AWCA Resource Center
AWCA Resource Center

Medicare

Medicare Parts A & B (Medicare Original)

Medicare Original is the traditional fee-for-service health insurance program managed by the federal government. It allows beneficiaries to visit any doctor or hospital in the United States that accepts Medicare. Medicare Original consists of two primary components: Part A (Hospital Insurance) and Part B (Medical Insurance).

*OBBBA (One Big Beautiful Bill Act) implementations may affect eligibility and program details.

Medicare Part A (Hospital Insurance)

Part A covers essential inpatient services. Most individuals qualify for premium-free Part A if they or their spouse paid Medicare taxes for at least 10 years (40 quarters). Those with shorter work histories may purchase Part A for a monthly premium.

  • Inpatient Hospital Care: Includes semi-private rooms, meals, general nursing, and drugs provided during inpatient treatment.
  • Skilled Nursing Facility (SNF): Covers skilled nursing or rehabilitation services following a qualifying 3-day inpatient hospital stay.
  • Hospice Care: Specialized care for terminally ill beneficiaries focused on comfort and pain management.
  • Home Health Services: Covers part-time or intermittent skilled nursing care and physical therapy for homebound individuals.

Part A Costs (2026)

Costs are based on benefit period:

  • Days 1-60: Deductible of $1,736 per benefit period.
  • Days 61–90: Hospital Coinsurance of $434 per day.
  • Days 91–150: Lifetime Reserve Days of $868 per day (up to 60 days available over lifetime).
  • Days 151~: 100% personal contribution.
  • SNF
    • Days 1-20: $0 per day.
    • Days 21–100: $217 per day.
    • Days 101~: 100% personal contribution.
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  • Hospice Care: $0 copayment (small copayments may apply for outpatient prescription drugs or short-term respite care).

Medicare Part B (Medical Insurance)

Part B covers medically necessary services and preventive care. Unlike Part A, most beneficiaries must pay a monthly premium for Part B.

  • Doctor Services: Visits to primary care doctors and specialists.
  • Outpatient Care: Services received at a hospital without being admitted (e.g., ER visits or outpatient surgery).
  • Preventive Services: Includes flu shots, screenings (cancer, diabetes), and an annual wellness visit.
  • Durable Medical Equipment (DME): Covers items like walkers, wheelchairs, and oxygen equipment.

Part B Costs (2026)

  • Standard Monthly Premium: $202.90 (May be higher based on income—see IRMAA).
  • Annual Deductible: $283 per year.
  • Coinsurance: Generally 20% of the Medicare-approved amount after you meet your deductible.

Eligibility

  • 65 or older: U.S. citizens or legal permanent residents who have resided in the U.S. for at least five continuous years.
  • Under age 65 receiving Social Security Disability Insurance (SSDI) benefits or have Amyotrophic Lateral Sclerosis (ALS, ‘Lou Gehrig’s disease’) or End-Stage Renal Disease (ESRD).

Enrollment

Medicare enrollment may be automatic or manual depending on the applicants’ situation. Enrolling into Medicare during the enrollment window is critical; missing it can result in a lifelong monthly premium penalty.

Enrollment PeriodTimingCoverage StartKey Notes
Initial Enrollment Period (IEP)3 months before and after the 65th birthday month (7 months)Varies by time of application (typically 1st day of birthday month)Critical period to enroll when you become eligible for Medicare. Missing this window may lead to monthly penalties.
Annual Enrollment Period (AEP)October 15 – December 7January 1 of the following yearPrimary period for maintaining, changing, or dropping existing plans.
Special Enrollment Period (SEP)Within 8 months of employer-sponsored coverage ending.The 1st day of the following month of applicationFor those who delayed Medicare enrollment because they were covered under active employment. Also triggered upon sudden loss of coverage or relocation.
General Enrollment Period (GEP)January 1 – March 31The 1st day of the following month of applicationFor individuals who missed their IEP.

Automatic Enrollment (No Action Needed)

Medicare enrollment is automatic if:

  • Already Receiving Benefits: The individual has been receiving Social Security or Railroad Retirement Board (RRB) benefits for at least four months before turning 65.
  • Disability: The individual has been receiving Social Security Disability Insurance (SSDI) for 24 months.
  • ALS/ESRD: Individuals with Lou Gehrig’s disease (ALS) or End-Stage Renal Disease (ESRD) have specific automatic or expedited enrollment rules.

Manual Enrollment (Action Required)

If an individual is not receiving Social Security benefits (for example, because they are still working or delaying retirement), they must manually sign up for Medicare. 
  • Initial Enrollment Period (IEP): A 7-month window that includes the month of the 65th birthday, the three months before, and the three months after.
  • Apply Online: Enroll directly through Social Security Administration (SSA).
*Individuals who don’t enroll when first eligible may have to pay a late enrollment penalty. For more information visit Medicare.gov/avoid late penalties.

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