Overview

You have two main choices for hospital and medical coverage: Original Medicare (Parts A and B), which is run by the federal government, or a Medicare Advantage plan (Part C), which is sold by private insurers. If you have Original Medicare, you may also choose to add a Prescription Drug Plan (Part D) and/or a Medicare Supplement (Medigap) plan, which helps pay some out-of-pocket costs, such as deductibles and co-payments.

    Benefit Period

    is the way the Original Medicare program measures your use of inpatient hospital and skilled nursing facility (SNF) services. It begins the day that you enter a hospital or SNF and ends when you have not received inpatient hospital or Medicare-covered skilled care in a SNF for 60 days in a row.
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  • What are my Medicare coverage options?

    Short Answer:

    The two main options for hospital and medical coverage are Original Medicare (Parts A & B), provided by the federal government, or Medicare Advantage (Part C), approved by the government but sold through private insurers. If you opt for Original Medicare, you can fill coverage gaps and help your lower out-of-pockets costs by adding a Prescription Drug Plan (Part D) and/or a Medicare Supplement plan (Medigap).

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    Original Medicare

    Original Medicare (Parts A & B) helps cover hospital and medical expenses but doesn't include prescription drug coverage, dental and vision care, and some other common health services. Many people like to consider other options to expand their coverage or help them pay out-of-pocket costs, including deductibles and co-pays.

    What are the other options to consider?

    • Medicare Advantage plans (Part C), which are approved by the federal government but sold through private insurers, replace Original Medicare. They are required to offer at least the same benefits, typically also include drug coverage, and often provide more, such as coverage for dental and vision care.
    • Prescription Drug Plans (Part D) help with prescription drug coverage for anyone with Original Medicare.
    • Medicare Supplement Insurance (Medigap) can help reduce your out-of-pocket costs and, depending on the policy, fill in some of the coverage gaps left by Original Medicare.

    Mixing and matching

    Many of the options can be combined together to provide the most coverage.  One important rule to know: You are not allowed to have both Medicare Advantage and a Medicare Supplement plan.

    Here are some of the combinations available to you:

    • Original Medicare (Parts A & B).  This is the basic hospital-and-medical coverage option available from the government, with no additional benefits.
    • Original Medicare (Parts A & B) + Prescription Drug Plan.  This combination adds coverage for your prescribed medicines but does not include common healthcare services that Original Medicare (Parts A & B) doesn't cover, such as dental and vision care. Your out-of-pocket costs for medical coverage in this combo: Part B pays for approximately 80% of the costs; you are on the hook for the remaining 20%.
    • Medicare Advantage.  In addition to providing the same hospital and medical benefits as Original Medicare's Parts A and B, most Medicare Advantage plans include prescription drug coverage (often referred to as Medicare Advantage Prescription Drug plans or MAPD), and many cover other healthcare services as well.
    • Original Medicare (Parts A & B) + Medicare Supplement plan.  Adding a Medicare Supplement plan can help lower your overall costs and fill some coverage gaps in Original Medicare. There are many different Medicare Supplement plans to choose from, each labeled with a letter of the alphabet and with different levels of benefits.  Prescription drug coverage is not included.
    • Original Medicare (Parts A & B) + Medicare Supplement + Prescription Drug.  This combination offers the broadest coverage under the Original Medicare program.

    There are also less common Special Needs Plans and other coverage options that you may qualify for.

  • What is a 5-star rated plan?

    Short Answer:

    A 5-star plan is the highest-rated plan in Medicare. Medicare Advantage (Part C) and Prescription Drug Plans (Part D) are rated on a scale of 1 to 5 stars using feedback from member surveys, plans, and health care providers.

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    Medicare star ratings are designed to help you compare plans based on quality and performance.

    According to the U.S. Centers for Medicare & Medicaid Services (CMS), the ratings take into account factors in five categories:

    • Staying healthy: screening tests and vaccines
    • Managing chronic (long-term) conditions
    • Member experience with the health plan
    • Member complaints and changes in the health plan's performance
    • Health plan customer service

    The ratings are updated every fall for the next calendar year.

    The rating scale is as follows:

    • 5-star rating: Excellent
    • 4-star rating: Above Average
    • 3-star rating: Average
    • 2-star rating: Below Average
    • 1-star rating: Poor

    5-star rated plans have their own Special Enrollment Period (SEP).

  • Can I switch from Medicare Advantage to Medicare Supplement?

    Short Answer:

    Yes, you can switch from Medicare Advantage (Part C) to a Medicare Supplement (Medigap) plan, but typically only during certain times of the year. For most people, this enrollment period is between October 15th and December 7th (the Annual Election Period).

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    Outside of the annual election period, there are two other circumstances when you can switch from a Medicare Advantage to a Medicare Supplement plan.

    If you’re in your first year of Medicare Advantage, you can switch to a Medicare Supplement plan at any time. Or, if you leave a Medicare Advantage plan for a 5-star Prescription Drug Plan (Part D) during what's known as a 5-star Special Election Period (SEP), you can also add a Medicare Supplement plan.

    Generally, if you sign up for a Medicare Supplement plan outside of the first time you become eligible—typically that means buying a policy within six months of enrolling in Medicare Part B—insurers are not legally obligated to sell you a Medicare Supplement plan. Or they may sell you a policy but subject you to medical underwriting, which could result in you paying a much higher premium or having certain pre-existing conditions excluded from coverage (though some states prohibit this practice).

