How does Original Medicare work?
Original Medicare is one of your health coverage choices as part of Medicare. You’ll have Original Medicare unless you choose a Medicare health plan. Original Medicare is coverage managed by the federal government. Generally, there’s a
cost for each service. See below for the general rules for how it works.
Can I get my health care from any doctor, other health care provider, or hospital?
In most cases, yes. You can go to any doctor, other health care provider, hospital, or other facility that’s enrolled in Medicare and accepting new Medicare patients.
Are prescription drugs covered?
With a few exceptions (see pages 32 and 48), most prescriptions aren’t covered. You can add drug coverage by joining a Medicare Prescription Drug Plan (Part D).
Do I need to choose a primary care doctor?
Do I have to get a referral to see a specialist?
In most cases, no, but the specialist must be enrolled in Medicare.
Should I get a supplemental policy?
You may already have employer or union coverage that may pay costs that Original Medicare doesn’t. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy. See pages 67–71.
What else do I need to know about Original Medicare?
You generally pay a set amount for your health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (coinsurance/copayment) for covered services and supplies. There’s no yearly limit for what you pay out-of-pocket.
You usually pay a monthly premium for Part B. See pages 108–109 for information about help paying your Part B premium.
You generally don’t need to file Medicare claims. The law requires providers (like doctors, hospitals, skilled nursing facilities, and home health agencies) and suppliers to file your claims for the covered services and supplies you get.
What do I pay?
Your out-of-pocket costs in Original Medicare depend on:
Whether you have Part A and/or Part B. Most people have both.
Whether your doctor, other health care provider, or supplier accepts “assignment.”
The type of health care you need and how often you need it.
Whether you choose to get services or supplies Medicare doesn’t cover. If you do, you pay all costs unless you have other insurance that covers it.
Whether you have other health insurance that works with Medicare.
Whether you have Medicaid or get help from your state paying your Medicare costs.
Whether you have a Medicare Supplement Insurance (Medigap) policy.
Whether you and your doctor or other health care provider sign a private contract. See page 66.
What are Medicare Summary Notices?
If you have Original Medicare, you’ll get a “Medicare Summary Notice” (MSN) in the mail every 3 months that lists all the services billed to Medicare. The notice shows what Medicare paid and what you may owe the provider. This notice isn’t a bill. Read it carefully and do the following:
If you have other insurance, check to see if it covers anything that Medicare didn’t.
Keep your receipts and bills, and compare them to your notice to be sure you got all the services, supplies, or equipment listed. See pages 122–125 for information on Medicare fraud.
If you paid a bill before you got your notice, compare your notice with the bill to make sure you paid the right amount for your services.
If an item or service is denied, call your doctor’s or other health care provider’s office to make sure they submitted the correct information. If not, the office may resubmit the claim. If you disagree with any decision made, you can file an appeal.
If you need to change your address on your notice, call Social Security at 1‑800‑772‑1213. TTY users should call 1‑800‑325‑0778. If you get Railroad Retirement Board (RRB) benefits, call the RRB at 1‑877‑772‑5772. TTY users should call 1‑312‑751‑4701.
Check your MSN on MyMedicare.gov
You don’t have to wait for your MSN to come in the mail to view your Medicare claims or file an appeal. Visit MyMedicare.gov to look at your Medicare claims or view electronic MSNs. Your claims generally will be available for viewing within 24 hours after processing. You can also download your claims information by using Medicare’s Blue Button. See page 133.
Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. Make sure your doctor, provider, or supplier accepts assignment Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services. Here’s what happens if your doctor, provider, or supplier accepts assignment:
Your out-of-pocket costs may be less.
They agree to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share.
They have to submit your claim directly to Medicare and can’t charge you for submitting the claim.
If your doctor, provider, or supplier doesn’t accept assignment
Non-participating providers haven’t signed an agreement to accept assignment for all Medicare‑covered services, but they can still choose to accept assignment for individual services. These providers are called “non‑participating.” Here’s what happens if your doctor, provider, or supplier doesn’t accept assignment:
You might have to pay the entire charge at the time of service.
Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare‑covered services they provide to you. They can’t charge you for submitting a claim. If they don’t submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048. Note: In some cases, you might have to submit your own claim to Medicare using form CMS‑1490S to get paid back. Visit Medicare.gov/medicareonlineforms, or call 1‑800‑MEDICARE for the form and instructions.
They can charge you more than the Medicare-approved amount, but there’s a limit called “the limiting charge.” The limiting charge applies only to certain Medicare-covered services and doesn’t apply to some supplies and durable medical equipment. Call 1-800-MEDICARE to find out if you were charged the right amount.
To find out if your doctors and other health care providers accept assignment or participate in Medicare, visit Medicare.gov/physician or Medicare.gov/supplier. You can also call 1‑800‑MEDICARE, or ask your doctor, provider, or supplier if they accept assignment.
What are private contracts?
A “private contract” is a written agreement between you and a doctor or other health care provider who has decided not to provide services to anyone through Medicare. The private contract only applies to the services provided by the doctor or other provider who asked you to sign it.
Rules for private contracts
You don’t have to sign a private contract. You can always go to another provider who gives services through Medicare. If you sign a private contract with your doctor or other provider:
Medicare won’t pay any amount for the services you get from this doctor or provider, even if it’s a Medicare-covered service.
You’ll have to pay the full amount of whatever this provider charges you for the services you get.
If you have a Medicare Supplement Insurance (Medigap) policy, it won’t pay anything for the services you get. Call your insurance company before you get the service if you have questions.
Your provider must tell you if Medicare would pay for the service if you get it from another provider who accepts Medicare.
Your provider must tell you if he or she has been excluded from Medicare.
You can always get services not covered by Medicare if you choose to pay for them yourself.
Note: You can’t be asked to sign a private contract for emergency or urgent care.
You should contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider. See pages 141–144 for the phone number.
Can I add drug coverage (Part D) to Original Medicare?
In Original Medicare, if you don’t already have creditable prescription drug coverage (for example, from a current or former employer or union) and you would like Medicare prescription drug coverage, you must join a Medicare Prescription Drug Plan. These plans are available through private companies under contract with Medicare. If you don’t currently have creditable prescription drug coverage, you should think about joining a Medicare Prescription Drug Plan as soon as you’re eligible. If you don’t join a Medicare Prescription Drug Plan when you’re first eligible and you decide to join later, you may have to pay a late enrollment penalty. See pages 94–95 for more information.
If you have creditable prescription drug coverage from an employer or union, call your employer or union’s benefits
administrator before you make any changes to your coverage. Your employer or union plan will tell you each year if your prescription drug coverage is creditable. If you drop your employer or union coverage, you may not be able to get it
back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependents.