Learning Center > A Guide To Medicare Part B

A Guide To Medicare Part B

With thousands of Americans turning 65 every day, Medicare plans are in the news, on commercials, and on people’s minds more than ever before. To make the best choices for coverage, it’s important to have a solid understanding of the program, starting with Original Medicare.

In this guide to understanding Medicare Part B, we’ll cover some Medicare frequently asked questions and details about the medical services aspect of Original Medicare, including:

  • What Is Medicare Part B?
  • What Benefits Are Covered Under Medicare Part B?
  • Who Is Eligible For Medicare Part B?
  • Do I Have to Apply for Medicare Part B?
  • How Do I Sign Up for Medicare Part B?
  • Who Gets Medicare Part B Automatically?
  • Can I get Part B If I Have Kidney Failure (ESRD)?
  • I Have Medicare Part A – Do I Need To Get Medicare Part B?
  • Delaying Part B Enrollment
  • Medicare Part B And Medigap
  • How Much Does Medicare Part B Cost?
  • How To Get Help With Part B Premiums

What Is Medicare Part B?

Medicare Part B is the part of Original Medicare that covers outpatient medical care. Medicare Part B covers outpatient services from doctors and other health care providers, home health care, durable medical equipment, and some preventive services.

In other words, you can think of Medicare Part B as Medicare medical insurance that doesn’t require an inpatient hospital stay. (Hospital coverage falls under Medicare Part A.)

Part B is a part of Original Medicare (along with Part A), but you can also choose to receive your Medicare Part B benefits as part of a Medicare Advantage plan.

If you go this route, rest assured that Medicare Advantage plans are required to cover everything that Medicare Part B covers, so you won’t be missing out on any benefits if you choose to use this private health insurance option.

What Does Medicare Part B Cover?

Medicare Part B offers comprehensive coverage that is broken down into 2 categories:

  • Medically necessary services, which are intended to diagnose or treat a medical condition.
  • Preventive services, which prevent or detect illnesses at an early stage.

You will be covered under Part B when you use these services:

  • Doctor’s visits, including specialists
  • Preventive screenings
  • Physical and occupational therapy
  • Mental health coverage
  • Durable medical devices (DME)
  • Infusion-based cancer treatments, like chemotherapy
  • Limited prescription drugs and certain vaccines
  • Outpatient hospital services, including same-day surgeries

Although most vaccines are covered by Medicare Part D, Medicare Part B will cover the COVID-19 vaccine. Medicare Part B also covers the flu, hepatitis B, and pneumococcal vaccines.

Medicare Part B generally only covers medications that you’d receive at a doctor’s office. Meanwhile, prescription drugs that you fill at a pharmacy are covered under Medicare Prescription Drug Plans.

Does Medicare Part B Cover Dental, Vision, And Hearing?

Medicare Part B offers minimal coverage for dental, vision and hearing services.

Part B covers medically-necessary procedures like glaucoma screening, but doesn’t cover routine vision, hearing, or dental services.

However, many Medicare Advantage plans do offer coverage for routine vision, hearing, and dental care.

How Much Does Medicare Part B Cost?

There are 2 different types of costs associated with Medicare Part B:

  • Premiums you pay to have coverage, and
  • Costs you pay out of pocket when you receive covered services and procedures.

When you enroll in Medicare Part B, you will have to pay a monthly premium. For 2021, the base premium is $148.50. The premium might have been higher, but it was capped by Congress due to the 2021 changes to Medicare.

You will also have to pay out-of-pocket costs when you use your Medicare Part B benefits. You can expect to pay these costs out of pocket:

  • Medicare Part B deductible: $203 for 2021.
  • Medicare Part B coinsurance: 20% of the Medicare-approved charge for every covered service or procedure.
  • Medicare Part B excess charges: Up to 15% of the Medicare-approved charge for services and procedures administered by providers who don’t accept Medicare-approved prices.

It’s important to note that unlike private health insurance, your costs are not capped under Original Medicare Part B. For this reason, many people choose to add Medigap coverage, or switch from Original Medicare to a Medicare Advantage plan. And you must continue to pay the Part B premium even if you choose to enroll in a Medicare Advantage plan.

If you receive retirement income from Social Security or the Railroad Retirement Board, your Medicare Part B premium will be automatically deducted from your checks.

Cost of Medicare Part B for Higher Earners

Higher earners may also have an additional charge added to their Part B premiums. The extra amount, known as IRMAA (Income Related Monthly Adjustment Amount), kicks in for single taxpayers with incomes over $88,000 and joint filers with incomes over $176,000.

There are six income levels of IRMAA. As an example, if you are a single filer with an income of $90,000, your total Medicare Part B premium for 2021 would be $207.90. Of this amount, the base premium is $148.50 and the IRMAA amount is $59.40.

Click here to see a full list of all IRMAA amounts for 2021.

How To Get Help With Medicare Part B Premiums

Medicare is designed to be as affordable as possible, but the premiums may be challenging to those on smaller, fixed incomes.

Medicare Savings Programs can help qualifying Medicare beneficiaries with the costs of their premiums. Beneficiaires may also qualify for assistance with Medicare Part B deductibles and coinsurance amounts.

To qualify for one of the Medicare Savings Programs, you must meet certain income and asset limits. Generally speaking, if you qualify for Medicaid, you will qualify for Medicare Savings Programs. Depending on your level of Medicaid benefits, you might not have to pay any part of the Medicare Part B premium.

