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Medicare Choices Made Easy

Medicare Part A-B-C-D

In general, Part A covers:

 

Inpatient hospital care

How often is it covered?

Medicare Part A (Hospital Insurance) covers hospital services, including semi-private rooms, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care you get in these facilities:

 

  • Acute care hospitals

  • Critical access hospitals

  • Inpatient rehabilitation facilities

  • Long-term care hospitals

It also includes inpatient care as part of a qualifying clinical research study and inpatient mental health care given in a psychiatric hospital or other hospital.

What's not covered

 

  • Private-duty nursing

  • Private room (unless medically necessary)

  • Television and phone in your room (if there's a separate charge for these items)

  • Personal care items, like razors or slipper socks

Who's eligible?

All people with Part A are covered when all of these are true:

 

  • A doctor makes an official order which says you need 2 or more nights of medically necessary to treat your illness or injury and the hospital formally admits you.

  • You need the kind of care that can be given only in a hospital.

  • The hospital accepts Medicare.

  • The Utilization Review Committee of the hospital approves your stay while you're in a hospital.

Your costs in Original Medicare

 

  • $1,364 deductible for each benefit period.

  • Days 1–60: $0 coinsurance for each benefit period.

  • Days 61–90: $341 coinsurance per day of each benefit period.

  • Days 91 and beyond: $682 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime).

  • Beyond lifetime reserve days: all costs.

Note

You pay for private-duty nursing, a television, or a phone in your room. You pay for a private room unless it's medically necessary.

 

Part A premium, Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $437 each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $437. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $240.  

Part B premiums

You pay a premium each month for Part B. If you get Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, your Part B premium will be automatically deducted from your benefit payment. If you don’t get these benefit payments, you’ll get a bill. 

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

2019

The standard Part B premium amount in 2019 will be $135.50 (or higher depending on your income). However, some people who get Social Security benefits pay less than this amount ($130 on average). You'll pay the standard premium amount (or higher) if:

 

  • You enroll in Part B for the first time in 2019.

  • You don't get Social Security benefits.

  • You're directly billed for your Part B premiums (meaning they aren't taken out of your Social Security benefits).

  • You have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard premium amount of $135.50)

  • Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount. If so, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

If your yearly income in 2017 (for what you pay in 2019) was then You pay each month (in 2019)

File individual tax return File joint tax return File married & separate tax return

$85,000 or less$170,000 or less$85,000 or less$135.50

above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable$189.60

above $107,000 up to $133,500 above $214,000 up to $267,000 Not applicable$270.90

above $133,500 up to $160,000 above $267,000 up to $320,000 Not applicable$352.20

above $160,000 and less than $500,000 above $320,000 and less than $750,000 above $85,000 and less than $415,000 $433.40

$500,00 0 or above$750,000 and above$415,000 and above$460.50

Part B deductible & coinsurance

You pay $185 per year 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 

Note

In 2018, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits. Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost.

A drug in a lower tier will generally cost  

It may be to your advantage to join a Medicare Prescription Drug Plan because most Medigap drug coverage isn't creditable. You may pay more if you join a drug plan later.

Medigap policies can no longer be sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. If you join a Medicare drug plan, your Medigap insurance company must remove the prescription drug coverage under your Medigap policy and adjust your premiums. Call your Medigap insurance company for more information.

 you less than a drug in a higher tier. Sometimes, if your prescriber thinks you need a drug that's on a higher tier, you or your prescriber can ask your plan for an exception to get a lower copayment.

A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:

 

  • Provide written notice to you at least 60 days prior to the date the change becomes effective.

  • At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.  

Part B late enrollment penalty

In most cases, if you don't sign up for Part B when you're first eligible, you'll have to pay a late enrollment penalty. You'll have to pay this penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it. Also, you may have to wait until the General Enrollment Period (from January 1 to March 31) to enroll in Part B. Coverage will start July 1 of that year.

Usually, you don't pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period.

If you have limited income and resources, your state may help you pay for Part A, and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.

 

Part C ( Medicare Advantage )

 

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 extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.

