Medicare Questions & Answers: Medicare Part A
Medicare Part A Q&A
Showing 36 questions
What's the financial risk of sticking with Original Medicare without a Medigap plan?
A specific example: I've got a client at CMC who had some heart issues. The bill was $65,000. Thankfully, they have a Medigap policy, which will pay all of their 20% for them. Had they not had the Medicare Medigap supplement policy, they'd be paying $13,000 out of pocket, and I don't know who has that just laying around.
So please, before you make any decisions or non-decisions on Medicare, Original Medicare, Supplement, or Medicare Advantage, speak to someone like myself who deals with it every single day with clients and has real-life experience and real stories to tell about horror stories from making the wrong decisions.
I would be glad to help you. We'll go over the pros and cons of Original Medicare, sticking with that, or doing a Medicare supplement to add to A and B that will pay all of your out-of-pocket costs, or even going to a Medicare Advantage plan, which I believe would be better than sticking with just Original Medicare. Anyway, we're here to help. My office is right on Kelly Street in Manchester, Tony Capraro State Farm. Have a great weekend!
Is it ok to meet with multiple Medicare Brokers and Agents as I start looking for help?
I would suggest talking with a couple different Insurance Agents or Brokers as you start looking for Medicare help. Some Agents or Brokers only work with one carrier for supplemental plans. Some are too pushy, some may have the knowledge but can't communicate that well to transfer that knowledge to the people they are helping. Many different reasons to talk to a couple different people.
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?
The Original Medicare ( Part A and Part B) only covers part of your healthcare costs. Beneficiaries must enroll in supplemental insurance plans to cover prescription drug costs, deductibles, co-pays, co-insurance, and the lack of a yearly out-of-pocket limit.The coverage gaps include prescription drug coverage, you can enroll in a stand-alone Part D drug plan.
Other gaps are routine vision, dental, and hearing. Consider enrolling in a Medicare Advantage plan. These plans are an alternative way to get the Original
Medicare, Part A, Part B, and additional benefits.
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?
Yup. If you don't speak to an experienced and honest agent, you won't know what your monthly payments will be. For example, there is a premium for the Part B, for the Part B one-time per year deductible, possibly a Medigap plan along with a Part D(rug) plan. If you want better coverage for the more expensive Dental, Vision & Hearing procedures, that can also be an extra cost per month. Sounds like you tried to get around using an agent whereas YOU are not paying for the agent's commission since the firm you chose pay the agents!I chose Original Medicare to keep my doctors, but now I'm drowning in bills. Should I have gone with Advantage instead?
Basic Original Medicare by itself is just a starting point. It covers doctor visits and hospital stays. You usually pay a monthly Part B premium and must meet yearly deductibles. Original Medicare will then cover 80% of the approved amount, and you're responsible for the remaining 20% of the cost of your care. There is no limit to your out-of-pocket costs each year. Enrolling in a supplement plan is advisable if you want to keep your Original Medicare to cover your share of costs.Medicare Advantage helps you control costs. The plans support your entire well-being so you can live a better, healthier life. In one package, the plans give you Part A and Part B coverage, plus Part C coverage, and many of them also include Part D prescription drug coverage and other benefits. The plans have limited out-of-pocket costs, more predictable co-pays, and a cap on your yearly out-of-pocket expenses.
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?
The Part A (IN-patient hospital) copay per day will vary among Advantage plan companies. However, the $1,676.00 has been determined by Medicare itself every new year. Since that figure is the maximum that you'll pay for that one specific hospital visit, the daily rate will be applied toward that amount. Thus, if you're in the hospital for the typical 3 days, $1,050.00 ($350.00 times 3) will be applied toward the $1,676.00. That means that you have yet to arrive at the annual deductible in that example. Since Medicare keeps track of your Inpatient hospital stays, there will be the leftover amount of $626.00 that will remain as your responsibility should you be officially admitted to a hospital within that same calendar year.
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.
You will have a charge of the Part B deductible first which as of 2025 will be $257 and then 20% of the charge of the ambulance company charge in your area (state/city) you live.
Why is regular Medicare better than an advantage plan?
Making the choice between regular Medicare with Medigap/Medicare Supplement or a Medicare Advantage Plan depends on individual healthcare needs, preferences, and financial situations. Regular Medicare with Medigap/Medicare Supplement provides notable advantages in terms of flexibility, coverage, predictability, and support. Choosing to prioritize these factors you may find regular Medicare with Medigap/Medicare Supplement to be a superior option. Understanding the differences and benefits of each choice is essential for making an informed decision about healthcare coverage.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?
