Parts A and B
Original Medicare: what Parts A and B actually cover
Original Medicare is Part A and Part B together, provided directly by the federal government. It works with any provider in the country who accepts Medicare, with no network and no referrals. It also has no limit on what you can pay in a bad year, which is the single most important thing to understand about it, and the reason nearly everyone adds something on top.
What Part A covers
Part A is hospital insurance. It covers inpatient hospital stays, skilled nursing facility care following a qualifying hospital stay, hospice care, and some home health care.
Most people pay no premium for Part A, because they or a spouse paid Medicare taxes for at least ten years. If you did not, you can usually still buy it.
The benefit period, which is not a calendar year
Part A costs are organized around benefit periods rather than years, and this trips up almost everyone.
A benefit period begins the day you are admitted as an inpatient and ends after you have been out of a hospital or skilled nursing facility for 60 consecutive days. If you are readmitted after that, a new benefit period starts and you pay the deductible again.
There is no annual limit on the number of benefit periods. Two separate hospitalisations months apart mean two deductibles, which in 2026 is $1,736 each.
Longer stays cost more
The deductible covers the first 60 days of a stay. From day 61 a daily coinsurance applies, and it rises again once you begin drawing on lifetime reserve days, of which you get 60 across your entire life. Current amounts are published at Medicare.gov.
The observation status trap
Being in a hospital bed does not always mean being admitted. Patients kept under observation are outpatients, billed under Part B, and those days do not count toward the three-day inpatient stay that Part A skilled nursing coverage requires. Ask directly about your status, and ask again if it changes.
What Part B covers
Part B is medical insurance. It covers doctor visits, outpatient care, preventive services, laboratory work, mental health care, ambulance services, and durable medical equipment.
Nearly everyone pays a monthly premium, $202.90 in 2026 for most people and higher for higher incomes. There is an annual deductible, $283 in 2026, and after that you generally pay 20 percent of the Medicare-approved amount for most services.
The 20 percent has no ceiling
This is the defining gap in Original Medicare. Twenty percent of a routine office visit is trivial. Twenty percent of a course of chemotherapy, a major surgery, or a year of specialist infusions is not, and nothing caps it.
Medicare Advantage plans include an annual out-of-pocket maximum. Original Medicare on its own does not, and that difference is the reason supplemental coverage exists.
Assignment and excess charges
A provider who accepts assignment agrees to Medicare’s approved amount as full payment. A provider who does not may bill up to 15 percent above it, known as a Part B excess charge. Some states prohibit this, and some Medigap plans cover it.
What Original Medicare does not cover
- Prescription drugs taken at home, which require Part D
- Long-term custodial care, the largest gap of all
- Routine dental care, dentures and most oral surgery
- Routine eye exams and eyeglasses
- Hearing exams for fitting hearing aids, and hearing aids themselves
- Most care received outside the United States
- Cosmetic surgery and routine foot care
Some of these can be added through a Medicare Advantage plan or a standalone dental and vision policy. Long-term care is not covered by any of them and is a separate planning question.
Why almost nobody keeps it alone
Original Medicare on its own leaves an uncapped 20 percent and no drug coverage. There are two established ways to close that, and you choose one.
Add a Medigap policy
Keeps every advantage of Original Medicare, covers much of the cost sharing, and pairs with a separate Part D plan. Higher premium, highly predictable.
How Medigap works →Switch to Medicare Advantage
A private plan replaces how your benefits are delivered, adding a network and an out-of-pocket cap, usually with drug coverage included.
How Medicare Advantage works →Where Original Medicare is genuinely strong
- Any provider in the country who accepts Medicare, with no network to check
- No referrals needed to see a specialist
- Prior authorization is rarely required, unlike many private plans
- Coverage travels with you anywhere in the United States and its territories
- Your coverage does not change because a plan renegotiated a hospital contract
For people who travel, split the year between two states, or receive care at specialized centers that sit outside local networks, these advantages usually outweigh the higher premium of adding a supplement.
