How Plans Work

Each year in the fall, you should review your health and prescription needs because your health, finances, or plan’s coverage may have changed. If you decide other coverage will better meet your needs, you can switch plans during certain times.

When looking for coverage, you should consider factors such as cost, benefits, doctor and hospital choices, convenience, prescription drug offerings, and pharmacy choices.

Cost:

• What will you pay out-of-pocket, including premiums, deductibles, copayments or coinsurance? Some plans help pay your share of the cost (coinsurance, copayments, or deductibles) of Medicare-covered services.
• How much do you pay for services like hospital stays or doctor visits?
• Check the Plan Comparison and Plan Detail reports in this tool to see plan costs.

Doctor and Hospital choice:

• Can you see the doctors you want?
• Are the doctors you want to see accepting new patients?
• Do you need a referral to see a specialist?
• Can you go to the hospital you want?
• Check the Plan Comparison and Plan Detail reports in this tool to see how much choice a plan offers and whether you need referrals.
• Contact the plan for more information about their doctors and hospitals.

Prescription Drugs:

• Are your drugs covered under the plan's formulary (list of covered drugs)?
• What will your prescription drugs cost under the plan?
• What is the premium for the plan?
• What is the deductible for the plan?
• Does the plan provide some coverage in the gap?
• Check the Plan Comparison and Plan Detail reports in this tool, or go to the Medicare Prescription Drug Plan Finder, to get formulary information.

Convenience:

• Where are the doctor’s offices?
• What are their hours?
• Which pharmacies can you use?
• Can you get your prescriptions by mail?
• Do the doctors use electronic health records or prescribe electronically?
• Contact the plan for more information about their doctors and hospitals.

Original Medicare is a fee-for-service plan managed by the Federal government. It includes Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); most people have both parts. In most cases, when you first get Medicare, you’re in Original Medicare. Generally there is a cost for each service. Usually, with Original Medicare.

• You use your red, white, and blue Medicare card when you get health care.
• You can go to any doctor, supplier, hospital or other facility that’s enrolled in Medicare and is accepting new Medicare patients.
• You pay a set amount for your health care (a deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (your coinsurance or copayment ) for covered services and supplies. There’s no yearly limit for what you pay out-of-pocket.
• You usually pay a monthly premium for Part B (Medical Insurance).
• You can add prescription drug coverage by choosing and joining a Medicare Prescription Drug Plan. You may also want to consider a Medigap policy or other supplemental coverage that may pay deductibles, coinsurance, or other costs not covered by Original Medicare.
• Learn about the services and supplies Original Medicare covers from the booklet “Your Medicare Benefits.”

Medigap policies are health insurance policies sold by private insurance companies to fill "gaps" in Original Medicare coverage. If you choose to join a Medicare Advantage Plan (like an HMO or PPO), the plan will provide all of your Part A, Part B, and often Part D prescription drug coverage. You don’t need a Medigap policy if you join a Medicare Advantage Plan. Every Medigap policy must follow Federal and state laws designed to protect you and it must be clearly identified as “Medicare Supplement Insurance”. Usually, with a Medigap policy.

• You get help paying for some of the health care costs that Original Medicare doesn’t cover.
• You may also get benefits not covered by Original Medicare, like medical care when you travel 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.
• Learn more about Medigap from the guide “Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.”

Medicare Advantage Plans are health plan options offered by private companies approved by Medicare. They’re part of the Medicare Program, and sometimes called "Part C." When you join a Medicare Advantage Plan, you’re still in Medicare—it’s not a supplemental plan. With Medicare Advantage Plans

• Some of the plans require referrals to see specialists.
• In addition to your monthly Part B premium, you usually pay a monthly premium for the services included.
• Each Plan can charge different out-of-pocket costs and have different rules for how you get services. Check with the plans you’re interested in 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, or you may pay more.
• They generally offer extra benefits, and many include prescription drug coverage.
• You don’t need to buy a Medigap policy.
• It may be a Health Maintenance Organization (HMO); Preferred Provider Organization (PPO); Private Fee-for-Service (PFFS) Plan; Medicare Medical Savings Account (MSA) Plan; or Medicare Special Needs Plan.
• Learn more about these types of organizations and plans from the booklets “Your Guide to Medicare’s Preferred Provider Organization (PPO) Plans,” “Your Guide to Private Fee-for-Service Plans,” “Your Guide to Medicare Medical Savings Account Plans,” and “Your Guide to Medicare Special Needs Plans (SNPs).”.

Some types of Medicare health plans aren’t part of Medicare Advantage (Part C), but still are part of the Medicare Program. With these plans, you generally get all your Medicare-covered health care through that plan. Some cover prescription drugs. These types of Medicare health plans include.

• Medicare Cost Plans
• Demonstration/Pilot Program
• PACE (Programs of All-inclusive Care for the Elderly)

Each of these plans has special rules so you should contact any plan you're interested in to get more details.