Original Medicare Parts A & B

Introduction to Original Medicare

Original Medicare is the federal health insurance program that provides health coverage to people 65 and older, as well as some younger individuals with certain disabilities. It consists of two parts: Part A, which is hospital insurance, and Part B, which is medical insurance. Together, these two parts form the foundation of Medicare benefits that millions of Americans rely on for their health care needs.

If you are a Michigan resident turning 65, already enrolled in Medicare, or helping a family member navigate their coverage decisions, understanding how Original Medicare works is an important first step. This program is administered by the federal government through the Centers for Medicare & Medicaid Services, not by private insurance companies—though private options like Medicare Advantage (Part C), Part D drug plans, and Medigap policies can be added to it.

Sunnyside Medicare is a Michigan-based Medicare insurance agency with licensed agents who can help explain your medicare options and walk you through the differences between plans. We are not affiliated with Medicare or any government agency, but we are here to help you understand what coverage might work best for your situation.

Key Takeaways

• Original Medicare always includes Part A (hospital insurance) and Part B (medical insurance), and most people qualify for premium-free Part A based on their work history or a spouse’s work history.
• Part A covers inpatient hospital care, skilled nursing facility care after a qualifying hospital stay, some home health care services, and hospice care for those who are terminally ill.
• Part B covers doctor visits, outpatient care, preventive services like screenings and vaccines, lab tests, and durable medical equipment such as wheelchairs and walkers.
• Original Medicare does not cover most dental care, routine vision exams, routine hearing exams, long-term custodial care, or prescription drugs—you need a separate Part D plan for drug coverage.
• Costs under Original Medicare include premiums, deductibles, copays, and coinsurance, with no annual out-of-pocket maximum, which is why many people consider adding Medigap, Part D, or switching to a Medicare Advantage plan.
• Enrollment timing matters—missing your Initial Enrollment Period for Part B without qualifying employer coverage can lead to late penalties and gaps in health coverage.
• Michigan residents can contact Sunnyside Medicare to review whether Original Medicare alone or with supplemental coverage fits their needs.

What Is Original Medicare?

Original Medicare, sometimes called traditional Medicare or fee-for-service Medicare, is the foundational Medicare program that has been administered by the federal government since 1965. It was created to provide guaranteed health insurance for older Americans regardless of income, pre-existing conditions, or health status.

Original Medicare is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). Under this fee-for-service model, you can see any doctor, specialist, or hospital nationwide that accepts Medicare, and Medicare pays its approved amount for covered services. You do not need referrals to see specialists, and there are no network restrictions like you might find with some private health plans.

Enrollment in Original Medicare is handled through the Social Security Administration (or the Railroad Retirement Board for certain railroad workers), not through private insurance agents. Here is how the different parts of Medicare fit together:

• Part A (Hospital Insurance): Covers inpatient care, skilled nursing, hospice, and some home health services
• Part B (Medical Insurance): Covers doctors services, outpatient care, preventive care, and medical supplies
• Part C (Medicare Advantage): An alternative to Original Medicare offered by private insurance companies that bundles A, B, and often D
• Part D (Prescription Drug Coverage): Standalone plans that cover prescription drugs, purchased separately from Original Medicare
• Medigap (Medicare Supplement Insurance): Private policies that help pay some of the out of pocket costs that Original Medicare does not cover

Only Part A and Part B together make up Original Medicare. The other options are additions or alternatives you can choose based on your needs.

What Original Medicare Covers (Overall)

Original Medicare generally covers most medically necessary services and supplies—things your doctor or provider determines are needed to diagnose or treat a medical condition. It also covers many preventive services designed to help detect or prevent illness before it becomes serious.

Coverage under Original Medicare depends on three factors: what the service is, who provides it, and where it is provided. A service might be covered when you receive it in a hospital but not covered in the same way at a different type of facility. Medicare has national coverage rules called National Coverage Determinations, as well as Local Coverage Determinations that can affect what is covered in your specific area.

Here are the major categories of health care services covered across Part A and Part B:

• Inpatient hospital care when you are admitted as a patient
• Skilled nursing facility care for short-term rehabilitation after a qualifying hospital stay
• Hospice care for comfort and support when someone is terminally ill
• Limited home health care when ordered by a doctor
• Doctor and specialist visits
• Outpatient hospital services and clinic visits
• Lab tests, X-rays, MRIs, and other diagnostic imaging
• Preventive screenings and vaccines
• Durable medical equipment like wheelchairs, hospital beds, and oxygen equipment

Even with this coverage, you still pay part of the cost through deductibles, copays, and coinsurance. And unlike most Medicare Advantage plans, Original Medicare does not have an annual out-of-pocket maximum—meaning your medical costs could add up significantly if you have a serious illness or injury.

