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What is original Medicare?

Originally conceived as a big step toward ensuring health care coverage and financial stability for our nation’s older population, Medicare is a federal insurance program that provides guaranteed health insurance for people age 65 and older and for younger people who qualify because of a disability. More commonly known as original Medicare or traditional Medicare, the program refers to the first two parts of Medicare, Part A and Part B, included in a bill that President Lyndon B. Johnson signed into law in 1965.

Medicare eligibility isn’t based on your income or assets, and you can’t be denied coverage or charged more because of existing medical conditions. With original Medicare, you can use any doctor or other provider in the United States that participates in the program. More than 95 percent of surgeons, about 90 percent of physicians who aren’t pediatricians, 80 percent of most other specialists and 60 percent of psychiatrists are accepting new Medicare patients.

Other parts of Medicare were introduced later and are not considered original Medicare.

How much do I pay for original Medicare?

Medicare isn’t free. You’ll find that original Medicare has fees similar to private-sector insurance you probably had during much of your work life.

Premiums. Most people don’t have to pay premiums for Part A because they or their spouse had Medicare taxes withheld from their paychecks for 40 quarters, 10 years of work that don’t have to be continuous. Almost everyone pays a premium for Part B, typically $170.10 a month in 2022 and $164.90 in 2023; high earners can expect to pay more.

Deductible. You must pay this predetermined amount of out-of-pocket costs before your Medicare coverage kicks in.

Copayment. After you meet your deductible, you’ll pay a fixed dollar amount for certain services and supplies, such as $20.

Coinsurance. Also after you meet your deductible, you’ll pay a set percentage of certain bills, such as 20 percent of the cost for most Part B services.

Do I need to buy any supplemental policies?

While original Medicare covers a lot of health care expenses, its coverage has some gaps. Consider whether you need extra policies for:

Prescription drug coverage. Original Medicare doesn’t cover prescriptions, but you can buy a Part D policy from a private insurer.

If you don’t have other drug coverage considered to be at least as good as Medicare’s, called “creditable coverage,” you must sign up for Part D or you could face a late-enrollment penalty later. Drug coverage from an employer, a former employer, Tricare for career military members and retirees, or the Department of Veterans Affairs can be considered creditable coverage.

You can buy a Part D policy when you first enroll in Medicare or within two months of losing other prescription coverage. You also have an option to sign up or switch policies every year during open enrollment, which runs from Oct. 15 to Dec. 7. Coverage will start Jan. 1.

Medigap insurance. Many people with original Medicare buy a Medicare supplement policy, also known as Medigap, to help pay Medicare’s deductibles and copayments.

Private insurance companies can sell you these policies at any time. But be forewarned: Insurers in most states may reject you or charge more if you have preexisting medical conditions unless you buy a policy during certain times.

How do original Medicare and Medicare Advantage differ?

You have the option to get Medicare coverage either from federally run original Medicare or through a private Medicare Advantage plan. The choices have some key differences.

With original Medicare, you can use any doctor, provider or facility in the United States that accepts Medicare, and you don’t need permission to use a specialist. You will have to pay deductibles and copayments for Part A and Part B, and prescription drug coverage isn’t automatically included.

With a Medicare Advantage plan, your coverage comes from a private insurer even though you sign up for Part A and B through the federal government. You still must pay the Part B premium, and these plans must provide at least as much coverage as original Medicare, but they can have different out-of-pocket costs.

Advantage plans may offer additional coverage not part of original Medicare, such as dental, hearing, prescriptions and vision. Because most Medicare Advantage plans have a provider network, doctors you have already who are not part of the network could cost you more or not be covered at all. You may need permission from the plan’s officials, called prior authorization, to see a specialist.

You can choose from several Medicare Advantage plans available in your area and can enroll in Medicare Advantage during your initial enrollment period or during open enrollment each year.

Keep in mind

The time frame for signing up for original Medicare and the steps you need to take depend on whether you’re already receiving Social Security benefits and if you or your spouse is still working.

Some have automatic enrollment. If you’re receiving Social Security benefits at least four months before you turn age 65, the first day of your birthday month marks the day you’re enrolled in Medicare Part A and Part B. If your birthday is on the first of the month, your Medicare coverage will begin the first day of the previous month.

Some register themselves. You can sign up during your seven-month initial enrollment period, which starts three months before the month you turn 65 and ends three months after your birthday month. So, if your birthday is May 15, you can sign up as early as Feb. 1 or as late as Aug. 31.

Some can sign up later. If you choose to enroll after age 65, you may have to pay a late-enrollment penalty unless you or your spouse is still working and you have health insurance from a current employer. In that case, you may be able to delay signing up for Part A and Part B until eight months after you or your spouse leaves the job and you lose that coverage.

Updated December 9, 2022

     

        


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