Understood Care (04/22/25)

Q: How do I know if a service is covered under Part A or Part B?

The general rule is that Part A covers care where you are an admitted inpatient at a facility, while Part B covers outpatient services and doctor visits. If you go to the emergency room but are not formally admitted, that visit falls under Part B. If you are admitted to the hospital from the emergency room, the hospital stay falls under Part A. Your Medicare Summary Notice will show which part was billed for each service.

Written by Debbie Hall - Director of Operations at Understood Care | 20+ years of experience in CDPAP program management and home care coordination | Updated February 2026

Medicare Part A covers hospital stays, skilled nursing care, hospice, and some home health services. Medicare Part B covers doctor visits, outpatient care, preventive screenings, and medical equipment. Most people pay $0 for Part A and $185 per month for Part B in 2026.

Key Takeaways

Part A covers hospital stays, skilled nursing, hospice, and some home health - most people pay $0 in premiums if they worked 10+ years.
Part B covers outpatient care, doctor visits, lab tests, and preventive services - the standard 2026 premium is $185/month.
Neither Part A nor Part B covers dental, vision, hearing, or long-term care - you need supplemental coverage for these.
Delaying Part B enrollment past your Initial Enrollment Period triggers a permanent 10% penalty for each 12-month period you were eligible but did not enroll.
You need both Part A and Part B to enroll in Medicare Advantage (Part C) or a Medigap supplement plan.

This article is part of our Complete Guide to Medicare and CDPAP in New York - a comprehensive resource covering Medicare benefits, CDPAP eligibility, caregiver pay rates, appeals, and patient advocacy.

Quick Answer

Medicare Part A covers hospital stays, skilled nursing, hospice, and home health (most people pay $0 in premiums). Part B covers doctor visits, outpatient care, and preventive services ($185/month in 2026). You need both for complete coverage. Neither covers long-term personal care at home.

If you are new to Medicare, all the different parts and plans can feel confusing. But here is the good news - you really only need to understand two pieces to start. Part A and Part B together make up what is called Original Medicare, and they handle different types of care.

Let us break down exactly what each part covers, what you will pay out of pocket in 2026, and how to avoid costly penalties for signing up late.

Quick Summary

Part A = Hospital Insurance. Covers hospital stays, skilled nursing, and hospice. Usually free.
Part B = Medical Insurance. Covers doctor visits, lab tests, and preventive care. Costs $185/month in 2026.
You need both for full coverage. Most people get them together.
Sign up 3 months before you turn 65 to avoid late penalties.
If your income is above $106,000, you pay extra for Part B (called IRMAA).

What Does Medicare Part A Cover?

Part A is your hospital insurance. It kicks in when you need serious medical care that involves a stay at a facility or intensive services at home. Think of Part A as the part that covers you when something big happens.

Part A covers four main categories:

1. Inpatient Hospital Stays

When you are admitted to a hospital as an inpatient, Part A covers your room, meals, nursing care, medications given during your stay, lab tests, and surgeries. It does not cover your private-duty nursing or a private room unless medically necessary.

For 2026, here is what you pay for a hospital stay:

Days 1 through 60: You pay the $1,676 deductible once per benefit period, then $0
Days 61 through 90: You pay $419 per day
Days 91 and beyond: You use lifetime reserve days at $838 per day (you get 60 of these total, ever)

A benefit period starts the day you are admitted and ends when you have been out of the hospital or skilled nursing facility for 60 days in a row. If you go back to the hospital after that, a new benefit period starts and you pay the deductible again.

2. Skilled Nursing Facility Care

If you need skilled nursing care after a qualifying hospital stay of at least 3 days, Part A covers up to 100 days per benefit period. This is not the same as long-term nursing home care, which Medicare does not cover.

Days 1 through 20: $0 after the Part A deductible
Days 21 through 100: You pay $209.50 per day in 2026
After day 100: You pay the full cost yourself

3. Hospice Care

If you have a terminal illness and choose comfort care over curative treatment, Part A covers hospice. This includes nursing care, pain management, counseling, and medication related to your terminal diagnosis. You pay $0 for most hospice services, though there may be a small copay of up to $5 for prescription drugs.

