Medicare coverage5 Important points about Medicare Part A and B coverage gaps
The term “Original Medicare” refers to Medicare Part A and Part B. Part A helps cover the cost of hospital-related care, including inpatient services, lab tests and surgery. Part B is the medical insurance component of Medicare, which helps cover doctor visits, outpatient care and certain preventive services. Both Part A and Part B are administered by the federal government.
The alternative to Original Medicare is Medicare Advantage.
2. Will I pay a premium for Part A or Part B?
Most people don’t have to pay a premium for Part A as long as they or their spouse paid Medicare taxes for at least 10 years while they were working.
There's also no premium for Part A if:
- You're receiving Social Security or , opens new window benefits at the time you enroll
- You’ve received disability benefits for at least 24 months.
There is a monthly premium for Part B, which is deducted from your Social Security or, for those who receive them, from their RRB benefits. For 2019, the standard premium for Part B coverage is $135.50, although some may pay a higher premium based on income.1
3. Are there any other costs for Original Medicare?
In addition to premiums, plan members are also responsible for paying a deductible and coinsurance with Original Medicare. The 2019 deductible for inpatient hospital stays is $1,364 per benefit period. The annual deductible for Part B is $185. Coinsurance is typically 20% of the Medicare-approved amount for most services.
4. What is a Medicare Advantage plan?
Medicare Advantage plans are offered by private insurance companies—like Humana—contracted by the federal government. Medicare Advantage, also referred to as Medicare Part C, covers the same healthcare services as Original Medicare, with the exception of hospice care. Many Medicare Advantage plans also include prescription drug coverage.
In addition, many Medicare Advantage plans include coverage for vision, dental and hearing care. Health and wellness benefits like fitness programs may be offered, as well.
5. How much does Medicare Advantage cost?
With Medicare Advantage plans, instead of paying your healthcare bills directly, the federal government pays private insurance companies—like Humana—to administer your coverage.
While there is a monthly premium for Medicare Advantage plans, many private insurance companies choose to offer affordable or $0 plan premiums to compete for your business. They also set the guidelines for your deductible, coinsurance and copays. This information is readily available on private insurers’ websites, or you can make an appointment with a licensed Humana sales agent to learn the details.
As with Original Medicare members, Medicare Advantage members must continue to pay their Part B premium.
6. Are prescription drugs covered by Medicare?
There are 2 ways to get Medicare prescription drug coverage:
- You can choose a Medicare Advantage plan that includes prescription drug coverage (these are called Medicare Advantage prescription drug plans)
- You can purchase a stand-alone prescription drug plan—called Part D—to add to your Original Medicare
Your out-of-pocket costs for prescription drug deductibles, copays and coinsurance vary from plan to plan. Be sure to check each plan’s Drug List (list of covered drugs) to see what drugs are covered.
7. What is supplemental Medicare coverage?
Medicare Supplement insurance, often called Medigap coverage, helps pay some of the healthcare costs that Original Medicare doesn't coverpay. That may include:
- Medical care , opens new window
You'll pay a monthly premium for a Medicare Supplement plan in addition to your Part B premiums. Medicare Supplement plans are not available with Medicare Advantage plans.
8. Can I get Medicare with a pre-existing condition?
Yes, even with a preexisting condition, you can enroll in Original Medicare or a Medicare Advantage plan as long as you sign up for coverage during your initial enrollment period. This is the 7-month window that starts 3 months before your birth month and continues through the 3 months after your birth month in the year you turn 65.
Note: With Medicare Advantage, you can't enroll in a plan if you have end-stage kidney disease.
9. Can I choose my doctor?
With Original Medicare, a primary care doctor is not required. You can visit any doctor who accepts Medicare.
With a Medicare Advantage plan, your choice of doctor depends on whether you select a health maintenance organization (HMO) or preferred provider organization (PPO) plan.
With an HMO plan, you can choose your primary care physician from any doctor in the plan's network. If you opt for a PPO plan, generally, choosing a primary care physician is optional. With both types of plans, you’ll usually save money by visiting a network provider.
It’s important to note that Medicare Advantage plans must offer emergency coverage outside of the plan's service area, anywhere in the U.S.
10. Can I use Medicare everywhere in the U.S.?
Medicare is widely accepted across the United States, but it's not universal. When reviewing plan options, pay close attention to which providers in your area accept Medicare to ensure that you have access to care when you need it.
- “Part B Costs,” Medicare.gov, last accessed May 2, 2019, , opens new window.
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