Original Medicare Explained
What Is Original Medicare?
Original Medicare is the traditional federal Medicare program and consists of Medicare Part A and Medicare Part B.
Part A is primarily hospital insurance.
Part B is primarily medical and outpatient insurance.
When you receive a Medicare-covered service, Medicare generally pays its portion of the Medicare-approved amount and you are responsible for the applicable deductible, coinsurance, or copayment.
Original Medicare is one of the two primary ways people can receive Medicare benefits. The other is Medicare Advantage, also known as Medicare Part C.
What Does Medicare Part A Cover?
Medicare Part A generally helps cover:
Inpatient hospital care
Skilled nursing facility care when Medicare requirements are met
Hospice care
Certain home health services
Part A should not be thought of as unlimited hospital coverage. Deductibles, coinsurance and benefit-period rules can apply.
What Does Medicare Part B Cover?
Medicare Part B generally helps cover medically necessary and preventive healthcare services, including:
Physician services
Specialist visits
Outpatient care
Diagnostic tests
Laboratory services
Preventive services
Durable medical equipment
Ambulance services when Medicare requirements are met
Mental health services
Certain outpatient medications and medications administered in medical settings
For many Part B-covered services under Original Medicare, a beneficiary is generally responsible for 20% of the Medicare-approved amount after meeting the Part B deductible, although the actual amount depends on the service and other coverage.
Can I See Any Doctor With Original Medicare?
One of the defining characteristics of Original Medicare is provider flexibility.
You generally may receive covered services from any Medicare-enrolled doctor, hospital, or healthcare provider in the United States that accepts Medicare patients.
Original Medicare does not use the same type of local HMO or PPO provider network commonly used by Medicare Advantage plans.
That does not necessarily mean every doctor accepts Medicare.
Before receiving care, ask:
“Do you accept Medicare?”
You may also want to ask:
“Do you accept Medicare assignment?”
A provider who accepts assignment agrees to accept the Medicare-approved amount as full payment for covered services, subject to the beneficiary's deductible and coinsurance.
Some providers may accept Medicare patients without accepting assignment for every service, which can result in additional costs where permitted.
Do I Need a Referral to See a Specialist?
With Original Medicare, you generally do not need a referral to see a specialist who accepts Medicare.
This can be particularly important for beneficiaries who:
See several specialists
Receive care in multiple states
Split their time between different residences
Prefer broad provider flexibility
Receive care from major medical centers outside their immediate area
Does Original Medicare Include Prescription Drug Coverage?
Original Medicare does not automatically include comprehensive outpatient prescription drug coverage.
Part B covers certain medications in limited circumstances, such as some medications administered by a physician or in an outpatient medical setting.
For broader outpatient prescription drug coverage, someone with Original Medicare can generally enroll in a separate Medicare Part D Prescription Drug Plan.
Does Original Medicare Have an Annual Maximum Out-of-Pocket Limit?
Original Medicare by itself generally does not have an annual maximum on what you may pay out of pocket for Part A and Part B-covered services.
That is an important distinction between Original Medicare alone and Medicare Advantage.
People using Original Medicare may have other coverage that helps with these expenses, such as:
Medicare Supplement Insurance
Medicaid
Employer coverage
Retiree coverage
Union coverage
Other qualifying supplemental insurance
What Is Medigap?
Medicare Supplement Insurance, commonly called Medigap, is private insurance designed to supplement Original Medicare.
It can help pay certain Medicare deductibles, coinsurance and copayments depending on the standardized Medigap plan selected.
Medigap does not replace Original Medicare.
Instead:
Medicare remains your primary health coverage → Medigap helps with certain remaining Medicare-approved costs.
You generally need both Medicare Part A and Part B to purchase Medigap coverage.
What Does Original Medicare Generally Not Cover?
Original Medicare does not cover everything.
Examples of services that are generally not covered include certain:
Routine dental services
Dentures
Routine eye examinations for eyeglasses
Hearing aids
Long-term custodial care
Routine physical examinations
Healthcare received outside the United States, except under limited circumstances
Certain services may be covered in specific medical circumstances, so beneficiaries should verify coverage before assuming something is excluded.
Who Might Want to Consider Original Medicare?
Original Medicare may be worth exploring if broad provider access is particularly important to you.
Questions to consider include:
Do I travel frequently within the United States?
Do I want access to providers across multiple states?
Do I see specialists at multiple health systems?
Am I comfortable purchasing separate Part D coverage?
Do I want to explore Medicare Supplement coverage?
There is no single Medicare coverage structure that is appropriate for everyone.
The Bottom Line
Think of Original Medicare as:
Part A + Part B
Then you may choose to add:
Part D
and potentially:
Medicare Supplement Insurance
Your complete Medicare strategy should consider your doctors, prescriptions, healthcare utilization, travel habits, finances and personal preferences.