Original Medicare Eligibility for part A and part B

• 65 or under with disabilities or health condition

• disability benefits from social security for 24 months

• Amyotrophic lateral sclerosisALS, Lou Gehrig’s Disease or ESRD

• U.S resident & citizen or lawful permanent resident  for 5 yrs in Medicare

• “Late enrollment penalty”

  • 10% Penalty for each 12 months period not enrolling when first eligible

  • waved if had creditable insurance

Individuals can enroll in Medicare 3 months prior to their 65 birthday, the month of their birthday, and 3 months after.

Original Medicare Part A:

• Inpatient deductible $1736 for each benefits period (begins when admitted to hospital & ends when individual 60 days in a row)

• 1-60 $0 after deductible 

• 61-90- $434 copay per day

• 91-150 $868 copay

• Skilled Nursing facility

  • 1-20 days $0 co pay

  • 21-100 days $217 co pay per day

  • 101 day and beyond all cost

• Covers

  • Inpatient hospital care

  • Blood

  • 100 days of home health care after hospital or skilled nursing facility stay

  • Hospice

  • Skilled nursing facility or rehab care up to 100 days (only after a 3 day hospital stay)

  • Inpatient Psychiatric care (up to 190 days)

Original Medicare Part B:

• Annual $283 deductible

• After deductible 20% coinsurance

• Part B Premium for 2026 is $202.90

• Covers

  • Physician or other professional care services

  • Outpatient hospital and emergency department services

  • Labs and diagnostic tests (X-rays, MRI, CT scans)

  • Durable medical equipment

  • Home health care (not covered by Part A)

  • Physical, Occupational, and Speech Therapy

  • Ambulatory surgical services

  • Chemotherapy (outpatient basis)

  • Ambulance

  • Limited chiropractor and acupuncture

  • Specific preventive care (flu shot, mammogram, bone mass measurements)

  • Diabetic supplies

  • Kidney Dialysis

  • Outpatient mental health

  • E-visits

Appeals for Part A and/or Part B coverage and payment

• Must be filed within 120 days of the date they receive the Medicare Summary Notice (MSN)

• If disagreed with appeal decision beneficiary has 180 days after decision to request reconsideration by a Qualified Independent Contractor

• Additional level of dispute $200 to administrative law judge

• For $1960 claims go to federal court

To enroll in Medicare call social security at 1-800-772-1213

Medicare Part C (Medicare Advantage plan)

• Offers Part A, Part B and Part D (with MAPD plans) through commercial carriers

• Plans typically include additional benefits such as dental, vision, and hearing coverage. Some plans also offer an Over-the-Counter (OTC) allowance that provides funds for approved items. Please note that benefits are based on the individual plan and may vary.

Part D  stand alone prescription drug plan (PDP)

• Offered by commercial carriers- generally original medicare, MA MSA PFFS, or cost plan can enroll in standalone PDP

• Initial phase pay 25% coinsurance ($615 FY2026; $700 deductible FY2027)

• Out of pocket cost reaches $2100 (FY2026) $2400 (FY2027) beneficiary is through initial coverage phase and reaches catastrophic

• Note: As of July 2026 CMS is implementing a short term program that will directly pay for GLP-1 drugs for weight loss

  • To qualify for the program you need a Body Mass Index (BMI) of 35 or BMI of 27 with certain diagnoses

  • $50 copay for the drug which will not go to deductible or max out of pocket

  • Program ends December 2027

Medicare supplemental Plans A-N (Medigap)

• Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a commercial health insurance carrier to help pay your share of out-of-pocket costs from Original Medicare in like copayments, coinsurance, and deductibles.

• Part D PDP is often recommended with a Medicare Supplement plan because Original Medicare and Medigap plans do not include prescription drug coverage. A separate Part D plan helps cover the cost of covered prescription drugs and can help avoid a late enrollment penalty if you go without creditable drug coverage