Medicare Questions & Answers: Medicare Part A
Medicare Part A Q&A
Showing 39 questions
Is it ok to meet with multiple Medicare Brokers and Agents as I start looking for help?
Yes, it is absolutely okay to meet with multiple Medicare brokers or agents as you start looking for help.As an agency owner and licensed agent myself, I actually think it is smart to compare who you are working with. Medicare is not a one-size-fits-all decision, and the person helping you should be focused on education first, not just enrollment.
Here are a few good questions to ask:
1. Do you offer the major carriers available in my ZIP code?
You want to know whether they can compare multiple options or if they are limited to only a few plans.
2. What does your enrollment process look like?
Listen for an answer that starts with education, doctor review, prescription review, plan comparison, and making sure you understand the trade-offs before enrolling.
3. Do you provide annual plan reviews?
Medicare is not a set-it-and-forget-it product. Plans, doctor networks, drug formularies, copays, and benefits can change every year. Ask them to explain exactly how they handle annual reviews and what kind of ongoing support they provide after enrollment.
The goal is to find someone who will help you understand your options, compare plans clearly, and support you beyond the initial enrollment.
Have a blessed day!
What's the financial risk of sticking with Original Medicare without a Medigap plan?
Sticking with Original Medicare (Parts A and B) without a Medigap (Medicare Supplement) plan can expose you to significant out-of-pocket costs because Medicare doesn’t have an annual limit on what you might pay for covered services. You’re responsible for 20% of all Part B expenses — including doctor visits, outpatient care, surgeries, and medical equipment — after meeting your deductible. If you face a serious illness or require frequent treatments such as chemotherapy, dialysis, or hospital stays, those 20% coinsurance payments can add up quickly and create major financial strain.In addition, Original Medicare doesn’t cover many common healthcare needs such as prescription drugs, routine dental or vision care, or extended stays in skilled nursing facilities beyond the limited covered period. Without a Medigap plan to help fill those coverage gaps, beneficiaries are essentially “self-insuring” against potentially high medical bills, making them financially vulnerable in the event of unexpected or chronic health issues.
I just enrolled in Medicare, and I've got my Part A and B, but I'm hearing there are gaps in coverage. What are these gaps exactly?
Yes — even with Original Medicare (Parts A & B), there are coverage gaps you should be aware of. Here’s the short breakdown:1. No prescription drug coverage
Part B covers some medications administered in a doctor’s office, but most prescriptions you fill at a pharmacy aren’t covered.
Solution: Add a Part D prescription drug plan.
2. No routine dental, vision, or hearing
Exams, glasses, hearing aids, and most dental work are not covered.
Some Medicare Advantage plans include limited benefits.
3. Long-term care
Medicare does not cover custodial care (assisted living, nursing home stays beyond short rehab).
Only short-term skilled nursing after hospitalization is covered.
4. Out-of-pocket costs
Deductibles, copays, and coinsurance can be significant.
Part A has hospital deductibles; Part B has a monthly premium and 20% coinsurance for most services.
Solution: Consider Medigap (Supplement) coverage.
5. Limited preventive coverage
Part B covers many preventive services, but some screenings or therapies may require extra approval or cost-sharing.
Bottom line: Original Medicare covers hospital and medical services but leaves gaps in prescriptions, dental/vision/hearing, long-term care, and out-of-pocket expenses.
I thought I signed up for both Part A and B when I got my Social Security, but now I'm getting bills for Part B. Did I miss something during the enrollment period?
Many people believe that when they sign up for Social Security, everything under Medicare is free. That is not exactly how it works.Medicare Part A usually does not have a monthly premium if you worked and paid Medicare taxes for at least 40 quarters, which equals 10 years. If someone worked fewer than 40 quarters, they may have a monthly premium under Part A.
Medicare Part B is different. Part B always has a monthly premium. The standard premium changes each year. For 2026, it is $202.90. Some individuals with higher incomes may pay more due to income IRMAA adjustments.
If you are receiving Social Security benefits, the Part B premium is usually deducted automatically from your monthly check. If you are not yet collecting Social Security, Medicare will send you a quarterly bill.
Receiving a bill does not necessarily mean you missed your enrollment period. It usually just means that Part B has a premium that must be paid directly.
If someone delays enrolling in Part B and does not have other creditable coverage, they face a late enrollment penalty. The penalty is 10 percent for every full 12-month period a person was eligible but not enrolled, and that penalty continues for as long as they have Part B.
If you would like, we can review your enrollment timeline together to make sure everything was processed correctly.
Educational Disclosure:
This information is provided for educational purposes only and is not a guarantee of benefits. Medicare premiums, deductibles, and penalties may change annually. Income adjustments may apply. I am not affiliated with or endorsed by the federal government or the Medicare program. For official Medicare information, please visit www.medicare.gov
or call 1-800-MEDICARE.
Janix Barbosa-Llanos, MBA, PMP, CEP, RSSA, FSN
Licensed Health Insurance Broker
I chose Original Medicare to keep my doctors, but now I'm drowning in bills. Should I have gone with Advantage instead?