You must apply for Medicaid and the Medicare Savings Programs through your home state.

Medicare Part B Eligibility Requirements

Anyone who qualifies for premium-free Part A is automatically eligible for Medicare Part B. If you must pay a premium for Medicare Part A, then your Medicare Part B eligibility depends on whether you’re a U.S. citizen, or a permanent legal resident for five or more continuous years.

If you meet the citizenship or residency requirement, you will become eligible to enter Medicare Part B when one of these applies:

  • You turn 65 years old,
  • You receive Social Security Disability Income for 24 consecutive months, regardless of age, or
  • You’re diagnosed with either End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig’s disease), regardless of age.

Do I Have to Apply for Medicare Part B?

Medicare Part B is a voluntary program, which requires paying a monthly premium. Generally speaking, you don’t need to apply for Part B if you have health insurance through your (or your spouse’s) current employer.

For example, if you or your spouse are still working past age 65 and have an employer or union health plan, you can delay Part B enrollment. We’ll talk more about this later.

If you don’t have health insurance that Medicare considers as creditable coverage, you should enroll in Part B when you’re first eligible to avoid a late enrollment penalty.

How Do I Sign Up For Medicare Part B?

Depending on your circumstances, you may be automatically enrolled into Medicare Part B, or you may need to sign up.

If you have to sign up manually, you can do so online on the Social Security Administration’s (SSA) website or in person at your local Social Security office. You can also apply for Social Security Medicare Part B benefits by phone, or fax an application to the SSA.

But if you sign up manually, you must be sure to enroll during a valid Medicare Part B enrollment period. There are 3 enrollment windows for Part B:

  • Medicare Part B Initial Enrollment Period (IEP): A 7-month period that begins 3 months before you turn age 65 (or meet the eligibility requirements) and ends 3 months after you meet the eligibility requirements.
  • Medicare Part B General Enrollment Period (GEP): An enrollment window that runs from January 1 to March 31 of each year. The GEP is for people who have missed their initial enrollment period and don’t qualify for a Special Election Period.
  • Medicare Special Election Periods (SEPs): Only available in special circumstances. The most common SEP is for those who work past age 65 and delay taking Medicare Part B. In this case, you would be eligible for a Medicare Part B Special Enrollment Period when your employer or union health insurance coverage ends.

Who Automatically Gets Medicare Part B?

If you’re turning 65 and aging into Medicare: You will automatically receive Part B coverage only if you’re already receiving benefits from Social Security or the Railroad Retirement Board at least four months before your 65th birthday.

If you qualify for Part B before age 65: You’ll be automatically enrolled if you receive Social Security or Railroad Retirement Board disability benefits for 24 consecutive months. Your Medicare Part B coverage will begin on the first day of the 25th month you receive disability payments.

If you’re automatically enrolled, you can expect to receive your Medicare Part B card up to three months before your 65th birthday or your 25th month of disability benefits.

Note: ALS patients of any age will enter Part B on the first day they receive Social Security Disability Income. But if you live in Puerto Rico, or if you have ESRD, your enrollment is not automatic. You will need to apply for Medicare Part B manually.

Can I Get Medicare Part B If I Have Kidney Failure (ESRD)?

Yes, you can qualify for Medicare Part B based on an ESRD diagnosis. However, your enrollment isn’t automatic, so you’ll need to apply for coverage.

The eligibility requirements for ESRD can be complicated and change based on whether or not you receive a kidney transplant.

However, most people will begin Medicare Part B coverage after receiving dialysis for 4 consecutive months at a dialysis treatment facility, or as early as the first month of starting dialysis at home.

When enrolling in Medicare Part B with ESRD, it’s important to keep in mind that you’ll get more complete coverage if you also enroll in Part A.

Note: Beginning January 1, 2021, Medicare beneficiaries with ESRD will be able to get coverage through Medicare Advantage plans as outlined in our 2021 changes to Medicare article.

Do I Need To Get Medicare Part B If I Have Medicare Part A?

Although most people receive Part A coverage without paying a premium, you will have to pay a monthly premium when you begin Part B, so you’ll want to make sure you really need Part B coverage before you enroll.

As mentioned earlier, most people should enroll in Medicare Part B when they first become eligible. However, if you’re still working and have qualifying health insurance, you may choose to delay taking Part B.

Retired military members who have TRICARE coverage and Medicare Part A must also have Part B to remain eligible for TRICARE.

Delaying Medicare Part B Enrollment

If you don’t need Medicare Part B coverage when you become eligible, you can delay enrollment. This way, you won’t pay a premium for coverage you don’t need.

You can consider delaying Medicare Part B when:

  • You are still working for an employer with more than 20 employees, and your drug and medical coverage meet certain Medicare requirements, or
  • You’re covered by a spouse’s employer or union plan that meets the same criteria.

It’s very important to enroll in Medicare Part B when you’re first eligible, or make certain that your employer coverage meets Medicare’s requirements for coverage. If you enroll late, or if your employer coverage isn’t adequate, you may have to pay the Medicare Part B penalty .

Late enrollment penalties are added to your base Medicare Part B premium (more details below). And you will pay the penalty as long as you’re enrolled in Medicare Part B, which is probably for the rest of your life.

Note: The Medicare Part B late enrollment penalty is 10% for each12-month period that you went without coverage. This amount can add up over the years, which is why it’s so important to enroll when you’re first eligible.

