What Is Original Medicare?
Original Medicare is the federal health insurance program for people age 65 and older, as well as certain younger people with disabilities or End-Stage Renal Disease (ESRD). It is administered directly by the federal government through the Centers for Medicare & Medicaid Services (CMS) and is made up of two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).
With Original Medicare, you can see any doctor or specialist in the country who accepts Medicare — no referrals, no network restrictions. This flexibility is one of its greatest strengths, especially for those who travel or have complex health needs.
Good to know: Original Medicare covers about 80% of approved medical costs. You are responsible for the remaining 20% (coinsurance), as well as deductibles — with no annual out-of-pocket maximum. This is the primary reason many beneficiaries add a Medicare Supplement (Medigap) policy or choose Medicare Advantage.
Medicare Part A — Hospital Insurance
Part A covers inpatient care in hospitals, skilled nursing facilities, hospice care, and some home health services. Most people receive Part A premium-free because they (or their spouse) paid Medicare payroll taxes for at least 10 years (40 quarters) while working.
What Part A Covers
- Inpatient hospital care — semi-private room, meals, general nursing, drugs, and other hospital services and supplies during a covered inpatient stay
- Skilled Nursing Facility (SNF) care — up to 100 days of skilled nursing care following a qualifying 3-day hospital stay
- Hospice care — pain relief, symptom management, and support services for people with a terminal illness with a life expectancy of 6 months or less
- Home health services — part-time or intermittent skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services
- Inpatient mental health care — care received in a psychiatric facility (lifetime 190-day limit for inpatient psychiatric facility care)
Part A Costs (2025)
- Premium: $0 for most people (if you have 40+ work credits); up to $518/month if you have fewer than 30 work credits
- Deductible: $1,676 per benefit period
- Coinsurance (Days 1–60): $0
- Coinsurance (Days 61–90): $419/day
- Coinsurance (Days 91+, Lifetime Reserve Days): $838/day
- SNF Coinsurance (Days 21–100): $209.50/day
Medicare Part B — Medical Insurance
Part B covers medically necessary outpatient services and preventive care. Unlike Part A, Part B always has a monthly premium. Enrollment is not automatic for everyone, so it's important to understand when and how to sign up.
What Part B Covers
- Doctor visits — primary care and specialist visits, including mental health professionals
- Outpatient care — surgeries, emergency room visits, and observation services
- Preventive services — annual wellness visits, cancer screenings, flu shots, cardiovascular screenings, and more (often at no cost to you)
- Durable medical equipment (DME) — wheelchairs, walkers, oxygen equipment, blood sugar monitors
- Ambulance services — when medically necessary
- Mental health — outpatient therapy and counseling
- Clinical lab tests — blood work, urinalysis
- Limited prescription drugs — drugs administered in a doctor's office (e.g., chemotherapy, some injectable medications)
Part B Costs (2025)
- Standard Premium: $185.00/month (higher earners pay an Income-Related Monthly Adjustment Amount, or IRMAA)
- Annual Deductible: $257
- Coinsurance: You typically pay 20% of the Medicare-approved amount after meeting your deductible
What Original Medicare Does — and Doesn't — Cover
✅ Covered
- Hospital stays & surgery
- Doctor visits (primary care & specialists)
- Outpatient procedures
- Preventive screenings & vaccines
- Skilled nursing facility (limited)
- Home health care (limited)
- Hospice care
- Durable medical equipment
- Mental health services
- Ambulance services
- Chemotherapy & radiation
- Physical & occupational therapy
❌ Not Covered
- Most prescription drugs (need Part D)
- Routine dental care & dentures
- Routine vision (eye exams, glasses)
- Hearing aids & exams
- Long-term custodial care
- Cosmetic surgery
- Routine foot care
- Acupuncture (most cases)
- Care outside the U.S.
- Massage therapy
- Private nursing
- No out-of-pocket maximum
Enrollment — When to Sign Up
Enrolling on time is critical. Missing your window can result in permanent late enrollment penalties. Here are the key enrollment periods:
- Initial Enrollment Period (IEP): A 7-month window — 3 months before your 65th birthday month, your birthday month, and 3 months after. This is the best time to enroll.
- Special Enrollment Period (SEP): If you're still working at 65 and covered by employer insurance, you can delay Medicare without penalty. When that coverage ends, you have an 8-month SEP to enroll.
- General Enrollment Period (GEP): January 1 – March 31 each year, for those who missed their IEP. Coverage begins July 1, and late penalties may apply.
Important: The Part B late enrollment penalty is 10% per 12-month period you were eligible but didn't sign up (and weren't covered by qualifying employer insurance). This penalty is added to your monthly premium for life. Don't miss your window — contact us to make sure you enroll at the right time.
What Are Your Next Steps?
Original Medicare is the foundation, but most people need additional coverage to protect themselves from unexpected costs. Your two main options are:
- Medicare Supplement (Medigap) — a private policy that helps pay the 20% coinsurance and deductibles that Original Medicare leaves behind. Use any Medicare-accepting doctor nationwide.
- Medicare Advantage (Part C) — an all-in-one alternative that bundles Part A, Part B, and usually Part D, often with added benefits like dental and vision.
Not sure which path is right for you? We can help. Our local Tucson experts will walk you through both options — free of charge.