In 2019, the standard Part B premium amount is $135.50 (or higher depending on your income). However, some people who get Social Security benefits pay less than this amount ($130 on average in 2019).

If you need a service that the plan says isn't medically necessary, you may have to pay all the costs of the service. But, you have the right to appealthe decision.

You can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won't pay for a service you think you need, you'll have to pay all of the costs if you didn't ask for an advance coverage decision. 

Part D - Drugs

 

2 ways to get 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.

 

Monthly premium for drug plans

Most Medicare Prescription Drug Plans charge a monthly fee that varies by plan. You pay this in addition to the Medicare Part B premium. If you join a Medicare Advantage Plan (Part C) or Medicare Cost Planthat includes Medicare prescription drug coverage, the plan's monthly premium may include an amount for drug coverage.

Get your premium automatically deducted

Contact your drug plan (not Social Security) if you want your premium deducted from your monthly Social Security payment. Your first deduction will usually take 3 months to start, and 3 months of premiums will likely be deducted at once.

After that, only one premium will be deducted each month. You may also see a delay in premiums being withheld if you switch plans. If you want to stop premium deductions and get billed directly, contact your drug plan.

How much does Part D cost?

Most people only pay their Part D premium. If you don't sign up for Part D when you're first eligible, you may have to pay a Part D late enrollment penalty.

If your modified adjusted gross income is above a certain amount, you may pay a Part D income-related monthly adjustment amount (Part D-IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS). You'll pay the Part D-IRMAA amount in addition to your monthly plan premium, and this extra amount is paid directly to Medicare, not to your plan. The chart below lists the extra amount costs by income.

Social Security will contact you if you have to pay Part D-IRMAA, based on your income. The amount you pay can change each year. If you have to pay a higher amount for your Part D premium and you disagree (for example, if your income goes down), use this form to contact Social Security [PDF, 125 KB].  If you have questions about your Medicare prescription drug coverage, contact your plan.

Note

The extra amount you have to pay isn’t part of your plan premium. You don’t pay the extra amount to your plan. Most people have the extra amount taken from their Social Security check. If the amount isn’t taken from your check, you’ll get a bill from Medicare or the Railroad Retirement Board. You must pay this amount to keep your Part D coverage.

If Social Security notifies you about paying a higher amount for your Part D coverage, you’re required by law to pay the Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA).  If you don’t pay the Part D-IRMAA, you’ll lose your Part D coverage.

Employer/Union coverage and Part D-IRMAA

Note

You pay your Part D-IRMAA directly to Medicare, not to your plan or employer.

You’re required to pay the Part D-IRMAA, even if your employer or a third party (like a teacher’s union or a retirement system) pays for your Part D plan premiums. If you don’t pay the Part D-IRMAA and get disenrolled, you may also lose your retirement coverage and you may not be able to get it back.

Things to remember

 

  • Pay your Part D-IRMAA bill to Medicare as soon as you get it. Find out how to pay your bill.

  • Keep your address current with Social Security, even if you don’t get a Social Security check.

Part D premiums by income

The chart below shows your estimated prescription drug plan monthly premium based on your income as reported on your IRS tax return. If your income is above a certain limit, you'll pay an income-related monthly adjustment amount in addition to your plan premium. 

2019

If your filing status and yearly income in 2017 was

File individual tax return File joint tax return File married & separate tax return ,You pay each month (in 2019)

$85,000 or less$170,000 or less$85,000 or less your plan premium

above $85,000 up to $107,000 above $170,000 up to $214,000 not applicable$12.40 + your plan premium

above $107,000 up to $133,500 above $214,000 up to $267,000 not applicable$31.90 + your plan premium

above $133,500 up to $160,000 above $267,000 up to $320,000 not applicable$51.40 + your plan premium

above $160,000 and less than $500,000 above $320,000 and less than $750,000 above $85,000 and less than $415,000 $70.90 + your plan premium

$500,000 or above$750,000 and above$415,000 and above$77.40 + your plan premium

 

How much is the Part D penalty?

The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.

Medicare calculates the penalty by multiplying 1% of the "national base beneficiary premium" ($35.02 in 2019) times the number of full, uncovered months you didn't have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.

The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.

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