How Medicare Plans Work
Original Medicare is a fee-for-service plan managed by the Federal Government. In general, with Original Medicare:
- You use your red, white, and blue Medicare card when you get health care.
- You can go to any doctor or supplier that accepts Medicare and is accepting new Medicare patients, or to any hospital or other facility.
- You pay a set amount for your health care (a deductible) before Medicare pays its part. Then, Medicare pays its
share, and you pay your share (your coinsurance or copayment) for covered services and supplies (unless you have a Medigap policy or other supplemental insurance that may pay for these costs.)
- You may have a Medigap policy or other supplemental coverage that may pay deductibles, coinsurance, or other costs that arent covered by Original Medicare.
Medigap policies are health insurance policies sold by private insurance companies
to fill "gaps" in Original Medicare coverage. In general, with a Medigap policy:
- You get help paying for some of the health care costs that Original Medicare doesnt cover.
- You also get benefits not covered by Original Medicare, like emergency health care outside the United States.
- You pay a monthly premium to the private health insurance company that sells you the policy. Medicare and
the Medigap policy both pay their shares of covered health care costs.
Medicare Health Plans (like HMOs and PPOs)
Medicare Advantage Plans are health plan options that are approved by Medicare but run by private companies. They are part of the Medicare Program, and sometimes called "Part C." When you join a Medicare Advantage Plan, you are still in Medicare. With Medicare Advantage Plans:
- Some of the plans require referrals to see specialists.
- In many cases, the premiums or the costs of services (co-pays and deductibles ) can be lower than they are in Original Medicare or Original Medicare with a Medigap policy. Medicare Health Plans charge different premiums and have different costs of services, so it is important to check with the plan before you join.
- The plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically-necessary services.
- They often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services.
- They generally offer extra benefits, and many include prescription drug coverage.
- In many cases, your costs for prescription drug coverage can be lower than in the stand-alone Medicare Prescription Drug Plans.
- Some of the plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you.
- You dont need to buy a Medigap policy.
Medicare Health Plans include:
Other Medicare Health Plans
There are some types of Medicare Health Plans that arent part of Medicare Advantage, but are still part of the Medicare Program. With these plans, you generally get all your Medicare-covered health care through that plan. Some plans cover prescription drugs.
Other Medicare Health Plans include:
Medicare Prescription Drug Plans
Medicare Prescription Drug Plans are offered by insurance companies and other private companies approved by Medicare. They add coverage to:
With a Medicare Prescription Drug Plan:
- Generally, you pay less for your prescriptions.
- You will get a plan member card after you enroll. You use this card when you go to the pharmacy to get your prescriptions filled.
- You will pay the copayment, coinsurance,
and/or deductible, if any.
If you have limited income and resources, you may get extra help to pay for your Medicare drug plan costs.
If you want to compare Medicare Prescription Drug Plans, use the
Medicare Prescription Drug Plan Finder.
You can view and print these publications by clicking on the title below. Or, you can call 1-800-MEDICARE (1-800-633-4227) to get free copies of these publications. TTY users should call 1-877-486-2048.