Choosing Original Medicare was not a mistake, but you missed a critical piece of the puzzle: a Medicare Supplement (Medigap) plan.Original Medicare (Parts A and B) is excellent for keeping your doctors, but it has no safety net. It only covers 80% of your outpatient bills, leaving you responsible for the remaining 20% out-of-pocket with no lifetime limit. If you face a serious medical issue, that 20% can easily lead to financial disaster.
Option 1: Add a Medigap (Medicare Supplement) Plan. This is the most direct fix if you want to keep your unlimited doctor access. Medigap plans are private insurance policies designed specifically to step in and pay that remaining 20% coinsurance for you.
The Primary Benefit: You keep 100% of your current doctors and can see any specialist in the country who accepts Medicare—no networks, no referrals, and no pre-authorizations.
The Cost Structure: You will pay a predictable monthly premium (usually between $120 and $250 a year, depending on your age and location). In exchange, plans like Plan G cover virtually all of your leftover medical bills, reducing your out-of-pocket medical expenses to almost zero
The Catch (Underwriting): Because you did not enroll in Medigap when you first started Part B, you may have passed your initial Medigap Open Enrollment Period. In most states (including New Jersey), private insurers are now allowed to look at your medical history and can deny you coverage or charge you more based on pre-existing conditions.
Option 2: Switch to a Medicare Advantage Plan
If you cannot pass medical underwriting for a Medigap plan, or if you cannot afford a monthly Medigap premium, switching to Medicare Advantage (Part C) is your alternative safety net. The Primary Benefit: These plans usually have $0 or very low monthly premiums, and they legally must include a Maximum Out-of-Pocket (MOOP) limit.
Part A Inpatient Hospital deductible $1,676 but if I have Part C Advantage Plan, the hospital $350 copay per day 1-7 so how does this work?
If you have Original Medicare (Part A and Part B), you’d normally pay the Part A inpatient hospital deductible, which in 2025 is $1,676 for each benefit period. After that deductible is paid, Medicare covers most of the cost for your hospital stay.However, if you have a Medicare Advantage (Part C) plan, that plan replaces Original Medicare coverage. You do not pay the Part A deductible — instead, you follow your plan’s own cost-sharing rules.
For example:
If your Medicare Advantage plan says $350 copay per day for days 1–7, that means each day you’re in the hospital (up to 7 days), you pay $350 per day. After that, the plan usually covers 100% for the rest of your stay (days 8–90), depending on the plan’s terms.
So in short:
You don’t pay both the Part A deductible and the $350 per day.
The Part C plan’s copay schedule replaces Medicare’s deductible and coinsurance.
Always check your Evidence of Coverage (EOC) for your plan’s exact inpatient hospital costs.
Why is regular Medicare better than an advantage plan?
This is one of the biggest debates in Medicare, and the answer depends on your priorities. Many people choose Medicare Advantage because the low premiums and extra benefits (like dental or vision) sound attractive. But here’s why Original Medicare (“regular Medicare”) is often considered better by doctors, hospitals, and patient advocates:Reasons why Original Medicare is often preferred include: 1. Freedom to See Any Doctor Nationwide. With Original Medicare, you can see any doctor or hospital in the U.S. that takes Medicare, no networks, no referrals. With Medicare Advantage, you’re limited to the plan’s network, and going out-of-network can mean big bills or no coverage at all; 2. Guaranteed Coverage for Medically Necessary Care; Original Medicare covers medically necessary care as defined by federal law. Medicare Advantage plans can require prior authorization, meaning the plan must approve before you get care.
This can delay or deny treatments; 3. No “Surprise” Network Changes. Doctors and hospitals can leave an Advantage network anytime during the year. With Original Medicare, as long as the provider accepts Medicare, you’re covered; 4. Easier When Traveling or Moving; Original Medicare works anywhere in the U.S.
Medicare Advantage plans are local/regional, move or travel, and your plan may not cover you. 5. Predictability with Medigap
If you add a Medigap supplement, your out-of-pocket costs with Original Medicare can be very low and predictable. Advantage plans have lower premiums up front, but if you get really sick, you could face thousands in costs (up to $8,850 per year in 2025, not including drugs).
The tradeoff is that Medicare Advantage = lower monthly costs, extra perks, managed care (but with restrictions). Original Medicare = more freedom, broader coverage, stronger protections (but you’ll likely pay more monthly if you add Medigap + Part D). Many people who value choice of doctors and fewer hassles prefer Original Medicare.
I'm on Original Medicare with no supplement, and I'm wondering how much I'd pay if I need an ambulance ride to the hospital tomorrow.
It’s hard to give you an exact number because ambulance charges vary by distance and service level, but here’s the general rule with Original Medicare and no supplement: ambulance rides are covered under Part B. You’d first pay the Part B deductible ($257 in 2025 if you haven’t met it yet), then 20% of Medicare’s approved amount for the ride. For example, if the approved amount was $1,000, your share would be about $450. One tip is to make sure the ambulance company accepts Medicare assignment, because if they don’t, your cost could be higher.
I just got Medicare Part A, and I'm worried about hospital stays. How do I know if my overnight stay will be covered fully?
