Original Medicare

Part A & Part B

What You Need to Know about Original Medicare Part A & Part B

Overview of Medicare Health Plans

Generally speaking, there are two avenues to get Medicare coverage.

Original Medicare:

Original Medicare Includes Medicare Part (Hospital insurance) A and Medicare Part B (Medical Insurance), where you will pay for services as you receive them. When receiving services, you will pay a deductible at the beginning of each year, and usually, 20% of the Medicare-approved service cost, called coinsurance. In addition, you can add a separate drug plan (Part D) if you are interested in having drug coverage.

Original Medicare may not pay for all of the cost for covered healthcare services and supplies. A Medicare Supplement Insurance (Medigap) policy can assist in paying some of the remaining health care costs (copayments, coinsurance, and deductibles). Some Medigap policies will even cover services that Original Medicare does not cover, like emergency medical care if you are traveling outside of the U.S.

Medicare Advantage:

Medicare Part C Plans (also known as Medicare Advantage Plans or Part C) are offered by Medicare-approved private health insurance companies rather than the government. Part C plans combine the coverage you would get in Part A and Part B and usually include benefits like prescription coverage, dental, vision, and hearing. They also set limits on your out-of-pocket costs for the year for covered services to protect you from unexpected costs. Generally, you will need to use healthcare providers within your plan’s network to get the lowest costs; however, some plans may offer out-of-network coverage, possibly at a higher cost.

Common types of Medicare Advantage Plans:

  • Private Fee-for-service (PFFS) Plans
  • Preferred Provider Organization (PPO) Plans
  • Special Needs Plans (SNPs)
  • Health Maintenance Organization (HMO) Plans

Less common Medicare Advantage Plans:

  • Hmo Point of service (Hmopos) Plans
  • Medicare Medical Saving Account (Msa) Plan

Click here to learn more about Medicare Advantage Plans

What is Original Medicare?

The federal government manages original Medicare coverage. Generally speaking, there are costs associated with each service. Below is additional information regarding Original Medicare:

Can I get health care through any doctor, hospital, or other health care provider?

In most cases, you may go to any doctor, hospital, other healthcare provider, or facility enrolled in Medicare and accepting new Medicare patients.

Are prescriptions covered in Original Medicare?

Original Medicare does not cover prescriptions, with a few exceptions. You can join a Medicare Drug Plan (Part D) to obtain drug coverage.

Do I need to specify a primary care doctor?

You do not need to choose a primary care doctor for Original Medicare.

Do I need a referral to see a specialist?

You don’t need a referral to see a specialist in most cases.

Should I consider getting a supplement policy?

Depending on whether or not you have employer or union coverage that pays costs that Original Medicare doesn’t, you may want to buy a Medicare Supplement Insurance (Medigap) policy.

Factors that affect Original Medicare out-of-pocket costs
  • If you have Part A and/or Part B. (Most people have both).
  • If your doctor, other health care provider, or supplier accepts assignment.
  • The type of health care you need, and how often you need it.
  • If you choose to get services or supplies not covered by Medicare. If you do, You will pay all the costs unless you have other insurance that covers it.
  • If you have other health insurance that works with Medicare.
  • If you have Medicaid or receive state help in paying your Medicare costs.
  • If you have a Medicare Supplement Insurance (Medigap) policy.
  • If you have signed a private contract with either your doctor or other health care provider.
What is Part A (Hospital Insurance)?

Part A is responsible for covering inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care.

What is Part B (Medical Insurance)?

Part B covers specific doctors’ services, Outpatient care, medical supplies, and preventative care services.

What are your Medicare rights?

Regardless of how you get Medicare, there are rights and protections in place designed to:

  • Protect you when getting health care.
  • Protect you from unethical practices.
  • Maintain your privacy.
  • Ensure you receive the health care services the law says you can get.

Medicare rights and protections for everyone

  • To be treated with respect, courtesy, and dignity at all times.
  • Protection from discrimination. You cannot be treated differently based on your color, race, national origin, disability, age, religion, or sex.
  • Privacy of your personal and health information.
  • To be provided with information in a way you understand and participate in treatment decisions.
  • To be able to get information regarding your treatment choices in a way you understand and participate in treatment decisions.
  • Receive Medicare information and health care services in a language that you understand.
  • Receive Medicare information in an accessible format (such as braille or large print). If you need another language other than English or provided Medicare information in an accessible format, contact your plan.
  • Have your questions regarding Medicare answered.
  • Have access to doctors, specialists, and hospitals for medically necessary services.
  • Receive Medicare-covered services in an emergency.
  • Get a decision regarding health care payment, coverage of items and services, or drug coverage. When you or your provider files a claim, you’ll get a notice letting you know what will and won’t be covered. This notice comes from one of these:
    • Medicare
    • Your Medicare Advantage Plan (Part C) or other Medicare health plan
    • Your Medicare drug plan for Medicare drug coverage (Part D)

If you disagree with the decision of your claim, you have the right to file an appeal.