Overnight stay in hospital can be classified into two statuses (Inpatient and outpatient admission). If your doctor ordered that you need to be admitted to the hospital as an inpatient for medical care overnight, Medicare Part A will cover the cost of your hospital stay, including drugs, accomodation and meals for the first 60 days after you meet your Part A deductible which is $1,676.00 in 2025, for each benefit period. You will also pay coinsurance for days 61-90 of each benefit period.If your doctor ordered that you be admitted as an outpatient for observation only, overnight, Medicare Part B will cover the costs, not Part A.
What happens if I delay Medicare Part A enrollment because I'm still on my spouse's employer plan?
Simple answer is nothing! Although I do suggest signing up for Part A and just delaying Part B, that way you are in the system and when Part B does need to be activated you have a fast turn around time!
I've heard Medicare covers home health care, but what exactly does that include?
Medicare generally covers part-time or intermittent home health care services when medically necessary, especially after a hospital stay or skilled nursing facility stay. This includes skilled nursing, physical therapy, occupational therapy, and speech-language pathology services, as well as medical social services and some home health aide care if it's related to skilled care. Medicare, however, does not cover 24-hour care, meal delivery, or personal care when it's the sole need. You can find more extensive break down online if you search or sit down with an agent sometime to go over all of it.
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?
Once you’re ready to re-enroll in Medicare Part B, you’ll need to complete form CMS-40B. This form allows you to show proof of prior creditable coverage, which helps you avoid a late enrollment penalty.
Does Medicare Part A cover outpatient surgery, or is that strictly under Part B?
Medicare Part A does not cover Outpatient surgery. Medicare Part B covers outpatient surgery with 20% coinsurance you are responsible for.
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 home health aide services after your surgery, but certain conditions must be met.Eligibility Criteria:
To qualify for Medicare-covered home health services, you must:
Be under the care of a doctor who certifies that you need intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy.
Be homebound, meaning it's difficult for you to leave your home without assistance due to your medical condition.
Boost Home Healthcare
Receive services from a Medicare-certified home health agency.
Services Covered:
If you meet these criteria, Medicare may cover:
Part-time or intermittent skilled nursing care (e.g., wound care, injections).
Therapy services, such as physical, occupational, or speech-language therapy.
Home health aide services, which provide personal care like bathing and dressing, but only if you're also receiving skilled care as mentioned above.
Medical social services to help with social and emotional concerns related to your illness.
Certain medical supplies and durable medical equipment (e.g., walkers, wheelchairs).
Limitations:
Medicare does not cover:
24-hour-a-day care at home.
Meals delivered to your home.
Homemaker services like shopping, cleaning, and laundry when these are the only services you need.
Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need.
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?
Original Medicare: Medicare premium $185/mo, $257 deductible + (20% of $20,000 to $40,000 + post care costs)$5-10K no max out of pocket.
Medigap Plan G: $200-225/mo+
Medicare premium $185/mo, $257 deductible is your max out of pocket for the year
Medicare Advantage: Medicare premium $185/mo (may be reduced by up to $174,70/mo) specialist copay $10-$45+ outpatient hospital copay $100-$300 + post op rehab $20-$40/visit maximum out of pocket could be less than $500. Max out of pocket $1000-$6700.
What is the Medicare Advantage 3 midnight rule?
The Medicare three midnight rule is a rule that requires traditional Medicare beneficiaries to have three consecutive nights in a hospital before they will cover care in a skilled nursing facility. They do not include any observational days or the day you are discharged. this rule may or may not apply if you are on a Medicare advantage plan because private carriers can waive the rule if they choose. If you have more questions about this rule, you can reach out tothe Center for Medicare and Medicaid services. You may also call a licensed professional for guidance.Are mental health services like therapy fully covered under Original Medicare?
Mental health is covered but it is up to you to review different company policies since they could vary widely from state to state. There is a limited number of days that should be covered. It is incumbent upon you to fully understand those limitations. This is why it is imperative to go over with a knowledgeable agent who can easily differentiate between what an Advantage plan covers vs. what a Med. Suppmt. (Medigap) covers in this extremely important area.
If we choose a Medicare Advantage plan and later regret it, can we go back to Original Medicare without penalties?
Yes! You can return to Original Medicare without penalties. But this can only be done during AEP, OEP, or SEP. Be careful when you're changing. I recommend meeting with a licensed Medicare agent or contacting Medicare directly.
What is the best MAPD plan in South Carolina?