The 2025 Medicare Part A deductible is $ 1,676 for the first 60 days of in-patient hospitalization. After that, it gets nasty: $ 419 copay per day for days 61 - 90 then $ 838 per day (that's not a typo!) for in-patient hospital stays for days 91 - 150. Noting that the average hospital stay for seniors ages 65 - 74 is 5.3 days (5.6 days for ages 75 - 84), most people with nothing other than Medicare Part A will be OK with the $ 1,676 deductible. But ... this is all about "what if" and to be on the hook for a monster bill (after 60 days of hospitalization) could be a financially catastrophic event, not to mention the physical issues. Get some insurance! Most Medicare plans have something called a "maximum out-of-pocket," or MOOP to protect yourself against a big hospital bill.
What happens if I delay Medicare Part A enrollment because I'm still on my spouse's employer plan?
If you delay Medicare Part A because you’re covered under your spouse’s active employer group health plan, you may be able to enroll later without a penalty — but it depends on the size of the employer.Here’s how it works:
• If your spouse works for a company with 20 or more employees, their employer plan usually pays first, and you can delay Part A (and Part B) without penalty.
• If the employer has fewer than 20 employees, Medicare typically becomes primary at age 65. In that case, delaying enrollment could leave you with coverage gaps and possible late penalties.
Most people qualify for premium-free Part A, so many enroll at 65 even if they keep employer coverage — but if you are contributing to an HSA, enrolling in Part A will stop you from being able to continue HSA contributions.
When your spouse retires or the employer coverage ends, you’ll qualify for a Special Enrollment Period (SEP) to sign up without penalty.
Because rules can vary depending on your situation, it’s always wise to review your specific coverage details before deciding to delay.
I signed up for part A. I'm still on my husband's insurance so I didn't sign up for part B. is there a form I need to fill out stating I'm still on my husbands insurance?
So the question is, I signed up for Part A, I'm still on my husband's insurance so I didn't sign up for Part B. Is there a form I need to fill out stating I'm still on my husband's insurance?
The first thing we need to pick apart is figuring out if your husband's or spouse's insurance is what's known as creditable coverage. Basically what that means is that it's as good as Medicare. Usually the insurance policy from your employer has to have prescription drug coverage, and it has to pay for hospital and medical services. One way to find out if it is deemed creditable is to basically find out from the benefits department of your employer or your spouse's employer.
As far as doing something to prove that you have insurance, you don't need to do that until the time comes for when you need to sign up for Part B. There's a form called a CMS L564 form, which is basically going to show Medicare, the government, that you've had health insurance and will not be hit with a late penalty for Part B.
And then there is a separate form if you have Part A already. That is known as a CMS 40B form, and that is your actual application for the Part B portion. What you do is you upload it on your Social Security portal to apply for Medicare.
But long short of it is that you do not have to prove anything at that time. It just comes down to when you are ready to retire. That's when you get those forms in place to apply.
I've heard Medicare covers home health care, but what exactly does that include?
Yes, Medicare covers home health services if you are homebound, need skilled care on a part-time or intermittent basis, and are under the care of a doctor.Covered services include skilled nursing care, physical and occupational therapy, speech-language pathology, and medical social services.
Medicare typically pays 100% of the approved costs for these services.
Eligibility Requirements:
Homebound: You have difficulty leaving your home without help, and it is a major effort to do so.
Skilled care: You need part-time or intermittent skilled nursing care or therapy services.
Doctor's order: A doctor or other qualified healthcare provider must certify that you need home health services and order your care.
Medicare-certified agency: Services must be provided by a Medicare-certified home health agency.
Services that may be covered:
Skilled nursing care: Wound care, injections, and education on managing a condition.
Therapy: Physical, occupational, and speech-language therapy.
Medical social services: Help with social and emotional issues related to your illness.
Home health aide: Medicare will pay for an aide if you also need skilled care, but not if you only need personal care.
What is generally not covered:
24-hour care: Medicare does not cover around-the-clock care at home.
Homemaker services: Shopping, cleaning, and meal delivery are typically not covered.
Custodial care: Help with daily activities like bathing, dressing, and eating is generally not covered, though it may be included as part of a care plan that also includes skilled care.
I need help at home after my surgery. Will Medicare cover a home health aide or am I on my own?
Yes, Medicare can cover a home health aide after surgery, but only if you also need part-time skilled nursing or therapy, are homebound, and get care from a Medicare-certified agency, as aides assist with personal care only when skilled care is part of the plan. If you just need help with daily activities like bathing or dressing (unskilled care) and no skilled services, Medicare won't pay for the aide, and you'd need other options like long-term care insurance or private pay, notes Homewatch Caregivers.Key Medicare Requirements for Home Health Aides:
Doctor's Order: A doctor must certify you need home health care.
Homebound: You must be mostly confined to your home.
Skilled Care Need: You must need intermittent skilled nursing, physical therapy, or speech-language pathology.
Medicare-Certified Agency: Care must come from an approved agency.
