Original Medicare Coverage

Medicare is a health insurance coverage in the United States managed by the federal government and primarily created for people at age 65 or older. However, Medicare coverage can also be provided for younger people with certain disabilities which are determined by Social Security Administration. Coverage also includes people with End-Stage- Renal Disease and Amyotrophic Lateral Sclerosis (commonly known as Lou Gehrig’s disease). Original Medicare consists of two main parts: Part A and Part B. Part A stands for hospital insurance and inpatient services, and Part B stands for medical insurance or outpatient services. Medicare coverage also consists of Part D, a prescription drug coverage, and Part C, commonly known as Medicare Advantage. Except for meeting these criteria, you also need specific documents when applying for Medicare coverage.

What Exactly Does Original Medicare Cover?

We have already established that Original Medicare has two parts- Part A and Part B. Part A is coverage for inpatient services and Part B is coverage for outpatient services.

Part A of Original Medicare covers:

inpatient hospital care: beneficiaries get this care after they are formally admitted to the hospital by a doctor. You will be covered for 90 days stay in the hospital each benefit period. The number of days starts to count when you are first admitted. You are fully covered from 1 to 60 days, and from 61 to 90 days, you need to pay daily coinsurance. Therefore, the benefit period starts the first day and ends the day when you are out of the hospital, after 60 days in a row. If you have used 90 days in the hospital but need to stay longer, Medicare can cover 60 additional days or lifetime reserve days. You also must pay daily coinsurance. These additional days are not renewable for each benefit period, after they are used up, beneficiaries can’t use them again.

skilled nursing facility care: this service is covered for a limited amount of time. Long-term care is not covered. Beneficiaries will be covered if they have benefit period days left to use and have spent at least 3 days in a row in a hospital. Also, your doctor thinks that staying in SNF is medically necessary for your care. You pay nothing for the first 20 days, and from 21 to 100 days you must pay a daily coinsurance for each benefit period. You will be responsible for all the costs if you need to stay longer than 100 days. Benefit periods are renewable, and each period ends (and a new one begins) if beneficiaries didn’t get SNF or inpatient hospital care for sixty consecutive days.

home health care: home health care providers give care that your doctor orders and include part-time skilled nursing care, physical and occupational therapy, and part-time home health care aide but only if you are getting services like nursing and therapy at the same time. Home health care doesn’t include coverage for: custodial care for daily activities like bathing and clothing nor 24-hour care at your home. If beneficiaries don’t meet all requirements through Part A, beneficiaries get home health services covered through Part B.

hospice care: beneficiaries can get this type of coverage if the provider concludes that the beneficiary has a terminal illness and they get it as long as medically necessary for their treatment.

Part B of Original Medicare covers:

provider services: all medically necessary services you get from health professionals

ambulance services: emergency transportation (from or to hospitals), as well as non-emergency transportation when is it medically necessary and other options of transportation, could put your health condition in danger

home health services:if you are homebound, which means that your doctor thinks that you can’t leave home because your health can get worse and you need medical equipment such as walkers, wheelchairs, etc. Additionally, such a condition includes help from a health professional- skilled nursing care or therapy care.

durable medical equipment: this includes wheelchairs, walkers, canes, blood sugar meters, hospital beds, nebulizers, crutches, scooters, etc.

mental health services:inpatient (if admitted to hospital) and outpatient (one depression screening per year, psychiatric evaluation, family counseling, diagnostic test, medication management, etc.) mental health care and partial hospitalization


lab tests

doctor in hospital for medicare coverage

What Is The Cost For Part B?

All Medicare beneficiaries must cover Part B’s monthly premium and deductible before coverage kicks in. In 2023, the Part B monthly premium will be 164.90$ and an annual deductible is 226$ next calendar year. This is a decrease in comparison to 2022 because the monthly premium is 170.10$ and the deductible 223$ a year. Since Medicare works on the cost-sharing principle, which means it pays only for 80% of services, beneficiaries are often responsible for the other 20% in the form of coinsurance and copays. Also, some beneficiaries might pay a higher monthly premium as long as they have Medicare coverage due to late enrollment penalties. Beneficiaries can pay late enrollment penalties if they don’t enroll in Part B when first eligible and don’t have other creditable coverage. The best time to enroll is during the Initial Enrollment Period which is a 7-month open window and lasts 3 months before 65 and three months after 65th birthday. If you still working and are under the employer’s plan and work in a company that has more than 20 employees you can delay Part B enrollment without paying a penalty. Some beneficiaries also may pay Part B excess charges if doctor which provided the services don’t accept Medicare Assignment, but these occasions are pretty rare.

