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PART

Part A

Medicare Part A covers certain hospital expenses. Part A has an annual deductible and coinsurance on some services. Most people do not pay a monthly premium.

Part A benefits include:

  • Inpatient care in a hospital 
  • Skilled nursing facility care 
  • Hospice care 
  • Home health care 

 

PART

Part B

Medicare Part B helps you pay for your medical expenses. After you meet your Part B deductible, you will typically pay about 20% of the approved cost for covered services. Part B has a monthly premium.

Part B benefits include services that help diagnose, treat, or prevent a condition or illness. They also cover ambulance services, mental health services, getting a second opinion before surgery, and limited outpatient prescription drugs. 

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What’s the difference between inpatient and outpatient care?

Inpatient care refers to when you are admitted to the hospital through a doctor’s order, while outpatient care means you are receiving hospital medical care without being admitted or for a stay of less than 24 hours.

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AM I ELIGIBLE TO ENROLL IN ORIGINAL MEDICARE?

All U.S. citizens and legal residents age 65 and up are eligible for Original Medicare, as well as people under 65 with a qualifying disability, End Stage Renal Disease (ESRD), or Lou Gehrig’s disease (ALS).

Your Initial Enrollment Period (IEP) is the first opportunity to sign up for Medicare and lasts for 7 months: it begins 3 months before your 65th birthday and ends 3 months after your 65th birthday. For example, if your birthday is in May, your IEP begins in February (3 months before) and ends in August (3 months after). During your IEP, you can sign up for Medicare Parts A and B and add on prescription drug coverage (Part D), a Medicare Advantage (Part C) plan, or a Medicare supplement plan.

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What if I miss my Initial Enrollment Period?

If you miss your Initial Enrollment Period (IEP), you can sign up for Parts A and B during the General Enrollment Period, which is January 1 to March 31, although you may have to pay a late enrollment penalty. You can then sign up for Medicare Advantage or a prescription drug plan (Part D) during the Annual Enrollment Period, which is October 15 to December 7.

You may also qualify to enroll during a Special Enrollment Period (SEP). There are many scenarios that warrant an SEP, but the most common is that you were still working and had creditable coverage through your employer, or had coverage through your spouse’s employer, when you first turned 65. You can sign up for Parts A and B as well as add on additional coverage during your SEP.

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Is there a penalty for enrolling late in Original Medicare?

Yes, there are penalties for not enrolling or enrolling late in certain parts of Medicare. You will have to pay a penalty for enrolling in Part B late unless you or your spouse have qualifying insurance through your employer. For each 12-month period that you delay your enrollment, you’ll have to pay a 10% Part B premium penalty. Talk to your employer before you delay your enrollment to make sure you won’t have to pay the penalty.

There’s also a Part A late enrollment penalty. If you aren’t eligible for premium-free Part A and you don’t buy it when you’re first eligible, your monthly premium may increase by 10%. You’ll have to pay this higher premium for twice as many years as you didn’t sign up for Part A. For example, you’d pay a higher Part A premium for 4 years if you delayed your enrollment 2 years.

You generally have to join a prescription drug (Part D) plan or add on a Medicare Advantage (Part C) plan that includes Part D coverage within 3 months of your Part A or Part B effective date to avoid getting a penalty. You may be able to avoid penalties altogether if you qualify for a Special Enrollment Period (SEP).

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Are there different eligibility requirements for different parts of Medicare?

The eligibility requirements for Original Medicare are the same. Private insurers may have additional eligibility requirements when purchasing a Medicare Advantage, Medicare supplement, or prescription drug coverage plan.

WHAT’S INCLUDED IN ORIGINAL MEDICARE

Original Medicare covers some of the costs for hospital and medical care.

You can enroll in a separate Part D plan to cover prescription drugs or a Medicare Advantage (Part C) plan that covers both medical and drug costs, as well as other services like dental, vision, and hearing.

WILL ORIGINAL MEDICARE COVER THIS BENEFIT?

 

This chart provides a high-level overview of the coverage included in Original Medicare. 

Covered services may be subject to deductibles, copays, or coinsurance.

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WILL ORIGINAL MEDICARE COVER THIS BENEFIT?

 

This chart provides a high-level overview of the coverage included in Original Medicare. 

Covered services may be subject to deductibles, copays, or coinsurance.

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Does Medicare cover dental, vision, or prescriptions?

