Medicare in more detail

Learn more about about the different parts of Medicare. What’s covered, what you’ll pay for, what to expect. Friendly licensed sales agents are available if you want to talk it over.

Original Medicare

Original Medicare Original Medicare

Original Medicare is made up of two parts: Part A is hospital insurance and Part B is medical insurance.

Part A (Hospital Insurance)

What's covered?
If you sign up for Original Medicare, you can access any doctor, hospital or other healthcare provider who accepts Medicare.

What will I have to pay?
Most people don’t have to pay a premium for Part A. But you may be required to pay a deductible per benefit period. In 2020 the deductible per benefit period is $1,408. You may also pay other out-of-pocket costs, like coinsurance and copays. A Medigap policy (more on this later) can help cover some of your out-of-pocket costs.

Part B (Medical Insurance)

What's covered?
Part B covers medically necessary services or supplies. This includes outpatient care such as doctor visits, ambulances, durable medical equipment (DME), x-rays, and physical, speech and occupational therapy. It also includes preventive services to help prevent or detect illness at an early stage.

What will I have to pay?
Most people will pay a monthly premium of $144.60 or higher depending on your income. Your premium is usually deducted from your Social Security check. The Part B deductible is $185 per year (due to change 2020). After this is met, you typically pay 20% of the Medicare-approved costs for most doctor services.

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Original Medicare

Original Medicare is made up of two parts: Part A is hospital insurance and Part B is medical insurance.

Medicare Advantage

Part A (Hospital Insurance)

What's covered?
If you sign up for Original Medicare, you can access any doctor, hospital or other healthcare provider who accepts Medicare.

What will I have to pay?
Most people don’t have to pay a premium for Part A. But you may be required to pay a deductible per benefit period. In 2020 the deductible per benefit period is $1,408. You may also pay other out-of-pocket costs, like coinsurance and copays. A Medigap policy (more on this later) can help cover some of your out-of-pocket costs.

Medicare Advantage

Part B (Medical Insurance)

What's covered?
Part B covers medically necessary services or supplies. This includes outpatient care such as doctor visits, ambulances, durable medical equipment (DME), x-rays, and physical, speech and occupational therapy. It also includes preventive services to help prevent or detect illness at an early stage.

What will I have to pay?
Most people will pay a monthly premium of $144.60 or higher depending on your income. Your premium is usually deducted from your Social Security check. The Part B deductible is $185 per year (due to change 2020). After this is met, you typically pay 20% of the Medicare-approved costs for most doctor services.

Medicare Advantage

Medicare Advantage Medicare Advantage (Part C)

A Medicare Advantage plan is a private health insurance plan approved by Medicare.

What's covered?
Medicare Advantage plans offer the same Part A and Part B benefits that Original Medicare provides. Some Medicare Advantage plans also offer additional benefits, like prescription drugs, vision, hearing and dental coverage for little or no additional cost.

'There are different plan types to choose from. Plan types provide the same benefits, rights, and protections as Original Medicare, but may do so with different rules, restrictions, and costs.

'The main differences between the plans is how much you pay and what you're covered for.

What will I have to pay?
Most plans have a dollar limit for yearly out-of-pocket costs. This means once you’ve spent up to your limit, the plan will pay 100% of your costs.

You have to pay a Part B premium for all Medicare Advantage plans.

Plan types

  • Health Maintenance Organization (HMO) plans

    HMO plans usually restrict your healthcare coverage to providers within the plan's network with limited exceptions. Your care is co-ordinated by a primary care doctor who may be required to refer you if you need to see specialists or receive care outside of their network. If you receive care outside of their network, you will likely pay 100% of the costs. Most plans usually include prescription drugs.

  • Preferred Provider Organization (PPO) plans

    Preferred Provider Organization (PPO) plans allow you to receive care outside of their network, but they will only pay for part of the total cost. You don’t need a primary care doctor or a referral to see specialists. Most plans usually include prescription drugs.

  • Private Fee-for-Service (PFFS) plans

    PFFS plans sets its own payment structure. The plan decides how much it will pay its Medicare providers, and how much you will pay as a patient. The plan doesn't require you to choose a primary care doctor. Some plans let you receive care from any provider that accepts Medicare and the provider’s payment terms. Others limit you to their network with additional costs if you use a provider not in the network.

  • Special Needs Plans

    SNPs are limited to people with certain chronic conditions or people living in long-term care facilities or people who qualify for both Medicare and Medicaid. Healthcare is generally restricted to the provider's network unless it’s for emergency care or you have end-stage renal disease (ESRD). All SNP plans must include drug coverage.

  • Health Maintenance Organization Point-of-Service (HMO-POS) plans

    HMP-POS are HMO plans that allow you to get care out of their network but at a higher cost.