Medicare Part B Special Enrollment Period If You’re Still Working After Age 65

If you delay taking Medicare Part B because you’re still working or covered by your spouse’s employer or union plan, you’ll receive a Special Enrollment Period when your employer coverage ends.

Typically, you’ll be eligible for an 8-month enrollment window, which begins the earlier of:

  • Your last day of employment, or
  • The last day of your employer coverage.

During this 8-month window, you can enroll in Medicare Part B and a private plan like Medicare Advantage or Medicare Supplement insurance, if you choose to.

How Medicare Part B Works With Medigap Plans

Due to the out-of-pocket costs you’re responsible for under Medicare Part A and B, you may choose to purchase private insurance coverage that enhances your Original Medicare benefits.

Medicare Supplement insurance, also known as Medigap, covers some or all of the out-of-pocket expenses that you would normally have to pay.

You get a one-time Medigap Open Enrollment Period which lasts for 6 months and begins as soon as both of these are true:

  • You are at least 65 years old, and
  • You are enrolled in Medicare Part B.

Since your open enrollment window doesn’t start until you actually enroll in Medicare Part B, you’ll still have the right to buy Medicare Supplement insurance even if you delay taking Part B past age 65.

The benefit of enrolling in Medigap during your open enrollment period is that your application can’t be denied and you can’t be charged more because of a health condition.

If you want to get Medigap after your 6-month open enrollment period, you will probably have to go through medical underwriting. If this is the case, your coverage can be declined, or you might be charged a higher premium for pre-existing conditions.

When you have Medigap, Original Medicare is your primary coverage, and your Medigap policy supplements it. You will show both your Original Medicare card and your Medigap card when you receive Medicare-covered services.

Understanding Medicare Part B Conclusion

As you approach Medicare Part B eligibility, consider these 3 tips before your Medicare Part B enrollment:

  • Know if you’re going to work beyond age 65. If you’ll have qualifying coverage from your employer or union, then you’ll want to delay taking Part B to avoid paying premiums.
  • If you’re automatically enrolled in Part B and don’t yet need it, you’ll have to contact Social Security to cancel your Medicare coverage. You will be asked to return your Medicare card.
  • Since you can be subject to late enrollment penalties, don’t delay taking Part B just because of the cost.

If you decide to keep Medicare Part B or apply if you’re not automatically enrolled, consider if you want to supplement your coverage. Most people choose to add one or more of these options to their Original Medicare coverage:

Other people choose to get their Original Medicare (Parts A and B) through Medicare Advantage (Medicare Part C). These plans combine Medicare Parts A and B, and most include prescription drug coverage. If you enroll in Medicare Advantage, you can’t have a Medigap policy at the same time.

To make a sound decision, be sure to consider your budget and healthcare needs while making sure your doctor accepts any potential plan. You’ll also want to ensure that your medications are covered by the plan.

For more help with understanding Medicare Part B or finding private Medicare plan options in your area, call 800-620-4519 to speak to a licensed insurance agent. You can also find Medicare Advantage plans or compare Medicare Part D plans online through our plan comparison tool.

