MEDICARE PART A covers:

• Inpatient care in a hospital
• Skilled nursing facility care
• Inpatient care in a skilled nursing facility (not custodial or long-term care)
• Hospice care
• Home health care

MEDICARE PART A eligibility:

You can get premium-free Part A at 65 if:

• You already get retirement benefitsfrom Social Security or the Railroad Retirement Board.
• You’re eligible to get Social Security or Railroad benefits but haven’t filed for them yet.
• You or your spouse had Medicare-covered government employment.

If you’re under 65, you can get premium-free Part A if:

• You got Social Security or Railroad Retirement Board disability benefits for 24 months.
• You have End-Stage Renal Disease (ESRD)and meet certain requirements.

If you have worked and filed taxes for at least 10 years or 40 credits, typically Medicare Part A is premium-free at age 65.

MEDICARE PART A premiums

If you buy Part A, you’ll pay up to $437 each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $437. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $240.

In most cases, if you choose to buy Part A, you must also:

• Have Medicare Part B (Medical Insurance)
• Pay monthly premiums for both Part A and Part B

For additional questions/information, please visit www.medicare.gov, www.ssa.gov, or call Medicare at 1-800-MEDICARE (1-800-633-4227), or Social Security Administration at 1-800-772-1213.

MEDICARE PART B covers:

• 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.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment. 

Part B covers things like:

• Clinical research
• Ambulance services
• Durable medical equipment (DME)
• Mental health
• Inpatient
• Outpatient
• Partial hospitalization
• Getting a second opinion before surgery
• Limited outpatient prescription drugs

MEDICARE PART B premiums

You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these:

• Social Security
• Railroad Retirement Board
• Office of Personnel Management

If you don’t get these benefit payments, you’ll get a bill. 

Most people will pay the standard premium amount. If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago. This is the most recent tax return information provided to Social Security by the IRS. 

The standard Part B premium amount in 2019 is $135.50. Most people will pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

Get more information about your Part B premium from Social Security [PDF, 341 KB]. 

Part B deductible & coinsurance

You pay $185 per year in 2019 for your Part B deductible. After your deductible is met, you typically pay 20% of the Medicare-approved amount for these:

• Most doctor services (including most doctor services while you’re a hospital inpatient)
• Outpatient therapy
• Durable medical equipment (DME)

For additional questions/information, please visit www.medicare.gov, www.ssa.gov, or call Medicare at 1-800-MEDICARE (1-800-633-4227), or Social Security Administration at 1-800-772-1213.

MEDICARE PART C covers:

A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits. Medicare Advantage Plans include:

• Health Maintenance Organizations
• Preferred Provider Organizations
• Special Needs Plans

If you’re enrolled in a Medicare Advantage Plan:

• Most Medicare services are covered through the plan
• Medicare services aren’t paid for by Original Medicare

Most Medicare Advantage Plans offer prescription drug coverage.

HEALTH MAINTENANCE ORGANIZATION (HMO)

In most HMO Plans, you generally must get your care and services from providers in your plan’s network, like:

• Doctors
• Other health care providers
• Hospitals

You may also need to get a referral from your primary care doctor. Find and compare HMO Plans in your area.

In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:

• Emergency care
• Out-of-area urgent care
• Out-of-area dialysis

In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider. This is called an HMO with a point-of-service (POS) option.

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don’t require a referral.

What else do I need to know about this type of plan?

• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
• If you get health care outside the plan’s network , you may have to pay the full cost.
• It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.

PREFERRED PROVIDER ORGANIZATION (PPO)

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C)offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.

Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.

Prescription drugs are covered in PPO Plans. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn’t offer prescription drug coverage, you can’t join a Medicare Prescription Drug Plan (Part D).

In most cases, you don’t have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.

• A PPO Plan isn’t the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.

• PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

SPECIAL NEEDS PLAN

How Medicare SNPs work

Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. Find out who can join a Medicare SNP.

Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:

• Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
• If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis

Special Needs Plans have:

• Specialists in the diseases or conditions that affect their members.
• Medicare prescription drug coverage.
• SNPs may require you to have a primary care doctor. Or, the plan may require you to have a care coordinator to help with your health care.

Generally, you need a referral to see a specialist in SNPs. Certain services don’t require a referral, like these:

• Yearly screening mammograms
• An in-network pap test and pelvic exam (covered at least every other year)

Other considerations and limitation on Special Needs Plans

• A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.
• Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.
• If you have Medicare and  Medicaid , your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.