Enrolling in Original Medicare
If you are already drawing Social Security at 65, enrollment in Parts A and B is generally automatic. If not, you enroll yourself through the Social Security Administration.
Your Initial Enrollment Period runs seven months around your 65th birthday. Delaying Part B without creditable employer coverage creates a penalty that lasts as long as you have Part B.
Our turning 65 page covers the timing, the employer-coverage rules, and the six-month Medigap window that opens once you have Part B.
Veterans should read our VA and Medicare page before deciding whether to take Part B, because VA coverage does not replace it.
Ask before you decide
Frequently asked questions about Original Medicare
Does Original Medicare have a network?
No. It works with any provider in the country who accepts Medicare. There is no network, no service area, and no referral requirement.
Is there a limit on what I can pay in a year?
No. That is the central gap. The 20 percent Part B coinsurance is uncapped, which is why people add a supplement or choose a Medicare Advantage plan.
Does it cover prescriptions?
Not for medications you take at home. You need a separate Part D plan, and going without creditable coverage for 63 days or more creates a permanent penalty.
Why did I pay two hospital deductibles in one year?
Part A works in benefit periods, not calendar years. A new benefit period begins if you are readmitted after 60 consecutive days out of a hospital or skilled nursing facility.
What is observation status?
Being in a hospital under observation makes you an outpatient billed under Part B. Those days do not count toward the three-day inpatient stay required for Part A skilled nursing coverage.
Does your help cost anything?
No additional fee is charged to you for O’Neal Insurance Group’s guidance. Agents may be compensated by an insurance carrier when an enrollment occurs.
Preventive care is covered in full
One of the more useful features of Original Medicare gets overlooked because nobody advertises free things. A long list of preventive services carries no coinsurance and no deductible when you use a provider who accepts assignment.
- The Welcome to Medicare visit during your first twelve months on Part B
- An Annual Wellness Visit every year after that
- Cardiovascular and diabetes screenings
- Many cancer screenings, including mammograms and colorectal screening
- Flu, pneumococcal, hepatitis B and COVID-19 vaccines
- Counseling for smoking cessation, alcohol misuse and obesity
The Annual Wellness Visit is not a physical examination, which surprises people. It is a review of your health risks and a plan for preventive care. If a provider addresses a new problem during the visit, that portion can be billed separately and cost sharing may apply.
How to read your Medicare Summary Notice
Every three months, Original Medicare sends a statement listing the services billed on your behalf. It is not a bill, but it is worth reading.
Check that you actually received each service listed, that the dates match your visits, and that the amount Medicare approved looks consistent with what your provider told you. Billing errors are common, and duplicate claims are the most frequent kind.
You can also review claims at any time in your account at Medicare.gov, usually within a day or two of processing rather than waiting for the quarterly mailing.
If something looks wrong, call the provider first, since most discrepancies are clerical. If it is not resolved, 1-800-MEDICARE can help, and you have the right to appeal a denied claim.
Important: Federal cost figures cited are for the 2026 plan year and change annually; confirm current amounts at Medicare.gov. Coverage rules depend on your specific circumstances. Nothing on this page is an offer of coverage or a statement of what any specific plan provides. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your State Health Insurance Assistance Program to get information on all of your options.
Official resource
What Original Medicare costs in 2026
These figures reset every January. The ones below are current for calendar year 2026 and come from CMS. Figures for 2027 are published in the autumn, and this page is updated when they are.
Part A. Free for most people, because they or a spouse paid Medicare taxes for at least 40 quarters. If you have 30 to 39 quarters it costs $311 a month; with fewer than 30 it is $565. The inpatient hospital deductible is $1,736 per benefit period.
Beyond day 60 of a hospital stay you pay $434 a day through day 90. After that you draw on 60 lifetime reserve days at $868 a day, and once used they are gone permanently. In a skilled nursing facility, days 1 to 20 are covered in full and days 21 to 100 cost $217 a day.
Part B. The standard premium is $202.90 a month and the annual deductible is $283. After the deductible you generally pay 20 percent of the approved amount, and that percentage has no annual ceiling.
If your income is above the threshold
Higher earners pay an income-related adjustment on top of the standard premium. The 2026 amount is based on the income reported on your 2024 tax return — a two-year lookback that catches people out constantly.
Single filers up to $109,000 and joint filers up to $218,000 pay the standard $202.90. Above that the total rises through five bands, reaching $689.90 a month for single filers at $500,000 or more and joint filers at $750,000 or more. A matching surcharge applies to Part D, from $14.50 up to $91.00 a month.
If your income has fallen since 2024 because you retired, sold a business, lost a spouse or had hours cut, you can ask Social Security to use current figures instead by filing form SSA-44. It is one of the most valuable forms in Medicare and one of the least used. Being charged from a tax year that no longer reflects your situation is not something anyone corrects for you.
Excess charges under Original Medicare: what is actually true
A provider who does not accept assignment may bill above the Medicare-approved amount, up to a federal limiting charge. Under Original Medicare that difference is yours to pay, and a Medigap Plan F or G covers it while Plan N does not.
In practice it is uncommon. MedPAC reported that 98 percent of clinicians billing the physician fee schedule were participating providers in 2023, and that 99.7 percent of fee-schedule claims in 2024 were paid at Medicare’s standard rate. Uncommon is not the same as impossible, and behavioural health is the specialty where it appears most.
You will often read that eight states prohibit excess charges outright: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont. That list does not survive a check against the actual statutes, and it is repeated on hundreds of insurance websites.
Ohio and Minnesota have genuine broad prohibitions. Massachusetts imposes one on physicians as a condition of licensure. New York caps the charge rather than banning it, and specifically exempts office and home visits. Vermont’s ban carries exceptions wide enough to cover most office visits and higher-income beneficiaries. And Connecticut’s own state counseling program publishes a fact sheet telling beneficiaries that excess charges can be billed there.
The practical point: before you decide that a plan’s excess-charge coverage is worthless where you live, check your own state’s law rather than the list. We will do that with you, and we will show you the statute rather than asking you to take our word for it.
Help paying for Original Medicare
Two federal programs reduce Original Medicare costs substantially, and both are badly underclaimed because people assume they earn too much to qualify.
The Medicare Savings Programs pay your Part B premium and, at the highest level, your deductibles and coinsurance as well. For 2026 in most states the Qualified Medicare Beneficiary level reaches about $1,350 a month for one person and $1,824 for a couple, with countable resources up to $9,950 and $14,910. Two further levels extend to roughly $1,616 and $1,816 a month for an individual.
Extra Help reduces Part D costs, with a 2026 income limit near $23,940 for one person and $32,460 for a couple, and resource limits around $18,090 and $36,100. The partial subsidy was abolished in 2024, so everyone who now qualifies receives the full one.
Not everything counts toward those limits. Your home and your car are generally excluded, and several states apply more generous rules than the federal floor or no asset test at all. That is why guessing is a poor substitute for asking.
Deciding what to put alongside Original Medicare
Almost nobody keeps Original Medicare on its own for long, and the reason is the uncapped 20 percent rather than any gap in the care itself. The two ways to close it pull in different directions. A Medicare Supplement costs more each month and asks almost nothing of you when you are ill. A Medicare Advantage plan costs less each month and asks you to work inside a network at exactly the moment that is hardest.
Whichever direction you lean, do it in the first year you are eligible if you can. The guaranteed right to buy a supplement without health questions opens once, and people who leave Original Medicare uncovered for a few years frequently find the door has closed behind them.
Check the source, then ask for personal help
Educational information is general. A licensed agent can help with plan comparisons; agents do not provide medical, legal, or official eligibility advice.
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Work out what to add to Original Medicare
We compare a supplement against the Medicare Advantage plans in your county, using your own doctors and prescriptions.
Medicare reference charts
The charts below cover the ground most questions start from.