Medicare Part A: What It Covers

Part A is often called hospital insurance because it primarily covers care when you are admitted as an inpatient to a hospital or similar facility. It also covers certain services you receive after leaving the hospital.

Here are the key benefits covered under Part A:

• Inpatient hospital care: Includes a semi-private room, meals, nursing care, medications administered during your stay, and other hospital services. Coverage is based on a benefit period, which starts the day you are admitted and ends after 60 consecutive days without inpatient care.
• Skilled nursing facility care: Covers up to 100 days of care in a skilled nursing facility following a qualifying 3-day hospital stay. This is for rehabilitation and skilled nursing, not long-term custodial care for help with daily activities.
• Home health care: Covers intermittent skilled nursing care, physical therapy, occupational therapy, and some other services when medically necessary and ordered by a doctor.
• Hospice care: Provides comfort-focused care for people who are terminally ill and have chosen to stop curative treatment. Includes pain management, counseling, and support for the patient and family.

Most people qualify for premium-free Part A if they or a spouse worked and paid Medicare taxes (FICA) for at least 40 quarters (roughly 10 years). Those who do not meet this requirement may still be able to purchase Part A by paying a monthly premium.

Even with Part A, you are responsible for deductibles at the start of each benefit period and daily coinsurance amounts for extended hospital or skilled nursing stays. These costs can add up, especially during longer hospitalizations.

Medicare Part B: What It Covers

Part B is medical insurance that covers outpatient and professional medical services—the care you receive outside of a hospital admission.

Here are the main categories of Part B coverage:

Doctor and specialist visits:

• Office visits with your primary care doctor or specialists
• Many telehealth services when allowed under Medicare rules
• Second opinions before surgery

Outpatient services:

• Same-day surgery centers
• Emergency room visits that do not result in hospital admission
• Hospital outpatient clinics

Preventive services:

• Flu shots, COVID-19 vaccines (when covered), and other immunizations
• Cancer screenings like mammograms, colonoscopies, and prostate exams
• The “Welcome to Medicare” preventive visit during your first year
• Annual wellness visit every 12 months after your first year on Medicare
• Many other preventive care screenings at no cost when they are the only service provided

Diagnostic tests and equipment:

• Lab tests and bloodwork
• X-rays, CT scans, MRIs, and other imaging when medically necessary
• Durable medical equipment such as walkers, wheelchairs, oxygen equipment, and certain diabetes supplies

Part B always requires a monthly premium, and most people also pay an annual deductible. After meeting your b deductible, you typically pay 20% coinsurance for most covered services. The actual premium amount can vary based on your income, with higher earners paying more through Income-Related Monthly Adjustment Amounts (IRMAA).

Enrollment in Part B is voluntary, but if you delay signing up without having qualifying employer coverage, you may face late enrollment penalties that permanently increase your premium payments. This is one of the most common and costly mistakes new Medicare beneficiaries make.

What Original Medicare Does NOT Cover

Understanding what original medicare doesn’t cover is just as important as knowing what it does cover. These gaps are a key reason many people add supplemental coverage to their Medicare plan.

Here are services that Original Medicare generally does not cover:

• Routine dental care: Cleanings, fillings, extractions, dentures, and dental implants are typically not covered
• Routine eye exams: Vision exams for glasses or contacts are not covered (though Medicare does cover some exams related to eye diseases and limited benefits after cataract surgery)
• Routine hearing exams and hearing aids: Hearing tests for fitting hearing aids and the hearing aids themselves are not covered
• Long-term custodial care: Nursing home care when you only need help with daily activities like bathing, dressing, and eating—not skilled medical care—is not covered
• Most prescription drugs: Medications you pick up at a pharmacy require separate prescription drug coverage through a Part D plan or a Medicare Advantage plan with drug coverage
• Cosmetic surgery: Procedures that are not medically necessary are not covered
• Care outside the United States: With very limited exceptions, Medicare does not cover health care services received in other countries

Some services may be covered under very specific circumstances, so it is always a good idea to ask your provider whether Medicare is expected to pay before receiving care.

These coverage gaps are why many people pair Original Medicare with a standalone Part D plan for prescription drugs, a Medigap (Medicare Supplement) policy to help with deductibles and coinsurance, or consider switching to a Medicare Advantage plan that may include extra benefits like limited dental care, vision, and hearing coverage.

Eligibility and Enrollment for Original Medicare (Part A & Part B)

Most people become eligible for Medicare at age 65. Some qualify earlier due to receiving Social Security disability benefits for 24 months, having end stage renal disease (ESRD), or being diagnosed with ALS (Lou Gehrig’s disease).