4. Home Health Services

Part A covers home health care when you are homebound and need skilled nursing or therapy on a part-time basis. This can include a visiting nurse, physical therapy, occupational therapy, and some medical supplies. You pay $0 for covered home health services. If you need ongoing home care coordination, understanding your Part A benefits is an important first step.

What Does Medicare Part B Cover?

Part B is your medical insurance. It covers the care you get outside of a hospital stay, which for most people is the bulk of their medical needs. Doctor visits, tests, preventive care, and medical equipment all fall under Part B.

Doctor and Outpatient Services

Part B covers visits to your doctor's office, specialist appointments, outpatient surgeries, diagnostic tests like X-rays and bloodwork, mental health services, and second opinions before surgery. After you meet your annual $257 deductible, you typically pay 20% of the Medicare-approved amount for most services.

Preventive Services

One of the biggest benefits of Part B is that many preventive services are covered at no cost to you, with no deductible and no coinsurance. These include:

Annual wellness visit
Flu, pneumonia, COVID-19, and hepatitis B shots
Mammograms and breast cancer screenings
Colonoscopies and colorectal cancer screenings
Cardiovascular screenings
Diabetes screenings and self-management training
Depression screenings
Bone density tests
Prostate cancer screenings

Keeping up with preventive care is one of the smartest things you can do - ask your doctor's office about scheduling your annual wellness visit.

Durable Medical Equipment

Part B also covers durable medical equipment, often called DME. This includes wheelchairs, walkers, hospital beds for home use, oxygen equipment, and blood sugar monitors. You pay 20% of the Medicare-approved amount after your deductible.

Ambulance Services

Part B covers ambulance transportation when other transportation would endanger your health. You pay 20% coinsurance after the deductible.

2026 Cost Comparison: Part A vs Part B

Cost	Part A (Hospital)	Part B (Medical)
Monthly premium	$0 for most people (up to $518 if you did not work 10+ years)	$185 per month (standard); higher if income above $106,000
Annual deductible	$1,676 per benefit period	$257 per year
Coinsurance	$0 for first 60 days; $419/day for days 61-90	20% of Medicare-approved amount
Out-of-pocket maximum	No cap	$2,700 new cap starting 2026

The Part B out-of-pocket cap of $2,700 is new for 2026. Before this year, there was no limit on how much you could spend on Part B services. This is a significant change that protects you from very high costs if you need a lot of outpatient care.

How Much Does Part A Cost in 2026?

Most people pay $0 in premiums for Part A. You qualify for premium-free Part A if you or your spouse paid Medicare taxes for at least 10 years, which equals 40 quarters of work.

If you do not have enough work credits:

30 to 39 quarters of work: You pay $285 per month
Fewer than 30 quarters: You pay $518 per month

Even though the premium may be $0, Part A still has significant costs when you actually use it. That $1,676 deductible per benefit period can add up, especially if you have multiple hospital stays in one year.

How Much Does Part B Cost in 2026?

The standard Part B premium for 2026 is $185 per month. This is up from $174.70 in 2025. Most people have this deducted automatically from their Social Security check.

If your modified adjusted gross income is above $106,000 as an individual or $212,000 as a married couple, you pay more. This extra charge is called IRMAA, which stands for Income-Related Monthly Adjustment Amount.

Individual Income	Married Couple Income	Monthly Part B Premium
$106,000 or less	$212,000 or less	$185.00
$106,001 to $133,500	$212,001 to $267,000	$259.00
$133,501 to $167,000	$267,001 to $334,000	$370.00
$167,001 to $200,000	$334,001 to $400,000	$480.90
Above $200,000	Above $400,000	$591.90

If your income has dropped since the tax year Medicare is using, for example because you retired or lost a spouse, you can appeal your IRMAA by filing a life-changing event form with Social Security.

When Do You Enroll in Part A and Part B?

Your Initial Enrollment Period is a 7-month window around your 65th birthday. It starts 3 months before the month you turn 65, includes your birthday month, and extends 3 months after.

If you are already receiving Social Security benefits when you turn 65, you are enrolled in both Part A and Part B automatically. If not, you need to sign up. For official enrollment details, visit medicare.gov.

There are also Special Enrollment Periods if you delayed Medicare because you had coverage through an employer. You get 8 months after that employer coverage ends to sign up without a penalty.

Your Next Step

Turning 65 in the next 3 months? Contact Social Security at 1-800-772-1213 to enroll in Medicare. You can also sign up online at ssa.gov.