What Medicare Covers (If You Qualify):
Home Health Aide: Assistance with personal care (bathing, dressing, toileting) if you're also receiving skilled nursing or therapy.
Skilled Nursing: Care that only a licensed nurse can provide (wound care, medication education).
Therapy: Physical, occupational, or speech therapy.
What Medicare Doesn't Cover (If That's Your Only Need):
24/7 care.
Help with daily living (bathing, dressing) if that's the only care you need.
Homemaking (cleaning, laundry, shopping) if it's the only help you need.
Next Steps:
Talk to Your Doctor: Discuss your needs with your doctor or hospital discharge planner.
Check Your Plan: If you have Medicare Advantage (Part C), you might need to use their network of agencies.
Find an Agency: Use the Medicare.gov Care Compare tool to find a Medicare-certified agency in your area.
Does Medicare Part A cover outpatient surgery, or is that strictly under Part B?
Medicare Part A: does not pay for outpatient surgery. Part A covers inpatient services to include inpatient hospital care up to 150 days and inpatient skilled nursing care for up to but no more than 100 days per stay. Part A has a modest deductible of $1676 for 2025, and is subject to per day coinsurance begining after day 60 of inpatient hospital care and day 20 of in-patient skilled nursing care. Medicare Part A does not pay for Long Term Care services.Medicare Part B: pays for outpatient surgery and all other Medicare appoved outpatient services like like Doctor Visits, Lab Work, Outpatient Surgery, Physical Therapy, etc. Part B has a monthly cost to obtain coverage. The cost in 2025 for most Americans is $185 per month. If your Adjustable Gross Income (AGI) is higher than most, the premium for Part B is higher.
I'm interested in a robotic knee replacement surgery that my surgeon recommends for my specific anatomy. How does Medicare coverage work for this advanced procedure?
Medicare generally covers knee replacement surgery when it’s medically necessary, and the fact that it’s robotic-assisted usually does not make it a separate, uncovered service. Coverage still depends on the usual Medicare rules: whether the surgery is inpatient or outpatient, whether the facility and surgeon participate in Medicare, and what your plan requires for cost-sharing or prior authorization.How it usually works
If the surgery is outpatient, Original Medicare Part B typically helps pay after the Part B deductible, and you usually pay coinsurance on the Medicare-approved amount. If it’s inpatient, Part A generally applies to the hospital stay after the Part A deductible. The robotic system itself is usually treated as part of the surgical technique, not as a separate billable benefit, so the “advanced” part does not automatically create extra Medicare coverage.
What may affect your costs
Your out-of-pocket amount can change based on where the surgery is done, whether you have Original Medicare plus Medigap, or a Medicare Advantage plan. If you have Medigap, it may cover some or all of the 20% coinsurance under Original Medicare, depending on the supplement plan. With Medicare Advantage, the plan may require you to use in-network doctors and facilities and may have its own copays or authorization rules.
Best questions to ask
Ask your surgeon’s office whether the robotic procedure is billed the same way as standard knee replacement and whether the facility is Medicare-approved. Also ask whether the surgeon and hospital are in network if you have Medicare Advantage, and whether prior authorization is required. It’s also smart to ask for the exact CPT or billing code so your plan can estimate your share more accurately.
Are mental health services like therapy fully covered under Original Medicare?
Short answer: no, not fully.Under Original Medicare, most outpatient therapy is covered by Part B—you pay the Part B deductible (if not yet met) and typically 20% coinsurance of the Medicare-approved amount; a Medigap plan can cover some/all of that.
Preventive screenings (e.g., annual depression screening) are generally $0 when you see a Medicare-enrolled provider.
Inpatient psychiatric care falls under Part A with its own deductible and day limits (including a 190-day lifetime cap in psychiatric hospitals).
Make sure your therapist is Medicare-enrolled and accepts assignment to avoid extra charges.
What is the Medicare Advantage 3 midnight rule?
The three-midnight rule actually applies to Original Medicare, not Medicare Advantage, and it refers to the requirement that a patient must be formally admitted as an inpatient for at least three consecutive midnights before Medicare will cover a skilled nursing facility stay. This rule trips up a lot of Medicare beneficiaries because hospitals sometimes place patients under observation status rather than formally admitting them, and observation stays do not count toward the three-midnight threshold even if you are sleeping in a hospital bed for several nights. Medicare Advantage plans handle skilled nursing facility coverage differently depending on the plan, and many have their own criteria that do not follow the three-midnight rule at all, so it is important to understand how your specific plan works before you need that benefit. If you or a loved one is ever hospitalized, it is worth asking the hospital staff directly whether you are being admitted as an inpatient or placed under observation, because that distinction can have a significant impact on what you owe.
If we choose a Medicare Advantage plan and later regret it, can we go back to Original Medicare without penalties?