  • Request a review, or appeal, of certain decisions about health care payment, coverage of items and services, or drug coverage.
  • Given the opportunity to file complaints, or grievances, including complaints about the quality of your care. You can file a complaint regarding concerns about the quality of care and other services you get from a Medicare provider.

Medicare rights and protections specifically for Original Medicare

With Original Medicare, you have the same rights as everyone with Medicare in addition to:

  • The ability to see any doctor or specialist or go to any Medicare-certified hospital that participates in Medicare.
  • Obtain specific information, notices, and appeal rights. These are used to help resolve issues when Medicare may not pay for health care.
  • Request an appeal regarding health coverage or payment decisions.
  • Buy a Medicare Supplement Insurance (Medigap) policy.

What does Part A cover?

Generally, Part A will cover:

  • Inpatient care in a hospital
  • Skilled nursing facility care
  • Hospice care
  • Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
  • Home health care

Medicare coverage is based on 3 main things

  • Federal and state law
  • Medicare deciding whether something is covered on a national level
  • Coverage decisions are made locally by companies in each state processing Medicare claims. These companies will determine if something is medically necessary and should be covered in their area.

How to find out if Medicare covers what you need

  • Talk with your doctor or other health care provider regarding why you need certain services or supplies and ask if Medicare will cover them. You might require something that’s ordinarily covered, but your provider, based on your situation, thinks that Medicare won’t cover it. In this instance, you would have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  • Search your item, service, or supply by searching on Medicare.gov.

What does Part B cover?

Part B is responsible for covering 2 types of service.

Medically necessary services – Services or supplies needed to diagnose or treat your medical condition, and that meet accepted standards of medical practice

Preventative Services –  Health care directed to preventing illness or detecting it at an early stage, when treatment is most likely to be most effective.

If you get health care services through a provider that accepts assignment, you will pay nothing for most preventative services.

Generally, Part B will cover things like:

  • Ambulance services
  • Clinical research
  • Durable medical equipment (DME)
  • Mental health
    • Inpatient
    • Outpatient
    • Partial hospitalization
  • Limited outpatient prescription drugs

Medicare coverage is based on 3 main things

  • Federal and state law
  • Medicare deciding whether something is covered on a national level
  • Coverage decisions are made locally by companies in each state processing Medicare claims. These companies will determine if something is medically necessary and should be covered in their area.

How to find out if Medicare covers what you need

  • Talk with your doctor or other health care provider regarding why you need certain services or supplies and ask if Medicare will cover them. You might require something that’s ordinarily covered, but your provider, based on your situation, thinks that Medicare won’t cover it. In this instance, you would have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  • Search your item, service, or supply by searching on Medicare.gov.

What’s not covered by Original Medicare?

  • Talk with your doctor or other health care provider regarding why you need certain services or supplies and ask if Medicare will cover them. You might require something that’s ordinarily covered, but your provider, based on your situation, thinks that Medicare won’t cover it. In this instance, you would have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  • Search your item, service, or supply by searching on Medicare.gov.
What is not covered by Original Medicare?

Original Medicare will not cover everything. Some things that are not covered include:

  • Most dental care
  • Eye exams related to prescribing glasses
  • Cosmetic surgery
  • Dentures
  • Acupuncture
  • Hearing aids and exams for fitting them
  • Routine foot care
  • Long-Term Care (custodial care)

For services that Medicare doesn’t cover, you will have to pay for them yourself unless you have other insurance or Medicare health plan that will cover them.

You must be lawfully present in the U.S. for Medicare to pay for your Part A & Part B claims, and you are not able to enroll in a Medicare Advantage Plan or Medicare drug plan.

What does Original Medicare cost?

Part A Costs

Premium-Free Part A

If you or your spouse have paid Medicare taxes for a certain length of time while working, it is likely that you will not have to pay a monthly premium for Medicare Part A (Hospital Insurance). This is sometimes referred to as “premium-free Part A.”

