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What Is Original Medicare and What Does It Cover?

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Medicare, a federal insurance program, provides guaranteed health insurance for people 65 and older and for younger people who qualify due to a disability. It was originally envisaged as a major step toward providing health care coverage and financial security for our nation’s elderly population. Original Medicare, also known as standard Medicare, is the name given to Medicare Parts A and B, which were included in a bill signed into law by President Lyndon B. Johnson in 1965.

Original Medicare provides many health care services and supplies, but it doesn’t pay all your expenses.

  • Inpatient care in a hospital or nursing home, as well as some forms of home care and hospice care, are all covered by Part A.

  • Benefits under Part B (Medical Insurance) are doctor visits, screenings, diagnostic procedures, outpatient treatment, even some forms of transportation, medical equipment, and some preventive services.

There is no financial threshold for Medicare eligibility, and preexisting conditions cannot be used to deny coverage or increase premiums. Those with original Medicare have access to services from any Medicare-approved doctor or hospital in the country. Ninety-five percent of surgeons, ninety-five percent of all other doctors (excluding pediatricians), eighty percent of most other specialties, and sixty percent of psychiatrists are taking new Medicare patients at this time.

This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it covers.

Additional Medicare benefits are not regarded as being part of the program’s original design.

Medicare Advantage is a Medicare-approved plan from private companies that offer alternative plans to Original Medicare for health and drug coverage.

How much do I pay for original Medicare?

The Medicare program is not free. Original Medicare costs about the same as the private insurance you had for many years of your working life.

Premiums.

For most people, Part A payments are waived since they or their spouse worked for 40 quarters (10 years of labor that need not be continuous) and had Medicare taxes taken from their wages. Part B premiums are paid by the vast majority of Medicare beneficiaries and are set at $170.10 per month in 2022 and $164.90 per month in 2023, with higher rates for those with higher incomes.

Deductible.

Once you reach a specific threshold of out-of-pocket expenses, Medicare will begin to pay for your care.

Copayment.

There are some treatments and materials for which you will pay a flat rate, say $20 after you’ve met your deductible.

Coinsurance. Additionally, after you reach your deductible, you’ll be responsible for a specific percentage of your medical expenses, such as 20% of the price for the majority of Part B procedures.

Do I need to buy any supplemental policies?

However, some medical costs are not covered under original Medicare. Think about whether you need any supplemental insurance for:

Assistance with the cost of prescription medications. Prescription drug coverage is not part of the original Medicare but provides a separate Part D policy from commercial insurers.

When you first become eligible for Medicare or within the first two months after losing other prescription coverage, you can sign up for a Part D program. Every year, from October 15th to December 7th, there is a period known as “open enrollment” in which you can sign up for coverage or change plans. 

Medigap policies.

Medigap, or Medicare Supplement Insurance, is purchased by many people with original Medicare to cover Medicare’s out-of-pocket expenses.

Such plans are always available for purchase from private insurance agencies. But beware: Unless you get insurance during specific times, insurers in most states can legally refuse to cover you or charge you extra money if you have preexisting medical conditions.

How do original Medicare and Medicare Advantage differ?

You can enroll in either traditional Medicare, which is managed by the federal government, or a Medicare Advantage plan, which is administered by private insurance companies. The options vary significantly in important respects.

You don’t need prior approval to see a specialist if you have original Medicare and can visit any doctor, provider, or facility in the United States that takes Medicare. Medicare Parts A and B both include out-of-pocket costs, and prescription drugs aren’t automatically covered.

The federal government handles enrollment in Parts A and B, but private insurance companies handle coverage under Medicare Advantage plans. Part B premiums are still required, and the coverage provided by these plans must be at least as good as that provided by traditional Medicare, but premiums and deductibles may vary.

Dental, hearing, prescription, and vision coverage are all outside the scope of traditional Medicare but may be available through Advantage plans. Most Medicare Advantage plans require you to use doctors who are part of their provider network, so if your current doctor is not in the network, you may have to pay extra out of pocket or not get any coverage at all. Prior authorization is the process of getting the okay to see a specialist from the plan’s administrators.

During the initial enrollment period, or “open enrollment,” each year, you can select a Medicare Advantage plan from among the many that are offered in your area.

Keep in mind

If you are receiving Social Security payments while you or your spouse are still employed, the timeline for enrolling in original Medicare and the steps you need to take will be different than if you are not.

In some cases, participation is mandatory. Medicare Parts A and B become effective on the first day of the month of your 65th birthday if you begin receiving Social Security payments at least four months before that date. Medicare coverage will start on the first of the month before your birthday if your birthday falls on the first of the month.

Some people may sign up on their own. The initial enrollment period lasts for seven months, beginning three months before the month in which you turn 65 and ending three months following your birthday month. You can join between February 1 and August 31 if your birthday is May 15.

Interested people can sign up at a later date. You may be subject to a late-enrollment penalty if you decide to sign up for coverage after age 65 unless you or your spouse are still gainfully employed and covered by an employer-sponsored health plan. If this is the case, you or your spouse may be eligible to put off enrolling in Medicare Parts A and B until eight months after you or they lose employment-based health insurance coverage.

FAQs

What is included in the original Medicare?

Part A (Hospital Insurance) and Part B (Medical Insurance) are the two components of Original Medicare, a fee-for-service health care plan (Medical Insurance). When you visit a doctor who is approved by Medicare, you will both pay a portion of the bill once you meet your deductible (coinsurance and deductibles).

What is a correct statement about Original Medicare?

Old-school Medicare is called “Original Medicare,” and it’s run by the federal government. The government will cover the whole cost of your medical care under Original Medicare.

What are good questions to ask about Medicare?

In either case, this manual can help you weigh your choices before and after Medicare enrollment.

  • Please explain the fundamentals.

  • To what extent may you customize your insurance?

  • How about signing up for Medicare Part D?

  • Do you qualify for any Medicare cost-saving programs?

  • Where can you get information to help you understand Medicare?

Can I use my original Medicare in any state?

With Original Medicare, you can travel within the United States and its possessions without worrying about medical costs. All 50 states, DC, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are included. Most medical facilities and doctors’ offices accept Original Medicare.

Does Original Medicare expire?

There is no simple solution to this question. A Medicare Advantage (MA) plan or Original Medicare (Parts A and B) will renew on its own every year if you are already enrolled. There are, however, details about enrollment and eligibility that you may have missed.

What is the difference between original Medicare and Medicare?

Part A of Original Medicare pays for healthcare received in a hospital or nursing home, whereas Part B includes visits to the doctor, other outpatient services, and some preventative care. All of the aforementioned is included in Medicare Advantage plans, as is Part B, and in many cases, prescription medicines as well (Part D).

Does Original Medicare cover 80%?

If you receive Medicare Part B eligible medical services, you will be responsible for paying a portion of the total bill to Medicare and Medicare will pay a portion to you. Most types of outpatient care and services will only cost you 20% of the total, with the remaining 80% covered by Medicare Part B. The regular Part B premium for the year 2023 is $164.90 per month.

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