Yes, there are no "penalties" if you choose to go back. You always have "original Medicare" that pays 80% of your costs. When you first turn 65, you have a choice to stay on original Medicare with a supplement or choose Advantage. If you choose the advantage, you can drop the plan and go back to original Medicare each year between Oct 15th and Dec. 7th. It's the SUPPLEMENT that is hard to get back on, just depending. 1.) When you turn 65, you have "guaranteed issue" rights to be on a supplement plan without going through underwriting. 2.) If your advantage plan drops you, you have another opportunity for "guaranteed issue" and can get a supplement without question. 3.) If you choose the supplement first, and want to try an advantage plan in the fall, you have a year to try it; if you do not like it, you can go back to the Supplement on "guarantee rights" again. "Your Trial Right". So you have several opportunities to go to a supplement plan, you just have to understand how it works, so you can make smart choices for yourself. Also, later in life, you can drop your Advantage plan, go back to original Medicare, and ASK for a Supplement Plan, but you will have to go through underwriting, and if you have any medical issues or preexisting conditions, they will not take you. However, Advantage Plans do not have "underwriting," they take everyone, it doesn't matter what their medical conditions. Hope this helps..... Kim Humphries
What is the best MAPD plan in South Carolina?
There is no single “best” MAPD plan in South Carolina — it depends on your county, doctors, prescriptions, and budget. Carriers like Aetna, Devoted Health, Wellcare, and BlueCross BlueShield of South Carolina often offer competitive 4-star or higher plans in many areas. The strongest plans typically balance low premiums, reasonable MOOP limits, solid Part D formularies, and broad provider networks. Star ratings, PPO vs. HMO structure, and local hospital participation should heavily influence the decision. The best plan is the one that aligns with your specific providers and medication profile.
When should my plan be reviewed?
The best time to do this is during Medicare’s Annual Enrollment Period (AEP):📅 October 15 – December 7 each year.
During this period, you can:
• Review your current coverage (whether you have Original Medicare + Part D or a Medicare Advantage plan).
• Compare new plan options for the coming year.
• Switch plans, add or drop drug coverage, or move back to Original Medicare.
Any changes you make take effect January 1 of the next year.
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🧭 You should also review your plan anytime your needs or costs change, such as:
• Your medications change or you start a new prescription.
• Your doctors or preferred hospitals are no longer in your plan’s network.
• You move to a new ZIP code or state (this can trigger a Special Enrollment Period).
• Your income changes and you may qualify for Extra Help or a Medicare Savings Program.
• Your plan announces premium or copay increases for the next year.
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Tip:
Even if you’re happy with your plan, check each fall that it still covers your medications, doctors, and pharmacies — plans update their benefits and drug lists every year.
After a surgery, should I expect out-of-pocket costs?
Yes, even with Medicare, you’ll usually have some out-of-pocket costs after surgery (like deductibles, copays, or 20% coinsurance).Original Medicare: You pay the Part A deductible for hospital stays and 20% coinsurance under Part B.
Medicare Advantage: You pay set copays/coinsurance until you reach your plan’s out-of-pocket maximum.
If you have a Medigap plan, it may cover most or all of these costs.
I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?
The notice you receive from Medicare, which includes details on why home health care was denied, will also include information regarding your appeal rights and the steps to take.First, you must file an internal appeal (redetermination) with the Medicare Administrative Contractor, which involves submitting a request form with supporting documents.
If the Medicare Administrative Contractor denies your coverage after reviewing, you may request reconsideration by a Qualified Independent Contractor.
If denied again, you can request an Administrative Law Judge hearing. This involves a formal hearing in front of the Judge, and you will present evidence and argue your case.
If the Judge denies your claim, you can appeal to the Medicare Appeals Council.
If you are still unsatisfied, you may have the right to seek judicial review in the Federal District Court.
What's the projected impact of an aging population on Medicare Part A hospital funds?
Answer from Janix Barbosa-Llanos, MBA, PMP, CEP, RSSA, FSN(Licensed Insurance Agent — For Educational Purposes Only)
During our working years, we pay Medicare taxes that go into the Hospital Insurance (HI) Trust Fund, which helps cover inpatient hospital, skilled nursing, hospice, and limited home health care. The program works on a pay-as-you-go basis—today’s workers fund current retirees.
As people live longer and fewer workers pay into the system, pressure on the Part A fund grows. About 10,000 Americans turn 65 every day, and the cost of care increases with age and chronic conditions.
According to the 2025 Medicare Trustees Report, the HI Trust Fund is expected to remain solvent until 2033. After that, if no policy changes occur, incoming revenue would cover roughly 89 % of projected costs.
The good news: current beneficiaries are not affected. Medicare continues to pay for covered hospital services as usual. The solvency discussion is about long-term sustainability, not today’s coverage.
__________________
Medicare / CMS Disclosure
For educational purposes only. Not affiliated with or endorsed by Medicare or any government agency. Plan availability and benefits vary by ZIP code and individual eligibility.
References:
2025 Medicare Trustees Report, page 6; Committee for a Responsible Federal Budget, June 2025.
Does Medicare part A and B cover urgent care office visits?
Yes, urgent care visits are covered, but they are covered specifically by Medicare Part B (Medical Insurance), not Part A.Here is the breakdown of how coverage and costs work for 2025:
Part B Covers the Visit: Medicare Part B covers urgent care visits for non-life-threatening illnesses or injuries (like a flu, small wound, or earache) that require immediate attention.