You may get premium-free Part A at 65 if:
  • You receive retirement benefits from Social Security or the Railroad Retirement Board.
  • You (or your spouse) had Medicare-covered government employment.
  • You are eligible for Social Security or Railroad benefits but have not filed for them yet.
You may get premium-free Part A under 65 if:
  • You received Social Security or Railroad Retirement Board disability benefits for 24 months.
  • You have End-Stage Renal Disease (Esrd) and meet specific requirements.
Part A Premiums

You can buy Part A if you do not qualify for premium-free Part A. If you choose not to buy Part A, you can still buy Part B.

Generally, if you buy Part A, you must also:
  • Have Medicare Part B (Medical Insurance)
  • Pay monthly premiums for both Part A and Part B

Part B Costs

Some people will automatically get Medicare Part B (Medical Insurance), while others will need to sign up for it. If you do not sign up when you are first eligible for Part B, you may need to pay a late enrollment penalty.

Part B Premiums
Each month you will pay a premium for Part B. It will be automatically deducted from your benefit payment if you get benefits from any of the following:
  • Social Security
  • Railroad Retirement Board
  • Office of Personnel Management

If you don’t receive any of these benefit payments, you will get a bill.

It is most common for people to pay the standard premium amount. However, if your modified gross income is above a certain threshold, you may pay an Income Related Monthly Adjustment Amount (IRMAA). Medicare will use the modified adjusted gross income reported on your IRS tax return from 2 years ago as it is the most recent tax return information provided to Social Security by the IRS.

After you meet your Part B deductible for the year, you will typically pay 20% of the Medicare-Approved Amount for:
  • Outpatient therapy
  • Durable Medical Equipment (Dme)
  • Most doctor services (including most doctor services while a hospital inpatient)

How do I pay Part A & Part B premiums?

If you receive Social Security or Railroad Retirement Board (RRB) benefits, your Part B (Medical Insurance) premium will automatically be deducted from your benefit payment.

If you do not receive benefits, you will get a bill from Medicare regarding your premiums for:
  • Part A (Hospital Insurance) – if you bought it.
  • Part B (Medical Insurance)
  • Part D income-related monthly adjustment amount (Part D IRMAA) – an additional amount you pay with your Part D plan premium if your income is over a certain amount.
When will I get a Medicare bill?

If you bought Part A or owe Part D IRMAA, you will receive a “Medicare Premium Bill” every month.

If you bought only Part B, you would receive a “Medicare Premium Bill” every 3 months.

Ways to pay your Medicare bill:
  • Online through your secure Medicare account via credit card, debit card, or directly from a checking or savings account.
  • From your checking or savings account using your bank’s online bill payment service.
  • Through Medicare Easy Pay (a free service that will deduct your premium from your bank account, usually on the 20th of each month)
  • Mail your payment directly to Medicare via check, money order, credit card, or debit card by filling out the payment coupon that comes with your bill. (Payments without the payment coupon included may be delayed).
Mail your Medicare payment coupon and payment to:

Medicare Premium Collection Center
PO Box 790355
St. Louis, MO 63179-0355

Be sure to look closely at your bill

The type of Medicare bill you receive will let you know if you are at risk of losing your Medicare coverage because of late payments:

  • This is not a bill – you enrolled in Medicare Easy Pay, and your premium will automatically be deducted from your bank account around the 20th. You do not need to do anything.
  • First Bill – your first bill or you’ve paid your last bill in full. You must send in the payment for the total amount due so that Medicare receives it by the bill’s due date, or it is considered late.
  • Second Bill – Medicare did not receive full payment of the first bill by the due date (Payment is late by 60 days). You must send in payment for the total amount due by the due date.
  • Delinquent Bill – Medicare has not received full payment by the second bill’s due date (Payment is late by 90 days). You must send in the total amount due by the due date. This is the last bill you will receive; you will lose your Medicare coverage if you do not pay the total amount due.
What if my premium payment is late?

You will get a Second Bill if your First Bill is late, including past amounts and the premium for next month. If you do not pay the total amount by the 25th of the month, you will get a Delinquent bill. If you are unable to pay the total amount for the Delinquent Bill due by the 25th of the month, you will lose your Medicare coverage.

Questions regarding my bill or my coverage status

For specific billing questions: Call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.

For questions about your coverage status: Call Social Security at 1-800-772-1213. TTY: 1-800-325-0778.

Help Paying Costs

Depending on your situation, some programs that may help you pay costs are:

  • Medicaid
  • A Medicare Savings Program (MSP)
  • PACE (program of all-inclusive Care for the Elderly)
  • Supplemental Security Income (SSI)

If you have trouble paying your premiums or have any questions regarding your Medicare premium bill, call 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.