What is Medicare?
Medicare is a federal health insurance program that covers millions of Americans. In general, you are eligible for Medicare if you are 65 or older, or if you already receive Social Security benefits or you are younger than 65 and meet criteria for certain disabilities.
Medicare doesn’t pay all your health care expenses.
Medicare covers only 80% of your Medicare part B expenses. Make sure you enroll in a Medicare supplement insurance plan. Enrolling in a Medicare supplement insurance plan can help you pay a portion of the 20% you would likely have to pay out of pocket. You may even have the option to enroll and get help with your Medicare deductibles.
How will I benefit from having extra Medicare coverage?
Medicare supplement insurance can make a big difference by helping you with some of the out-of-pocket costs which may occur when visiting a hospital or in a recovery process. Depending on the supplemental plan that you select, you can have access to benefits for covered skilled nursing facility stays, year round hospitalization, and covered emergency care outside of the United States.
- Medicare covers only 80% of Part B medical costs.
- Selecting the right supplement plan can help you pay a large portion of the out-of-pocket costs
Medicare Part A (Hospital Insurance)
You are entitled to receive Medicare Part A on the first day of the month you turn 65. In most cases, it’s free. You won’t pay a premium for Medicare Part A if you or your spouse paid Medicare taxes for at least 10 years.
Services that Medicare Part A helps to cover include the following:
inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
inpatient care in a skilled nursing facility (not custodial or long-term care)
hospice care services
home health care services
inpatient care in a Religious Nonmedical Health Care Institution
You automatically will get Part A if you already receive benefits from Social Security or from the Railroad Retirement Board (RRB). If you aren’t getting Social Security benefits (for example, if you are still working), you may need to sign up for Part A, even if you are eligible to receive Part A at no cost.
Medicare Part B (Medical Insurance)
Medicare Part B is optional coverage purchased from the federal government. If you are 65 or over, you are eligible. Most people pay a monthly premium for Part B, usually deducted from their Social Security benefit checks.
Services covered by Medicare Part B include the following:
office visits to a primary care physician or a specialist
some preventive services, such as flu shots and mammograms
laboratory costs, including blood work and X-rays
medical equipment, such as wheelchairs and walkers
outpatient physical therapy
mental health care
one initial physical exam within the first 12 months of enrollment
If you already get benefits from Social Security or the Railroad Retirement Board (RRB), you may be enrolled automatically in Part B, effective the first day of the month in which you turn 65. You also may be eligible for Part B if you are disabled, or, in certain situations, if you have end-stage renal disease (ESRD).
Medicare Part C (Medicare Advantage)
If you choose a Medicare Part C plan, which is offered by private insurers, you generally will have access to services not available through Original Medicare (Parts A and B). You likely will pay a copayment for covered services and see doctors in the plan’s network.
In addition to all services under Medicare Part A and Medicare Part B, many Medicare Advantage plans typically cover the following:
emergency and urgent care
health and wellness programs
Medicare Part D prescription drug coverage
Although all Medicare Advantage plans follow rules set by Medicare, each plan can charge different out-of-pocket costs and have different guidelines for how you get services. All services must be arranged by the Medicare Advantage plan you join.
If you participate in a Medicare Advantage plan, you will pay both your monthly Part B premium and a monthly health plan premium. Some Medicare Advantage plans have no monthly premiums.
Depending on which plan you select, you are responsible for paying any applicable annual deductibles, copayments, or coinsurance on certain items or services.
In most cases, you may join a Medicare Advantage plan if you are entitled to Part A and enrolled in Part B, if you live in the plan’s service area, and if you do not have end-stage renal disease (ESRD).
Types of plans
Considering a Medicare Advantage plan? There are many Medicare options. But generally speaking, the plan types can be broken down as follows:
Medicare Advantage HMO plans
may offer benefits in addition to Original Medicare (Parts A and B)
may include Medicare Part D prescription drug coverage
feature a network of providers that you must use for your care in most cases
require that if you visit out-of-network providers, you are usually responsible for the costs
Medicare Cost plans
Medicare Cost plans are available in certain areas of the country. In a Cost plan, if you go to a non-network provider, the services are covered under Original Medicare. You would pay the Part B premium, and any Part A and Part B coinsurance and deductibles.
Like Medicare Advantage, a Medicare Cost plan may offer benefits in addition to Original Medicare (Parts A and B) and may include Medicare Part D prescription drug coverage.
In a Cost plan you can do the following:
join even if you only have Part B
join anytime the plan is accepting new members
leave anytime and return to Original Medicare
either get your Medicare prescription drug coverage from the plan (if offered), or join a Medicare prescription drug plan (PDP) to add prescription drug coverage
Medicare Special Needs Plan (SNP)
The SNP is a type of Medicare Advantage plan for people with additional health care needs or limited incomes. You may be eligible for a Special Needs Plan if you:
live with a chronic or disabling condition
live in a nursing home or other institution
are eligible for both Medicare and state Medicaid benefits (called Medi-Cal benefits in California)
Medicare Part D (Prescription Drugs)
You are eligible to enroll in a Medicare Part D prescription drug coverage plan if you have Medicare Part A and/or Medicare Part B. You will enroll directly with your plan of choice (Medicare Part C), not through the Centers for Medicare & Medicaid Services (CMS) or Social Security, to get Medicare Part D coverage.
In general, there are two types of plans that offer Medicare Part D prescription drug coverage.
Medicare Advantage plans or Medicare Cost plans: HMO, PPO, or other plans that include Medicare Part D in the cost of their premiums
Medicare prescription drug plans (PDP): stand-alone plans that add drug coverage to Original Medicare (Parts A and B)
If you join a stand-alone Medicare prescription drug plan (PDP), you will have to pay that plan’s premium in addition to your Part B premium.
What will I pay for Medicare Part D?
Medicare Part D cost and coverage vary by plan. Medicare Part D has variable costs you will pay every year that correspond with your drug coverage. In some plans, you may pay a fixed-amount annual deductible for your Medicare Part D drugs before your drug or health plan begins to pay. The amount you pay for prescription drugs may change as your total drug cost and out-of-pocket expenses accumulate during the year.
Your out-of-pocket costs may include any copayments or coinsurance for your prescriptions once you’ve reached your annual deductible (if applicable). Different out-of-pocket costs may apply for people who have limited incomes, live in long-term care facilities, or have access to Indian/Tribal/Urban Indian Health Service.
You might have to pay a monthly premium for a Medicare Part D drug plan. Sometimes the monthly premium for a health plan includes the premium for Medicare Part D, but sometimes you will pay a drug plan premium in addition to Part B and any private plan or insurance premiums.
If you are on a limited income, you may qualify for a Medicare program that gives you extra help with your prescription drug costs. This program, known as the LIS, or low-income subsidy, assists you with Medicare Part D premiums, deductibles, and copays.