Part A eligibility:

• Most people qualify for premium-free Part A at 65 if they or a spouse worked and paid Medicare taxes for at least 40 quarters
• People who do not qualify for premium-free Part A may be able to buy it by paying a monthly premium
• Those receiving railroad retirement board benefits may also qualify through that system

Automatic vs. manual enrollment:

• If you are already receiving social security benefits or Railroad Retirement benefits when you turn 65, you will typically receive automatic enrollment in Parts A and B about three months before your birthday—unless you decline Part B
• If you are not yet taking Social Security, you must actively sign up for Medicare through the Social Security Administration online, by phone, or at a local office

Initial Enrollment Period (IEP): Your initial enrollment period is a 7-month window centered around your 65th birthday month. It begins 3 months before your birth month, includes your birth month, and extends 3 months after. This is the best time to enroll without penalties or delays in coverage.

Other enrollment opportunities:

• Special Enrollment Periods (SEPs) are available for people who delay Part B because they have qualifying employer-based health coverage from their own or a spouse’s current employment
• The General Enrollment Period runs from January 1 through March 31 each year for those who missed earlier opportunities, with coverage starting July 1

Understanding medicare eligibility and enrollment timing can be confusing. Sunnyside Medicare can help Michigan residents figure out which enrollment period applies to them and what steps to take, though final enrollment in Original Medicare is always completed through Social Security.

Costs Under Original Medicare

While Original Medicare helps pay for many health care costs, it does not cover 100% of your medical bills. Understanding how costs work can help you plan and decide whether you need additional coverage.

Unlike most medicare advantage plans, Original Medicare has no annual out-of-pocket maximum. This means your costs could continue to grow if you have significant health issues during the year.

Types of costs under Original Medicare:

Cost Type	Description
Premiums	Monthly amounts you pay to have coverage. Part B always has a premium; Part A is premium-free for most people based on work history.
Deductibles	The amount you pay each year (Part B) or each benefit period (Part A) before Medicare starts paying its share.
Copayments and Coinsurance	Your share of the bill for covered services. Part B typically requires 20% coinsurance after you meet the deductible.
Excess Charges	Additional amounts some providers may charge if they do not accept Medicare assignment (the medicare approved amount).

The actual dollar amounts for medicare premiums, deductibles, and coinsurance can change each year. Higher-income individuals may pay more for their part b premium through IRMAA surcharges. For current figures, check official Medicare resources at Medicare.gov.

Because there is no cap on how much you might spend, many people look at Medigap plans to help cover deductibles and coinsurance, Part D plans for drug coverage, or Medicare Advantage plans that include an out-of-pocket maximum along with extra benefits.

Original Medicare vs. Other Medicare Options

Original Medicare is one way to receive your medicare benefits, but it is not the only option. Medicare Advantage (Part C) offers an alternative approach through private insurance companies that contract with Medicare.

How Original Medicare compares to Medicare Advantage:

Feature	Original Medicare	Medicare Advantage
Administered by	Federal government	Private company approved by Medicare
Provider access	Any doctor or hospital nationwide that accepts Medicare	Usually limited to plan network (HMO/PPO)
Referrals needed	No	Often yes, especially for HMOs
Prior authorization	Rarely required	May be required for certain services
Out-of-pocket maximum	None	Yes, capped annually
Drug coverage included	No (requires separate Part D)	Most medicare advantage plans include it
Extra benefits	None built in	May include dental, vision, hearing, fitness programs

Supplemental options with Original Medicare:

• Medigap (Medicare Supplement Insurance): Policies from a private insurer that help pay some of the deductibles, coinsurance, and other out of pocket costs that Original Medicare leaves you responsible for. Cannot be used with Medicare Advantage.
• Standalone Part D Plans: Separate plans that provide prescription drug coverage. Purchased in addition to Original Medicare and often paired with Medigap.

There is no single “best” choice that works for everyone. The right fit depends on your health needs, which doctors and hospitals you want to use, your budget for premiums and potential out-of-pocket expenses, and whether you are comfortable with network restrictions and referral requirements.

Michigan residents can use Sunnyside Medicare as a resource to walk through the pros and cons of each approach based on their personal situation.

Common Mistakes and How to Avoid Them

New Medicare beneficiaries often encounter avoidable problems related to timing, coverage assumptions, and overlooked details. Being aware of these common mistakes can save you money and frustration.

Common enrollment and coverage mistakes:

• Waiting too long to enroll in Part B: If you delay Part B enrollment without having qualifying employer coverage, you may face a late enrollment penalty—a permanent increase to your part b premium of 10% for each 12-month period you could have had Part B but did not sign up.
• Assuming Original Medicare covers everything: Many people are surprised to learn that dental care, routine vision, hearing aids, and long-term nursing home care are not covered, leading to unexpected bills.
• Not checking if doctors accept Medicare assignment: While most providers accept Medicare patients, not all accept the medicare approved amount as full payment. Providers who do not accept assignment can charge up to 15% more.
• Skipping Part D drug coverage: Even if you take few medications now, going without Part D can result in penalties when you do enroll later—1% of the national base premium for each month you were eligible but not covered.
• Not comparing coverage options during the first year: Your first year on Medicare often offers the best opportunity to purchase Medigap without health underwriting. In Michigan, waiting too long may limit your choices or result in higher premiums.

