Original Medicare Enrollment | Brooks Insurance Group

Original Medicare is the traditional government-run health insurance program for people aged 65 and older. Certain individuals under the age of 65 with certain disabilities may also qualify. It’s made up of two main parts: Part A, which covers hospital care, and Part B, which covers doctor visits and outpatient services.

Original Medicare is a strong foundation—but it’s important to understand how it works and what additional coverage you may need. Since Part A and Part B only cover 80% of your hospital and medical costs think about enrolling in an additional plan called a Medigap/Supplement plan to help pay the other 20% or enrolling in an Medicare Advantage plan that includes Part A and Part B which does not require a 20% Medigap plan. Not sure where to begin? That’s where we come in.

You’ve received Social Security Disability Insurance (SSDI) for at least 24 months.

You get a disability pension from the Railroad Retirement Board (RRB) and meet specific criteria.

You receive SSDI due to Lou Gehrig’s disease (ALS).

You worked in a government job, paid Medicare taxes, and received SSDI for 24+ months.

You’re a child or surviving (including divorced) spouse over 50 of a worker who paid into Social Security or Medicare-covered government employment and meet SSDI criteria.

You have end-stage renal disease (ESRD), need dialysis or had a kidney transplant, and meet one of these:

Worked long enough under Social Security or the railroad retirement system.

Worked in a Medicare-covered government job.

Are the child or spouse (including divorced) of a qualifying worker, living or deceased.

If you are age 65 or older and are a U.S. citizen or a legal permanent resident who has lived in the country for at least five continuous years, you may qualify for Medicare coverage if any of the following situations apply to you:

You are currently receiving retirement benefits from either the Social Security Administration or the Railroad Retirement Board (RRB), or you are eligible to begin receiving those benefits based on your work history.

Your spouse—whether currently living, deceased, or from a previous marriage that ended in divorce—either receives or is eligible to receive Social Security or Railroad Retirement Board benefits based on their own work record.

You or your spouse have worked in a government position where you paid into the Medicare system through payroll taxes for the required length of time, even if you did not earn Social Security benefits.

You are the dependent parent of a deceased child who was considered fully insured under Social Security. This means your child worked long enough to qualify for Social Security benefits before their passing.

Part A helps cover:

Inpatient hospital stays - Part A covers inpatient hospital stays which includes room, meals, general nursing, drugs and other hospital services and supplies. Part A also covers care in a skilled nursing facility, hospice care, and some home health care.

Part A usually covers inpatient hospital care if you meet both of these conditions:

You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury.
The hospital accepts Medicare.

Skilled Nursing Facility Care- Medicare Part A provides short-term or limited time coverage for care in Skilled Nursing Facilities, typically after a hospital stay due to an illness or injury If certain conditions are met. It covers rehabilitation and medical treatment in a skilled nursing setting, often within a nursing home. However, Medicare Part A does not cover long-term or custodial care in a nursing home. If you’re receiving Medicare-approved skilled nursing care, Part A generally also covers the cost of prescription drugs related to your stay.

Inpatient Mental Health Services:

Medicare Part A (Hospital Insurance) covers mental health care services you get when you're admitted as a hospital inpatient. Mental health care services help diagnose and treat people with mental health disorders, like depression and anxiety.

You can get these inpatient services either in a general hospital or a psychiatric hospital (a facility that only cares for people with mental health disorders).
If you're in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.

Home Healthcare:

Home health Care is a wide range of health care services that you can get in your home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or a Skilled Nursing Facility.

Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible home health services as long as you need part-time or intermittent skilled services and you’re “homebound,” which means:

You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.
Leaving your home isn’t recommended because of your condition.
You’re normally unable to leave your home because it’s a major effort.

Covered home health services include:

Medically necessary part-time or intermittent skilled nursing care, like:
Wound care for pressure sores or a surgical wound
Patient and caregiver education
Intravenous or nutrition therapy
Injections
Monitoring serious illness and unstable health status
Physical therapy, occupational therapy, and speech-language pathology services (if you meet certain conditions)
Medical social services
Part-time or intermittent home health aide care (only if you’re also getting skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy at the same time), like:
Help with walking
Bathing or grooming
Changing bed linens
Feeding
Injectable osteoporosis drugs for women who meet certain criteria
Durable medical equipment
Medical supplies for use at home

A doctor or nurse practitioner must assess you face-to-face before certifying that you need home health services. A doctor or a nurse practitioner must order your care, and a Medicare-certified home health agency must provide it.

