Medicare is the United States federal health insurance program regulated by the federal government for individuals 65 years old or older or those with disability benefits. It is first introduced in 1966 and designed to cover hospital and medical expenses for their beneficiaries. Original Medicare is made up of two parts – Part A and Part B. Benefits of prescription drug coverage are later added to the Medicare program, named Medicare Part D.
The Medicare program is the same in each state because it is regulated on a federal level.
Original Medicare Eligibility
Because Medicare is regulated on a federal level, there are unique eligibility requirements set by CMS that apply to every state, Texas included. To be eligible for Medicare in Texas you need to be a U.S. citizen or a permanent resident with at least 5 years of continuous living in the U.S.
Eligibility requirements for Medicare Part A and Part B are:
- to be age 65 or older
- to have been receiving Social Security disability benefits for at least 24 months in a row
- to have been diagnosed with End-stage Renal Disease (ESRD)
- to have been diagnosed with Amyotrophic Lateral Sclerosis
Original Medicare Coverage
As stated before, Medicare Part A is designed to be insurance for inpatient hospital services, and Part B is designed to cover most outpatient services. Let`s have a deeper look at what is covered under each part, and what is not covered.
Medicare Part A
Medicare Part A is the first half of Original Medicare, and it is usually referred to as hospital insurance. It covers services provided to you during your inpatient hospital stay.
In general, Medicare Part A in Texas covers:
- inpatient hospital care during the hospital stay
- skilled nursing facility care
- hospice care
- nursing home care
- home health care
On the other hand, Medicare Part A does not cover all expenses incurred during a hospital stay. Part A does not cover the first 3 pints of blood, with an exception if the blood is received from a central blood bank. It does not cover private rooms, no matter if you are staying in a hospital or skilled nursing facility. Inpatient care covered under Part A is only in semi-private rooms. Part A also does not cover long-term care.
Medicare Part B
Medicare Part B is commonly referred to as medical insurance, and generally, it covers almost any medically necessary service. People enrolled in Part B in Texas will have coverage for:
- physical exams (1 per year)
- doctor visits
- laboratory and diagnostic tests
- durable medical equipment
- ambulance services
- mental health services
- preventive services
- limited skilled-nursing facility care and home health care for those who are homebound
Like Part A, Medicare Part B also does not cover all possible outpatient services. Here is a list of services that are not covered by Part B:
- long-term care
- DHV services (Dental, hearing, and vision)
- cosmetic procedures
- prescription drug coverage
- foreign travel health care outside the U.S.
Original Medicare Enrollment
Like eligibility, Medicare enrollment is also regulated on the federal level, so the rules of enrollment are the same no matter which state you are in, Texas included. For most beneficiaries, enrollment in Original Medicare goes automatically. If you are receiving Social Security benefits before your 65th birthday, then when you turn 65 you will automatically be enrolled in Part A and B of Medicare.
Those who are not entitled to automatic enrollment must apply through Social Security (online or in-person) during one out of three enrollment periods.
The initial enrollment period is personalized for every individual and it happens once in a lifetime when you reach the year of your 65th birthday. It starts three months before your 65th birthday and lasts until three months after your birthday. During this period you are required to enroll in Medicare or you will be exposed to a late enrollment penalty.
The special enrollment period is designed for those who have been getting health coverage through their employment. Special enrollment starts a month after your coverage ended, and it lasts for 8 months. In a case where you enrolled in Medicare during special enrollment, you will not be exposed to a late enrollment penalty.
The general enrollment period happens at beginning of every year, from January 1st to March 31st. It is designed for everyone that failed to enroll during their initial enrollment, but it does not save them from a late enrollment penalty.
Original Medicare costs
Original Medicare is not free. You are required to pay for a monthly premium, coinsurances, copayments, and deductibles. Every part of Medicare has different payment requirements. There are a lot of Medicare Supplement plans that can help with paying the costs of Original Medicare, so you should read our blog about it. Here is a breakdown of costs for each part of Original Medicare.
Part A costs
With Part A, you are required to pay only a monthly premium. However, most people qualify for premium-free Part A. The only condition to be eligible for premium-free Part A is to have been paying Medicare taxes while working for at least 40 quarters or approximately 10 years of work. If your situation is different, then you will have to pay Medicare Part A monthly premium, which is from $278 up to $506 in 2023.
Be aware of the costs produced by a longer hospital stay. If you are staying in the hospital for up to 60 days, your copayment is $0 per day. But if you stay longer than that, you will be required to pay for each day. From day 61 to day 90 your copayment will be $389 per day, and from day 91 on it will be $778 per day.
Part B costs
Medicare Part B in Texas besides requires you to pay a monthly premium, together with coinsurance, copayments, and deductibles. The standard premium for Part B in 2023 is $164.90 per month. Part B has an annual deductible, which in 2023 will be $226. You pay coinsurance in the cost-sharing way, where Medicare pays for 80% and you are responsible for 20% of costs. That means that you will have to pay 20% of all charges occurred by providing outpatient medical services.
If you have trouble paying Medicare costs, look at our blog about Medicare Savings Program in Texas.