Part A Does Not Apply: Part A generally only covers inpatient hospital stays. Unless you are transferred from urgent care and admitted directly into a hospital as an inpatient, Part A will not pay for the visit.
Your Costs for Urgent Care (in 2025)
If you have Original Medicare (Part A and Part B), you will pay the following for an urgent care visit:
Part B Deductible: You must pay the first $257 of medical costs for the year (if you haven't met this deductible yet).
Coinsurance (20%): Once the deductible is met, you pay 20% of the Medicare-approved amount for the visit and any services received (like X-rays or stitches).
Copayment: You may also be charged a fixed copayment depending on the specific facility's rules and if the visit takes place in a hospital outpatient setting.
Important Note: To avoid higher costs, you should verify that the urgent care center accepts Medicare assignment. If they do not, they may charge you up to 15% more than the Medicare-approved amount (known as an "excess charge").
If a patient had surgery with more than a 3 day stay in the hospital and needed to recover from the surgery before starting rehab, can the rehab stay be delayed by up to 90 days pending recovery?
Yes, the start of a rehab stay can be delayed by up to 90 days, but with important conditions for Medicare coverage, especially for Original Medicare. For Original Medicare to cover the rehab stay, the patient must have a qualifying hospital stay of at least three days and be admitted to the facility within 30 days of discharge. If the delay is longer than 30 days, it must be medically inappropriate to begin rehab sooner for coverage to continue.Key considerations for Medicare coverage
Hospital stay: The patient must have been admitted to the hospital as an inpatient for at least three consecutive days, not including the day of discharge. Observation time does not count toward this requirement.
Timing: The rehabilitation facility stay must begin within 30 days of being discharged from the hospital.
Medical necessity: The patient must require daily skilled nursing or rehabilitation services that can only be provided in a skilled nursing facility.
Delayed rehab: If the rehab stay is delayed by more than 30 days, it must be medically inappropriate to begin sooner to remain covered. This exception is based on the patient's recovery from surgery.
Medicare Advantage plans: If the patient has a Medicare Advantage plan, they must follow that plan's specific guidelines, which may differ from the rules of Original Medicare. The plan will still require approval based on medical necessity, and they are not subject to the "3-day rule".
What to do
Confirm inpatient status: Before leaving the hospital, ask a hospital representative to clarify the patient's inpatient status, as this is a key requirement for Medicare coverage.
Contact the plan: If enrolled in Medicare Advantage, call the plan provider to understand their specific rules for skilled nursing facility (SNF) care.
How long after I apply for Medicare A&B will I receive my Medicare card?
There’s no definitive answer, but in general the typical time is between 3-6 weeks. Allow 2-4 weeks for application processing (it’s faster if you apply in person or online) and about 2 weeks for the physical card to be delivered. Your number should be available online immediately after approval, and you don’t need your physical card to apply for your supplemental coverage. You just need the number (your agent will still verify eligibility in the system).The fastest way to check status is through a my Social Security account:
(https://www.ssa.gov/myaccount) or by calling the SSA.
Is there a penalty for Medicare Part A or B for a 65-year-old green card holder who hasn’t met the five-year U.S. residency requirement and has no other insurance?
No, there is no penalty for not having Medicare at age 65 if you do not yet meet the residency requirement.Medicare penalties only begin to accrue once you are eligible to enroll and choose not to. Since a green card holder is generally not eligible for Medicare until they have lived in the U.S. continuously for at least five years, the "penalty clock" does not start until that five-year mark is reached.The Rules for Your SituationEligibility Gap: As a green card holder, you must be 65 or older and have 5 years of continuous U.S. residency to qualify for Medicare.No "Pre-Eligibility" Penalty: You cannot be penalized for not having a service you aren't legally allowed to buy yet.When the Penalty Starts: Once you hit your 5th anniversary of residency, your Initial Enrollment Period begins. If you do not sign up at that time (and don't have other "creditable" coverage like a job-based plan), you will then face lifetime late-enrollment penalties for Part B and Part D.Important ExceptionsThere is one major way you might be eligible before the five-year mark:Spousal Credits: If you have been married for at least one year to a U.S. citizen or green card holder who is at least 62 and has worked in the U.S. for 10 years (40 quarters), you may be able to qualify for Medicare based on their work record. In this specific case, the five-year residency rule is waived.What should you do in the meantime?Since you are currently ineligible for Medicare, you may want to look into:The Health Insurance Marketplace: Lawfully present immigrants can purchase plans through the ACA Marketplace (Healthcare.gov) even if they haven't been here for five years. You may even qualify for subsidies depending on your income.Short-Term "New Immigrant" Insurance: Some private companies offer temporary medical insurance specifically for new green card holders waiting for Medicare eligibility.
Does Medicare cover shoulder replacement surgery?
Yes. Medicare may cover shoulder replacement surgery when it is medically necessary, but how it’s covered depends on the type of Medicare coverage you have.Medicare Part A helps cover inpatient hospital care if you are formally admitted to the hospital for the surgery. This can include your hospital stay, meals, nursing care, and some rehabilitation services after surgery.