If your provider decides you need home health care, they should give you a list of agencies that serve your area. They must tell you if their organization has a financial interest in any agency listed.

In most cases, "part-time or intermittent" means you may be able to get skilled nursing care and home health aide services up to 8 hours a day (combined), for a maximum of 28 hours per week. You may be able to get more frequent care for a short time (less than 8 hours each day and no more than 35 hours each week) if your provider determines it's necessary.

Nursing Home or Long Term Care:

Nursing homes are residential facilities that provide long-term care, full-time medical and personal care. The majority of care in nursing homes is custodial, which includes assistance with daily activities such as bathing, dressing, and eating. Original Medicare does not cover custodial care if it is the only type of care you require. However, Original Medicare may cover skilled nursing care—either in a nursing home or through home health services—if it is needed on a short-term basis due to an illness or injury and specific eligibility requirements are met.

Hospice Care -

Hospice Care is end-of-life care for people with illnesses that cannot be cured. Only your hospice doctor and your regular doctor can certify that you’re terminally ill and have a life expectancy of 6 months or less. After 6 months, you can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies (after a face-to-face meeting with the hospice doctor or hospice nurse practitioner) that you’re still terminally ill.

You qualify for hospice care if you have Medicare Part A (Hospital Insurance) and meet all of these conditions:

Your hospice doctor and your regular doctor certify that you’re terminally ill with a life expectancy of 6 months or less.
You accept comfort care (palliative care) instead of care to cure your illness.
You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.

If you qualify, you can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods. You have the right to change your hospice provider once during each benefit period.

You can usually get Medicare-approved hospice care in your home or other facility where you live, like a nursing home. You can also get hospice care in an inpatient hospice facility. If your hospice care team determines you need inpatient care at a hospital, they must make the arrangements for your stay. If they don’t, you might be responsible for the entire cost of your hospital care.

Part A Hospice Costs

You pay nothing for hospice care if you get your care from a Medicare-approved hospice provider.
You pay a copayment of up to $5 for each prescription for outpatient drugs for pain and symptom management. In the rare case the hospice benefit doesn't cover your drug, your hospice provider should contact your plan to find out if Part D covers it. The hospice provider will inform you if any drugs or services aren’t covered, and if you’ll be required to pay for them.
You may pay 5% of the Medicare-approved amount for inpatient respite care (short-term care to help give caregivers a rest). Your copay can’t exceed the inpatient hospital deductible for the year.

Original Medicare will still pay for covered benefits for any health problems that aren't part of your terminal illness and related conditions, but you'll owe any deductible and coinsurance amounts that apply. Once you choose hospice care, your hospice benefit will usually cover everything you need.

You may have to pay for room and board if you live in a facility (like a nursing home) and choose to get hospice care.

If your hospice care team determines you need inpatient care at a hospital, they must make the arrangements for your stay. If they don’t, you might be responsible for the entire cost of your hospital care.

Medicare Part B covers a wide range of outpatient services that are crucial for senior wellness, including:

Medicare Part B (Medical Insurance) helps cover 2 types of services:

Medically necessary services: Services or supplies that meet accepted standards of medical practice to diagnose or treat your medical condition.
Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage when treatment is likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Services from doctors and other health care providers

Outpatient Care

Hospital Observation

Radiology

EKG

MRI Scan

CT Scan

Ambulance

Annual Wellness Visits

Preventive Services

Physical Therapy

Occupational Therapy

Health Screenings:

Preventive Services

Home health Care

Durable Medical Equipment

Diabetes Pump

Continuous Glucose Monitor

Oxygen

C-PAP Continuous Positive Airway Pressure

Depression Screening

Mental Health Counseling and Psychotherapy

Obesity Counseling

Smoking Cessation Counseling

Medicare Part B (Medical Insurance) Prescriptions:

Covers a limited number of outpatient prescription drugs under certain conditions. Usually, Part B covers drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting.

