Navigating the world of Medicare can feel overwhelming, especially when you’re first approaching eligibility. Original Medicare, comprised of Part A and Part B, forms the foundation of healthcare coverage for millions of Americans aged 65 and older, as well as some younger individuals with disabilities or specific conditions. Understanding the ins and outs of Original Medicare, including what it covers, what it costs, and how it works, is crucial for making informed decisions about your healthcare needs. This guide provides a detailed breakdown of Original Medicare, helping you confidently navigate your coverage options.

What is Original Medicare?

Original Medicare is the traditional fee-for-service health insurance program offered by the federal government. It consists of two parts: Part A (hospital insurance) and Part B (medical insurance). It allows you to see any doctor or hospital that accepts Medicare, anywhere in the United States.

Medicare Part A: Hospital Insurance

Medicare Part A primarily covers inpatient hospital care, skilled nursing facility care, hospice care, and some home healthcare services. Think of it as the insurance that kicks in when you need to be admitted to a hospital.

• Coverage Examples:

Inpatient hospital stays: Covers room, meals, nursing care, lab tests, and other hospital services.

Skilled nursing facility (SNF) care: Covers a short-term stay following a qualifying hospital stay (minimum 3 days).

Hospice care: Provides comfort care for terminally ill individuals.

Home healthcare: Covers part-time or intermittent skilled nursing care and therapy services.

• Cost: Most people don’t pay a monthly premium for Part A because they paid Medicare taxes while working. In 2024, the deductible for each benefit period is $1,600. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility and ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row.
• Actionable Takeaway: Check your Social Security statement to see if you’ve earned enough work credits to qualify for premium-free Part A.

Medicare Part B: Medical Insurance

Medicare Part B covers doctor’s services, outpatient care, preventive services, and some medical equipment. It helps pay for the things you need to stay healthy outside of a hospital setting.

• Coverage Examples:

Doctor visits: Covers visits to your primary care physician and specialists.

Outpatient care: Includes services like lab tests, X-rays, and surgeries performed outside of a hospital.

Preventive services: Covers annual wellness visits, screenings (like mammograms and colonoscopies), and vaccinations (like flu shots).

Durable medical equipment (DME): Helps pay for items like wheelchairs, walkers, and oxygen equipment.

• Cost: In 2024, the standard monthly premium for Part B is $174.70. The annual deductible is $240. Some people with higher incomes may pay more for Part B. After you meet your deductible, you typically pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment.
• Actionable Takeaway: Explore the Medicare website or talk to a Medicare representative to understand how your income may affect your Part B premium.

What Original Medicare Doesn’t Cover

While Original Medicare provides substantial coverage, it doesn’t cover everything. Understanding these gaps is crucial for planning your healthcare needs.

Common Coverage Gaps

• Prescription Drugs: Original Medicare (Part A and Part B) generally does not cover most prescription drugs you take at home. You’ll typically need a separate Medicare Part D plan for prescription drug coverage.
• Dental Care: Most dental care, like cleanings, fillings, and dentures, is not covered by Original Medicare.
• Vision Care: Routine eye exams, eyeglasses, and contact lenses are generally not covered.
• Hearing Aids: Hearing exams and hearing aids are typically not covered.
• Long-Term Care: While Part A covers some skilled nursing facility care, it doesn’t cover custodial or long-term care services (like help with bathing, dressing, or eating).
• Care Outside the U.S.: Original Medicare usually doesn’t cover healthcare services you receive outside the United States.

Addressing the Gaps: Medicare Supplement Insurance (Medigap)

To help fill these coverage gaps, many people choose to purchase a Medicare Supplement Insurance policy, also known as Medigap. Medigap plans are offered by private insurance companies and can help pay for some of the costs that Original Medicare doesn’t cover, such as deductibles, copayments, and coinsurance. Some Medigap plans also offer coverage for services like dental, vision, or hearing care, as well as emergency healthcare services when traveling outside the U.S.

• Example: Imagine you need a knee replacement. With Original Medicare, you’ll pay the Part A deductible ($1,600 in 2024) and 20% of the cost for doctor’s services under Part B after meeting your Part B deductible ($240 in 2024). A Medigap plan could help cover some or all of these costs.
• Actionable Takeaway: Research Medigap plans in your area to determine which one best fits your needs and budget. Consider enrolling during your Medigap open enrollment period (a one-time 6-month period that starts when you’re 65 or older and enrolled in Part B) for the best selection of plans and guaranteed issue rights.

Enrollment in Original Medicare

Understanding the enrollment process and deadlines is essential to avoid late enrollment penalties.

Initial Enrollment Period (IEP)

The IEP is a 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you are already receiving Social Security benefits, you’ll likely be automatically enrolled in Part A and Part B. If you aren’t receiving benefits, you’ll need to actively enroll.

• Example: If your birthday is in June, your IEP begins in March and ends in September.
• Actionable Takeaway: Even if you’re covered by employer-sponsored health insurance, it’s wise to explore your Medicare options during your IEP to understand what’s available to you.

Special Enrollment Period (SEP)

You might be eligible for an SEP if you’re covered by an employer-sponsored health plan through your own (or your spouse’s) current employment after you turn 65. This allows you to delay enrolling in Part B without penalty. You have 8 months after your employment or the employer-sponsored coverage ends to enroll in Part B.

• Example: You work past age 65 and are covered by your employer’s health plan. You can delay enrolling in Part B until you retire.
• Actionable Takeaway: Keep records of your employer-sponsored health coverage to prove your eligibility for an SEP if you choose to enroll in Medicare later.

General Enrollment Period (GEP)

If you miss your IEP or SEP, you can enroll in Part A and/or Part B during the GEP, which runs from January 1 to March 31 each year. Your coverage will start on July 1 of that year.

• Cost: Enrolling in Part B during the GEP may result in a late enrollment penalty, which is a permanent increase in your Part B premium. The penalty is 10% for each full 12-month period you could have had Part B but didn’t.
• Actionable Takeaway: Avoid the GEP if possible by enrolling during your IEP or SEP to avoid potential penalties.

Making the Most of Original Medicare

Once enrolled, there are several ways to ensure you’re maximizing your benefits and staying healthy.

Understanding Preventive Services

Original Medicare covers a wide range of preventive services designed to help you stay healthy and detect potential health problems early.

• Examples:

Annual Wellness Visit: A yearly appointment with your doctor to create or update a personalized prevention plan.

Screenings: Coverages for screenings like mammograms, colonoscopies, prostate cancer screenings, and bone density tests.

Vaccinations: Flu shots, pneumonia shots, and other vaccinations are covered.

• Actionable Takeaway: Take advantage of the preventive services offered by Medicare to maintain your health and potentially detect problems early.

Managing Your Healthcare Costs

While Original Medicare covers many healthcare expenses, understanding your out-of-pocket costs is crucial for budgeting and planning.

• Tips:

Keep track of your healthcare expenses: Monitor your medical bills and Explanation of Benefits (EOB) statements to understand your costs.

Consider supplemental insurance: A Medigap plan can help cover deductibles, copayments, and coinsurance, reducing your out-of-pocket expenses.

Compare prices: If you need a service that isn’t fully covered by Medicare, compare prices from different providers.

Ask your doctor about cost-effective alternatives: Discuss potential lower-cost treatment options or medications with your doctor.

• Actionable Takeaway: Actively manage your healthcare costs by understanding your coverage, exploring supplemental insurance options, and communicating openly with your healthcare providers.

Original Medicare vs. Medicare Advantage

It’s essential to understand the difference between Original Medicare and Medicare Advantage (Part C) plans, as they offer different ways to receive your Medicare benefits.

Key Differences

• Original Medicare:

Fee-for-service: You can see any doctor or hospital that accepts Medicare, anywhere in the U.S.

Administered by the federal government.

Usually requires a separate Part D plan for prescription drug coverage.

May require supplemental insurance (Medigap) to cover gaps in coverage.

• Medicare Advantage:

Offered by private insurance companies.

Often includes additional benefits like vision, dental, and hearing coverage.

May have lower out-of-pocket costs than Original Medicare.

Typically requires you to use a network of doctors and hospitals.

Often includes prescription drug coverage (MAPD).

• Example: If you travel frequently and value the freedom to see any doctor, Original Medicare might be a better fit. If you prefer lower monthly premiums and don’t mind using a network of providers, Medicare Advantage could be a good option.
• Actionable Takeaway: Compare the benefits, costs, and provider networks of Original Medicare and Medicare Advantage plans to determine which option aligns with your healthcare needs and preferences.

Conclusion

Understanding Original Medicare is a crucial step in navigating your healthcare coverage options as you approach age 65 or become eligible due to a disability. By understanding what Part A and Part B cover, the potential gaps in coverage, enrollment periods, and strategies for maximizing your benefits, you can make informed decisions that ensure you receive the care you need while managing your healthcare costs effectively. Consider your individual health needs, financial situation, and preferences when choosing between Original Medicare and Medicare Advantage to make the best decision for your overall well-being.