Medicare Options

Original Medicare consists of Part A and Part B and covers medically necessary services. Part A covers inpatient services such as hospitalization, home health care, nursing home care and hospice. Part B covers outpatient services such as doctors’ visits, labs, and preventive care.

There are 2 main ways to get your Medicare coverage – Original Medicare or Medicare Advantage (MA) Plans:

1. In addition to Original Medicare, you can buy a Medicare Supplement Insurance Plan (Medigap) to fill in the gaps of some costs not covered by Medicare. These policies help pay your share (coinsurance, copayments, or deductibles) of the costs of Medicare-covered services and are accepted by all doctors and hospitals accepting Medicare. You can also buy a Medicare Prescription Drug Plan (Part D) to help with the costs of your prescription drugs.
2. Medicare Advantage (MA) Plans (also called Part C), are health plans approved by Medicare and run by private companies. MA plans provide all part A and B services and supplies and may include extra benefits such as vision, dental, and hearing. They also may include a Medicare prescription Drug Plan (MA-PD). If you join an MA Plan, you may have to use a network of doctors and/or hospitals.

Original Medicare only covers medically necessary services and procedures. It does not cover long-term care (such as care in a nursing home) or routine services such as vision or dental care, hearing aids, eyeglasses, or private‑duty nursing.

Additionally, Original Medicare has out-of-pocket costs like coinsurance, copayments, or deductibles and does not have a cap on expenses (also known as maximum-out-of-pocket). It’s important that you consider the 2 main ways to get your Medicare coverage–Original Medicare with a Medicare Supplement Insurance Plan (Medigap) and Part D or a Medicare Advantage (MA) Plan. See question above.

Each Medicare Prescription Drug Plan has a formulary or list of covered drugs and must include a range of drugs in the most common categories. This makes sure that people with different medical conditions can get the treatment they need. All Medicare Prescription Drug Plans generally must cover at least 2 drugs in each category, but plans can choose which specific drugs are covered in each category.

Costs vary depending on the plan and your specific drugs. Most people will pay a monthly premium plus a share of the cost of their prescriptions, including a deductible (if the plan has one), copayments, and/or coinsurance. All Medicare Prescription Drug Plans have to provide at least a standard level of coverage set by Medicare. However, some Medicare Prescription Drug Plans might offer more coverage and additional drugs, generally for a higher monthly premium.

People with limited income and resources may be able to get extra help paying for their Medicare drug plan costs. If you have a higher yearly income, you might also have to pay a Part D Income-Related Monthly Adjustment Amount (IRMAA).

If you’re already getting Social Security benefits, you’ll be automatically enrolled in Medicare. You’ll get your Initial Enrollment package, which includes your Medicare card and other information, about 3 months before you turn 65 (coverage begins the first day of the month you turn 65), or 3 months before your 25th month of disability benefits (coverage begins your 25th month of disability benefits).

If you’re not getting retirement benefits from Social Security or the Railroad Retirement Board (RRB), you must sign up to get Medicare.

Having coverage through an employer while you or your spouse are still working can affect your Part B enrollment rights. If you or your spouse are covered through active employment, you have a Special Enrollment Period (SEP).

This means you can join Part B any time that you or your spouse are working, and covered by a group health plan through the employer, or during the 8-month period that begins the month after the employment ends or the group health plan coverage ends, whichever happens first. Usually, you don’t pay a late enrollment penalty if you sign up during an SEP. You should contact your employer or union benefits administrator to find out how your insurance works with Medicare, and whether it would be to your advantage to delay Part B enrollment.

Generally, no. In most cases, it’s against the law for someone who knows you have Medicare to sell you a Marketplace plan, because that would duplicate your coverage. Medicare isn’t part of the Marketplace. If you have Medicare, you’re covered and don’t need to do anything about the Marketplace.

If you become eligible for Medicare after you join a Marketplace plan, generally it’s to your advantage to sign up when you’re first eligible for Medicare because:

• Once you’re eligible for Medicare, you won’t be able to get lower costs (subsidy) for a Marketplace plan based on your income.
• If you enroll in Medicare after your Initial Enrollment Period ends, you may have to pay a late enrollment penalty for as long as you have Medicare.