Original Medicare Plan

Under the Original Medicare Plan, which is managed by the Federal government and available nationwide, you can visit the hospital, doctor, or health care provider of your choice who accepts Medicare patients. Medicare pays a set percentage of the expenses, and you are responsible for certain deductibles and coinsurance payments--the portion of the bill Medicare does not pay. Because the Original Medicare Plan doesn’t pay for all of your health care, you may want to buy a Medicare supplemental insurance or “Medigap” policy.

A Medigap policy is a health insurance policy sold by private insurance companies to fill “gaps” in Original Medicare Plan coverage. In all states, except Massachusetts, Minnesota, and Wisconsin, a Medigap policy must be one of 10 standardized policies so you can compare them easily. Each policy has a different set of benefits.

In addition, any standardized policy may be sold as a “Medicare SELECT” policy. Medicare SELECT policies usually cost less because you must use specific hospitals and, in some cases, specific doctors to get full insurance benefits from the policy.  In an emergency, you may use any doctor or hospital.

The best time to buy a Medigap policy is during your “Medigap open enrollment period.” Your Medigap open enrollment period lasts for six months. It starts on the first day of the month in which you are both age 65 or older and are enrolled in Medicare Part B. Once the six-month Medigap open enrollment period starts, it can’t be changed.

During this period, an insurance company can’t deny you insurance coverage, place conditions on a policy (like making you wait for coverage to start) or charge you more for a policy because of your past or present health problems. They must also shorten the waiting period for pre-existing conditions based on your previous health coverage.

If you don’t buy a Medigap policy during your open enrollment period, you may not be able to buy the one you want later, or you may be charged more for the policy. In addition, if you drop your Medigap policy, you may not be able to get it back.

If you are age 65 or older, and you or your spouse are working, and you have health coverage through an employer or union based on your or your spouse’s current employment, you may want to wait to enroll in Medicare Part B and delay your Medigap open enrollment period.

You can get more detailed information about Medigap policies from the publications Medigap Policies, The Basics or Guide to Health Insurance for People with Medicare. To get copies, call the Medicare toll-free number 1-800-633-4227 or go to www.medicare.gov on the Internet and click on “Publications.”

Medicare Savings Programs can also help people with limited income and resources save money each year. The State-run programs pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance.

To be able to apply, you must have Medicare Part A (hospital insurance), a limited income, and your assets, such as bank accounts, stocks, and bonds, must not be more than $4,000 for a single person or $6,000 for a couple.

To find out if you qualify, contact your State medical assistance office.

Medicare Advantage Plans

You can get your coverage through the Original Medicare Plan or Medicare Advantage Plans (formerly known as “Medicare + Choice”). Congress created the Medicare Advantage program to provide you with more choices and, sometimes, extra benefits by letting private companies offer you your Medicare benefits.  Medicare pays a set amount of money for your care every month to these private health plans. In turn, the Medicare Advantage Plan manages the Medicare coverage for its members.  If you are in a Medicare Advantage plan, you don’t need to buy a Medicare supplemental insurance or “Medigap” policy.  If you join a Medicare Advantage Plan, you may have the following choices:

Medicare Managed Care Plans

One available option, which may save you money and provide additional benefits, is joining a managed care plan. The most common plans are health maintenance organizations (HMOs).

Medicare Managed Care Plans that have contracts with the Medicare program must provide all hospital and medical benefits covered by Medicare. However, usually you must obtain services from your Managed Care Plan’s network of health care providers (doctors, hospitals, skilled nursing facilities, for example). In most cases, neither the Managed Care Plan nor Medicare will pay for services not authorized by your Managed Care Plan (except emergency services or services urgently required while you are out of the Managed Care Plan’s service area).

Each Managed Care Plan that has a contract with Medicare gets paid every month for services it provides to you. As a Medicare Managed Care Plan member, you will have to enroll in Medicare Part B. You may also have to continue to pay some or all of your Part B monthly premium.

Many Managed Care Plans that have contracts with Medicare also provide benefits beyond those Medicare pays for. The benefits may vary by Managed Care Plan and you’ll need to read the individual descriptions to determine which benefits are offered by each.

Preferred Provider Plan

A Medicare Preferred Provider Organization Plan (PPO) works with many of the same rules as Medicare Managed Care Plans; however, in a PPO you don’t need referrals to see a specialist although you may have to get plan approval before getting certain services. In a PPO you can see any doctor or provider that accepts Medicare (in most cases). However, if you go to doctors, hospitals, or other providers who aren’t part of the plan (“out of network” or “nonpreferred”), it may cost extra.

Private Fee-for-Service Plan

This is a health care choice in some areas of the country. A Private Fee-for-Service Plan is a Medicare health plan offered by a private insurance company. It is not the same as the Original Medicare Plan, which is offered by the Federal government. In a Private Fee-for-Service Plan, Medicare pays a set amount of money every month to the private company. The private company provides health care coverage to people with Medicare on a pay-per-visit arrangement. The insurance company, rather than the Medicare program, decides how much you pay for the services you get.

Medicare Specialty Plans

Medicare is working to create specialty plans, which are new ways to provide more focused health care for some people. These Medicare specialty plans are designed to give you all your Medicare health care, as well as more focused care to manage a disease or condition such as congestive heart failure, diabetes, or end-stage renal disease. The goal is to provide your health care in an efficient, effective, high quality manner.

More Information About Other Plans

You can get more information about your health care options from the following publications:

• Medicare & You.--This general guide describes the benefits, costs, and health care service options available.
  
• Guide to Health Insurance for People with Medicare.--A guide to how other health insurance plans supplement Medicare and some shopping hints for people looking at those plans.

To get a copy of these, or any other, publications, call the Medicare toll-free number 1-800-633-4227 or go to www.medicare.gov on the Internet and click on “Publications.”

Some publications may instruct you to call or visit an office of the Social Security Administration for assistance. Railroad retirement beneficiaries should contact the nearest Railroad Retirement Board office.

For information on other health care plan options in your area, call the Medicare toll-free number 1-800-633-4227 and ask for a free, up-to-date list of all the plans offered where you live. Or you can go to www.medicare.gov on the Internet and click on “Medicare Personal Plan Finder,” where you can also get a summary of your health care options and what each plan in your area offers.

If you need to talk to someone about deciding which plan is right for you, you can call your State Health Insurance Assistance Program and a volunteer counselor will help you. You can get the telephone number of the program in your State by calling the Medicare toll-free number. Or you can go to www.medicare.gov, click on “Helpful Contacts” and then “General Medicare Information.”

Need More Information?

Railroad retirement beneficiaries should contact the nearest Railroad Retirement Board office for general information on their Medicare coverage. They can also use the Board’s automated toll-free number and Web site or Medicare’s information sources.

First	Back	Next	Last