Medicare Plans

About Medicare Plans

The four parts of Medicare and what they cover

Medicare Part A: Hospital Insurance

Part A covers:

  • Up to 150 days in the hospital
  • Up to 100 days in a skilled nursing facility (after a 3-day qualifying inpatient hospital stay)
  • Home health care
  • Hospice care

You’re responsible for:

  • Copays
  • Deductibles
  • Coinsurance

Medicare Part B: Medical Insurance

Part B covers:

  • Doctor visits (for regular screenings, vaccines, an annual wellness visit, and illnesses or injuries)
  • Outpatient surgery
  • Ambulance (in an emergency)

You’re responsible for:

  • Copays
  • Deductibles
  • Coinsurance

Gaps in Original Medicare

Original Medicare covers a lot, but it doesn’t pay for all the health care you may need. If you only have Part A and Part B coverage, you’ll pay the full cost for services Original Medicare doesn’t cover, including:

  • Routine dental care
  • Hearing aids
  • Routine eye exams and eye wear
  • Routine physical exams
  • Fitness club memberships
  • Prescription drugs you may take at home
  • Care in a skilled nursing facility without a qualifying 3-day hospital stay
  • Most care you receive when traveling outside the U.S.

Medigap Plans

If you choose Original Medicare, you can buy extra coverage from private insurance companies to help pay for things that Medicare Part A and Part B don’t cover. Medigap plans, also known as Medicare Supplement plans cover things like coinsurance and copays, deductibles, your share of extended hospital stays, blood transfusions, and foreign travel emergencies. Medicare Supplement plans do not include Medicare Part D outpatient prescription drug coverage.

Medicare Part C: Medicare Advantage plans

Part C is also known as Medicare Advantage. These are private plans that cover everything Original Medicare does plus many include prescription drugs coverage and other extras.

Medicare Advantage plans cover:

  • Everything Original Medicare covers
  • Extras like vision, dental, and fitness benefits (depending on the plan)
  • Many also include Medicare Part D outpatient prescription drug coverage

You’re responsible for:

  • Monthly premiums
  • Copays
  • Deductibles
  • Coinsurance

You can purchase Medicare Part D coverage from private health care companies to help cover the cost of your prescriptions. There are two ways to get Part D:

  • As part of a Medicare Advantage plan (MA-PD)
  • As a separate, standalone prescription drug plan (PDP)

Medicare Part D covers:

  • Prescription drugs you take as long as they are on your plan’s drug list or formulary. Drug lists vary by plan, so it’s important to check that your prescriptions are included before you pick a plan.

A note on penalties

You don’t have to get a Part D plan when you enroll in Medicare. But if you don’t sign up when you first become eligible, you may pay a late enrollment penalty if you decide to sign up later. You’ll pay the penalty for as long as you have Part D coverage. To learn more about penalties related to Part D enrollment, visit the Medicare website.

Phases of Part D coverage

Part D coverage is broken into a few phases:

  • Deductible
  • The initial coverage phase is where you’ll pay co-insurance specified in your plan. Once your total drug costs (what you and your plan pay) reach $4,430, you move into what’s called the coverage gap.
  • During the coverage gap, you receive a 75% discount on drug costs. You pay 25% of the drug costs until your total out-of-pocket costs, including what you paid out-of-pocket in the deductible and initial coverage phase, reaches $7,050.
  • Once you’ve reached $7,050 in out-of-pocket costs, you enter catastrophic coverage, during which the plan will pay most of the cost of your drugs. You will be responsible for small copay or 5% coinsurance, whichever is greater.

You’re responsible for:

  • Monthly premiums
  • Copays
  • Deductibles
  • Coinsurance

When to enroll in Medicare

Most people are eligible for Medicare at age 65. If you’re already receiving Social Security benefits, you’ll be enrolled automatically.

If you’re not receiving Social Security benefits, you’ll need to sign up for Medicare. You have seven months to sign up for Medicare – three months before your 65th birthday, the month of your 65th birthday, and three months after your 65th birthday.

Example:
Your birthday
July 4

Check with your employer if you need to enroll in Medicare first because there is the option to wait to enroll. If you or your spouse plan to keep working and have active employer group coverage with a large employer you can wait to enroll.

How to enroll in Medicare

You can sign up for Medicare three ways:

  • Online at www.ssa.gov (external link)
  • By phone at 1-800-772-1213
  • In person at a Social Security Office

Getting a Medicare Advantage, Medigap, or Medicare Part D plan

Once you’re enrolled in Original Medicare, you can decide to enroll in a Part C (Medicare Advantage), Medicare Part D (Prescription drug coverage), or Medigap plan from a private insurance company.

There are three election periods where you can enroll in or change your plan choice:

Initial Enrollment

This is when you first become eligible for Medicare. During this time, you can enroll in Medigap and a Part D plan (if you choose Original Medicare) or a Medicare Advantage Plan for the current year.

Annual Election Period

After your initial enrollment, you can make changes to your plan choices for the following year during the Annual Election Period (AEP) from October 15 to December 7.

Disenrollment Period

From January 1 to March 31 every year or if you are newly eligible to Medicare, within the first three months. During this time, if you are enrolled in a Medicare Advantage plan, you change plans once during this election. You can enroll in another Medicare Advantage plan or disenroll from your plan and return to Original Medicare.

In addition to these election periods, there are special circumstances in which you can enroll or make changes called Special Election Periods (SEP). For example, if you were covered by your employer’s plan and didn’t enroll during the initial enrollment period or you moved to a new area with different plan options.

For all of the details on enrollment guidelines and requirements, visit www.Medicare.gov (external link).

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U11843 05/2022