plans are optional. You’ll have a monthly premium that you will pay to the insurance carrier. In return, they give you significantly lower copays on your medicines than you would pay if you had no Part D insurance.

Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. This page explains how to get prescription drug coverage and offers tips for making the right choices for you.

If you decide NOT to get Medicare drug coverage when you’re first eligible, you’ll likely pay a late enrollment penalty if you join later, unless one of these applies:

  • You have other creditable prescription drug coverage
  • You get Extra Help

Generally, you’ll pay this penalty for as long as you have Medicare prescription drug coverage.

To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.

There are 2 ways to get prescription drug coverage

  1. Medicare Prescription Drug Plan (Part D) . These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
  2. Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.

See if any of these apply to you:

I take specific drugs: We can go over all the drug plans that include your prescription drugs on their Formulary (a list of prescription drugs covered by a drug plan). Then find the plan that will cover all your medication at the lowest cost.
I want extra protection from high prescription drug costs: We can go over the drug plans offering coverage in the coverage gap, and then check with those plans to make sure they cover your drugs in the gap.
I want my drug expenses to be balanced throughout the year: We can look at the drug plans with No or  Low Deductible, or with additional coverage in the coverage gap.
I take a lot of generic prescriptions: We can look at drug plans with “tiers” that charge you nothing or low co-payments for generic prescriptions.
I don’t have many drug costs now, but I want coverage for peace of mind and to avoid future penalties: We can look at the drug plans with a low to sometimes $0 monthly premium for drug coverage. If you
need prescription drugs in the future, all plans still must cover most drugs used by people with Medicare.
I like the extra benefits and lower costs available by getting my health care and prescription drug coverage from one plan, and I’m willing to pick a drug plan with restrictions on what doctors, hospitals, and other health care providers I can use: We can go over all the Medicare Advantage Plans with prescription drug coverage that are available in your county.

 

Joining a Medicare drug plan may affect your Medicare Advantage Plan 

Your Medicare Advantage Plan (Part C) will disenroll you and you’ll go back to Original Medicare if both of these apply:

  • Your Medicare Advantage Plan includes prescription drug coverage.
  • You join a Medicare Prescription Drug Plan (Part D)

There are rules for when you can enroll and dis-enroll from these drug plans, so be sure to Contact Us for more details about how your drug coverage under Medicare will work.

Many people confuse the terms Parts and Plans. There are only 4 Medicare Parts:

  1. Part A
  2. Part B
  3. Part C
  4. Part D

We’ve had consumers ask us about their Part F or that they cancelled their Plan B. All the other letters are Medigap plans. Medigap plans are optional supplemental coverage that you can buy to fill in the gaps in Medicare (Government). You don’t enroll in these at the Social Security office.

After you have joined Medicare and received your new Medicare card then you can choose you Medicare Supplement plan.

Everyday we explain Medicare parts and how they work to folks like you and you too will soon be an expert at different parts of Medicare, how they work and what they cover. If you need help understanding Medicare coverage, the first step to setting up proper coverage and a plan that will work for you is knowledge. Let us help you answer your questions and guide you through the Medicare maze. Contact Us Remember, our help is always 100% free.