Medicare: Part A – Part D
Medicare is health insurance for the following:
- People 65 or older
- People under 65 with certain disabilities
- People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
Medicare Part A – Hospital Insurance
This includes hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, hospice, as well as quality home health care.
How Much Does Part A Cost?
Most people don’t pay a Part A premium because they paid Medicare taxes while working. This is called “premium-free Part A.” If you aren’t eligible for premium-free Part A, you may be able to buy Part A if you meet one of these conditions:
- You’re 65 or older, you’re entitled to, or enrolling in Part B, and you meet the citizenship or residency requirements.
- You’re under 65, disabled, and your premium-free Part A coverage ended because you returned to work. (If you’re under 65 and disabled, you can continue to get premium-free Part A for up to 8.5 years after you return to work.)
In most cases, if you choose to buy Part A, you must also acquire Part B and pay monthly premiums for both. If you have limited income and resources, your state may help you pay for Part A and/or Part B.
How Do I Get Part A?
Some people automatically receive Part A. Learn how, and when, you can sign up for Part A.
What Does Part A Cover?
To find out if Part A covers something specific, visit Your Medicare Coverage. In general, Part A covers:
- 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 Non medical Health Care Institution.
Medicare Part B – Medical Insurance
Part B helps cover medically-necessary services like doctors’ services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Check your Medicare card to find out if you have Part B.
How Much Does Part B Cost?
If you have Part B, you pay a Part B premium each month. Most people will pay the standard premium amount. Social Security will contact some people who have to pay more depending on their income. If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.
How Do I Get Part B?
Some people automatically get Part B. Learn how and when you can sign up for Part B.
What Does Part B Cover?
To find out if Part B covers something specific, visit Your Medicare Coverage. Part B covers two types of services:
- Medically-necessary services — Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services — Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
Medicare Advantage (Part C)
What is a Medicare Advantage Plan (Part C)?
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non‑emergency or non-urgent care). These rules can change each year.
Different Types of Medicare Advantage Plans
Health Maintenance Organization (HMO) Plans
Preferred Provider Organization (PPO) Plans
Private Fee-for-Service (PFFS) Plans
Special Needs Plans (SNP)
There are other less common types of Medicare Advantage Plans that may be available:
HMO Point of Service (HMOPOS) Plans— An HMO plan that may allow you to get some services out-of-network for a higher cost.
Medical Savings Account (MSA) Plans – A plan that combines a high deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year.
How Much Does a Medicare Advantage Plan Cost?
In addition to your Part B premium, you usually pay one monthly premium for the services included. Each Medicare Advantage Plan can charge different out of-pocket costs. Your out-of-pocket costs in a Medicare Advantage Plan depend on:
Whether the plan charges a monthly premium.
Whether the plan pays any of your monthly Part B premium.
Whether the plan has a yearly deductible or any additional deductibles.
How much you pay for each visit or service (copayments or coinsurance).
The type of health care services you need and how often you get them.
Whether you follow the plan’s rules, like using network providers.
Whether you need extra benefits and if the plan charges for them.
The plan’s yearly limit on your out-of-pocket costs for all medical services.
What Does a Medicare Advantage Plan Cover?
In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).
How Do I Get a Medicare Advantage Plan?
Not all Medicare Advantage Plans work the same way, so before you join, take the time to find and compare Medicare Health Plans in your area. Once you understand the plan’s rules and costs, you may be able to join by completing a paper application, calling the plan, or enrolling on the plans website. Medicare also has information on quality to help you compare plans.
A Few Extra Things You Should Know about Medicare Advantage Plans
New—Making changes to your coverage after December 31 Between January 1–February 14, 2011, if you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.
During this period, you can’t do the following:
Switch from Original Medicare to a Medicare Advantage Plan.
Switch from one Medicare Advantage Plan to another.
Switch from one Medicare Prescription Drug Plan to another.
Join, switch, or drop a Medicare Medical Savings Account Plan.
As with Original Medicare, you still have Medicare rights and protections, including the right to appeal.
Check with the plan before you get a service to find out whether they will cover the service and what your costs may be.
You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs. Check with the plan.
You can join a Medicare Advantage Plan even if you have a pre existing condition, except for End-Stage Renal Disease.
You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan.
If the plan decides to stop participating in Medicare, you‘ll have to join another Medicare health plan or return to Original Medicare.
Medicare Part D
Medicare offers prescription drug coverage to everyone with Medicare. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty.
To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.
