Medicare Benefits

Medicare is divided into two types of coverage. Hospitalization insurance (Part A) pays hospital bills and certain skilled nursing facility expenses. Medical insurance (Part B) pays doctors' bills and certain other charges.

Medicare's health benefits include coverage for certain health care services and durable medical equipment. To have full Medicare coverage, Medicare beneficiaries must have both Part A (hospital insurance) and Part B (medical insurance).


Part A (Hospital Insurance Benefits)

Part A helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions. Most people do not have to pay a monthly payment, called a premium, for Part A because they or a spouse paid Medicare taxes while they were working. You are eligible for premium-free Medicare Part A if:

  • You are 65 or older. You are receiving or eligible for retirement benefits from Social Security or the Railroad Retirement Board, or
  • You are under 65. You have received Social Security disability benefits for 24 months, or
  • You are under 65. You have received Railroad Retirement disability benefits for the prescribed time and you meet the Social Security Act disability requirements, or
  • You or your spouse had Medicare-covered government employment, or
  • You are under 65 and have end-stage renal disease.

If you (or your spouse) did not pay Medicare taxes while you worked and you are age 65 or older, you still may be able to buy Part A. The Part A premium for people who are not eligible for premium-free Part A is $407.00 per month in 2015.

If you do not get premium-free Part A, you may be able to buy it:

  • If you (or your spouse) are not entitled to Social Security because you did not work or did not pay enough Medicare taxes while you worked and are age 65 or older, or
  • If you are disabled but no longer get free Part A because you returned to work.

If you are not sure if you have Part A, look on your red, white, and blue Medicare card. If you have Part A, Hospital (Part A) is printed on the lower left corner of your card. You can also call the Social Security Administration at 1-800-772-1213 or call your local Social Security Office for more information about buying Part A. If you get benefits from the Railroad Retirement Board (RRB) call your local RRB office or 1-800-808-0772.


Part B (Medical Insurance)

Part B helps pay for your doctors' services, outpatient hospital care and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. You may receive these services anywhere (a doctor's office, clinic, nursing home, hospital, or at home) when they are medically necessary. It does not cover prescription drugs, dental care, physicals, or other services not related to treatment of illness or injury.

Enrolling in Part B is your choice. There are three times when you can sign up for Medicare Part B:

  • Initial Enrollment Period
  • General Enrollment Period
  • Special Enrollment Period

Initial Enrollment Period

If you are turning age 65 in the next three months and have not applied for Social Security or Railroad Retirement benefits, or Medicare Part A, you can sign up for Medicare Part B when you apply for retirement benefits or Medicare Part A. You can sign up for Part B during your Initial Enrollment Period. The Initial Enrollment Period:

  • Begins three months before the month you turn age 65.
  • Ends three months after the month you turn age 65.

Note: Start date for Medicare Part B may be delayed if you wait until you are 65 or sign up during the last three months of your Initial Enrollment Period. To apply, you can visit your local Social Security office or call Social Security at 1-800-772-1213. You may be able to apply at www.socialsecurity.gov if you meet certain conditions. If you are a railroad employee or railroad retirement beneficiary, contact your local Railroad Retirement Board (RRB) field office at www.rrb.gov/accessrrbgov/ZipLocator/zip_enter.asp or call 1-800-808-0772 to apply.

Note: Information is available at www.medicare.gov to help you make decisions about joining Medicare Part B.

General Enrollment Period

If you did not sign up for Medicare Part B when you first became eligible, you may sign up during the General Enrollment Period. Below is specific information about the General Enrollment Period:

  • The General Enrollment Period runs from January 1 through March 31 of each year.
  • Your Medicare Part B coverage will start on July 1 of the year you sign up.
  • The cost of Medicare Part B will go up 10% for each 12-month period that you could have had Medicare Part B but did not take it, except in special cases. You will have to pay this extra amount as long as you have Medicare Part B.
  • During this time, you can sign up for Medicare Part B at your local Social Security office. If you get benefits from the RRB, call your local RRB field office www.rrb.gov/accessrrbgov/ZipLocator/zip_enter.asp or 1-800-808-0772.

