What is Original Medicare?

Original Medicare is a federal program designed to cover certain health insurance costs for eligible individuals 65 or older, as well as those with certain disabilities. Original Medicare covers certain medical services and supplies in hospitals, doctors’ offices and other health care settings. Also known as “traditional” Medicare, it includes Part A and Part B, and is health care insurance provided through the federal government.

What is Medicare all about?

Medicare is the federal health insurance program for people who are:

  • 65 or older
  • Certain younger people with disabilities
  • Individuals with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

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There are different parts of Medicare to help cover specific health care services:

  1. Medicare Part A
  2. Medicare Part B
  3. Medicare Part C
  4. Medicare Part D

Read further to find out more about these parts.

Medicare Part A (Hospital Insurance)

Coverage for inpatient care in hospitals or inpatient skilled care in a nursing facility as well as hospice and home health care.

  • You are eligible for Part A if you or your spouse paid into Social Security for at least 10 years through your employment and if you are a citizen or permanent resident of the U.S. Most individuals do not pay a premium for Part A because they or their spouse paid Medicare taxes while working.
  • Part A has deductibles, copayments and coinsurance.

There are a few things you need to know:

Deductible: This is the amount you pay first before sharing your costs with us.

Copay: A fixed amount, like $25 you pay when you receive care or pick up a prescription.

Coinsurance: This is similar to a copay but instead of a fixed dollar amount, it is a percentage of the total bill. For example, if your child’s eyeglasses are $100 and you’ve met your deductible, your coinsurance payments of 50% would be $50. We would pay the rest, or $50.

Out-of-pocket maximum: This is the most you could ever pay in a year on covered health care services, excluding your monthly premium. Any deductible, copay, coinsurance or out-of-pocket cost for covered services goes towards your out-of-pocket maximum. If you reach this amount, all you need to do is to continue paying your monthly premium. We’ll pay 100% of the cost when you get care for covered services.

Medicare Part B (Medical Insurance)

Coverage for services and supplies to treat a medical condition and preventive services to prevent or detect a medical illness in the early stages.

  • Doctor visits.
  • Outpatient hospital care.
  • Lab tests and other medical services.
  • Individuals residing in the United States (except residents of Puerto Rico) who become entitled to premium-free Part A become eligible for Part B.
  • Part B requires a monthly premium which most people have deducted directly from their monthly social security check.
  • In addition, there is a Part B annual deductible amount and other costs (such as copayments and coinsurance) may also apply.

Medicare Part C (Medicare Advantage Plans)

Medicare Advantage plans are Medicare-approved health insurance plan options offered by private health insurance companies like Excellus BlueCross BlueShield.

When you enroll in a Medicare Advantage plan, your Part A (hospital insurance) and Part B (medical insurance) will be covered under a single plan. Many of our Medicare Advantage plans include extra benefits such as prescription drugs, dental, vision, routine physicals, hearing and/or health and wellness programs. Please note that hospice services are not covered under Medicare Advantage plans, as they are paid for by Original Medicare when you enroll in a Medicare-approved hospice program.

Medicare Advantage Plans include:

  • Health Maintenance Organizations (HMO & HMO-POS)
  • Preferred Provider Organizations (PPO)
  • Most of our Medicare Advantage Plans also offer prescription drug coverage.
Preferred Provider OrganizationHealth Maintenance OrganizationHealth Maintenance Organization—Point-of-Service
No Primary Care PhysicianPrimary Care PhysicianPrimary Care Physician
In-Network & Out-of-Network ProvidersIn-Network ProvidersIn-Network & Out-of-Network Providers

If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan and aren’t paid for under Original Medicare.

Medicare Part D (prescription drug coverage)

Part D prescription drug coverage is a way to cover the cost of your prescription drugs and is available through private health insurance companies like Excellus BlueCross BlueShield. We offer Medicare prescription drug coverage through Medicare Advantage plans that include both health care and prescription drug coverage. Medicare Part D is available for eligible participants from Excellus BlueCross BlueShield.

Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

Medicare and Medicaid

Often confused, these US-based health care programs are not the same. Medicare is a health insurance program which is funded by the federal government and largely serves individuals 65 and over, with some exceptions (including certain disabilities and people of all ages with end-stage renal disease). Medicaid is a joint federal and state program that helps eligible low-income individuals or families pay for the costs associated with long-term medical and custodial care. Although the majority of funding comes from the federal government, Medicaid is administered by states and program benefits may vary. Individuals who are eligible for both Medicaid and Medicare are known as Medicare dual eligibles.