Does Original Medicare cover 80%?

Original Medicare, sometimes called traditional Medicare, works on a cost-sharing principle. This means that Parts A and B usually cover 80% of services, and beneficiaries are responsible for the other 20% of the costs in form of deductibles, coinsurance, and copays. You will usually pay 20% for outpatient services and the cost is a Medicare-approved amount for provided service.

This reimbursement can differ for some outpatient services, which means that instead of 20% you can pay a flat copayment. However, you can get help with covering the other 20% with Medicare Supplement plans or choosing a Medicare Advantage plan as your primary source of coverage instead of Original Medicare.

Does Medicare Cover 100% of Hospital Bills?

No, Medicare doesn’t cover 100% of hospital bills. As already said, Medicare Part A is your hospital insurance and provides beneficiaries with hospital stays. However, those stays are not 100% covered. Even though you have insurance you still have to pay a part of the bill alongside the premiums, deductibles, and copayments which are subject to change every calendar year. Medicare Part A deductible bear on each benefit period. The benefit period bears on the length of the time beneficiary has been admitted to the hospital through 60 days in a row after you have been released from the hospital.

In other words, if you haven’t used all 60 days in a row and have been admitted to a hospital again, you don’t need to pay a deductible because your new benefit period began. However, if you have used 60 consecutive days, and have to stay in the hospital again you will need to pay another deductible.

When you meet the deductible, Medicare will cover hospital stays for up to 60 days. Also, if you need to stay in the hospital longer than 60 days in the same benefit period Medicare will cover additional 30 days but with daily coinsurance. The co-payment is 400$ per day in 2023. If, you need to stay in the hospital longer than 90 days (91-150) is 800$ per day while using your 60 lifetime reserved days. After 150 days, beneficiaries are responsible for all the costs.

Do You Have To Pay For Traditional Medicare

Yes, you have to pay for Traditional Medicare in some ways. Most people qualify for “Part A free premium” if they worked for 10 years and paid Medicare taxes. But, every beneficiary must pay Part B monthly premium regardless of their working years. Also, Medicare covers only 80% of services and the other 20% can be charged to you in form of deductibles and coinsurance.

However, if you haven’t paid Medicare taxes long enough you will be responsible for paying Part A monthly premium. If you have worked from 20 to 39 quarters your monthly premium will be 278$ in 2023, and if is it less than 20 quarters you have to pay 506$ each month.

What is the 2023 Medicare deductible?

A deductible is the amount of money you are responsible for paying before Medicare starts to pay its share of the health services you receive. In 2023 Medicare Part A deductible is 1600$ per each benefit period which is an increase in comparison to 2022 when the deductible was 1556$. However, the Part B deductible is lower in 2023, and it will be 226$ while in 2022 is 233$.

Deductibles for Part D which is prescription drug coverage can differ from plan to plan. However, neither of them can have a deductible higher than 505$ which is an increase in regards to 2022, where the amount can’t be higher than 480$.

Medicare Advantage plans, which are sold by private insurance companies, can have their own deductibles which also differ from plan to plan. Some Medicare plans have zero dollars deductible.

What Does Medicare A Cover?

Medicare Part A is your hospital insurance and covers inpatient hospitals, skilled nursing facilities, hospice care, rehabilitation, and some forms of home health care. Therefore, Medicare cover up to 90 days of hospital stays for each benefit period plus 60 lifetime reserve days. You have 100 days in a skilled nursing facility if you fulfill the requirements that are explained above in the blog. Home health care is covered if you have trouble leaving your home, due to illness or injury and need part-time skilled nursing or therapy. This is also valid if your doctor prescribed to you that home health care is needed. Home healthcare providers need to have a contract with Medicare.