  • Medical Savings Account (MSA) plans

    MSA plans combine a high deductible health plan with a bank account. The MSA plan puts money into your account. You can use the money to pay for your health care services during the year. You can use any doctor who accepts Medicare. This plan does not include prescription drug coverage.

Good to know...

You need to be enrolled in Original Medicare before you can enroll in Medicare Advantage. You can enroll for both at the same time.

Medicare Advantage (Part C)

A Medicare Advantage plan is a private health insurance plan approved by Medicare.

What's covered?

Medicare Advantage plans offer the same Part A and Part B benefits that Original Medicare provides. Some Medicare Advantage plans also offer additional benefits, like prescription drugs, vision, hearing and dental coverage for little or no additional cost.

There are different plan types to choose from. Plan types provide the same benefits, rights, and protections as Original Medicare, but may do so with different rules, restrictions, and costs.

The main differences between the plans is how much you pay and what you're covered for.

What will I have to pay?

Most plans have a dollar limit for yearly out-of-pocket costs. This means once you’ve spent up to your limit, the plan will pay 100% of your costs.

You have to pay a Part B premium for all Medicare Advantage plans.

Plan types

  • Health Maintenance Organization (HMO) plans

    HMO plans usually restrict your healthcare coverage to providers within the plan's network with limited exceptions. Your care is co-ordinated by a primary care doctor who may be required to refer you if you need to see specialists or receive care outside of their network. If you receive care outside of their network, you will likely pay 100% of the costs. Most plans usually include prescription drugs.

  • Preferred Provider Organization (PPO) plans

    Preferred Provider Organization (PPO) plans allow you to receive care outside of their network, but they will only pay for part of the total cost. You don’t need a primary care doctor or a referral to see specialists. Most plans usually include prescription drugs.

  • Private Fee-for-Service (PFFS) plans

    PFFS plans sets its own payment structure. The plan decides how much it will pay its Medicare providers, and how much you will pay as a patient. The plan doesn't require you to choose a primary care doctor. Some plans let you receive care from any provider that accepts Medicare and the provider’s payment terms. Others limit you to their network with additional costs if you use a provider not in the network.

  • Special Needs Plans

    SNPs are limited to people with certain chronic conditions or people living in long-term care facilities or people who qualify for both Medicare and Medicaid. Healthcare is generally restricted to the provider's network unless it’s for emergency care or you have end-stage renal disease (ESRD). All SNP plans must include drug coverage.

  • Health Maintenance Organization Point-of-Service (HMO-POS) plans

    HMP-POS are HMO plans that allow you to get care out of their network but at a higher cost.

  • Medical Savings Account (MSA) plans

    MSA plans combine a high deductible health plan with a bank account. The MSA plan puts money into your account. You can use the money to pay for your health care services during the year. You can use any doctor who accepts Medicare. This plan does not include prescription drug coverage.

Good to know...

You need to be enrolled in Original Medicare before you can enroll in Medicare Advantage. You can enroll for both at the same time.

Prescription Drug Plan (Part D)

Original Medicare Prescription Drug Plan (Part D)

Medicare Prescription Drug Plans (Part D) help pay for both brand name and generic drugs.

What's covered?
Prescription Drug Plans (PDP) can be paired with Original Medicare to help you manage the cost of your prescription drugs.

'All Prescription Drug Plans must provide a standard level of coverage set by Medicare. But individual plans may differ in the prescription drugs they cover, how much you have to pay, and which pharmacies you can use.

'

What will I have to pay?
You’ll pay a monthly premium if you’re pairing your PDP with Original Medicare.

In addition to the premium you’ll pay a yearly deductible, copayments and coinsurance. Then there’s the coverage gap (or donut hole). When you’ve spent up to a certain limit on your plan you'll pay no more than 25% for both covered generic and brand name drugs.

Brand name vs generic drugs

Brand name drugs

These are the drugs you may have heard of and have seen advertised. Choosing these will cost you more than generic drugs in more cases.

Or

Generic drugs

Generic drugs are created to be the same as an existing, FDA-approved brand-name drug. Choosing generic drugs may lower your costs for prescription drugs.

Good to know...

If you don’t sign up for a Prescription Drug Plan when you first become eligible, you may have to pay a late enrollment penalty. Some Medicare Advantage Plans (like HMOs or PPOs) also offer prescription drug coverage.

Prescription Drug Plan (Part D)

Medicare Prescription Drug Plans (Part D) help pay for both brand name and generic drugs.

What's covered

Prescription Drug Plans (PDP) can be paired with Original Medicare to help you manage the cost of your prescription drugs.

All Prescription Drug Plans must provide a standard level of coverage set by Medicare. But individual plans may differ in the prescription drugs they cover, how much you have to pay, and which pharmacies you can use.