The Medicare Program is divided into four sections which include Medicare Part A which covers hospital bills, Medicare Part B which covers medical insurance coverage and Medicare Part D which covers prescription drugs. Medicare Part C is Medicare-approved health insurance plan options offered by private health insurance companies, including Excellus BlueCross BlueShield, and includes combined coverage of Parts A and Part B.

Source of FundingFederal GovernmentFederal & State Governments
Who Is EligibleIndividuals 65 & Older with exceptions for certain disabilities and individuals with end stage renal disease of all agesIndividuals & Families of all ages whose eligibility is need-based and mainly determined by income
What is CoveredPart A provides hospital insurance coveragePart B provides medical insurance coveragePart C is offered by private health insurance companies and includes Parts A & B as well as additional plan optionsPart D provides prescription drug coverageMandatory benefits include (states may provide additional benefits):Inpatient hospital servicesOutpatient hospital servicesEPSDT: Early and Periodic Screening, Diagnostic, and Treatment ServicesNursing Facility ServicesHome health servicesPhysician servicesRural health clinic servicesFederally qualified health center servicesLaboratory and X-ray servicesFamily planning servicesNurse Midwife servicesCertified Pediatric and Family Nurse Practitioner servicesFreestanding Birth Center services (when licensed or otherwise recognized by the state)Transportation to medical careTobacco cessation counseling for pregnant women

Medicaid is a program that is not only funded at the federal level, but at the state level as well, with states providing up to half of the funding for Medicaid. In some states, counties will also contribute funds. Although not required, all states have participated in the Medicaid program since 1982. Unlike Medicare, Medicaid is need-based, with eligibility determined largely by income. The primary factor in determining Medicaid eligibility is limited income and financial resources, a factor which plays no role in determining Medicare coverage.

Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities.

Medicaid also covers a wider range of health care services than Medicare. Since Congress passed Medicare into federal law in 1965 as part of the Social Security Act, coverage has been expanded to include additional benefits and increased who is eligible to receive Medicare benefits.

Difference between Medicare supplement Plans and Medicare Advantage Plans

The main differences between Medicare Advantage and Medicare Supplement plans are who covers you (whether it’s Medicare or Excellus BlueCross BlueShield) and the benefits that are covered. Both types of plans require you have Original Medicare (Parts A and B).

  • With a Medicare Advantage plan, Excellus BlueCross BlueShield is your primary insurer, rather than Medicare, and covers your healthcare costs. Some Medicare Advantage plans include vision, hearing, and dental coverage, and most include Part D prescription drug coverage.
  • With Medicare Supplement plans, however, Medicare acts as the primary insurer and pays the majority of your healthcare costs, while Excellus BlueCross BlueShield pays any extra copays and deductibles you might have. And unlike Advantage plans, Supplement plans don’t offer extra benefits like dental, vision, or hearing coverage.
  • New Medicare Supplement plans aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a separate Medicare Prescription Drug Plan (Part D) or join a Medicare Advantage plan (Part C).

Do you Need Medicare?

  • There are specific rules to follow if you are over 65 and not yet enrolled in Medicare. Certain time frames must be followed in order to avoid late-enrollment penalties once you stop working, or if you work beyond age 65.
  • When your employer coverage ends, or when you retire or stop working at or beyond age 65, you should generally opt in to Medicare Part A, as there is no premium if you or your spouse contributed to Medicare payroll taxes for 10 years. If you want medical coverage, you would also need to enroll in Medicare Part B, regardless of whether your employer offers COBRA.
  • Many people choose to work beyond age 65 for full retirement benefits, but Medicare enrollment is based on the size of your company.

Situation 1:

If you are currently working at a company with 20 or more employees, then you can wait to sign up for Medicare Part B because your employer insurance will still be the primary payer. To avoid potential penalties later on, be sure to ask your employer if the prescription drug coverage provided with your plan is creditable, meaning it covers at least as much as Medicare Part D. If you retire or lose your employer sponsored coverage, see the Special Election Period information below.

Situation 2:

If you are currently working at a company with fewer than 20 employees and become eligible for Medicare, you should enroll in Medicare because Medicare will be your primary insurance once you become eligible. If you do not enroll in Medicare, it will be as if you do not have any coverage.