Original Medicare (Parts A and B) does not include dental or vision care, and only limited outpatient drugs are covered.

Medicare Advantage (Part C) plans often include dental coverage such as basic cleanings and x-rays, but typically have an annual coverage cap. These plans may include vision and hearing depending on the plan. Many insurance companies also offer buy-up options if you want to add on more dental, vision, and hearing coverage to your Medicare Advantage plan.

To get prescription drug coverage, you can purchase a stand-alone prescription drug (Part D) plan through a private insurance provider or get a Medicare Advantage plan that includes Part D coverage.

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Will my doctor be covered?

It depends on the doctor and what type of Medicare plan that you have. Over 90% of doctors accept some form of Medicare, whether Original Medicare (Parts A and B) or Medicare Advantage (Part C). If your doctor isn’t part of a Medicare participating provider, the doctor can choose on an individual basis to accept or treat a person on Medicare. If you enroll in a Medicare Advantage plan, your doctor may or may not be in your insurance provider’s network. We recommend checking your private insurance provider’s directory to make sure your doctor is in network. If you have a Medicare supplement plan, you can see any doctor that accepts Medicare.

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How do I get coverage for something not covered by Medicare?

Original Medicare (Parts A and B) helps cover some—but not all—of the costs of medical care, so many people choose to add on more coverage through a private insurance company. If you want more coverage, you can enroll in a Medicare Advantage (Part C), Medicare supplement, or prescription drug coverage (Part D) plan during your Initial Enrollment Period (IEP) or your Special Enrollment Period (SEP) if you are eligible. Members can change their Medicare Advantage or Part D plan each year during the Annual Enrollment Period (AEP).

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Will Medicare be my primary insurance if I’m still working?

Your primary insurance will depend on your employer’s insurance policy, so it’s best to discuss your options with them before enrolling. Depending on the size of the company, some employers may require you to take full Medicare benefits, while with others, you can wait until you retire to sign up.

Talk to your employer before you turn 65 to understand how Medicare may affect your medical insurance.

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What is preventive care?

Preventive services help you identify and treat health problems early so you can stay healthy. These include exams, shots, lab tests, and screenings, among others. Medicare Part B covers some preventive care services, although you may have a 20% coinsurance on services after you have met your deductible. If you have a Medicare Advantage (Part C) plan, your private insurance provider will have a list of preventive services they cover.

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HOW MUCH DOES ORIGINAL MEDICARE COST?

For many Medicare recipients who have worked most of their lives, Part A of Medicare has no monthly premium. If you do not meet the minimum working requirements, you may have to pay a premium. Part A has a deductible and may have a coinsurance for certain services. 

When it comes to Part B, most people pay the standard monthly premium. However, if your income is above a certain amount, you may have to pay a higher premium. You can find this year’s monthly premium amount on medicare.gov. Part B typically has a 20% coinsurance on covered services after you meet the deductible.

Part A and Part B do not have an annual out-of-pocket maximum, which is a cap on how much you would pay for services each year.

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Are Medicare costs based on income?

Your modified adjusted gross income may determine how much you pay for certain parts of Medicare. If you have a higher income, you may have to pay a higher monthly premium for Medicare Part B, which covers medical insurance.

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What if I can’t afford Medicare?

Medicare is designed to provide healthcare to all eligible individuals. You can get help from your state paying your Medicare premiums. You can also sign up for a Medicare Savings Program, which can help with monthly premiums, deductibles, coinsurance, and copayments if you meet certain conditions. And depending on your income, you may be eligible for Medicaid as well, which offers low-income families and individuals free or low-cost health coverage.

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How do I make payments for Medicare premiums?

If you are receiving benefit payments from Social Security, the Railroad Retirement Board, or the Office of Personnel Management, your Part B premium will be automatically deducted from your benefit payment. If you don’t get one of these benefit payments, you’ll receive a Medicare Part B bill in the mail with instructions about your payment options, which include paying by check, money order, credit, or debit. You can also set up automatic payments for your premiums through your bank or Medicare Easy Pay.

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IS ORIGINAL MEDICARE RIGHT FOR ME?

Remember that Original Medicare only covers hospital and medical benefits, so you’ll likely need to add more coverage if you want help paying for prescription drugs, dental, vision, hearing, or other specialized care. If need more coverage than what Original Medicare provides, you can purchase a Medicare Advantage (Part C) plan that may also include drug coverage, a stand-alone Part D plan, or a Medicare supplement plan.

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