Hospice care is covered for people with illnesses that are life-threatening ( like prenamment kidney failure) and life expectancy is no longer than 6 months. This type of coverage does not include the treatment of illness. It includes treatment by doctors and nurses, medical equipment, physical, occupational and speech therapy, and grief counseling as well.

What 3 Services Are Not Covered by Medicare?

The main service that Medicare doesn’t cover is drug prescription, dental, vision, and hearing. Even though Medicare doesn’t cover outpatient drug prescriptions you can get this coverage through  Medicare Part D or Medicare Advantage plan (Part C).  Part D is a stand-alone plan which you can purchase alongside the Original Medicare while the Medicare Advantage plan includes drug coverage all in one plan.

Medicare will not cover any dental services like routine checkups, teeth cleanings, fillings, tooth extractions, etc. However, you can buy a dental policy or dental discount plan. Some Medicare Advantage plans include basic dental services in their coverage.

Medicare will not cover routine eye exams or glasses in general. However, Medicare may cover things that are. medically necessary like cataract surgery or an annual eye exam if you have diabetes. To have vision coverage you can buy a separate policy or get covered under the Medicare Advantage plan.

You will not get coverage from Medicare for routine hearing exams or hearing aids. However, some Medicare Advantage plans can include fitting exams and a hearing aid in their services.

Does Medicare Cover Blood Work?

Medicare Part A will cover all medically necessary blood tests. This means that those tests can be ordered by doctors for inpatient hospital skilled nursing facility, hospice care, and home health care which are all services that are normally covered under Part A.

Outpatient blood tests will be covered under Part B which are ordered by doctors and normally are related to blood work screenings that help to diagnose and manage conditions. Some Medicare Advantage Plans also provide blood work screening and can provide additional tests that are not basically covered under Original Medicare.

What Are The Four Parts of Original Medicare?

Original Medicare has only two main parts: Part A and Part B. Part A is your hospital insurance, while Part B is medical insurance coverage. Other parts of Medicare are Part C, commonly known as Medicare Advantage, and Part D, which is a stand-alone drug prescription plan.

Medicare Advantage plans are sold by private insurance companies and if beneficiaries choose Medicare Advantage plan it becomes the primary source of coverage, instead of Original Medicare. Medicare Advantage must provide the same basic coverage benefits as Original Medicare but they often have additional benefits like dental, drug prescription, vision, and hearing included all in one plan. However, Part D is a stand-alone drug prescription plan which can be purchased additionally, if you have Original Medicare (Parts A and B).

Is Medicare Part A and B Free?

No, it is not. Some people qualify for “Part A free premium” but Original Medicare which is consisted of Parts A and B covers only 80% of the services, which means you are responsible for costs like deductibles, premiums, and coinsurance for provided treatments. Even though Part A is premium free for most beneficiaries who have paid Medicare taxes while working for a minimum of 10 years, beneficiaries always have to pay Part B monthly premium. Alongside premium, there is Part A hospital deductible each benefit period and Part B annual deductible as well as 20% of coinsurance for some services.

Is Medicare Part A Free At The Age of 65?

Medicare Part A is Free for beneficiaries at age of 65 if they are U.S. citizens or are legally admitted citizens who have worked in the U.S. for 40 quarters which equals 10 years and paid Medicare taxes. If you have received your Social Security benefits of pension from Railroad Retirement Board you will be automatically enrolled in Parts A and B when first eligible. You can get Part A free premium earlier than 65 due to disability if you receive Social Security Benefits for Disability, etc.  

If you don’t meet any of the requirements above you can still qualify for Part A but you will have to pay a monthly premium for it. If you have worked from 20 to 39 quarters premium in 2023 2768$ and if you haven’t worked at all or worked lesser than 20 quarters premium will be 506$ per month.

However, you can also. get Part A free premium coverage through your spouse’s coverage if he or she meets some of the requirements mentioned above.

What Is Medicare Part B Premium In 2023?

