Skip Navigation

How Original Medicare works

Original Medicare is coverage managed by the federal government. Generally, there's a cost for each service. Here are the general rules for how it works:

In most cases, yes. You can go to any doctor, other health care provider, hospital, or other facility that's enrolled in Medicare and is accepting new Medicare patients.

With a few exceptions, most prescriptions aren't covered in Original Medicare.

You can add drug coverage by joining a Medicare Prescription Drug Plan (Part D).

No, in Original Medicare you don't need to choose a primary care doctor.

In most cases, no. In Original Medicare, you don't need a referral, but the specialist must be enrolled in Medicare.

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.

  • 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.  
  • 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.

Factors that affect Original Medicare out-of-pocket costs

  • 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 the 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 state help 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.

What is Part A (Hospital Insurance)? 

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

What is Part B (Medical Insurance)?

Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.