What will I have to pay?

You’ll pay a monthly premium if you’re pairing your PDP with Original Medicare.

In addition to the premium you’ll pay a yearly deductible, copayments and coinsurance. Then there’s the coverage gap (or donut hole). When you’ve spent up to a certain limit on your plan you'll pay no more than 25% for both covered generic and brand name drugs.

Brand name vs generic drugs

Brand name drugs

These are the drugs you may have heard of and have seen advertised. Choosing these will cost you more than generic drugs in most cases.

Generic drugs

Generic drugs are created to be the same as an existing, FDA-approved brand-name drug. Choosing generic drugs may lower your costs for prescription drugs.

Good to know...

If you don’t sign up for a Prescription Drug Plan when you first become eligible, you may have to pay a late enrollment penalty. Some Medicare Advantage Plans (like HMOs or PPOs) also offer prescription drug coverage.

Medicare Supplement

Original Medicare Medicare Supplement

Also known as Medigap, these plans help pay some of the healthcare costs that Original Medicare doesn’t cover.

What's covered?
Medicare Supplement insurance works with Original Medicare, and helps cover out-of-pocket costs like deductibles, coinsurance and copays. Some Medigap plans also cover services that Original Medicare doesn't cover, like medical care when you travel outside the US.

'There are 10 standardized plan types available in most states which all offer different levels of coverage.

What will I have to pay?
Monthly premiums vary depending on the plan you choose. The plans with higher premiums, like G and F, can significantly reduce your out-of-pocket costs.

Medicare Supplement benefits

All Medicare Supplement plans cover between 50% and 100% of the following benefits.

  • Medicare Part A coinsurance
  • Medicare Part B coinsurance or copayment
  • Blood (first 3 pints)
  • Part A hospice care coinsurance or copayment

Some plans cover at least 50% of some or all of these additional benefits

  • Skilled nursing facility care coinsurance
  • Part A deductible
  • Part B deductible
  • Part B excess charges
  • Foreign travel emergency medical coverage

If you buy a Medigap plan after January 1, 2020, it will not cover your Part B deductible.

Good to know...

If you don’t sign up for a Prescription Drug Plan when you first become eligible, you may have to pay a late enrollment penalty. Some Medicare Advantage Plans (like HMOs or PPOs) also offer prescription drug coverage.

Medicare Supplement

Also known as Medigap, these plans help pay some of the healthcare costs that Original Medicare doesn’t cover.

What's covered

Medicare Supplement insurance works with Original Medicare, and helps cover out-of-pocket costs like deductibles, coinsurance and copays. Some Medigap plans also cover services that Original Medicare doesn't cover, like medical care when you travel outside the US.

There are 10 standardized plan types available in most states which all offer different levels of coverage.

What will I have to pay?

Monthly premiums vary depending on the plan you choose. The plans with higher premiums, like G and F, can significantly reduce your out-of-pocket costs.

You can’t use Medicare Supplement insurance with Medicare Advantage plans.

Medicare Supplement benefits

All Medicare Supplement plans cover between 50% and 100% of the following benefits.

  • Medicare Part A coinsurance
  • Medicare Part B coinsurance or copayment
  • Blood (first 3 pints)
  • Part A hospice care coinsurance or copayment

Some plans cover at least 50% of some or all of these additional benefits

  • Skilled nursing facility care coinsurance
  • Part A deductible
  • Part B deductible
  • Part B excess charges
  • Foreign travel emergency medical coverage

If you buy a Medigap plan after January 1, 2020, it will not cover your Part B deductible.

Good to know...

You have a guaranteed issue right when you buy a Medigap plan within 6 months of turning 65. After this time, pre-existing medical conditions will be considered and you may be charged more or turned down for coverage.

Ready to find a plan?

“I’m Mary-Beth*. I can carefully walk you through our step-by-step process to help you find a plan that meets your needs.”

Find a plan* Mary-Beth is a digital avatar and not a licensed sales agent.

“I’m Mary-Beth*. I can carefully walk you through our step-by-step process to help you find a plan that meets your needs.”

Find a plan* Mary-Beth is a digital avatar and not a licensed sales agent.

Prefer to talk?

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(866) 576-2956 or TTY 711

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I wish I’d known this before I bought my plan…

Helpful things callers learn from our sales agents

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It’s important that people review their plan each year – because premiums, coverage, and drug costs can change.

Andrew Sivatjian
V.P. of Medicare Sales & Licensed Agent
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It’s always worth remembering that Medicare won’t pay for long term care, or care in a retirement community, nursing home or assisted living community.

Silvia Barrera
Sales Manager & Licensed Agent
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Some callers are surprised by how much they could save if they switched to a new plan.

Mark Laemmert
Medicare Site Leader & Licensed Agent