Medicare Part B premium cost in 2023 will be 164.90$ per month. This is a decrease of approximately 5$ in comparison to the year 2022 in which the monthly premium is 170.10$.

What Medicare Does Not Cover?

Medicare does not provide dental, vision, hearing services, or drug prescription coverage. Medicare will also not provide coverage for any services that are related to long-term care. Medicare will provide coverage for some part-time skilled nursing services but none of them include custodial care such as help with daily activities which include help with bathing, dressing, etc.  Medicare will also not cover any foreign travel emergencies.

doctor in hospital treating patients with medicare coverage

What Is The Benefit Of Choosing Medicare Advantage Rather Than Original Medicare? 

Medicare Advantage, commonly known as Part C, is sold by private insurance companies and those plans often provide additional benefits such as drug prescription coverage, dental, vision, and hearing all in one plan which is not offered by Original Medicare. However, Original Medicare has an unlimited network of providers while with the Medicare Advantage plan you often need to stay in a network which means you have to go to doctors and hospitals which accept your plan to avoid out-of-pocket costs.

Some Medicare Advantage plans have monthly premiums of zero dollars, which is not the case with Original Medicare. Medicare Advantage plans also have a maximum-of-out pocket cost limit which means that you can’t go above the determined limit amount of cost per year. When you reach this limit in one year your plan needs to cover all the costs. In 2022, the maximum out-of-pocket limit is 7550$.  Original Medicare doesn’t have a cap on out-of-pocket costs. Premiums for drug prescription with Medicare Advantage plans are often 0$ whilst the average premium for a Part D plan is 33$. If you have Original Medicare you must purchase Part D if you want drug prescription coverage. However, with the Medicare Advantage plan, you still need to pay Part B monthly premium.

You can’t buy any Medigap policy if you are on a Medicare Advantage plan. Medigap policies are designed to cover the gaps that are left by Original Medicare. Be aware that Medicare Advantage plans are not free, and the costs can be determined by each insurance company because they are sold through them so they can have their own rules.

What Are Disadvantages Of Original Medicare?

With Original Medicare, your costs can be unpredictable because Medicare doesn’t cover all services 100% and there is no out-of-pocket maximum to cap out the costs. So, without a Medigap plan, which helps cover the gaps left by Original Medicare your costs can be unpredictable.  Original Medicare doesn’t cover additional services like drug prescriptions, dental, vision, and hearing. To get drug coverage you must purchase a Part D stand-alone plan.

Why Would Someone Choose Original Medicare?

With Original Medicare, the network is not limited which means you can go and seek services from Medicare-approved providers in the United States.  Also, part A premium is free for most citizens, and referrals to see specialists are not required. Also, if you have any type of terminal illness Medicare hospice benefits will cover it. 

What Is Original Medicare Maximum-Out-Of-Pocket?

Original Medicare doesn’t have a maximum out-of-pocket limit, so your costs can be unpredictable if you don’t. have a Medigap plan alongside the Original Medicare coverage because those plans help beneficiaries cover the costs left by Parts A and B.

Why Do I Need Medicare Part C?

You don’t need to purchase Medicare Part C or Medicare Advantage plan if you don’t want to. Medicare Part C, also known as Medicare Advantage plans are sold by private insurance companies and if you choose to purchase them they become your primary source of coverage instead of Original Medicare. Those plans provide additional benefits such as dental, vision, hearing, and medications alongside the basic benefits which are also covered by Parts A and B. If you rather want to stay under Original Medicare than purchase a Medicare Advantage plan you can purchase a Medigap policy for additional coverage. If you have a Medicare Advantage plan, you cannot purchase a Medigap policy.

Can I Go Back to Original Medicare?

Yes, if you want to drop your Medicare Advantage plan, you can go back to Original Medicare. However, you can do this through specific enrollment periods that happen each year. The first period when you can switch is the Annual Enrollment Period which occurs from the 15th of October till the 7th of December each year. When you do this during AEP your switch will be effective January the first of the following year.

The second time when is available to make a switch is during Medicare Advantage Enrollment Period which lasts from January 1st through March 31st.

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