What does Original Medicare cover?

Hospitalization Part A and Medical Services Part B are the only benefits covered under Original Medicare. Part A covers inpatient hospitals, skilled nursing facilities, hospices, and home health services, which are among the Part A benefits. Here are some of the services and items that Original Medicare covers:

Medicare Part A (Hospital Insurance):

• Inpatient hospital care
• Skilled nursing facility care
• Hospice care
• Home health care (limited)

Medicare Part B (Medical Insurance):

• Doctor visits
• Outpatient care
• Preventive care services (e.g., annual wellness visits, flu shots, cancer screenings)
• Diagnostic tests and lab services
• Ambulance services
• Durable medical equipment (e.g., wheelchairs, walkers)
• Mental health care services (e.g., therapy, counseling)

Part B covers 80% of the doctor's or non-physician professional's outpatient and professional services. Clinical lab services, durable medical equipment, preventive care, and other outpatient medical services are all covered under Part B benefits.

While Original Medicare covers many healthcare services and items, it does not cover all health-related costs. For example, Original Medicare Parts A and B do not cover most prescription drugs, routine dental, hearing, vision care, or long-term care.

Original Medicare primarily covers hospital services (Part A) and medical services (Part B). It does NOT provide coverage for many prescription drugs you take at home.

Medicare Part D Prescription drug coverage is not included in Original Medicare (Medicare Parts A and B). However, there are penalties if the beneficiary enrolls in Part D prescription drug coverage after 63 days past any prior creditable drug coverage expires, such as an employer-based health insurance policy.

Medicare Part D is a separate, Medicare-mandated program that provides prescription drug coverage. Medicare Part D prescription drug plans are offered by private insurance companies that are approved by Medicare. These insurance companies are responsible for designing and administering the Part D plans, including determining the specific drug formularies covered, the cost-sharing structure, and any premiums. Beneficiaries can enroll in a standalone Part D prescription drug plan (PDP) or choose a Medicare Advantage plan (Part C) that includes prescription drug coverage.

To access prescription drug coverage under Original Medicare, you need to enroll in a Part D prescription drug during specific enrollment periods. Part D coverage for prescription drugs This coverage helps offset the costs of prescription medications, including both generic and brand-name drugs. Each Part D plan has its own formulary (list of covered drugs) and cost-sharing structure, such as deductibles, copayments, and coinsurance. There is a penalty for not having Medicare Part D prescription drug coverage if you are eligible for it, but do not enroll when you initially become eligible. This penalty is known as the Part D, Late Enrollment Penalty (LEP). The penalty is added to your Medicare Part D premium and is calculated as a percentage of the national base beneficiary premium for each month you were without creditable coverage. The national base beneficiary premium may change each year. It's important to note that the Part D late enrollment penalty is permanent, meaning you will have to pay this penalty for as long as you have Medicare Part D coverage. The penalty amount can vary depending on the number of months you were without creditable coverage.

To avoid the Part D late enrollment penalty, 3 Ways to Avoid Medicare Part D Late Enrollment Penalties. It's generally recommended to enroll in Medicare Part D prescription drug coverage during your Initial Enrollment Period (IEP) when you first become eligible for Medicare. If you don't have creditable coverage from another source, enrolling in a Part D plan during your IEP or a Special Enrollment Period (SEP) is crucial to avoid incurring the penalty.

It's important to note that if you have original Medicare and need to obtain prescription drug coverage, it is advisable to enroll in a standalone Medicare Part D plan or consider a Medicare Advantage plan that includes Part D coverage. Medicare Advantage Part C allows you to have hospital and medical services, some equipment coverage, possibly prescription drug coverage, as well as ancillary benefits.