Original Medicare (Parts A + B)
Original Medicare is the federal fee-for-service program covering inpatient (Part A) and outpatient (Part B) care for Americans 65+ or with qualifying disability. Appeal rights follow a separate 5-level track from MA.
What this plan type is
Original Medicare comprises Part A (hospital insurance, automatic for those 65+ who paid Medicare taxes) and Part B (medical insurance, premium-based, voluntary). It's a federal fee-for-service program: Medicare pays providers directly at fixed fee-schedule rates. Most beneficiaries also buy Medigap (Medicare Supplement) or have Part D drug coverage and may have employer or union retiree coverage on top.
Your appeal rights
Five-level appeal track for Original Medicare: (1) Redetermination by the Medicare Administrative Contractor (MAC), (2) Reconsideration by a Qualified Independent Contractor (QIC), (3) ALJ hearing at OMHA, (4) Medicare Appeals Council, (5) federal court review. Standard redetermination: 60 days. Each level has specific filing deadlines and amount-in-controversy thresholds.
Common denial patterns
- Service not covered under Local Coverage Determination (LCD) or National Coverage Determination (NCD)
- Frequency exceeded (e.g., screening too soon)
- Documentation deficit (CARC 16/226/252)
- Not medically necessary per MAC review
What's unique about this plan type
- Pure fee-for-service — no network, but providers must accept assignment
- Most denials are LCD/NCD-driven, not plan-level
- Medigap fills cost-sharing gaps but does NOT add appeal rights
- ABN (Advance Beneficiary Notice) shifts responsibility to the patient if they choose service knowing it won't be covered
Frequently asked questions
What is a Original Medicare (Parts A + B)?
Original Medicare comprises Part A (hospital insurance, automatic for those 65+ who paid Medicare taxes) and Part B (medical insurance, premium-based, voluntary). It's a federal fee-for-service program: Medicare pays providers directly at fixed fee-schedule rates. Most beneficiaries also buy Medigap (Medicare Supplement) or have Part D drug coverage and may have employer or union retiree coverage on top.
What appeal rights does a Original Medicare (Parts A + B) member have?
Five-level appeal track for Original Medicare: (1) Redetermination by the Medicare Administrative Contractor (MAC), (2) Reconsideration by a Qualified Independent Contractor (QIC), (3) ALJ hearing at OMHA, (4) Medicare Appeals Council, (5) federal court review. Standard redetermination: 60 days. Each level has specific filing deadlines and amount-in-controversy thresholds.
What's unique about a Original Medicare (Parts A + B)?
Pure fee-for-service — no network, but providers must accept assignment Most denials are LCD/NCD-driven, not plan-level Medigap fills cost-sharing gaps but does NOT add appeal rights ABN (Advance Beneficiary Notice) shifts responsibility to the patient if they choose service knowing it won't be covered
Other plan types
- Prudent Layperson StandardEmergency services coverage
- ACA Marketplace (individual / family) planIndividual and family plans purchased through Healthcare.gov or a state-based exchange. Appeal right
- Employer-sponsored fully-insured planAbout 35% of employer-covered Americans are on fully-insured employer plans — the employer pays prem
- ERISA self-funded employer planAbout 65% of employer-covered Americans are on a self-funded ERISA plan. The employer (or a TPA) bea
- FEHB (federal employees + retirees)The Federal Employees Health Benefits Program covers ~8 million federal employees, retirees, and dep
Sources
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