Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. 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. The following information will help clear up some of the confusion, making it easier to select the coverage you need.
Part A Coverage
- Hospital care
- Skilled nursing facility care
- Nursing home care (as long as custodial care isn't the only care you need)
- Home health services
Part A Costs
You usually don't pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes while working. This is sometimes called "premium-free Part A." If you buy Part A, you'll pay up to $411 each month. You can get premium-free Part A at 65 if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You're eligible to get Social Security or Railroad benefits but haven't filed for them yet.
- You or your spouse had Medicare-covered government employment.
If you're under 65, you an get premium-free Part A if:
- You got Social Security or Railroad Retirement Board disability benefits for 24 months.
- You have End-Stage Renal Disease (ESRD) and meet certain requirements.
Part B Covers 2 types of Services:
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
Part B covers things like:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health
- Partial hospitalization
- Getting a second opinion before surgery
- Limited outpatient prescription drugs
How much does Part B cost? Part B premiums include:
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. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.
The standard Part B premium amount is $121.80 (or higher depending on your income). However, most people who get Social Security benefits will continue to pay the same Part B premium amount as they paid in 2015. This is because there wasn't a cost-of-living increase for 2016 Social Security benefits.
You'll pay a different premium amount if:
- You enroll in Part B for the first time in 2016.
- You don't get Social Security benefits.
- You're directly billed for your Part B premiums.
- You have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard premium amount of $121.80.)
- Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount.
If you're in 1 of these 5 groups, here's what you'll pay:
|If your yearly income in 2014 (for what you pay in 2016) was...||You pay (in 2016)|
|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||$121.80|
|above $85,000 up to $107,000||above $170,000 up to $214,000||Not applicable||$170.50|
|above $107,000 up to $160,000||above $214,000 up to $320,000||Not applicable||$243.60|
|above $160,000 up to $214,000||above $320,000 up to $428,000||above $85,000 and up to $129,000||$316.70|
|above $214,000||above $428,000||above $129,000||$389.80|
Part B deductible & coinsurance
You pay $166 per year for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy, and durable medical equipment.