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The illnesses that fall under the heart disease category include: Coronary artery disease (CAD) Heart rhythm problems Congenital heart disease Infections of the heart tissue Heart valve disease Cardiovascular Disease Risk Factors Many of the biggest risk factors of cardiovascular disease are lifestyle related. And while there’s a general assumption that these factors are the sole cause, many people are actually born with heart disease. It can be congenital and hereditary. But those with lifestyle risk factors have control over heart disease prevention. The main risk factors and causes of heart disease include: Obesity High cholesterol Diabetes Smoking High blood pressure And these causes of heart disease can be directly tied to such behaviors as: Poor diet Poor physical activity Too much alcohol Tobacco use Genetics or heredity Simply put, the lifestyle habits (good or bad) that we form are what lead to the major risk factors for cardiovascular disease. Genetics and heredity may then play a role in whether or not we actually develop heart disease. 4 Tips To Prevent Cardiovascular Disease CVD As we mentioned above, the fact that so many of the risk factors for CVD are lifestyle related can be a silver lining, meaning we can make smart choices and avoid unhealthy behaviors to protect our hearts. Now let’s walk through some healthy habits to maintain good heart health. #1. Stop Smoking Quitting smoking is almost universally hailed as the biggest step to reduce your risk of heart disease. Smoking is considered the most easily avoidable lifestyle factor that leads to cardiovascular disease. So if you currently smoke, make an attempt to stop now. Quitting smoking will also save you money, making this heart disease prevention tip a no-brainer. #2. Eat Healthy Diet also plays a big role in the health of your heart. A poor diet multiplies and compounds risk factors, but a smart, healthy diet can reduce your risks and get your heart in great shape. You should always speak with your doctor about nutrition and heart healthy diet options. But generally speaking a heart healthy diet may include: Fruits and vegetables Whole grains Low-fat dairy products Skinless poultry and fish Nuts and legumes In addition to eating these nutritious foods, another suggested tip is to limit your saturated fat, sodium, and sugar intake. This type of diet fits into the DASH (Dietary Approaches to Stop Hypertension) eating plan. #3. Stay Active There’s no getting around the fact that an active lifestyle is a healthy one. But you don’t have to jump right in and overdo it. In fact, gentle but steady exercises can be great way to help prevent heart disease, including: Walking 30 minutes per day Cycling Swimming The main point is to pick an activity that you enjoy. So if you have a scenic path, beach, or lake nearby, consider talking walks or riding your bike there. You should also have a backup plan for poor weather or to keep safe and healthy during COVID-19. Research home workout apps or programs on platforms like YouTube or you Smart TV. But just remember: If you over-commit to exercise and activity, you may fall off the wagon completely. Instead, start small, and add time and distance gradually. If you make it a firm part of your routine, you’ll stick to it. Again, always be sure to consult your doctor before developing an exercise or activity regimen for heart health. #4. Stay Informed About Your Cardiovascular Disease CVD Risks One of the most important heart disease prevention tips is to stay proactive and empowered about your own personal health. This is especially true if you have a family history or genetic predisposition. Here are some key strategies: Don’t miss or delay your doctor’s appointments. If recommended, make sure you get cardiovascular screenings and tests. If you’re on heart disease medications, be sure to consistently take them and follow your treatment plan. Ask questions and be proactive when it comes to your health and wellbeing. How Does Medicare Cover Cardiovascular Disease CVD? If you’re on Medicare or aging into Medicare,and cardiovascular disease prevention and treatment is important to you, you’re in luck. All aspects of the Medicare program cover heart disease related measures. This includes Medicare cardiovascular screening, treatment, and healthy lifestyle tools. Heart disease prevention and treatments are covered by: Original Medicare Part A Original Medicare Part B Medicare Part D drug plans Medicare Advantage plans (Part C) Medicare Supplement Insurance (Medigap plans) In the most basic sense, Medicare will cover all the stages of cardiovascular disease, including: Annual screenings (covered by Part B) Doctor’s visits, both primary and specialists (covered by Part B) Heart condition medications (covered by Part D) Cardiovascular tests and procedures (covered by Part B) Hospitalizations (when admitted as an in-patient, covered by Part A) When you use Medicare Part B under Original Medicare, you can expect to pay: Part B deductible ($203 for 2021) Part B coinsurance (20% of the Medicare-approved charges) Part B excess charges (up to 15% of the Medicare-approved charges if you use providers who don’t agree to Medicare’s prices) When you use Part A coverage under Original Medicare, your costs may include: Part A deductible ($1,484 per benefit period) Part A coinsurance of $0 per day (after you pay the deductible) for hospital stays of up to 60 days Part A coinsurance of $371 per day for hospital stays over 60 days Medicare Cardiovascular Screenings Medicare covers cardiovascular screenings, which involves a blood test once every five years. 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Tip: You can use our prescription lookup tool to see if your drugs are covered under Medicare Part D. Medicare Chronic Condition / Disease Management Programs If you have more than one chronic condition, you can qualify for special disease management programs. These are also covered by Original Medicare, but you’ll still be responsible for your standard cost sharing. You may also have to pay a monthly fee to participate in these chronic care management services. Under these management programs, you’ll work with your healthcare professionals to craft a comprehensive health plan tailored to your heart condition. A chronic care management plan may include: Goal setting and health evaluations Working with all of your specialists Managing your medications Cardiovascular Disease And Private Medicare Plans So far, we’ve reviewed your coverage and costs under Original Medicare. But if you choose a private plan option like Medicare Advantage or Medigap, these plans will cover your cardiovascular health as well. If you enroll in a Medicare Supplement plan, your plan will pay part of the costs you’d normally pay out of pocket. If you enroll in a Medicare Advantage plan, you’ll likely pay small copayments - similar to what you’d pay under Original Medicare. But with Medicare