Special Enrollment Period

This period is available if you are eligible for Medicare and waited to enroll in Medicare Part B because you or your spouse were working and had group health plan coverage through an employer or union based on this current employment. If this applies to you, you can sign up for Medicare Part B:

  • Any time you are still covered by an employer or union group health plan, through your or your spouse's current employment, or
  • During the eight months following the month that the employer or union group health plan coverage ends or when the employment ends (whichever is first).

If you already get Social Security or Railroad Retirement benefits, you are automatically enrolled in Part B starting the first day of the month you turn age 65. If you are under age 65 and disabled, you are automatically enrolled in Part B after you get Social Security or Railroad Retirement benefits for 24 months. Your Medicare card will be mailed to you about three months before your 65th birthday or your 25th month of disability benefits. If you do not want Medicare Part B, follow the instructions that came with the Medicare card.

If you sign up for Part B coverage, the premium for 2015 is $104.90 per month. The Part B premium is determined by a means test. See below for details. This amount is automatically taken out of your Social Security check each month. New premium rates become effective every January. In some cases, this amount may be higher if you did not sign up for Part B when you first became eligible. The cost of Part B may go up 10% for each 12-month period that you could have had Part B but did not sign up for it. You will have to pay this extra amount as long as you have Part B, except in special cases.

Your Part B Premium is Based on Your Income

As required in the federal Medicare Modernization Act of 2003 (MMA), in 2008, single Medicare beneficiaries with annual incomes over $85,000 and married couples with incomes over $170,000 will pay a higher percentage of the cost of Medicare Part B coverage, reducing Medicare's share. These higher-income beneficiaries will pay a monthly premium equal to 35, 50, 65, or 80 percent of the total cost, depending on their income level, by the end of the 3-year transition period.

Part B Income-Related Premium

The 2015 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return, including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year, or joint tax return are:

Beneficiaries who file an individual tax return with income:Beneficiaries who file a joint tax return with income:Income-related monthly adjustment amountTotal monthly premium amount
Less than or equal to $85,000Less than or equal to $170,000$0.00$104.90
Greater than $85,000 and less than or equal to $107,000 Greater than $170,000 and less than or equal to $214,000$42.00$146.90
Greater than $107,000 and less than or equal to $160,000Greater than $214,000 and less than or equal to $320,000$104.90$209.80
Greater than $160,000 and less than or equal to $213,000Greater than $320,000 and less than or equal to $426,000$167.80$272.70
Greater than $214,000Greater than $428,000$230.80$335.70

In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at some time during the taxable year are:

Beneficiaries who are married but file a separate tax return from their spouse:Income-related monthly adjustment amountTotal monthly premium amount
Less than or equal to $85,000$0.00$104.90
Greater than $85,000 and less than or equal to $129,000$167.80$272.70
Greater than $129,000$230.80$335.70

If you choose to enroll in Part B, the premium is usually taken out of your monthly Social Security, Railroad Retirement, or Office of Personnel Management retirement payment. In these cases, you will not get a bill for your premium. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every three months. If you do not get your bill by the 10th of the month, call the Social Security Administration at 1-800-772-1213 or your local Social Security Office. If you get benefits from the Railroad Retirement Board (RRB), call your local RRB office or 1-800-808-0772.

If you are close to age 65 and are not yet getting either Social Security or Railroad Retirement Benefits or Medicare, you can apply for both at the same time. You can also apply for Medicare only. You can sign up for Part B during your Initial Enrollment Period. Your Initial Enrollment Period begins three months before the month you turn 65 and ends three months after you turn 65. If you wait until you are 65, or sign up during the last three months of your Initial Enrollment Period, your Medicare Part B start date will be delayed. To apply you can call or visit your local Social Security office, or call Social Security at 1-800-772-1213. You may be able to apply at the Social Security Administration on the Web if you meet certain rules.