What Happens If You Sign Up Late?

Late enrollment penalties can follow you for life, so this is worth paying attention to.

Part A penalty: If you have to pay a Part A premium and you do not sign up when first eligible, your premium goes up 10%. You pay this higher amount for twice the number of years you could have had Part A but did not.

Part B penalty: Your premium goes up 10% for every full 12-month period you could have had Part B but did not sign up. This penalty is added to your premium permanently. If you waited 3 years, that is a 30% surcharge on your Part B premium for the rest of your life.

The General Enrollment Period runs from January 1 through March 31 each year, with coverage starting July 1. If you missed your initial window and do not qualify for a Special Enrollment Period, this is when you can sign up.

Do You Need Both Part A and Part B?

The short answer is yes, in almost every case. Part A and Part B work together. Without both, you have significant gaps in coverage.

For example, if you only have Part A and you break your arm, the emergency room visit and X-rays are outpatient services covered by Part B, not Part A. You would only be covered if you were formally admitted to the hospital.

If you only have Part B and need surgery that requires an overnight hospital stay, you would be responsible for the full cost of the hospital portion of your care.

Together, Part A and Part B form Original Medicare. Many people also add a Part D prescription drug plan and a Medigap supplemental policy to fill in the cost-sharing gaps. Understanding what is and is not covered helps you review your medical bills for errors and avoid surprise charges. A patient advocate can help with billing disputes.

What Medicare Part A and Part B Do Not Cover

Even with both parts, Original Medicare has notable gaps:

Prescription drugs (you need a separate Part D plan)
Dental care, including cleanings and dentures
Vision care, including eyeglasses and routine eye exams
Hearing aids and hearing exams for fitting hearing aids
Long-term custodial care in a nursing home (for home-based care, see CDPAP eligibility)
Care received outside the United States, with limited exceptions

Some Medicare Advantage plans, which are an alternative way to get your Part A and Part B benefits through a private insurer, do include dental, vision, and hearing coverage.

Real-Life Scenarios: Is It Part A or Part B?

Medicare's split between Part A and Part B confuses almost everyone. This table maps common medical situations to the correct part of Medicare.

Scenario	Part A or Part B?	What Medicare Pays
You break your hip and need surgery	Part A (hospital stay) + Part B (surgeon's fee)	Part A covers the room. Part B covers the doctor.
You visit your doctor for a checkup	Part B	100% for most preventive visits. 80% for diagnostic.
You need a CT scan at an imaging center	Part B	80% after deductible. You pay 20%.
You are admitted to a skilled nursing facility after hospital	Part A	100% for days 1-20. Coinsurance for days 21-100.
You need home health care after surgery	Part A (if homebound) or Part B	100% for skilled nursing and therapy. 80% for equipment.
You need an ambulance to the ER	Part B	80% after deductible.
You receive chemotherapy at an outpatient clinic	Part B	80% after deductible. You pay 20%.
You are in the hospital as an outpatient (observation status)	Part B (not Part A!)	80%. This is a costly surprise for many patients.
You enter hospice care	Part A	Nearly 100%. Small copays for drugs and respite care.
You need a wheelchair or oxygen equipment	Part B (DME)	80% after deductible for approved equipment.

The observation status trap: If you are in a hospital bed but classified as "outpatient observation" instead of "admitted," Part A does not apply. You pay Part B coinsurance for the hospital stay, and the stay does not count toward the 3-day requirement for skilled nursing facility coverage. Always ask your hospital whether you are admitted or under observation.

2026 Medicare Costs at a Glance

These are the official 2026 costs published by the Centers for Medicare & Medicaid Services (CMS).

Cost	Part A	Part B
Monthly Premium	$0 for most (if 40+ work quarters). Up to $518 if not.	$185/month standard. Higher if income exceeds $106,000 (IRMAA).
Annual Deductible	$1,676 per benefit period	$257 per year
Coinsurance	$0 for days 1-60. $419/day for days 61-90. $838/day lifetime reserve.	20% of Medicare-approved amount after deductible.
Out-of-Pocket Maximum	No cap (Original Medicare has no OOP max)	No cap (Original Medicare has no OOP max)

Important: Original Medicare (Part A + Part B) has no out-of-pocket maximum. This is why many beneficiaries add a Medigap supplement plan or switch to Medicare Advantage (Part C), which is required to cap your annual costs.