Medicare Part B helps cover outpatient medical services, including doctor visits, imaging, the surgeon’s fees, outpatient surgery centers, durable medical equipment like slings or walkers, and physical therapy. Part B typically covers 80% of approved costs after your deductible, leaving you responsible for the remaining 20% unless you have supplemental coverage.
Medicare Part C (Medicare Advantage) combines Part A and Part B coverage through a private insurance company. These plans must cover everything Original Medicare covers, but costs, prior authorization requirements, hospital networks, copays, and rehabilitation coverage can vary by plan, so it’s important to review your specific benefits carefully.
Does Medicare have a deductible?
Yes Medicare has deductibles for both Part A and B. Part A i(Hospital) is not a standard yearly deductible, but a deductible for a benefit period of $1,736 if you have an inpatient hospital stay. A benefit period begins when you are admitted to a hospital and ends when you haven't received inpatient care for 60 days in a row. You can have multiple benefit periods in a single year. If you have multiple benefit periods, your Part A deductible will reset.Part B (Medical) has a standard yearly deductible of $283. Once the deductible has been met, Medicare pays 80% and you pay 20%. If you add an Advantage Plan, deductibles wil vary by plan. If you add a Prescription Drug Plan, deductibles will vary but are capped at $615 per year by the government.
Part A has no premium, Part B has a premium of $202.90. If you decide to add other sevices, like a Supplement Plan and a Prescription Drug Plan (Part D) you will still need to pay your Part B premium and whatever premium you have for a supplement or drug plan.
Is just Medicare Part A and Part B enough coverage, or do I need supplemental insurance?
I don't recommend that anyone just have part A and B alone. There are some significant gaps in coverage, and no maximum out of pocket cost.Adding a supplemental plan can be the best approach to cover those gaps, for most seniors, as the premiums are predictable and your retirement savings is protected against significant out of pocket costs. Seniors with Medicare plus a Medicare Supplement can see any Medicare doctor in the country, or go to any hospital, without worrying about networks or approvals.
Medicare Advantage can also help limit out of pocket costs and will cost less in the short term. However, advantage plans are known as "managed care" meaning that you have to stay within a network, they can require referrals and pre-approvals, plus you'll pay cost sharing (co-pays, co-insurance) up to a maximum out of pocket limit that must be reached before you're covered in full. Out of pocket limits will typically average $5000 to $7000 in network and much higher if any of your providers was an out of network provider.
For most seniors, the predictable costs, freedom of choice, and limited out of pocket exposure makes a Medicare Supplement plan the best long term choice.
Can you get Medicare if you never worked or didn't pay into the system?
Yes, you can get Medicare if you never worked or didn't pay into the system, but you will likely have to pay a monthly premium for Part A (hospital insurance). To get it for free, you generally need 10 years (40 quarters) of work or qualify for low income Medicaid!Does Medicare cover memory care facilities?
The short answer is no, Medicare does not cover the cost of living in a memory care facility (room and board).Because memory care is considered "custodial care" (help with daily activities like dressing or eating) rather than "medical care," it falls outside of Medicare's standard coverage.
What Medicare Will Pay For
While it won't pay for the facility itself, Medicare still covers the medical needs of someone living in memory care, such as:
Medical Services: Doctor visits, physical therapy, and diagnostic tests.
Hospice Care: End-of-life care if the patient meets the criteria.
Medications: Prescription drug coverage (Part D) for cognitive or other health issues.
Short-Term Rehab: Limited stays in a skilled nursing facility after a qualifying 3-day hospital stay.
How People Typically Pay for Memory Care
Since Medicare doesn't cover the rent, most families use:
Medicaid: For those with limited income and assets (this is the primary government source for long-term care).
Long-Term Care Insurance: Private policies specifically designed for this.
VA Benefits: Aid and Attendance benefits for eligible veterans and spouses.
Private Funds: Savings, home equity, or social security.
In summary, Medicare treats memory care like an apartment—it covers the "doctor" inside the building, but not the "rent" for the building itself.
Do my Medicare hospital days reset every year?
No. Medicare hospital days are based on a Benefit Period, not the calendar year. A benefit period starts the day you are admitted and ends when you've been out of the hospital (or SNF) for 60 consecutive days. Once you’ve gone 60 days without inpatient care, a new benefit period begins where you receive a new set of hospital days and a new deductible applies.
I’m 67, working full time, and previously had a 4-month job gap. I enrolled in Medicare A and B to avoid penalties, but SSA won’t let me disenroll from A. I haven’t claimed Social Security and don’t need Part A, which blocks my HSA. What can I do?
Under IRS rules, you cannot contribute to a Health Savings Account (HSA) while enrolled in any part of Medicare. Because premium-free Medicare Part A comes automatically when you are over 65, the only legal way to unenroll from Part A to restore your HSA eligibility is to formally withdraw your Social Security application and pay back any retirement benefits already received. So whoever is saying that you cannot disenroll is incorrect. It is however not a good idea. When you are on Medicare, and HSA can be achieved in other ways. Namely through what is called an MSA account i.e. Medicare Medical Savings account. This is a Medicare Advantage plan.What does Medicare Part A cover, and is it really free?