2015 Part A Hospital Insurance Benefits

Inpatient Hospital Care
(Semi-private room and meals, general nursing and miscellaneous hospital services) For Each Benefit Period*

You pay:

  • The first $1,260.00 in each benefit period**
  • $315.00 a day coinsurance for days 61 through 90**
  • All charges for coverage after 90 days in any benefit period unless you have "lifetime reserve" days available and use them
  • $630.00 a day coinsurance for each lifetime reserve day used**
  • All costs after 150th day

Skilled Nursing Facility Coverage (SNF)

You Pay:

  • Nothing to the 21st day
  • $157.50 daily coinsurance for days 21 through 100 in each benefit period**
  • All costs for care after 100 days in a benefit period*
  • All costs for care that is less than the level of care Medicare covers in a SNF
  • All costs if you were not transferred to the SNF in a timely manner after a qualifying hospital stay
  • For care in a general nursing home, or in a SNF not approved by Medicare, or just custodial care in a Medicare-approved SNF
  • The first 3 pints of blood unless you or someone else donates blood to replace what you use
Hospital Stays
Semiprivate room, meals, general nursing, and other hospital services and supplies. This includes inpatient care you get in critical access hospitals and mental health care. This does not include private duty nursing or a television or telephone in your room. It also does not include a private room, unless medically necessary. Inpatient mental health care in a psychiatric facility is limited to 190 days in a lifetime.
Skilled Nursing Facility Care
Semiprivate room, meals, skilled nursing and rehabilitative services, and other services and supplies (only after a related three-day inpatient hospital stay).
Home Health Care
Limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy, and speech-language therapy that are ordered by your doctor and provided by a Medicare-certified home health agency. Also includes medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Hospice Care
For people with a terminal illness, includes drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare (grief counseling). Hospice care is usually given in your home (which may include a nursing facility if this is your home). However, Medicare covers some short-term hospital and inpatient respite care (care given to a hospice patient so that the usual caregiver can rest).
Blood
Pints of blood you get at a hospital or skilled nursing facility during a covered stay.

Costs for these services vary, depending on the plan you choose.

*A benefit period begins the first day that you receive inpatient hospital or skilled nursing facility services and ends after you are no longer in the hospital or the skilled nursing facility for 60 consecutive days.
**Deductible and coinsurance are for 2015 only.


Part B Medical Insurance Benefits

You Pay:

  • $147.00 annual deductible
  • 20% of all Medicare-approved charges. Medicare pays 80% of the approved charges. You pay the difference between the approved and actual or limiting charge, whichever is less

Note: Unless your doctor or other health care provider accepts Medicare assignment, you are responsible for any charges that are higher than those approved by Medicare. You are also responsible for any services that Medicare considers unnecessary. Call your Medicare carrier if you have questions about your Medicare Part B coverage.

Medical and Other Services
Doctors' services (not routine physical exams except for a "Welcome to Medicare" one-time physical exam within the first six months you have Part B), outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers). It also covers a second, and sometimes a third, surgical opinion for surgery that is not an emergency (in some cases), outpatient mental health care, and outpatient occupational and physical therapy, including speech-language services. (These services are also covered for long-term nursing home residents.)
Clinical Laboratory Services
Blood tests, urinalysis, some screening tests, and more.
Home Health Care
Limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services as well as physical therapy, occupational therapy, and speech-language therapy that are ordered by your doctor and provided by a Medicare-certified home health agency. Also includes medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.
Outpatient Hospital Services
Hospital services and supplies received as an outpatient as part of a doctor's care.
Blood
Pints of blood you get as an outpatient or as part of a Part B-covered service.
Custodial Care in a Nursing Home, Dental Care, Eye Care, Hearing Aids, Routine Check-ups
You pay for all these items.

Costs for these services vary, depending on the plan you choose.