Medicare Enrollment Windows: When to Sign Up

Missing your enrollment window for Part B can cost you permanently. Here are the three windows you need to know.

Initial Enrollment Period (IEP)

When: 7-month window around your 65th birthday (3 months before, birth month, 3 months after)

Best option. No penalties. Coverage starts the month you turn 65 if you enroll during the first 3 months.

General Enrollment Period (GEP)

When: January 1 - March 31 each year. Coverage starts July 1.

Late penalty applies. 10% added to your Part B premium for each 12-month period you could have enrolled but did not.

Special Enrollment Period (SEP)

When: Available if you delayed because of employer coverage. 8-month window after employer coverage ends.

No penalty. Must have had continuous employer coverage to qualify.

The penalty is permanent. If you delayed Part B for 2 years without qualifying employer coverage, you pay 20% more on your Part B premium for the rest of your life. At the 2026 standard rate, that is an extra $37/month - or $444/year - forever.

What Medicare Does NOT Cover

Original Medicare (Part A + Part B) leaves significant gaps. Understanding these gaps is critical for planning your healthcare costs.

Service	Covered by Part A/B?	How to Get Coverage
Dental (cleanings, fillings, dentures)	No	Medicare Advantage (many plans include it), standalone dental plan, or pay out of pocket
Vision (eyeglasses, contacts, routine exams)	No (Part B covers glaucoma tests and cataract surgery)	Medicare Advantage or standalone vision plan
Hearing Aids	No (Part B covers diagnostic hearing exams)	Medicare Advantage or out of pocket ($1,000 - $6,000 per pair)
Prescription Drugs	No (only Part B drugs administered by a doctor)	Part D plan or Medicare Advantage with drug coverage
Long-Term Care (nursing home, assisted living)	No (Part A covers skilled nursing up to 100 days only)	Medicaid (if eligible), long-term care insurance, or private pay
Overseas Healthcare	No (except limited ER in Canada)	Travel insurance or Medigap plans C, D, F, G, M, N

For New York residents who qualify for both Medicare and Medicaid (dual-eligible), programs like CDPAP can fill the long-term care gap by providing paid home caregivers at no cost to the patient.

Watch: Medicare Parts A, B, C, and D (Explained)

This video from AARP walks through the four parts of Medicare - Part A (hospital), Part B (medical), Part C (Medicare Advantage), and Part D (prescriptions) - in plain language. Helpful if you want a visual overview before diving into the details above.

Key Takeaway

Part A covers hospital stays and is usually free. Part B covers doctor visits and costs $185 per month in 2026. You need both for full coverage. Sign up during your Initial Enrollment Period to avoid late penalties.

Frequently Asked Questions

Is Medicare Part A really free?

For most people, yes. If you or your spouse worked and paid Medicare taxes for at least 10 years, you pay $0 in premiums for Part A. You still have out-of-pocket costs like the $1,676 deductible when you use hospital services, but the monthly premium itself is $0.

Can I have Part A without Part B?

Yes, you can enroll in Part A only. Some people do this if they still have employer coverage that handles their outpatient and doctor visit needs. However, if you delay Part B past your Initial Enrollment Period without qualifying coverage, you will face a permanent late enrollment penalty when you do sign up.

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare is Part A plus Part B administered by the federal government. Medicare Advantage (Part C) is offered by private insurers - it must cover everything Original Medicare covers but often adds dental, vision, and drugs, with the tradeoff of requiring in-network providers.

Does Part B cover prescription drugs?

Part B covers a small number of drugs administered by a doctor, such as chemotherapy infusions or certain injections given in a medical office. It does not cover prescriptions you fill at a pharmacy. For that, you need a separate Part D prescription drug plan. If medication costs are a concern, ask your pharmacist about generic alternatives or visit medicare.gov to compare Part D plans.

How do I know if a service is covered under Part A or Part B?

The general rule is simple. Part A covers care where you are an admitted inpatient at a facility. Part B covers outpatient services and doctor visits. If you go to the emergency room but are not formally admitted, that visit falls under Part B. If you are admitted to the hospital from the emergency room, the hospital stay falls under Part A. Your Medicare Summary Notice will show which part was billed for each service.