Original Medicare (Medicare Part A and B)
What is Original Medicare?
Part A and Part B are often referred to as "Original Medicare". Original Medicare is managed by the Federal government and lets people with Medicare go to any doctor, hospital, or other health care provider who accepts Medicare. It is a fee-for-service plan, meaning that the person with Medicare usually pays a fee for each service. Medicare pays its share of an approved amount up to certain limits, and the person with Medicare pays the rest.
The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that runs Medicare. CMS is part of the U.S. Department of Health and Human Services. Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.
How Original Medicare Works
|Source: Information from the official government handbook published by the Centers for Medicare and Medicaid Services: Medicare & You 2010 and 2011|
|Are prescription drugs covered?||Only in limited situations like when you are a hospital inpatient. You can keep original medicare and add comprehensive drug coverage by joining a Medicare Prescription Drug Plan (Part D).|
|Can I get my health care from any doctor or hospital?||Yes. You can go to any doctor, supplier, hospital, or other facility that is enrolled in Medicare and is accepting new Medicare patients.|
|Do I have to get a referral to see a specialist?||No.|
|Do I need a supplemental policy?||You may already have employer or union coverage that may pay costs that Original Medicare doesn't. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy.|
|What else do I need to know about Original Medicare?||* Each year, you generally must pay a set amount for your health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (coinsurance) for covered services and supplies. * If you have Part A, you can generally get the covered services listed in Part A Benefits. * If you have Part B, you can generally get the covered services listed in Part B Benefits. You usually pay a monthly premium for Part B. See How Much Does Original Medicare Cost? * You generally don't need to file Medicare claims. Providers (like doctors, hospitals, skilled nursing facilities, and home health agencies) and suppliers are required by law to file Medicare claims for the covered services and supplies you get.|
What is Not Covered by Original Medicare?
Original Medicare doesn't cover everything. For example, it doesn't cover cosmetic surgery, health care you get while traveling outside of the United States (except in limited cases), hearing aids, most hearing exams, long-term care (like care in a nursing home), most eyeglasses, most dental care and dentures, and more. Generally, Original Medicare does not cover prescription drugs, although it does cover some drugs in limited cases such as immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs. Some of these services not covered by Original Medicare may be covered by a Medicare Advantage Plan (like an HMO or PPO).
How Much Does Original Medicare Cost?
People usually don't pay a monthly premium for Medicare Part A coverage if they or their spouse paid Medicare taxes while working. For Part B, most people pay a standard monthly premium. Some people may pay a higher Part B premium based on their income. Additional information about Part B premiums can be found on our Medicare Part B page.
Getting Services from a Health Care Provider Through Original Medicare "Assignment"
Original Medicare pays for health care services through a process called Assignment. Assignment is an agreement between you, Medicare, and doctors, other health care providers, or suppliers. When you "assign" a claim to your doctor, Medicare will pay your doctor, provider, or supplier directly for the services you get.
Getting services and supplies from a doctor, provider, or supplier who accepts assignment can reduce your out-of-pocket costs.
If your doctor, provider, or supplier accepts assignment:
- Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. In some cases they must accept assignment, like when they have a participation agreement with Medicare and give you Medicare-covered services.
- If a doctor, provider, or supplier accepts assignment, they agree to only charge you the Medicare deductible or coinsurance amount and will wait for Medicare to pay its share.
- All doctors, providers, and suppliers that give you Medicare-covered services have to submit your claim to Medicare directly. They can't charge you for submitting the claim.
To find doctors and suppliers who accept assignment, visit www.medicare.gov, select "Find a Doctor" or "Find Suppliers of Medical Equipment in Your Area". You can also call 1-800 MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If your doctor, provider, or supplier does NOT accept assignment
- They still must submit a claim to Medicare when they give you Medicare-covered services. If they don't submit the claim for these services, you should contact the company that handles Medicare claims for your State to file a complaint. You can call 1-800-MEDICARE (1-800-663-4227) for their telephone number. TTY users should call 1-877-486-2048. In the meantime, you might have to pay the entire charge at the time of service, and then submit your claim to Medicare to get paid back.
- They may charge you more than the Medicare-approved amount, but there is a limit called "the limiting charge." They can only charge you 15% over the Medicare-approved amount (but may be lower in your state). The limiting charge applies only to certain services and doesn't apply to some supplies and durable medical equipment.