Advantage, you’ll have out-of-pocket spending protection, since these plans put a cap on your annual health spending. Most Medicare Advantage plans and some Medigap plans also offer access to non-Medicare health and wellness benefits. These can include gym memberships, SilverSneakers or other health programs that can help you lower your risks of cardiovascular disease. Conclusion: Medicare & Cardiovascular Disease Coverage With lifestyle and healthy habits, you can control many of the factors that may lead to cardiovascular disease. And if you currently have heart disease, you can manage your condition with a healthy lifestyle and tests, specialists, and medications covered by Medicare. To make the most of your private Medicare coverage (Part C or Part D): Check to ensure your medications are covered by the plan you’re considering. Make sure you’ll remain in-network with your doctors and specialists. And if you want help choosing a Medicare plan, you can work with a licensed insurance agent who can help you find Medicare plans and give you free Medicare quotes (with no obligation to enroll in a plan). Just call 1-800-620-4519 to speak with one of our licensed insurance agents, or use our Medicare plan comparison tool to find Medicare plans in your area. Note: This article is for general education purposes and does not replace the advice of a medical professional. Always seek the guidance of your physician or a medical professional for medical advice, diagnosis, and treatment.
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If you’re enrolled in Part A and B before age 65 due to a disability or chronic condition, you’re still eligible for Medicare Advantage coverage. How Do Medicare Advantage Plans Work? Medicare Advantage health care plans work like the employer-sponsored health insurance plans you may be used to from your previous or current job. Medicare Advantage plans provide comprehensive coverage, and you usually need to stay in-network to receive care. You’ll typically have some out-of-pocket expenses when you receive services and procedures under your Medicare Advantage policy. These costs typically come in the form of copayments or coinsurance that you’ll pay to your provider when you receive care. An important point to remember is that all Medicare Advantage plans have an annual out-of-pocket (OOP) maximum that limits the total amount you can spend in any year. But you do not have an OOP with Original Medicare. What Types Of Medicare Advantage Plans Are Available? There are 6 types of Medicare Advantage plans, including: Medicare Advantage HMOs (Health Maintenance Organizations) Medicare Advantage PPOs (Preferred Provider Organizations) Medicare Advantage PFFS (Private Fee-For-Service Plans) Medicare Advantage SNP (Special Needs Plans) Medicare Advantage HMO-POS (HMO Point-Of-Service Plans) Medicare Medical Savings Plans (MSPs) In this Medicare Advantage guide, we’ll focus on Medicare Advantage PPO plans and Medicare Advantage HMO since they’re the most common types of MA plans. The Difference Between Original Medicare and Medicare Advantage The primary difference between these programs is that Medicare Advantage is an alternative to Original Medicare. When you join a Medicare Part C plan, you no longer receive your Medicare benefits through Original Medicare. Medicare Advantage plans are offered and administered by private insurance companies. But these private insurance companies must comply with many rules and regulations set by the Medicare program. Pros And Cons Of Medicare Advantage Plans vs. Original Medicare Medicare Part C plans have many advantages when compared to Original Medicare. The 3 biggest pros of Medicare Advantage plans are: Annual Out-of-Pocket Maximum spending cap Availability of prescription drug coverage* Extra benefits for things not covered by Original Medicare *Note: Some MA plans are available without prescription drugs. These additional benefits from Part C make Medicare Advantage a more complete coverage option than Original Medicare. MA plans can have their drawbacks in comparison to Original Medicare, depending on your healthcare needs. The 3 biggest pros of Original Medicare are: #1. You can see any doctor or go to any facility anywhere in the country, as long as they accept Medicare. #2. There are no networks. Most Medicare Advantage plans have some kind of network restrictions. #3. You don’t need referrals to see specialists. With some Medicare Advantage health care plans, such as HMOs and Special Needs Plans, you usually need referrals from your primary care physician to visit a specialist. What Does Medicare Advantage Cover? Medicare Advantage plans provide coverage that matches Original Medicare Parts A and B. Generally speaking, your Medicare Advantage plan will cover the same service or procedure as Original Medicare. But there is one exception to this rule, which we’ll cover below. Medicare Advantage plans cover the following services. Medicare Part A Services Medicare Part A covers services that take place in healthcare facilities or institutions like: Inpatient hospital stays Skilled nursing services (not room and board) Hospice care In-home care Note: Hospice care is usually not covered by Medicare Advantage plans. Instead, hospice care is covered under Original Medicare, even if you’re enrolled in a Medicare Advantage plan. However, a new test program in 2021 will explore Medicare Advantage plans providing hospice benefits. Medicare Part B Services Medicare Part B services and procedures are considered more routine and non-emergency in nature than Part A. Common Medicare Part B services include: Doctor’s visits, including specialists Physical and occupational therapy Lab and diagnostic testing services like blood work and x-rays Durable medical equipment Mental health services Ambulance services Some cancer treatments, including chemotherapy As mentioned, Medicare Advantage plans cover all of these services with the exception of hospice care. Medicare Advantage And Prescription Drugs Most Medicare Advantage plans offer prescription drug coverage. These plans are also known as Medicare Advantage Prescription Drug Plans (MAPDs), and they include Medicare Part D. Medicare Advantage Extra Benefits When considering Medicare Advantage pros and cons, it’s essential to take extra benefits that Medicare Advantage could offer to you. Many of these benefits are not provided through Original Medicare. Medicare Advantage benefits may include: Fitness programs: SilverSneakers, gym memberships, and fitness trackers. Vision care: Eye exams, contact lenses, and sometimes eyeglass frames. Hearing care: Exams and often discounted hearing aids. Dental coverage: Some plans have basic dental benefits built in, others offer dental coverage for an extra premium. Transportation: Rides to and from medical appointments. Meal Deliveries: For qualified people returning home from the hospital or skilled nursing facility Telemedicine services and virtual healthcare. Note: Medicare Part C