Medicare Part A acts as your hospital insurance. It primarily covers inpatient care in hospitals, skilled nursing facilities, hospice, and some home health care. It is "premium-free" for most people (meaning $0 monthly), but you still must pay deductibles, copayments, and coinsurance when you use the services.What Does Part A Cover?
Inpatient Hospital Stays: Covers semi-private rooms, meals, nursing care, and medications administered during a hospital stay.
Skilled Nursing Facility (SNF): Covers short-term care in a specialized facility following a qualifying hospital stay of at least three days.
Hospice Care: Covers comfort care for terminally ill patients, including drugs and medical equipment.
Home Health Care: Covers part-time, medically necessary skilled care for homebound patients.
Is It Really "Free"?The Premium: It is premium-free for anyone who worked and paid Medicare taxes for at least 10 years (40 quarters). If you (or your spouse) did not meet this requirement, you can buy Part A for a monthly premium of up to $565.Out-of-Pocket Costs: Even if your premium is $0, Part A is not entirely free. You must meet a hospital deductible (e.g., $1,736 per benefit period). After meeting the deductible, hospital stays are usually covered in full for the first 60 days, but you will pay a daily coinsurance for days 61 through 90.
If I already have part A and am already terminal on hospice care, do I need to get on part B and go through the MAPD/MedSup enrollment process?
Medicare Part A covers 100% hospice related services. Some of these services include nursing care, medical equipment (such as oxygen, hospital beds and wheelchairs), hospice aide services, counseling, and respite care.The only exceptions that are not covered by Medicare are co-pays for prescription medication dealing with pain management. These co-pays are limited to a $5 charge. If respite care is used, there is a 5% co-insurance.
Respite care is where relief is provided for primary caregivers. This allows a break for caregivers while making sure their person is still safe. Respite care is covered up to 5 days at a time.
Whether or not you should get on Part B depends on your prognosis from your doctor. Hospice care is designed to support individuals with a life expectancy of six months or less if their illness follows its natural course. Hospice can be extended as long as the patien continues to meet eligibility standards. Recently, former President Carter was in hospice for 22 months before he passed away in December 2024.
Overall statics show the median length of hospice care in the US is 18 days. 50% of patients pass away in the first three weeks. Up to 15% of patients survive longer than 6 months. With those statistics in mind, I would suggest to someone that they go through the Part B process only if they have a complete understanding of their remaining life expectancy from their doctor.
Some people will stay enrolled in Part B and Advantage or Supplement Plans if they need medical care or prescriptions unrelated to the hospice diagnosis. Obviously you want to have coverage if you have needs for non-medical care or prescriptions. Conversely, I suspect someone on hospice is not going to have a need to see an orthopedic surgeon. My best advice is use common sense based on your current condition.
How to sign up for A & B?
You can sign up for Medicare Part A and Part B online through the Social Security Administration (SSA) website during your 7-month Initial Enrollment Period (3 months before to 3 months after your 65th birthday). The process takes about 10 minutes, and you will need to create a login.gov account.Several ways to Enroll:
- Online, visit SSA.gov and click "Sign up for Medicare".
- Phone: Call Social Security at 1-800-772-1213
- In-Person: Visit your local Social Security office.
Does Medicare cover hospital observation stays, and how is that different from being admitted as an inpatient?
Yes — Medicare does cover hospital observation stays, but this is one of the most misunderstood areas of Medicare and it can create major unexpected costs for seniors.Many people think if they stay overnight in a hospital, they’ve automatically been admitted as an inpatient. That is NOT always the case.
Under Medicare, “observation status” is considered outpatient care — even if you stay in a hospital bed for several days.
Here’s why that matters:
• Observation stays are generally covered under Medicare Part B
• Inpatient admissions are covered under Medicare Part A
• Your costs, deductibles, copays, and coverage can be very different depending on how the hospital classifies you
One of the biggest issues involves Skilled Nursing Facility coverage.
Medicare typically requires a qualifying 3-day inpatient hospital admission before it will help cover rehabilitation or skilled nursing care afterward. Observation days usually do NOT count toward that requirement.
So someone could spend multiple nights in the hospital thinking they qualify for rehab coverage — only to later discover they were never officially admitted as an inpatient.
This is why I always encourage seniors and families to ask the hospital directly:
“Am I admitted as an inpatient or am I under observation status?”
That one question can make a huge financial difference.
I help seniors understand these gaps and how different Medicare plans may help protect them from unexpected costs and confusion — always at no cost.
Chuck Winslow
US Marine Veteran 🇺🇸
Retirement & Legacy Planner
Contact me.
How much is the Medicare deductible in 2026?
For 2026, the Medicare deductibles are:Part A (Hospital Insurance): $1,736 per benefit period for inpatient hospital stays.
Part B (Medical Insurance): $283 annual deductible. After you meet it, Original Medicare generally pays 80% of covered services, and you pay the remaining 20% unless you have additional coverage.
Keep in mind that Part A has a deductible for each benefit period, while Part B has one deductible per calendar year.
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