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Original Medicare is a federally funded health insurance plan. It's designed for people age 65 or older and some disabled people under age 65. Medicare Part A pays for inpatient hospital care, skilled nursing facility care, and hospice care. Medicare Part B pays for outpatient surgery, doctor visits, and many other medicare services not covered by Part A. With Original Medicare, you get easy access to care.
- You can use any doctor or hospital that accepts Medicare (and most do)
- Original Medicare doesn't require you to select a primary care provider (PCP) or get a referral to seek care from a specialist
A Medicare Advantage plan is an alternative to Original Medicare and often Medicare Part D benefits which provides you with complete coverage for your Medicare benefits and often additional benefits beyond Original Medicare, such as routine vision care, routine dental coverage, and more. Many Medicare Advantage plans include Part D prescription drug coverage. Medicare Advantage plans are offered by private companies approved by Medicare.
Medicare Part D is a prescription drug option provided by Medicare-approved private insurance companies to help cover the cost of prescription drugs. Medicare offers prescription drug coverage to everyone with Medicare. Even if you don't take a lot of prescriptions now, you should still consider joining a Medicare drug plan. To get Medicare prescription drug coverage, you must join a plan offered by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. If you decide not to join a Medicare drug plan when you're first eligible, and you don't have other creditable prescription drug coverage, you will likely pay a late enrollment penalty when you do join.
There are two ways to get Medicare prescription drug coverage:
- Medicare Prescription Drug Plans: 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.
- Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called "MA-PDs."
To join a Medicare Prescription Drug Plan, you must have Medicare Part A and B. To join a Medicare Advantage Plan, you must have Part A and Part B. You must also live in the service area of the Medicare plan you want to join.
If you have employer or union coverage, call your benefits administrator before you make any changes, or before you sign up for any other coverage. If you drop your employer or union coverage, you may not be able to get it back. You also may not be able to drop your employer or union drug coverage without also dropping your employer or union health (doctor and hospital) coverage. If you drop coverage for yourself, you may also have to drop coverage for your spouse and dependents.
If you have limited income and resources, you may qualify for Extra Help to pay for Medicare prescription drug coverage. You may also be able to get help from your state.
You may join or leave a plan only at certain times. For example, each year you'll be able to choose a different Medicare Part D prescription or Medicare Advantage plan during an annual election period. If you're eligible for both Medicare and Medicaid, you may change plans at any time. (Limitations may apply).
The annual election period for Medicare Part D and Medicare Advantage plans is October 15 through December 7.
These insurance plans are offered by private insurance companies to help you cover health care costs, including co-insurance, copayments and deductibles—"gaps" in Original Medicare coverage.
Open enrollment in Medicare supplement plans vary by plan. You can enroll in a Blue Cross Blue Shield of Massachusetts Medex plan at any point during the year. You have, by law, at least 30 days to review a Medicare supplement policy. If you decide you don't want the coverage, you can get a full refund of any premiums you've paid during this "free look" period.
If you have both Medicare and Medicaid, you already qualify for low-income assistance to help pay for your prescriptions. If you don't qualify for Medicaid, you may still qualify for some assistance. If you're a Massachusetts resident, contact the Prescription Advantage Program at 1-800-AGE-INFO (1-800-243-4636), (TTY: 1-877-610-0241), Monday through Friday, 9 a.m. to 5 p.m. ET.
If you aren't getting extra help, you can see if you can qualify by calling:
- 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) 24 hours a day/seven days a week
- The Massachusetts Department of Elder Affair's SHINE program office at 1-800-AGE-INFO (243-4636)
- The Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778) Monday through Friday, 7:00 a.m. to 7:00 p.m. ET
Yes, you may have the option to have these premiums deducted from your Social Security check (just like your Part B premium). If you're enrolled in an employer plan you're ineligible for the deduction from your Social Security check.
If your employer offers to continue your group health coverage after you retire, carefully weigh your options and consider Medicare coverage alternatives available to you as an individual. If you decline your group health coverage you may not be able to return to it if you change your mind later. Ask your benefits administrator for more information.
MACRA is the Medicare Access and CHIP Reauthorization Act, a federal law passed in 2015 to change how Medicare reimburses health care providers. The MACRA model reimburses health care providers based on the quality of their services, rather than the quantity of services they perform. The value of care takes precedence over the volume of care.
The new MACRA law became effective January 1, 2020. It continues to help control overall health care costs, and manages “waste” in the health care system by limiting federal reimbursements to health care providers. To see how this law may affect you, visit the dedicated Frequently Asked Questions about the federal MACRA Mandate page.