plans have the ability to choose which, if any, extra benefits to offer. These insurance companies may also make changes to their Medicare benefits and offerings each year. Who Is Medicare Advantage Good For? You should consider enrolling in Medicare Advantage if: You want to put a cap on your total out-of-pocket spending under Original Medicare. You want prescription drug coverage without paying for a separate Part D drug plan. You need some of the extra benefits (vision, hearing, private home aides) that come with many Medicare Part C plans. You don’t want to pay for Medicare Supplement (Medigap) plans. You don’t mind using a network of doctors and facilities. You don’t mind needing referrals to see specialists. You don’t mind paying small copays each time you see a doctor. How Much Does Medicare Advantage Cost? Medicare Advantage plans have several costs associated with them. Before we dive into each cost, it’s important to remember that you always have to pay your Part B premium in order to have Medicare Advantage. Now, some Medicare Advantage plans offer a benefit that covers part, or all, of your Part B premium. But check the plan benefits closely to see if this is offered by a specific Medicare Advantage plan. Beyond this Part B premium, you might face the following Medicare Advantage plan costs: Monthly premium Annual deductible Copayment Coinsurance You might have a monthly premium for your Medicare Advantage plan, but these premiums tend to be low. For example, the average Medicare Advantage premium was $23.63 per month in 2020. However, many Medicare Advantage plans do not have a monthly premium. In 2020, 60% of people enrolled in Medicare Advantage didn’t pay a monthly premium. Some Medicare Part C plans have an annual deductible, but again, many do not. If your plan does have an annual deductible, this means you’ll have to pay a certain amount before the plan begins paying benefits. Note that there may be separate deductibles for drug coverage and medical benefits. Beyond premiums and deductibles, the most common expenses you’ll have with Medicare Advantage plans are copayments and coinsurance. These two terms are referred to as “cost-sharing.” This is what you’ll pay out of pocket when you receive covered services. All the amounts you pay during the year count towards your annual out-of-pocket cap. Examples Of Medicare Advantage Costs Let’s look at 3 examples of how these Medicare Advantage costs work in a Medicare Advantage HMO plan. (Note: These costs are not the actual costs for any specific plan, but rather, in the range of costs for plans that you may have access to.) Scenario 1: Medicare Part B Services You injure yourself shoveling snow on your property, and you go to the doctor for an examination. You’ll pay a copay of $20 to see your primary care physician who then refers you to an orthopedic specialist. Your orthopedic specialist charges you a $35 copay for the office visit and wants you to get x-rays. You pay a $50 copay for the x-rays. Fortunately, nothing is broken or torn, so your specialist refers you to physical therapy. You pay a copay of $40 for four physical therapy sessions. Your total out-of-pocket spending for this injury is $265, spread out over a month-long period. All of these costs count towards your Medicare Advantage out-of-pocket maximum. Scenario 2: Medicare Part A & B Services You experience the symptoms of an irregular heartbeat, so you’re admitted to the hospital as an inpatient. You spend two nights in the hospital. You pay a copay of $300 per day, which amounts to a total of $600. After you’re released from the hospital, you continue to see a cardiologist, and you pay a $35 copay to see this specialist each time you visit. Scenario 3: Cancer You’re diagnosed with a treatable cancer, and you’re given chemotherapy. The copay for this treatment is 20% of the Medicare-approved cost. Although 20% amounts to more than $20,000, you hit your annual out-of-pocket maximum, so your costs are capped at $5,900 for the year. When Can You Enroll In Medicare Advantage? You can normally enroll in or change your Medicare Advantage coverage during 3 periods of time: Your Initial Enrollment Period (IEP) when you’re first eligible for Medicare. The Medicare Annual Enrollment Period (AEP), which runs from October 15 to December 7 each year. The Medicare Advantage Open Enrollment Period from January 1 to March 31 each year - however, this MA open enrollment is only for those already in a Medicare Advantage plan. Enrolling In Medicare Advantage For The First Time If you’re turning 65, you can enroll in Medicare Advantage during your Initial Enrollment Period (IEP). Your IEP lasts for 7 months, which begins 3 months before your 65th birthday, includes that birthday month, and ends 3 months after you turn 65. If you’re under 65, your first chance to enroll in Medicare Advantage starts: After your 24th month of receiving Social Security disability benefits, or At any age if you have Amyotrophic Lateral Sclerosis (ALS), also called Lou Gherig’s Disease, or if you have End-Stage Renal Disease (ESRD). Changing Your Medicare Coverage During AEP The Medicare Open Enrollment Period, also called the Medicare Annual Enrollment Period or Annual Election Period, is a good time to decide whether Medicare Advantage or Original Medicare is right for you. Also keep in mind that Medicare Advantage plan benefits can change annually. So if you have a MA plan, you should check to make sure the plan still meets your needs. Here are the actions you can take during AEP: Change from Original Medicare to a Medicare Advantage plan. Change from one Medicare Advantage plan to another. Disenroll from your Medicare Advantage plan and go back to Original Medicare. Change from one prescription drug plan (Medicare Part D) to another. Enroll in a prescription drug plan. Cancel your prescription drug coverage. If you enroll in, or switch your Medicare Advantage insurance during AEP, your new coverage will be effective on January 1st of the following year. You may also be able to enroll in a Medicare Supplement plan if you drop your Medicare Advantage coverage during AEP. The Medicare Advantage Open Enrollment Period If you’re enrolled in a Medicare Advantage plan, you have access to another enrollment period beyond AEP: The Medicare Advantage Open Enrollment Period (MA-OEP). MA-OEP runs from January 1 to March 31 of each year. During the MA-OEP, you can: Change from one Medicare Advantage plan to another. Drop Medicare Advantage, and return to Original Medicare. Add a Prescription Drug Plan if you return to Original Medicare. It’s important to keep in mind that the MA-OEP is only for people who already have a Medicare Advantage plan. If you change plans during the MA-OEP, your new coverage will be effective on the first day of the month after you enroll. Medicare Advantage & ESRD Coverage For all years before 2021, there was an exclusion for people with permanent kidney failure, known as End-Stage Renal Disease (ESRD). ESRD