Understanding Medicare Part A and Part B: An Educational Guide for New Medicare Agents

Overview

Medicare Part A and Part B are the cornerstones of the Original Medicare program, offering essential healthcare coverage to millions of Americans. As a newly licensed Medicare agent, understanding the details of these parts is crucial to effectively assisting your clients. Here’s a comprehensive overview based on the latest 2025 updates from CMS.

Medicare Part A: Hospital Insurance

What It Covers: Medicare Part A primarily covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Here are the specifics:

  • Inpatient Hospital Care: Includes semi-private rooms, meals, general nursing, and drugs as part of your inpatient treatment.
  • Skilled Nursing Facility Care: Covers skilled nursing care, rehabilitation services, and other medically necessary services for a limited time after a qualifying hospital stay.
  • Hospice Care: For terminally ill patients, it includes pain relief, symptom management, and support services for both the patient and their family.
  • Home Health Care: Covers intermittent skilled nursing care, physical therapy, speech-language pathology services, and continued occupational services.

Costs:

  • Premiums: Most beneficiaries don’t pay a monthly premium for Part A if they have at least 40 quarters of Medicare-covered employment. For those with fewer than 40 quarters, the premium can be up to $506 per month in 2025.
  • Deductibles and Coinsurance: In 2025, the inpatient hospital deductible is $1,632 per benefit period. Beneficiaries pay $408 per day for days 61-90 of a hospital stay and $816 per day for lifetime reserve days. For skilled nursing facilities, the daily coinsurance is $204 for days 21-100​ (Centers for Medicare & Medicaid Services)​​ (Centers for Medicare & Medicaid Services)​.

What It Doesn’t Cover:

  • Long-term care (custodial care)
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and exams for fitting them

Eligibility Requirements for Medicare Part A

Medicare Part A, also known as Hospital Insurance, provides coverage for inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. Here are the basic eligibility requirements:

  1. Age Requirement:
    • Individuals aged 65 or older are eligible if they or their spouse have worked and paid Medicare taxes for at least 10 years (40 quarters).
  2. Disability:
    • Individuals under 65 can qualify if they have been receiving Social Security Disability Insurance (SSDI) for 24 months.
  3. End-Stage Renal Disease (ESRD):
    • Any age, if they require regular dialysis or have had a kidney transplant and have worked the required amount under Social Security, the Railroad Retirement Board, or as a government employee.
  4. Amyotrophic Lateral Sclerosis (ALS):
    • Individuals automatically qualify when they begin receiving SSDI benefits.
  5. Enrollment in Social Security or Railroad Retirement Board Benefits:
    • Most people are automatically enrolled in Medicare Part A when they turn 65 if they are already receiving these benefits.
  6. Premium-Free Part A:
    • No monthly premium is required if the individual or their spouse paid Medicare taxes while working for at least 10 years.
    • If they worked 30-39 quarters, the Part A premium is $278 per month in 2025.
    • For those with fewer than 30 quarters, the premium is $506 per month in 2025.
  7. Voluntary Enrollment:
    • Individuals not automatically enrolled can sign up during their Initial Enrollment Period (IEP), which is a seven-month period that includes the three months before turning 65, the month they turn 65, and the three months after.
    • General Enrollment Period (GEP): January 1 to March 31 each year, with coverage starting July 1.
    • Special Enrollment Periods (SEP) are available for those who delayed enrollment due to certain circumstances, such as having employer coverage.

Medicare Part B: Medical Insurance

What It Covers: Medicare Part B covers medically necessary services and preventive services. This includes:

  • Doctor Services: Visits to primary care physicians and specialists.
  • Preventive Services: Screenings, vaccines, and annual wellness visits.
  • Outpatient Care: Services you get from a hospital or outpatient facility without being admitted.
  • Durable Medical Equipment (DME): Items like wheelchairs, walkers, and oxygen equipment.
  • Mental Health Services: Outpatient counseling and therapy, partial hospitalization, and limited inpatient care.

Costs:

  • Premiums: The standard Part B premium for 2025 is $174.70 per month, though higher-income beneficiaries may pay more.
  • Deductibles and Coinsurance: The annual deductible for Part B is $240 in 2025. After meeting the deductible, beneficiaries typically pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and DME​ (Centers for Medicare & Medicaid Services)​​ (Centers for Medicare & Medicaid Services)​.

What It Doesn’t Cover:

  • Routine dental, vision, and hearing exams
  • Most prescription drugs (covered under Part D)
  • Cosmetic surgery
  • Acupuncture
  • Long-term care

Eligibility Requirements for Medicare Part B

Medicare Part B, which covers medical insurance, including doctor services, outpatient care, home health services, durable medical equipment, and many preventive services, has specific eligibility criteria. Here are the simple terms of the eligibility requirements based on the latest information from CMS:

  1. Age Requirement:
    • Individuals aged 65 or older are eligible if they are citizens or permanent residents of the United States.
  2. Disability:
    • Individuals under 65 qualify if they have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months.
  3. End-Stage Renal Disease (ESRD):
    • Any age, if they require regular dialysis or have had a kidney transplant.
  4. Amyotrophic Lateral Sclerosis (ALS):
    • Individuals automatically qualify when they begin receiving SSDI benefits.
  5. Enrollment in Social Security or Railroad Retirement Board Benefits:
    • Most people are automatically enrolled in Medicare Part B when they turn 65 if they are already receiving these benefits.

Enrollment Periods

  • Initial Enrollment Period (IEP): A 7-month period starting three months before turning 65, including the month you turn 65, and ending three months after.
  • General Enrollment Period (GEP): January 1 to March 31 each year, with coverage starting July 1.
  • Special Enrollment Periods (SEP): For those who qualify due to specific circumstances, such as losing employer coverage or moving out of a plan’s service area​ (Centers for Medicare & Medicaid Services)​​ (Medicare)​.

How to Enroll

Self-Enrollment:

  • Online: Via the Social Security Administration website (www.ssa.gov).
  • Phone: Call Social Security at 1-800-772-1213.
  • In Person: Visit a local Social Security office.

Assistance from Medicare Agents: As a licensed Medicare agent, you can provide invaluable assistance by:

  • Explaining Coverage Options: Help clients understand the differences between Part A and Part B and what they cover.
  • Verifying Eligibility: Ensure clients meet the eligibility requirements and advise them on the best enrollment periods.
  • Completing Enrollment Forms: Assist with filling out and submitting the necessary forms.
  • Providing Additional Resources: Offer resources like the “Welcome to Medicare” package, which includes detailed information about coverage and benefits​ (Medicare)​​ (Centers for Medicare & Medicaid Services)​.

By understanding these key aspects of Medicare Part A and Part B, you can confidently guide your clients through the enrollment process and help them make informed decisions about their healthcare coverage.

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