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How does Original Medicare Work?

Original Medicare is one of your Medicare health coverage choices. You will have Original Medicare unless you choose a Medicare Advantage Plan or other type of Medicare health plan.

You generally have to pay a portion of the cost for each service Original Medicare covers. There is no limit to what you will pay out of pocket in a year unless you have other coverage (like Medigap, Medicaid, or employee or union coverage) or enroll in a Medicare Advantage Plan.

Can I get my health care from any doctor, other health care provider, or hospital?

In most cases, yes. You can go to any Medicare-enrolled doctor, other health care provider, hospital, or other facility that accepts Medicare patients anywhere in the U.S

Does it cover prescription drugs?

No, with a few exceptions, Original Medicare does not cover most drugs. You can add Medicare drug coverage Part D by joining a separate Medicare drug plan.

Do I need to choose a Primary Care Doctor?


Do I have to get a referral to see a specialist?


Should I get a supplement Policy?

You may already have Medicaid, military retiree, or employer or union coverage that may pay costs that Original Medicare does not. If not you may want to buy a Medicare Supplement Plan.

How do insurance companies set prices for Medigap policies?

Each insurance company decides how it will set the price, per premium, for its Medigap policies The way they set the price affects how much you pay now and in the future. Medigap policies can be prices or “rated” in 3 ways:

  1. Community-rates (not age rated)
  2. Issue-age-rated (entry age rated)
  3. Attained age rated

Each of these ways of pricing Medigap policies is described in the table below. The examples below show hour your age affects your premiums, and why it is important to look at how much the Medigap policy will cost now and in the future. The amounts in the examples are actual costs. Other factors like where you live, medical underwriting, and discounts can also affect the amount of your premium.

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What is Medicare Supplement High Deductible Plan?

Another variation of a Medicare supplement policy available to you is a “high deductible option” on Plan F or G. Generally, the premium for a high deductible Plan F or G will be lower than that company’s same Medicare supplement plan without the higher deductible. The benefits for a high deductible Plan F or G are identical to any other Plan F or G. The only difference is that the plan will not pay benefits until you have met the deductible (the amount you must pay out of your pocket) for the calendar year.

For those eligible for Medicare prior to January 1, 2020, Plan F High Deductible is available. For those eligible for Medicare on or after January 1, 2020, Plan G High Deductible will be the only high deductible plan available.

Frequently Asked Questions:

Who is Medicare Beneficiary?

An individual entitled to benefits under Medicare Part A, Part B, or both.

What is catastrophic coverage?

The stage of Medicare Part D coverage that begins after you reach your out-of-pocket limit. For the rest of the year, part D should pay more of your drug costs.

What is Drug Coverage Tier?

A way prescription drug plans categorize different medications according to the cost the patient will be expected to have.

What is Co-insurance?

The percentage of cost you will have to pay for a medical service or prescription drug coverage , after any relevant deductibles are paid. For example, you may pay 20%.

What is Co-pay?

Your share of the cost for medicare service or prescription that is a fexed amount. For example, you may pay $30.

What is Coverage Gap (Donut Hole)?

The Medicare Part D stage that begins once your total drug costs reach your initial coverage liit. From then on, you pay higher percentage of drug costs until you reach the plan’s catastriphic coveraeg stage.

What does Formulary mean?

List of medicines that your health insurance plan will cover or pay for.


Care in a hospital that requires admission as as inpatietn and usually requires an overnight stay.

What does Inital Coverage Limit mean?

The amount you and your plan haev spent before you reach the Coverage Gap (Donut Hole).

What is the Initial Coverag Phase?

The Medicare part D coverage stage that begins after you’ve reached the deductible, where you will only pay the plan’s co-pay for covered medications.

Low Income Subsidy (LIS or Extra Help)

A government program for eligible beneficiaries that helps pay for Medicare Part D prescription drug costs.

What is Medicare?

A federal government insurance plan that provides healthcare coverage options and drug benefits for people over 65 and younfer people with disabilities.

What is Medicare Advantage Plan?

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Also known as Medicare Part C.

What is Medicare Supplement Insurance (Medigap)?

An insurance policy , sold by private companies, that can help pay some of the healthcare costs that Medicare Part A and Part B do not cover.

What is Medicare Part A?

The part of Medicare that covers hospitalization, including most inpatient hospital, skilled nursing facility, hospice, lab tests, surgery, and home health care.

What is Medicare Part B?

The part of Medicare that covers medical services, including most doctor’s and other providers’ services and outpatient care, preventitve care, durable medical equipment, hospital outpatient services,laboratory tests, X-rays, and mental healthcare.

What is Medicare Part C?

Not a seperate benefit. It is the part of Medicare policy that allows private health insurance companies to provide your Medicare benefits through what are called Medicare Advantage (MA) plans.

What is Medicare Part D?

A seperate coverage option that adds prescription drug coverage to your part A and B benefits.

Out-of-pocket (OOP) Costs

The share of Medicare prescription drug costs that you are responsible for paying.

What are Patient Assistance Foundations?

Independent charitable foundations that provide financial assistance to qualified patients who are unable to afford their co-pay costs.

State Pharmaceutical Assistance Programs (SPAPs)

State programs that coordinate with Medicare’s Part D drug benefit to help their residents pay for prescription drugs. Read More.

What are Patient Assistance Foundations?

Independent charitable foundations that provide financial assistance to qualified patients who are unable to afford their co-pay costs.

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