medicare options

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Medicare A & B

Cost 

Part A - Premium free if you worked 10 years or 40 quarters under Social Security.

Part B - $135.50/Month (However, individuals/couples with income higher than $85,000/$170,000 will pay an increased Part B premium in accordance with their income).   


Coverage

Part A – full hospital coverage after a benefit period deductible of $1,364.00

Part B – 80% coverage for doctors/medical – beneficiary pays 20% + $185.00 annual deductible    

Traditional/Original Medicare Parts A and B only – The Medicare Program does not provide comprehensive coverage. The major gaps in coverage include the Part A hospital deductible of $1,364.00, the Part B annual deductible of $185.00 and the Part B 20% co-insurance for doctors/medical services, no coverage for foreign travel and no coverage for prescription drugs. (Medicare offers prescription coverage under Medicare Part D. See below.) Beneficiaries who choose traditional Medicare may also purchase a Medicare Supplement plan to augment their Medicare coverage. 


You can extend Medicare A and B coverage in one of two ways:

Option 1

Medicare Supplement insurance is also called Medigap insurance because it fills the gaps in Medicare coverage. In Massachusetts there are seven insurance providers selling Supplement/Medigap Insurance plans. Each offers the same 2 standardized products; Supplement Core and Supplement 1. Medical providers that accept Medicare will also accept a supplement plan


Supplement Core: is the lower cost product – It does not cover the $1,364 hospital deductible, the $185 Part B deductible and the $170.50 Co-Pay for SNF after 20 days. It does, however, cover the 20% co-insurance for doctors/medical services. Supplement Core may also cover some foreign travel.


Supplement 1: is more comprehensive and covers all the gaps including the hospital deductible, the Part B deductible, SNF Co-Pay and foreign travel. There are no out-of-pocket expenses for medical services provided when enrolled in Supplement 1.

 If you choose traditional Medicare with a supplement:


Pro: You have freedom of choice – can go to any doctor without a referral, any hospital and no office co-pays. 


Con: If Medicare Part A and/or B doesn’t cover the service, the Medicare Supplement plan will not cover the service. For instance, Medicare does not cover some routine care such as dental or vision care. Therefore, the Medigap plan  will not cover dental or vision care. For drug coverage you need a separate drug plan (See below)

Option 2

Medicare Advantage Plan aka Medicare Part C – Medicare Advantage Plans contract with the Center for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare. The Advantage plans under contract agree to provide enrollees with all the benefits to which they are entitled under Medicare. The plan providers administer and become your primary coverage. Plans can offer extra benefits such as limited vision, hearing, and dental services. Medicare Advantage plans also provide comprehensive drug coverage within their plan. (Note: Members still must pay Part B premium)  

Medicare Advantage plans - Part C

Medicare HMO (Health Maintenance Organization) Plans


The premiums for an HMO with or without the Part D prescription coverage vary depending on county and

coverage options. 


Pro: HMOs encourage preventive care such as an annual physical (annual physicals are not 

normally covered under Medicare except for the “Welcome to Medicare” physical).

Con: You must stay within a provider network. If you go out of network, the HMO will not pay and Medicare      will not pay. (Emergency/urgent care will be covered)


Medicare PPO (Preferred Provider Organization) Plans

The premium for a PPO with or without the Part D prescription add-on vary depending on county and 

coverage options.


Pro:  PPOs encourage preventive care such as an annual physical. They allow members to receive   

health care from in-network and out-of-network providers.


Con: Out-of-network care may result in higher out of pocket costs for the member.

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medicare prescription coverage

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Beneficiaries who become eligible for Medicare can enroll in a Part D plan when their enrollment in Medicare A or B becomes effective. Coverage begins on the first of the month following enrollment or on the date their Medicare A or B takes effect. While this is a voluntary program, people who do not join during their initial enrollment period or when they became newly eligible will face a lifetime late enrollment penalty. Part D is private insurance that provides help with prescription drug costs and protection for catastrophic costs. The standard plan requires members to pay a monthly premium, an annual deductible, co-pays and co-insurance. 


Medicare beneficiaries can enroll in a stand alone Medicare Prescription Drug Plan (PDP) offered by companies under contract with CMS. While the companies must offer plans that provide coverage at least as good as the standard plan described above, they can provide additional options and coverage. Beneficiaries should explore the plans available to ensure that they choose the most cost effective plans that covers their specific medications. Information about the plans is available on the Medicare website www.Medicare.gov . (Note: Medicare beneficiaries who enroll in a Medicare HMO or PPO plan can only enroll in Part D coverage offered by their plan. They cannot enroll in one of these stand alone PDP.)