For additional questions/information, please visit www.medicare.gov, www.ssa.gov, or call Medicare at 1-800-MEDICARE (1-800-633-4227), or Social Security Administration at 1-800-772-1213.

MEDICARE PART D covers:

Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. This page explains how to get prescription drug coverage and offers tips for making the right choices for you.

If you decide not to get Medicare drug coverage when you’re first eligible, you’ll likely pay a late enrollment penalty if you join later, unless one of these applies:

• You have other creditable prescription drug coverage
• You get Extra Help

Generally, you’ll pay this penalty for as long as you have Medicare prescription drug coverage.

To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.

2 ways to get prescription drug coverage

1. Medicare Prescription Drug Plan (Part D) . These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
2. Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.

Consider all your drug coverage choices

Before you make a decision, learn how prescription drug coverage works with your other drug coverage. For example, you may have drug coverage from an employer or union, TRICARE, the Department of Veterans Affairs (VA), the Indian Health Service, or a Medicare Supplement Insurance (Medigap) policy. Compare your current coverage to Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options.

If you have (or are eligible for) other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefits administrator, insurer, or plan provider before you make any changes to your current coverage.

Joining a Medicare drug plan may affect your Medicare Advantage Plan 

Your Medicare Advantage Plan (Part C) will disenroll you and you’ll go back to Original Medicare if both apply:

Your Medicare Advantage Plan includes prescription drug coverage.

You join a Medicare Prescription Drug Plan (Part D)

For additional questions/information, please visit www.medicare.gov, www.ssa.gov, or call Medicare at 1-800-MEDICARE (1-800-633-4227), or Social Security Administration at 1-800-772-1213

A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn’t cover, like:

• Copayments
• Coinsurance
• Deductibles

Medigap policies are sold by private companies.

Some Medigap policies also cover services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, here’s what happens:

• Medicare will pay its share of the Medicare-approved amount for covered health care costs.
• Then, your Medigap policy pays its share.

8 things to know about Medigap policies:

• You must have Medicare Part A and Part B.
• A Medigap policy is different from a Medicare Advantage Plan.  Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
• You pay the private insurance company a monthly Premium for your Medigap policy. You pay this monthly premium in addition to the monthly Part B premium that you pay to Medicare.
• A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.
• You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one.
• Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
• Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
• It’s illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you’re switching back to Original Medicare.

Medigap policies don’t cover everything. Medigap policies generally don’t cover:

• Long-term care
• Vision
• Dental care
• Hearing aids
• Eyeglasses
• Private-duty nursing.

Some types of insurance aren’t Medigap plans, they include:

• Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)
• Medicare Prescription Drug Plans
• Medicaid
• Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP)
• TRICARE
• Veterans’ benefits
• Long-term care insurance policies
• Indian Health Service, Tribal, and Urban Indian Health plans

Dropping your entire Medigap policy (not just the drug coverage)

You may want a completely different Medigap policy (not just your old Medigap policy without the prescription drug coverage). Or, you might decide to switch to a Medicare Advantage Plan that offers prescription drug coverage.

If you decide to drop your entire Medigap policy, you need to be careful about the timing. When you join a new Medicare drug plan, you pay a late enrollment penalty if one of these applies:

• You drop your entire Medigap policy and the drug coverage wasn’t  Creditable prescription drug coverage
• You go 63 days or more in a row before your new Medicare drug coverage begins

MEDICARE COST PLANS

Some types of Medicare health plans that provide health care coverage aren’t Medicare Advantage Plans but are still part of Medicare. Some of these plans provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, while most others provide only Part B coverage. Some also provide Medicare prescription drug coverage (Part D).

These plans have some of the same rules as Medicare Advantage Plans. However, each type of plan has special rules and exceptions, so contact any plans you’re interested in to get more details.

Medicare Cost Plans

Medicare Cost Plans are a type of Medicare health plan available in certain areas of the country.

Here are important facts about Medicare Cost Plans:

• You can join even if you only have Part B.
• If you have Part A and Part B and go to a non-network provider, the services are covered under Original Medicare . You would pay the Part A and Part B Coinsurance and Deductible.
• You can join anytime the plan is accepting new members.
• You can leave anytime and return to Original Medicare.
• You can either get your Medicare prescription drug coverage from the plan (if offered), or you can join a Medicare Prescription Drug Plan (Part D) .

Another type of Medicare Cost Plan only provides coverage for Part B services. These plans never include Part D. Part A services are covered through Original Medicare. These plans are either sponsored by employer or union group health plans or offered by companies that don’t provide Part A services.