Before you enroll or make changes to your coverage, create a simple checklist that includes your current doctors and specialists, the prescriptions you take, any travel plans (especially outside the U.S.), and your budget for monthly premiums versus potential out-of-pocket costs. Asking questions before you commit to a plan can prevent costly surprises later.

What to Do Next (Next Steps for Michigan Residents)

You do not have to figure out Medicare on your own, especially if you are approaching 65 or preparing for retirement. Taking a few simple steps now can help you make more confident decisions about your health coverage.

• Confirm your Medicare eligibility date, which is usually the first day of the month you turn 65, and find out whether you will be enrolled automatically or need to sign up through Social Security
• Make a list of your current doctors, clinics, and hospitals in Michigan to ensure any future coverage supports the providers you want to keep seeing
• Write down your current prescription medications, including dosages, so you can compare Part D or Medicare Advantage drug plans later
• Consider whether you prefer the flexibility of Original Medicare with Medigap and Part D, or the bundled approach of a Medicare Advantage plan with built-in drug coverage and an out-of-pocket maximum
• When you are ready and in the correct enrollment period, contact the Social Security Administration to enroll in Part A and Part B
• Reach out to Sunnyside Medicare to speak with a licensed Michigan Medicare agent for a no-obligation review of your options

Frequently Asked Questions About Original Medicare

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare is the federal program with Part A and Part B coverage, allowing you to see any provider nationwide that accepts Medicare. Medicare Advantage is an alternative offered by private insurance companies that bundles Part A, Part B, and often Part D into one plan with network restrictions but may include extra benefits like dental, vision, and an annual out-of-pocket cap.

Do I have to pay for Medicare Part A and Part B?

Most people receive Part A with no monthly premium if they or a spouse paid Medicare taxes while working. Part B always requires a monthly premium, which is income-based. You also pay deductibles and coinsurance for covered services under both parts.

Does Original Medicare cover prescription drugs?

No, Original Medicare does not include coverage for most prescription drugs you pick up at a pharmacy. You need a separate Part D plan or a Medicare Advantage plan with drug coverage to help with prescription costs.

Can I keep my doctor with Original Medicare?

In most cases, yes. Original Medicare covers doctor visits with any provider who accepts Medicare, and over 90% of physicians do. However, it is always a good idea to verify that your specific doctors accept Medicare and accept assignment before scheduling appointments.

Do I need a Medicare Supplement (Medigap) policy?

It depends on your budget and how much financial risk you are comfortable with. Medigap policies help pay for costs that Original Medicare does not cover, like deductibles and the 20% coinsurance under Part B. Some people find this coverage details gives them peace of mind, while others prefer to self-insure or choose Medicare Advantage instead.

What happens if I keep working past 65?

If you have health coverage through your own or a spouse’s current employer with 20 or more employees, you may be able to delay enrolling in Part B without penalty. When that employer coverage ends, you will have a Special Enrollment Period to sign up. It is important to understand these rules, as mistakes can lead to coverage gaps or permanent premium increases.

Does Original Medicare cover care outside the United States?

In most cases, no. Medicare generally does not pay for health care services received outside the U.S., with very limited exceptions near U.S. borders or on cruise ships. Some Medigap policies include limited foreign travel emergency coverage, which may be worth considering if you travel internationally.

Who can help me understand my Medicare choices in Michigan?

Sunnyside Medicare’s licensed agents can explain Original Medicare, Medigap, Part D, and Medicare Advantage options based on your situation. While our agents provide education and guidance, official Medicare information and enrollment is handled through the Social Security Administration and Medicare.gov.

Talk With a Licensed Michigan Medicare Agent

If you are turning 65, preparing to retire, or helping a parent understand their Medicare choices, you do not have to sort through all of this alone. Sunnyside Medicare’s licensed agents are available to Michigan residents who want a clear, straightforward conversation about how Original Medicare works and what additional coverage might make sense.

Our conversations are educational, and there is no obligation to enroll in any plan through us. We can help you compare costs, review and part b coverage options, and understand how different plans work with your doctors and medications. We represent a variety of carriers and can walk you through the differences so you can make an informed decision.

Keep in mind that Sunnyside Medicare is not part of Medicare or any government agency. Enrollment in Original Medicare itself is completed through the Social Security Administration. But if you want help understanding whether to add Medigap, Part D, or consider a Medicare Advantage plan—or just want someone to answer your questions—our Michigan-based team is here to help. Bring your list of doctors and medications, and let us help you find coverage that fits your health care needs and budget.