Introduction
Medicare looks simple until the bills arrive. Two parts, separate premiums, deductibles that reset on different schedules, and coinsurance that kicks in at different points. Many people assume "Medicare covers it" means "Medicare pays for it all." It doesn't.
Original Medicare is the federal program made up of Part A (hospital insurance) and Part B (medical insurance). This guide explains what each part covers, what it costs in 2026, what it leaves out, and how to plan your next steps.
Costs change every year. Confirm current figures with Medicare.gov or CMS before making a decision.
Key Takeaways
- Part A covers inpatient hospital, skilled nursing, hospice, and some home health care.
- Part B covers doctors, outpatient care, and prevention.
- Most people pay no Part A premium; the 2026 deductible is $1,736 per benefit period.
- Part B costs $202.90 a month in 2026, more at higher incomes, plus a $283 deductible.
- Original Medicare has no annual out-of-pocket cap, which is why many people add other coverage.
Medicare Part A: What It Covers and Costs
What Medicare Part A generally covers
Part A is hospital insurance. Medicare.gov lists four main categories:
- Inpatient hospital care
- Qualifying skilled nursing facility (SNF) care
- Hospice care
- Some home health care
Coverage depends on eligibility, medical necessity, and whether the facility meets Medicare requirements. Hospice requires a certified terminal illness with a life expectancy of six months or less.
Inpatient versus observation matters. You need a formal inpatient order. Observation is outpatient care, even if you stay overnight. Ask the hospital which status you have, because it changes which benefits and costs apply.
Skilled nursing and long-term care distinctions
Part A may cover skilled nursing or rehabilitation after a qualifying hospital stay, generally three consecutive inpatient days. Count the admission day, not the discharge day, and not observation time. CMS gives an example: one observation day plus two inpatient days does not qualify.
Three weeks of physical therapy after a hip replacement is skilled rehab, and Part A may pay. Months of help with bathing and dressing in a nursing home is custodial care, and Part A does not cover it on its own.
How much Part A costs
Most people pay no premium. You generally qualify with 40 quarters (about 10 years) of Medicare-taxed work, yours or your spouse's. The bigger cost is cost sharing, as the 2026 figures from CMS show:
| 2026 Part A item | Your cost |
|---|---|
| Premium, 40+ quarters | $0 |
| Premium, 30-39 quarters | $311/month |
| Premium, fewer than 30 quarters | $565/month |
| Inpatient deductible | $1,736 per benefit period |
| Hospital days 1-60 | $0 after deductible |
| Hospital days 61-90 | $434/day |
| Days 91+ (lifetime reserve, 60 days total) | $868/day |
| SNF days 1-20 | $0/day |
| SNF days 21-100 | $217/day |
| SNF day 101+ | All costs |
A benefit period isn't a calendar year. It ends after 60 consecutive days without inpatient hospital or skilled SNF care, and a new one can trigger another deductible.
Hospice covered care costs $0, with up to $5 per pain or symptom prescription. Covered home health is also $0.
Medicare Part B: What It Covers and Costs
What Medicare Part B generally covers
Part B is medical insurance. It helps pay for:
- Medically necessary physician services
- Outpatient care and diagnostic tests
- Preventive services and mental health services
- Ambulance services
- Durable medical equipment
- Some home health and provider-administered drugs
Most outpatient prescriptions fall under Part D instead.
Preventive examples, per Medicare.gov, cost $0 when the provider accepts assignment:
- Annual wellness visit: every 12 months. It isn't a routine physical, so extra services may cost you.
- Diabetes screening: up to twice a year for eligible people with risk factors.
- Lung cancer screening: annually, ages 50-77, with a 20 pack-year history and a provider order.
How Part B costs are calculated
For 2026, the standard premium is $202.90 a month and the deductible is $283 a year. After that, you usually pay 20% coinsurance.
What you owe depends on the Medicare-approved amount (the rate Medicare sets for a service). Participating providers accept it as full payment. Nonparticipating providers may charge up to 15% more in many cases.
Income-related adjustments
Higher earners pay more. CMS uses modified adjusted gross income (MAGI) from your tax return from two years earlier. For 2026, that's your 2024 return.
| Individual MAGI | Joint MAGI | Monthly premium |
|---|---|---|
| $109,000 or less | $218,000 or less | $202.90 |
| Over $109,000 to $137,000 | Over $218,000 to $274,000 | $284.10 |
| Over $137,000 to $171,000 | Over $274,000 to $342,000 | $405.80 |
| Over $171,000 to $205,000 | Over $342,000 to $410,000 | $527.50 |
| Over $205,000 to under $500,000 | Over $410,000 to under $750,000 | $649.20 |
| $500,000 or more | $750,000 or more | $689.90 |
Married filing separately and living with your spouse? Different thresholds apply. If income dropped because of a life event such as retirement or a spouse's death, use Form SSA-44 to request a new determination.
Additional Part B cost considerations
Original Medicare has no annual out-of-pocket limit. Medigap, Medicare Advantage, or Medicaid can change that exposure.
The late-enrollment penalty is permanent. Your premium rises 10% for each full 12-month period you could have had Part B but didn't enroll. You generally pay it as long as you have Part B.
You may delay without penalty if you have qualifying current employment coverage. The Special Enrollment Period lasts while that coverage continues plus eight months after it or the job ends. COBRA doesn't extend the clock, and retiree coverage doesn't qualify. Confirm with Social Security or Medicare before declining Part B.
