Medicare explained...

What is Original Medicare?

Original Medicare is the federal health insurance program in the United States primarily designed for individuals aged 65 and older, although it also provides coverage for certain younger individuals with disabilities or specific medical conditions like End-Stage Renal Disease (ESRD). Established in 1965, Original Medicare serves as the cornerstone of healthcare coverage for millions of Americans. It is administered by the Centers for Medicare & Medicaid Services (CMS) and consists of two main parts: Part A and Part B.

Part A: Hospital Insurance

Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services.

Inpatient Hospital Care: Includes coverage for stays in a hospital for treatment of illnesses or injuries. This typically covers semi-private rooms, meals, general nursing, and medications as part of inpatient treatment. Skilled Nursing Facility (SNF) Care: Covers short-term stays in a SNF for rehabilitation or specialized nursing care following a hospital stay of at least three days. Hospice Care: Provides comprehensive care for terminally ill patients, including pain management, emotional support, and counseling. Home Health Care: Limited coverage for medically necessary skilled nursing care and therapy services provided in a patient’s home.

Part A typically has no monthly premium for individuals who have paid Medicare taxes for at least 10 years (40 quarters). However, it does include deductibles and coinsurance for covered services.

Part B: Medical Insurance

Medicare Part B covers outpatient care, preventive services, medically necessary services, and durable medical equipment (DME).

Outpatient Care: Includes visits to doctors, specialists, and clinics, as well as outpatient surgeries and diagnostic tests like X-rays and lab work. Preventive Services: Covers screenings, vaccines, and wellness visits to help detect or prevent illnesses early. Medically Necessary Services: Encompasses treatments or procedures deemed necessary to diagnose or treat a medical condition. Durable Medical Equipment (DME): Covers equipment such as wheelchairs, walkers, and oxygen equipment prescribed by a healthcare provider.

Unlike Part A, Part B requires a monthly premium, which is based on your income. Additionally, you’ll be responsible for an annual deductible and 20% coinsurance for most services after the deductible is met.

Key Features of Original Medicare

Nationwide Coverage: Beneficiaries can use any healthcare provider or facility that accepts Medicare, without the need for referrals or staying within a network. Cost Sharing: Beneficiaries are responsible for deductibles, coinsurance, and premiums for Parts A and B. Supplemental insurance, such as Medigap, can help cover these costs. No Prescription Drug Coverage: Original Medicare does not include prescription drug coverage. Beneficiaries must enroll in a standalone Medicare Part D plan to receive coverage for medications. No Out-of-Pocket Maximum: Original Medicare does not cap annual out-of-pocket expenses, which can leave beneficiaries vulnerable to high healthcare costs.

What Original Medicare Does Not Cover

While Original Medicare offers comprehensive coverage, it does not cover everything. Some services not covered include:

Routine dental, vision, and hearing care, long-term custodial care, cosmetic procedures, or acupuncture.

For these additional services, beneficiaries often purchase supplemental insurance (Medigap) or enroll in Medicare Advantage plans (Part C).

Enrolling in Original Medicare

Most individuals are automatically enrolled in Original Medicare when they turn 65 if they are already receiving Social Security or Railroad Retirement Board benefits. Those who are not automatically enrolled must apply during their Initial Enrollment Period (IEP), which starts three months before their 65th birthday, includes their birth month, and ends three months after.

Who Is Eligible for Original Medicare?

You are eligible for Original Medicare if:

You are 65 or older and a U.S. citizen or permanent legal resident for at least five years. You are under 65 and have been receiving Social Security Disability Insurance (SSDI) for 24 months. You have a qualifying condition, such as ALS (Amyotrophic Lateral Sclerosis) or ESRD (End-Stage Renal Disease).

Why Choose Original Medicare?

Original Medicare provides flexible, reliable healthcare coverage accepted by providers nationwide. It is ideal for individuals who prefer to have access to a broad range of providers without being limited to a network. However, because of its cost-sharing structure and lack of prescription drug coverage, beneficiaries should carefully consider their options and explore supplemental plans or advantage plans to ensure comprehensive protection against healthcare expenses.