patients could not get new Medicare Advantage coverage. However, beginning January 1, 2021, ESRD patients will be able to enroll in or switch Medicare Advantage plans. Now the eligibility for Medicare Advantage and Original Medicare will be perfectly aligned. Medicare Advantage And Other Special Scenarios We mentioned earlier that Special Needs Plans (SNPs) are a type of Medicare Advantage insurance. Let’s take a look at some common types of SNPs, and how Medicare Advantage health plans are also helping people to get access to care and benefits during the coronavirus pandemic. Medicare Advantage And Chronic Conditions There are Medicare Advantage plan options for people with chronic conditions like diabetes and heart disease. These plans are known as Chronic Special Needs Plans (Medicare C-SNPs), and the benefits are tailored to help you treat and manage your chronic condition. These health plans often provide you with a care coordinator to make sure your needs are being met. These Special Needs Plans have Special Enrollment Periods (often called SEPs), so if you qualify for a C-SNP, you can enroll in it at any time. You won’t have to wait for an annual enrollment window. Medicare Advantage And Medicaid Another kind of Special Needs Plan exists for “Dual Eligibles” – people who are eligible for both Medicare and Medicaid. These plans, called Dual Eligible Special Needs Plans (D-SNPs), have cost-sharing that conforms to the Medicaid program, which means that most costs are $0. D-SNPs incorporate various prescription drug discount programs, depending on your income level - so you’ll save money on your prescriptions if you qualify. D-SNP plans also have more favorable enrollment windows, which allow you to access the benefits once you become eligible for Medicaid or extra help and at certain times during the year without waiting for an annual enrollment window. Medicare Advantage And COVID-19 Medicare provides Coronavirus coverage to help people combat the virus, which includes: No-cost lab testing. Antibody testing. All medically-necessary services and procedures, including hospitalizations and doctor’s visits. Coronavirus vaccine coverage, when one becomes available. Many Medicare Advantage health plans are waiving cost-sharing for these services. In this case, you wouldn’t pay a copayment or coinsurance for seeing a doctor or going to the hospital if you have COVID-19. Medicare has also approved an expanded role for telehealth and virtual doctor’s visits. And many Medicare Advantage health care plans offer these no-contact services with no out-of-pocket cost to you. Medicare Advantage Plan Ratings Every established Medicare Advantage plan is given a Medicare Start Rating by the Centers for Medicare & Medicaid Services (CMS). Star ratings range from 1 to 5, with 5 stars being the highest. Here’s a breakdown of what each rating means: 5-star rating: Excellent 4-star rating: Above Average 3-star rating: Average 2-star rating: Below Average 1-star rating: Poor Medicare Advantage plans are rated on several different metrics and are given an overall rating. This Medicare star ratings system is designed to help you get a feel for the level of quality and satisfaction a MA plan offers. Star ratings also give you an idea of how well a plan treats its members. Plans are rated on how quickly it responds to appeals and complaints and how they cover health screenings and preventative services. Plans are also rated for both medical benefits and prescription drug benefits, if the plan has drug coverage. How To Enroll In A Medicare Advantage Plan If you want to enroll in a Medicare Advantage plan, you’ll want to consider 3 things before joining: Make sure you find a plan that’s available in your area. Most Medicare Advantage plans are restricted to specific counties or states. Make sure your current doctors and medications are covered. This is especially important if you’re looking at a Medicare Advantage HMO plan. You’ll have to use the doctors that are in-network, and you’ll only get coverage for medications that are on the plan formulary. So make sure you investigate these before enrolling. Pay attention to star ratings. This can help you compare the overall quality among different plans. But keep in mind that new plans are not given star ratings until enough data has been collected for CMS to calculate a rating. Once you’ve found a plan, you have a few options to enroll, including: Online, by phone, or paper enrollment directly with the insurance company. Working with a licensed health insurance agent who can help you find, compare, and enroll in a Medicare Advantage plan of your choice. Medicare Advantage Guide Conclusion Medicare Advantage plans can be a great way to manage your out-of-pocket spending while enjoying extra benefits we covered, if you qualify. And they can offer some compelling advantages over Original Medicare, depending on your healthcare needs. So if you'd like to learn more about Medicare Advantage plans in your area, call 800-620-4519 to reach a licensed insurance agent who may be able to guide you to the right plan for your needs. You can also try online Medicare plan comparison tool.
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The transition from 2020 to 2021 offers many opportunities for people on Medicare. Whether you use Original Medicare, Medicare Advantage, or Medicare Supplement Insurance, you’ll find plenty of changes on the horizon. In this guide to 2021 changes to Medicare, we’ll review what happened during 2020, and dive into the Medicare changes and opportunities for 2021. Review of 2020 Medicare Changes To say that a lot happened in 2020 is a cosmic understatement. The big disruptor, of course, was COVID-19. The pandemic led to some sizable changes in the Medicare program. Some of the highlights from 2020 include: Medicare Supplement (Medigap) Plans C, F, and High Deductible F (HDF) were no longer available to newly-eligible beneficiaries as of 1/1/2020. For the second year in a row, the infamous “Donut Hole” was closed for Part D drug plans. Medicare expanded access to telehealth/virtual doctor appointment services. Many insurance companies, including the major Medicare Advantage plan sponsors, reduced or waived copayments for COVID-19-related care. Other than the COVID-19-related changes, the loss of Medigap Plans C, F, and HDF was probably the biggest change to Medicare for 2020. Those plans became unavailable for beneficiaries who first became eligible after 12/31/2019. This leaves Plan G as the most comprehensive Medigap plan available to all new Medicare beneficiaries. This plan will cover 100% of your Medicare deductibles, copayments, and coinsurance except for the Part B deductible. You’re responsible for the first $198 in Part B expenses for 2020. 