Here are some examples of Part B-covered drugs:

Monoclonal antibodies for the treatment of early Alzheimer’s Disease
Drugs used with some types of durable medical equipment (DME): If the drug used is medically necessary, Medicare covers drugs infused through DME (like an infusion pump or nebulizer).
Some antigen allergy tests and treatments: Medicare covers antigen tests to check for allergies and their treatment if a doctor or other health care provider prepares them, and they're given by a properly instructed person (who could be you, the patient) under appropriate supervision.
HIV prevention drugs.
Injectable osteoporosis drugs.
Erythropoiesis-stimulating agents: Medicare covers erythropoietin by injection if you have End-Stage Renal Disease (ESRD) or you need this drug to treat anemia related to certain other conditions.
Blood clotting factors: If you have hemophilia (a genetic bleeding disorder that keeps your blood from clotting properly), Medicare covers injectable clotting factors you give yourself or get in a doctor's office.
Injectable and infused drugs: Medicare covers most injectable and infused drugs when a licensed medical provider gives them.
Oral End-Stage Renal Disease (ESRD) drugs: Medicare covers all oral ESRD drugs.

Enteral and parenteral nutrition (intravenous and tube feeding): Medicare covers certain nutrients if you can’t absorb nutrition through your intestinal tract or take food by mouth.
Intravenous Immune Globulin (IVIG): Medicare covers IVIG you get at home if both of these conditions apply:
You've been diagnosed with primary immune deficiency disease.
Your health care provider decides that it's medically appropriate for you.
Part B also pays for other items and services related to you getting the IVIG at home.
Shots (vaccinations): Medicare covers flu shots, pneumococcal shots and COVID-19 vaccines. Medicare also covers Hepatitis B shots for certain people, and some other vaccines when they're directly related to treating an injury or illness.
Transplant / immunosuppressive drugs. Medicare covers transplant drug therapy (including certain compounded immunosuppressive drugs) if Medicare helped pay for your organ transplant. You must have Part A at the time of the covered transplant, and you must have Part B at the time you get immunosuppressive drugs.
If you only have Medicare because of End-Stage Renal Disease (ESRD) your Medicare coverage (including Immunosuppressive drug coverage) ends 36 months after a successful kidney transplant. Medicare offers a benefit to help you pay for your immunosuppressive drugs beyond 36 months if you don’t have certain types of other health coverage, Group, TRICARE or Medicaid that covers immunosuppressive drugs. This benefit only covers your immunosuppressive drugs and no other items or services. It isn’t a substitute for full health coverage.
Oral cancer drugs: Medicare covers some cancer drugs you take by mouth if the same drug is available in an injectable form, or it's a prodrug of the injectable drug. A prodrug is an oral form of a drug that, when ingested, breaks down into the same active ingredient found in the injectable drug.
Oral anti-nausea drugs: Medicare covers oral anti-nausea drugs you get as part of a cancer chemotherapeutic regimen if you take them before, during, or within 48 hours of chemotherapy, or you get them as full therapeutic replacement for an intravenous anti-nausea drug.
Self-administered drugs in hospital outpatient settings: Under very limited circumstances, Medicare may pay for some self-administered drugs if you need them for the hospital outpatient services you're getting.

Medicare drug plans (Part D) cover many drugs that Part B doesn't cover. If you have Original Medicare, you can join a Medicare drug plan to get Medicare drug coverage. If you join a drug plan, check your plan's drug list (also called a formulary) to find out what outpatient drugs it covers.

Part D generally covers all adult vaccines that the Advisory Committee on Immunization Practices (ACIP) recommends, including vaccines for Respiratory Syncytial Virus (RSV), shingles, whooping cough, measles, and more. Your drug plan won’t charge you a copayment or deductible for vaccines that ACIP recommends. Talk to your provider about which ones are right for you.

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Original Medicare

Original Medicare Part A and Part B

Qualifications for Those Under Age 65

Qualifications for Those Age 65 or Older

Part A (Hospital) Covers:

Part B (Medical) Covers:

Part D Covers: