How Does Original Medicare Work? | MedicareHealthPlans

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How Does Original Medicare Work?

Doctor and patient discussing how Original Medicare worksOriginal Medicare, managed by the federal government, allows those who are 65 or older and people with disabilities to get health care coverage with doctors, specialists, and other providers. We created this page to answer some basic questions about how the program works.

What are the basics?

Also referred to as Part A and Part B, it is health care coverage that is provided to all American citizens who are eligible for it. Usually this means retirees (who become eligible at age 65), but it also includes people with disabilities or end-stage renal disease.

It is funded mostly through payroll taxes that are paid by nearly all working people and employers. In exchange, it helps individuals get the care they need by providing access to and paying for health-related expenses. This includes coverage for doctors, specialists, hospitals, equipment, and more.

Most of it is set up as a “fee for service” system, which means there’s usually a cost for each health care service, too. As a beneficiary, you will pay a portion and Medicare will pay another portion to the provider.

What does it cover?

Original Medicare comes in two parts: Part A and Part B. Each part covers different types of health care services.

  • Part A pays for typical hospital and long-term care, including multi-day hospital stays, skilled nursing facilities and home health, and hospice care.
  • Part B covers common, non-hospital services such as doctor’s visits, outpatient surgeries, medical equipment and supplies, and preventive care.

What isn’t covered?

Part A and Part B don’t cover every type of health care service. Here are some of the most common things typically not covered:

  • Dental services
  • Routine vision care and eyewear
  • Hearing aids and hearing exams
  • Cosmetic surgery
  • Care while outside the United States, with a few exceptions
  • Prescription drugs, with a few exceptions

It also does not cover care that it considers not medically necessary. For some care, your provider will need to provide specific documentation to ensure that you get coverage.

What about prescription drugs?

Prescription drugs are typically not covered. However, you can get coverage for medications by enrolling in a Part D prescription drug plan.

How do I get care?

You can visit any doctor, specialist, or other provider who accepts Medicare and is accepting new patients. It is accepted nationwide and provides access to thousands of health care professionals. Just bring your Medicare ID card with you to your appointment.

You don’t have to choose a primary care physician or get a referral to see a specialist. Providers who accept Medicare must also “accept assignment” for the services they perform. This means that they agree to accept Medicare’s payment and coverage requirements as full compensation. They also agree to submit your claims to Medicare directly.

How much does it cost?

The cost can be broken down into several areas. Here’s what you can expect to pay:

  • $0 premium for Part A coverage (for most people)
  • Standard premium for Part B coverage, depending on income
  • Part A and Part B deductibles
  • Copayments and coinsurance for services
  • Any additional costs not covered by Part A and Part B or another health care plan

Do I have other options?

You have a few additional options besides Part A and B. First, you can add coverage with a Supplement, or “Medigap,” plan. These plans help pay for expenses leftover by it such as copayments and deductibles.

If you are currently working or have retirement coverage, you may be able to keep your employer-based coverage. This may be a good choice if the plan covers more than Plan A and Plan B.

You may also get a Advantage (Part C) plan from a private insurer. These plans, which you buy on the open market, replace your traditional Part A and Part B coverage and may include coverage beyond Part A and Part B. However, they often have additional costs such as premiums, deductibles, and more.

 

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