How Medicare Parts A and B Work Together
A simple comparison of Part A and Part B
| Part A | Part B | |
|---|---|---|
| Purpose | Hospital insurance | Medical insurance |
| Typical setting | Inpatient and facility care | Outpatient and doctor care |
| Examples | Hospital stay, SNF, hospice | Doctor visits, screenings, equipment |
| Premium | Usually $0 | $202.90 or more |
| Cost sharing | Per-benefit-period deductible, daily coinsurance | Annual deductible, 20% coinsurance |
How claims and cost sharing fit together
Key terms, using Medicare.gov's definitions:
- Premium: monthly amount you pay whether or not you use services
- Deductible: amount you pay before Medicare begins covering costs
- Copayment: a fixed amount
- Coinsurance: your percentage share
- Assignment: the provider accepts Medicare's approved amount as full payment
One hospital admission can involve both parts. Part A covers the facility stay; Part B covers most inpatient doctor services, with its own deductible and coinsurance. Your Medicare Summary Notice isn't a bill. It shows what was billed, what Medicare paid, and the most you may owe.
Having both parts doesn't mean Medicare pays everything. Services must be covered, medically necessary, properly billed, and delivered by an eligible provider.
Do you need both Part A and Part B?
Most people choosing Original Medicare enroll in both for broader hospital and medical coverage. Exceptions exist. Active employer or union coverage, disability eligibility, or other insurance can change the timing, so review your specific situation before you enroll.
Original Medicare compared with Medicare Advantage
Medicare Advantage delivers your Part A and B benefits through a private plan. It is not a supplement to Original Medicare.
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Providers | Any that accept Medicare | May require network |
| Prior authorization | Usually not | May be required |
| Annual out-of-pocket limit | None | Yes, varies by plan |
| Extra dental/vision/hearing | Generally excluded | Some plans offer |
| Part B premium | Yes | Yes, plus possible plan premium |
Prior authorization is a real tradeoff. KFF data shows Medicare Advantage insurers made 52.8 million determinations in 2024, and 7.7% were denied.
What Original Medicare Does Not Cover
Common coverage gaps
Original Medicare generally excludes:
- Routine dental care and dentures
- Routine eye exams for glasses
- Hearing aids and fitting exams
- Most outpatient prescription drugs
- Long-term custodial care when that is the only care needed
Exceptions exist. Dental work tied to a covered heart valve repair, transplant, or cancer treatment may qualify. An annual diabetic retinopathy exam is covered for eligible people.
Check the specific service, diagnosis, and provider rather than assuming a whole category is in or out.
Coverage options people may consider
- Part D: covers drugs Part B doesn't.
- Medigap: supplements Original Medicare only, never Medicare Advantage.
- Medicare Advantage: replaces how you receive Parts A and B.
- Medicaid: joint federal-state help for eligible low-income people, including some nursing-home and personal care.
- Medicare Savings Programs: QMB helps with premiums and cost sharing; SLMB and QI help with Part B premiums.
Eligibility, premiums, and rules differ for each. Muneris Benefits provides personalized Medicare guidance and Medicare supplement comparisons for eligible clients in Virginia and West Virginia.
If you want help comparing options, a licensed agent can lay out the tradeoffs. No one can promise a specific outcome.
Enrollment and Choosing Your Next Steps
Key enrollment windows and penalties
| Window | Rule |
|---|---|
| Initial Enrollment Period | Seven months: three before your 65th birthday month, the month itself, three after |
| Automatic enrollment | Generally if you receive Social Security or RRB benefits at least four months before eligibility |
| Disability | Automatic after 24 months of disability benefits |
| General Enrollment Period | January 1 to March 31; coverage starts the month after you enroll |
| Medigap Open Enrollment | Six months from the month you're 65+ and in Part B |
Delaying Part B or Part D without qualifying coverage can trigger late-enrollment penalties. The Part D penalty is 1% of the $38.99 2026 national base premium for each month without creditable coverage after a 63-day gap. It's separate from the Part B penalty.
A practical decision checklist
Review these before enrolling:
- Doctors and hospitals you rely on
- Current prescription medications
- Expected care use and travel
- Preferred level of care flexibility
- Premium and out-of-pocket budget
- Dental, vision, hearing, and drug needs
Compare total annual exposure, not just the monthly premium. Add deductibles, coinsurance, supplemental premiums, network limits, and possible assistance programs.
Where to verify information and get help
Start with Medicare.gov, CMS, Social Security, and your plan documents. Your State Health Insurance Assistance Program offers free counseling. Virginia's VICAP is 1-800-552-3402; West Virginia's SHIP is 1-877-987-4463.
Leaving employer coverage or managing complex health and financial needs? Get personalized guidance before you enroll, delay, or drop anything.
Frequently Asked Questions
How much will Medicare Part B cost me per month?
The standard 2026 premium is $202.90. Higher incomes pay more through income-related adjustments. Verify the benefit year on Medicare.gov or CMS.
Does Medicare Part A cover 100%?
No. Part A involves a $1,736 deductible per benefit period in 2026, daily coinsurance for longer stays, and eligibility rules.
How does Medicare Part B work?
After your premium and annual deductible, Part B generally pays 80% of the approved amount for covered medical and outpatient services. You pay the rest.
Do I need both Medicare Part A and B?
Many people choose both for broader coverage. Employer coverage, other insurance, disability, and timing can change the right decision.
What's the difference between Part B and Medicare Advantage?
Part B is medical insurance within Original Medicare. Medicare Advantage is a private alternative that provides Part A and B benefits under plan-specific rules.
What isn't covered by Medicare Part B?
Most routine dental, vision, hearing aids, long-term custodial care, and outpatient drugs. Exceptions and supplemental coverage may apply.
