About Original Medicare

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What is Original Medicare?

Simply put, Original Medicare is the Medicare plan that was originally put out by the federal government. The term refers to Medicare Part A and Medicare Part B.

Original Medicare is a health insurance system that is managed by the Center for Medicare and Medicaid Services (CMS). CMS is a federal agency that oversees the Medicare program. It provides Medicare-eligible persons with health insurance and the ability to see doctors or go to the hospital as needed.

It is important to note that Original Medicare is a fee-for-service program, which means that even though it is partially financed by tax dollars, recipients pay fees for each service they receive under this plan. However, the amount patients pay under this plan is usually far less than it would be if they had private insurance or no insurance at all.

How Original Medicare Works

Original Medicare covers basic health care needs.

  • Patients covered by Original Medicare can visit any doctor they want. There is no such thing as an out-of-network doctor under this plan, giving patients more freedom to make health care decisions for themselves.

  • There are no referrals needed. Unlike with traditional health insurance, Medicare does not require you to see your primary care doctor to get a referral to a specialist. You can make appointments directly with the specialist.

  • You don't have to worry about filing claims. By law, health care providers have to file claims with Medicare on your behalf, so you don't have to fill out paperwork or file insurance claims when you see a doctor or go to the hospital.

  • Coverage is NOT free to patients. Original Medicare requires you to meet a deductible each year before your coverage kicks in. That means that you have to pay a certain amount out of pocket before your Medicare coverage takes effect. In addition, most people have to pay a small monthly premium for Medicare Part B.

  • Prescription drugs are NOT covered. If you need prescription coverage, you can apply for Medicare Part D.

Part A

Part A of Medicare is also known as hospital insurance. Part A covers hospital and inpatient costs. For Part A to cover a service, it must be considered medically necessary. So, only services that help treat, diagnose, or prevent conditions are included. If you are ever unsure if a service will be covered by Medicare, you can search the service in the Medicare database. Part A covers the following: 

  • Inpatient care in a hospital (including rehab and long-term stays). 

  • Hospice Care (including doctor services, nursing care, medical equipment, physical therapy, occupational therapy, dietary counseling, speech-language pathology services, short-term respite care, and social work services). 

  • Home health care (including part-time nursing care, part-time home health aide services, medical social services, physical therapy, occupational therapy, and speech-language pathology services). 

  • Care in a skilled nursing facility (including meals, inpatient care, physical therapy, occupational therapy, dietary counseling, speech-language pathology services, and boarding in a semi-private room). 

Part A comes with costs like premiums, deductibles, and coinsurance. But, good news, you may be eligible to get your premium waived. If you meet one of the following requirements, you qualify for premium-free Part A coverage: 

  • You are 65 or older and receive benefits from Social Security or Railroad Retirement Board. Or if you are younger than 65, you have received those benefits for two or more years. 

  • You are 65 or older and haven’t filed for any Social Security or Railroad Retirement Board benefits even though you are eligible. 

  • You are 65 or older and you or your spouse were employed by the government and paid Medicare taxes. 

  • You have End-Stage Renal Disease.

If you do have to pay a premium for Part A, you will pay up to $437 each month. You could pay a lot less depending on how long you paid Medicare taxes. If you paid taxes for less than 30 quarters, you will pay $437. If you paid taxes for 30-39 quarters, your premium will be $240. Depending on your specific situation, you may have to pay a deductible of $1,364 each benefit period. If your hospital stay is longer than 60 days, you will have to pay a daily coinsurance of $341. If you stay longer than 90 days, the cost is increased to a daily $682. 

Part B

Part B of Medicare covers medically necessary and preventive outpatient services. So, just like with Part A, services need to either diagnose, treat, or prevent a condition. Part B covers the following: 

  • Clinical research (including involvement in a clinical research study). 

  • Mental Health Services (including family counseling, individual psychotherapy, group psychotherapy, psychiatric evaluation, one yearly depression screening, yearly wellness visit, non-self administered prescription drugs, and medication management). 

  • Outpatient prescription drugs (including injectable and infused drugs, some antigens, blood clotting factors, injectable osteoporosis drugs, erythropoiesis-stimulating agents, drugs used with durable medical equipment (DME), and oral End-Stage Renal Disease (ESRD) drugs). 

  • Ambulance Services (including transportation to a skilled nursing facility, hospital, or critical access hospital).

  • Second Opinions (including from a second health care professional before surgery). 

  • Durable Medical Equipment (DME) (including wheelchairs, scooters, hospital beds, walkers, crutches, canes, patient pumps, traction equipment, oxygen equipment, blood sugar testing supplies, commode chairs, continuous passive motion devices, nebulizers, lancet devices, and Continuous Positive Airway Pressure (CPAP) devices). 

Like Part A, Part B does come with some additional costs. Unlike with Part A, you must pay the Part B premium. If you receive benefits from Social Security, Railroad Retirement Board, or Office of Personnel Management, your premium will automatically be deducted from your benefit payment. If you do not receive benefits from any of the previous entities, you will receive a bill. Most people pay the standard $135.50 per month premium. Part B premiums are based on your modified adjusted gross income (MAGI). Depending on your MAGI, you can pay anywhere from $135.50- $460.50 per month in Part B premiums. To find out what you would pay, head to Medicare’s website. 

The deductible for Part B is $185 per year. Additionally, after your deductible is met, you will pay 20% of the Medicare-approved amount of outpatient therapy, most doctor services, and DME. 

What Part A and Part B Do Not Cover

Unfortunately, even the combination of both plans does not cover everything. Medicare is really a machine with a few missing parts. Medicare does not cover the following services and costs: 

  • Long-term care

  • Acupuncture 

  • Most dental care

  • Eye exams relating to prescribing glasses

  • Hearing aids and related exams

  • Routine foot care

  • Dentures 

  • Cosmetic Surgery

Fortunately, many health insurance providers offer Medicare supplement plans, or Medigap plans, to cover the extra out-of-pocket expenses Medicare leaves behind. There are ten available supplement plans: A, B, C, D, F, G, K, L, M, N. It’s important to note that plans C and F will be discontinued after January 1st, 2020. The available plans depend on the specific insurer. Each plan covers different aspects of out-of-pocket Medicare costs, but all plans must cover the following: 

  • Part A hospital coinsurance 

  • Medicare Part A supplemental hospital care for an additional 365 days after the benefits from Medicare ends

  • Part A coinsurance for hospice care

  • 20% of Medicare pre-approved Part B coinsurance for hospital outpatient services

  • First 3 pints of blood for transfusions each year.  

Most insurance companies will offer special benefits and features as part of their supplement plans. These special features include automatic enrollment into a vision plan, access to the Silver Sneakers fitness program, discounts on eyewear, discounts on contacts, and the ability to contact a nurse 24/7 by phone. It’s important to do some research before selecting an insurer for Medigap plans.