    What if you started with a Medicare Supplement plan, switched to Medicare Advantage, and now want to switch back to the plan you had originally?

    Your ability to switch depends on a couple of factors:

    1. The insurer needs to still be offering the same Medicare Supplement plan, which is not always the case. If the plan has been changed or discontinued, or if your medical circumstances have changed, you’ll likely have to choose a different plan.
    2. That said, if you’ve had Medicare Advantage for less than a year and you apply for a Medicare Supplement plan within 63 days of your coverage ending, insurance companies are required to sell you any Medicare Supplement plan that’s sold in your state. In other words, they cannot deny you coverage because of health problems or pre-existing conditions, or charge you more for your plan. There are other specific situations in which insurance companies must offer you a Medicare Supplement plan.
    3. One big thing to watch out for: If you’ve had Medicare Advantage for more than a year, or you wait more than 63 days to apply for a Medicare Supplement plan after your Medicare Advantage coverage ends, you could be denied Medicare Supplement coverage.
  • Who pays first if I have employer or union health coverage and Medicare?

    Short Answer:

    Who pays first depends on whether your coverage is from a current or former employer, how many employees the company has, and whether or not you’re disabled. The chart below shows who pays first if you have both employer health coverage and Medicare.

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  • What's the difference between a Medicare Advantage HMO and PPO?

    Short Answer:

    There are two main types of Medicare Advantage (Part C) plans: a Health Maintenance Organization (HMO), which typically only covers healthcare services from providers within a designated network, and Preferred Provider Organization (PPO) plans, which allow you to see out-of-network providers, but at a higher cost.

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    If you have an HMO plan:

    • Usually, you’ll have to go to doctors and other providers that are in your plan’s network.
    • Most HMO plans cover prescription drugs.
    • You’ll most likely have to choose a primary care physician.
    • You’ll have to get referrals to see specialists in many cases.

    If you have a PPO plan:

    • You can go to health care providers who are out of network, though you may pay more than you would if you were treated by in-network providers.
    • Most PPO plans cover prescription drugs.
    • You don’t need to choose a primary care physician.
    • You typically won’t need referrals to see specialists.
    • You have the ability to ask a doctor to take you as a patient if he or she is out of network, but the doctor can also refuse to take you as a client.
  • What is an HMO?

    Short Answer:

    A Health Maintenance Organization (HMO) is a managed health care system within a specific geographic area that limits coverage to care and services from providers within a specific network.

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    HMOs emphasize preventive medicine and early treatment with prepaid routine exams, stress management, and diagnostic screening techniques.

    With an HMO, you'll probably have to choose a Primary Care Physician (PCP), and you will be required to see your PCP to get a referral for treatment from a specialty physician.

    An HMO is generally more restrictive than a PPO, requiring you to get care and services from providers who are part of the HMO's network.

  • What is a PPO?

    Short Answer:

    A Preferred Provider Organization (PPO) plan offers you the flexibility of seeing healthcare providers both in and out of the plan's network. But you will pay more if you use doctors, hospitals, and other providers who do not belong to the designated network.

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    A PPO is generally less restrictive than a HMO, allowing you to be treated by both in-network and out-of-network providers. If you go out of network, however, you will pay more for the healthcare treatment and services you receive than if you use in-network doctors, hospitals, and other providers.

    PPO plans do not require you to choose a primary care doctor and you will usually not need referrals to see specialists.

    Most PPO plans also cover prescription drugs.

    You have the ability to ask a doctor to take you as a patient if he or she is out of network, but the doctor can also refuse to accept you into the practice.

  • What is PACE?

    Short Answer:

    PACE, or Programs of All-Inclusive Care for the Elderly, is a Medicare and Medicaid program that helps keep people with health issues in their communities and out of nursing homes or other facilities.

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    PACE provides health care and other services to people in their own homes, or at PACE centers.

    If you’re enrolled in PACE, you may need to use a PACE-preferred doctor.

    In order to qualify for PACE:

    • You must have either Medicare or Medicaid, or both
    • Be 55 or older
    • Live in the service area of a PACE organization
    • Need a nursing-home level of care
    • Be able to live safely with help from PACE

    PACE covers services such as adult day primary care, home care, emergency services, hospital care, laboratory/x-ray services, meals, prescription drugs, and more.

    You can find out if there’s a PACE plan in your area here, or contact your Medicaid office.

  • Who pays first if I have TRICARE and Medicare?

    Short Answer:

    If you have TRICARE and are active-duty military, TRICARE pays first. For inactive-duty military, Medicare pays first for Medicare-covered services.

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    TRICARE, a health care program for uniformed service members, retirees, and their families, will cover Medicare deductibles and coinsurance.

    TRICARE may also cover some services not covered by Medicare. You’ll pay for any services not covered by either TRICARE or Medicare.

    TRICARE pays for services received from a military hospital or other federal health care provider.

  • Does receiving Railroad Retirement benefits affect Medicare coverage?

    Short Answer:

    No. Your Medicare coverage will be the same as that of other Americans if you receive benefits from the Railroad Retirement Board (RRB). You’ll also be automatically enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance) at age 65 if you are receiving RRB benefits.

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    If you aren’t yet collecting RRB benefits and you’re approaching 65, contact your local RRB office to enroll in Medicare. You may still qualify for Medicare if you’re under 65 and disabled.

    Once enrolled, your Part B premium will usually be deducted from your RRB benefits each month.