There is no such thing as the "best" MAPD in any zip code. Many factors such as hospital and provider networks and prescription drug coverage must be taken into account. Additionally in and out of network maximum out of pocket (MOOP) varies significantly among plans: HMO's, PFFS's & PPO's. For example, there may be six HMO's available in a zip code and the MOOP can vary by $1000's per year. As well as the requirement for pre-authorizations and referral approvals before care can begin.
I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?
My concern would be why did they deny it.Home Health Care is a Skilled Nursing Code.
Doctor has to certify that you are home bound and that you need a nurse to come in and do basic MEDICAL needs for you. Example is wound care or Medicine care and PT.
They don't stay very long. They come in and do the medical care needed and leave.
They would have to have a reason why you can come to them to get approved.
It is also only approved for 30 days and can be extended if the doctor approves it. It has to be recertified every 60 days. It is meant for short term and that you are healing and getting better.
If you need it all the time and your not getting better then that will be under Long Term Care. That is a separate policy and not covered by Medicare.
If you want to file an appeal here is the link:
https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals
When should my plan be reviewed?
You should review every year, before Dec 7th.You should also make sure all your doctors take that plan
After a surgery, should I expect out-of-pocket costs?
That is vague question because it would be different depending on which plan you are utilizing. If you have Medicare Supplement (G or N) and have not satisfied your $257 deductible then you will owe up to that deductible. If you have already satisfied your deductible then you should not have any out of pocket costs accrued. However, if you are on a Medicare Advantage plan then you will be billed the set copayment for that procedure based upon which plan you are on with which carrier.
What's the projected impact of an aging population on Medicare Part A hospital funds?
I just searched online and the second article listed was written in 2008 and stated that Medicare Part A will have insufficient funds by 2019. Be careful of the information you read online. It's good to be informed but don't get caught in the weeds or buy into fear-based articles. If you called Medicare I would guess they would not be able to answer that question, other than Part A funds must be increased every year.
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 with a couple of caveats. Medicare will pay for inpatient rehab in a skilled nursing as long as the rehab stay is preceded by a 3 day stay in a hospital. This is called the "Medicare 3-day rule." And it is true that beginning the rehab stay can be delayed by up to 90 days after the hospital stay, pending recovery from the surgery. However, if the delay is longer than 30 days, it must be medically inappropriate to begin rehab sooner to remain covered. Also, the above rules apply to Original Medicare. If someone is enrolled in a Medicare Advantage plan, they will have to follow the guidelines set forth by their particular plan. Medicare Advantage members are not subject to the 3-day rule, but their plan will still have to approve any inpatient rehab stay based on medical necessity.
How long after I apply for Medicare A&B will I receive my Medicare card?
Once you have applied and social security has enrolled you you should receive your card within 30 days.
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?
Yes, a 65 year old green card holder without a 5 year residency or 10 year work history might face penalties for delaying Medicare Part A (if they have to pay for it) and definitely for Part B if they don't enroll when eligible.Does Medicare cover shoulder replacement surgery?
Yes it will cover it based on medical needsYou also may want to get a 2nd opinon so you have the best posdible outcome
Is just Medicare Part A and Part B enough coverage, or do I need supplemental insurance?
Original Medicare (Part A and Part B) is generally not enough coverage for most, as it typically leaves you with 20% coinsurance, high deductibles, and no maximum out-of-pocket limit. Supplemental insurance—such as Medigap or a Medicare Advantage plan—is usually required to cover these gaps and protect against high, unpredictable medical costs.
Can you get Medicare if you never worked or didn't pay into the system?
Yes, you can get Medicare, but you will have to pay for Medicare Part A and Medicare part B out of your own pocket
Does Medicare cover memory care facilities?
Does Medicare cover extended care and memory impaired patients. The answer is no. Medicare will cover medical treatment, But does not cover room and. Board
Do my Medicare hospital days reset every year?
They reset every benefit period. Medicare benefit periods under part A starts upon becoming an inpatient in the hospital and ends when you have been out of the hospital or skilled nursing facility for 60 days in a row.You also have extra lifetime days to use if you run out of days that Medicare will cover. These 60 lifetime days can only be used one time in your life.
Medicare advantage and Medigap plans are figured differently and provide you with more days.
Does Medicare cover hospital observation stays, and how is that different from being admitted as an inpatient?
Observation stays are covered by Medicare Part B. This means you are subject to the Part B deductible if you have not already met it. Then Medicare pays 80% of the cost, leaving you 20%. There will also be copays for any services performed or medications given during the stay.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?
Best to call 1 (800) Medicare to get clarification when you are getting conflicting information. There are rules and restrictions with HSA.
Does Medicare have a deductible?
Yes! It is important to know what the deductibles will look like for each person. Please contact us to discuss your options.
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.
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