2021 Medicare Costs 2021 Medicare Part A Costs Most people don’t pay a Part A premium because they paid Medicare taxes while working. So if you don’t get premium-free Part A, you pay up to $471 each month. Hospital Stays In 2021, you pay: $1,484 deductible per benefit period. $0 for the first 60 days of each benefit period. $371 per day for days 61–90 of each benefit period. $742 per “lifetime reserve day” after day 90 of each benefit period (up to a maximum of 60 days over your lifetime). Skilled Nursing Facility Stays In 2021, you pay: $0 for the first 20 days of each benefit period. $185.50 per day for days 21–100 of each benefit period. All costs for each day after day 100 of the benefit period. Medicare Part B Costs Most people will pay the Part B premium of $148.50 for 2021, but Social Security can share your exact Part B premium amount. You can also refer to the 2021 Medicare Costs guide from Medicare.gov for a complete breakdown of Part B premiums. Medicare Advantage Plan Changes For 2021 Many of the most exciting and notable 2021 changes to Medicare encompass Medicare Advantage plans. These plans, which are also known as Part C plans, are a private insurance alternative to Original Medicare. Medicare Advantage And ESRD The single biggest piece of news about Medicare Advantage for 2021 relates to those with End Stage Renal Disease (ESRD), also known as kidney failure. Beginning 1/1/21, Medicare beneficiaries with ESRD will be able to get coverage through Medicare Advantage plans. Prior to 2021, Medicare Advantage plans were generally able to exclude people with ESRD. This left ESRD patients in a tough spot, since under Original Medicare Part B, they paid 20% of the cost of dialysis. And this can get expensive very quickly since there was no out-of-pocket cap on their expenses under Original Medicare. Everyone with ESRD will now be able to get Medicare Advantage coverage. This may not reduce the amounts ESRD patients pay early in the year, since many Medicare Advantage plans charge a 20% coinsurance for dialysis as well. However, the great news for ESRD patients is that every Medicare Advantage plan has an annual out-of-pocket maximum. So once ESRD patients hit their annual spending caps, they’re not required to pay for any more medical expenses the rest of the year. Medicare Advantage And Hospice Benefits Another 2021 change to Medicare Advantage is a small test program for delivering hospice benefits. Historically, hospice coverage was provided by Original Medicare, even if you were in a Medicare Advantage plan. Starting in 2021, 53 Medicare Advantage plans across the country will provide hospice and palliative care. This is a very small number of plans, so it won’t affect most people at this point. However, if the test program works, you may see more Medicare Advantage plans offering this benefit in the future. Extra Benefits Through Medicare Advantage Plans Medicare Advantage is the subject of other big 2021 changes to Medicare. Beginning in 2021, additional benefits will be available. Extra benefits are benefits offered by Medicare Advantage plans that are not covered by Original Medicare. Examples may include: Dental coverage Vision and hearing coverage Chiropractic care For 2021, new Medicare benefits will be available. Many of them are designed to help you get care at home, and lend some support to caregivers. The new extra Medicare benefits in 2021 available through some Medicare Advantage plans include: Caregiver support Adult day health services In-home support services Therapeutic massage Acupuncture (for chronic low back pain only – this is also now covered under Original Medicare) But these extra benefits are not required or guaranteed. Instead, they are optionally provided by Medicare Advantage plans, and they can be changed or discontinued from year to year. Still, the availability of adult day health services and caregiver support will be beneficial for many of those on Medicare who struggle to care for themselves. For 2021, Medicare Advantage plan premiums are lower on average than in the past. In fact, the average Medicare Advantage plan premium is expected to be 11% lower in 2021 than in 2020. For 2021, the average Medicare Advantage plan premium will be $21 per month. On the other hand, the annual out-of-pocket maximum for in-network services is rising to $7,550. This is the highest it can be. Many plans will continue to offer lower out-of-pocket maximums. 2021 Changes To Medicare Drug Plans The other big news in 2021 changes to Medicare is the Part D Senior Savings Model. This model program, which is essentially a five-year test, will cap the price beneficiaries in participating to no more than $35 copays for a 30-day supply for many types of insulin. Under this new program for 2021, beneficiaries will have access to about 1,700 MAPDs (Medicare Advantage plans with Part D drug benefits) and stand alone Prescription Drug Plans that cap the cost of insulin. Another great detail about this program is that the cost for insulin won’t change, even if you enter the coverage gap during the year. You’ll still pay the same capped copayment. In addition, you won’t have to meet a deductible to get the $35 copay price. While not every plan has chosen to participate, CMS expects there to be at least one plan in all 50 states, the District of Columbia, and Puerto Rico. Given the effect of diabetes on the kidneys, patients with ESRD are in position to grab some great new benefits for 2021 and beyond. How To Prepare For 2021 Changes To Medicare For starters, you should make note that we expect a slight increase in Original Medicare costs, for 2021. Though we still don’t know what they’ll be, we expect there to be some increase in the Part B premium, even with the caps that will limit the total rise in costs. You can expect the same thing with deductibles. As with a normal Medicare Open Enrollment Period, also called the Medicare Annual Election Period (AEP), you should review your current coverage to see if switching plans for 2021 makes sense. New plans are available each year, so Medicare beneficiaries have until December 7 of each year to make a change to their plans for the following year. When comparing plans during the Medicare Open Enrollment Period, be sure to look at: The monthly premium (if any) Annual deductibles (if any) Cost structure, like copays and coinsurance amounts for Medicare Advantage and Prescription Drug Plans Out-of-pocket maximum amounts for Medicare Advantage plans Networks of doctors and medical facilities for Medicare Advantage plans Tip: It’s important to not just jump into a new plan because it has one appealing feature. You want to make sure that your doctors accept any new plan and that your current medications will be covered. If you use insulin, you may want to consider one of the standalone Prescription Drug Plans or MAPD plans participating in the Senior Savings Model program, if available. It’s estimated that those on insulin could save more than $400 per year on average. Besides savings on insulin through the Senior Savings Model program, ESRD patients who don’t currently have Medicare Advantage plan coverage should consider it for 2021. Moving to Medicare Advantage could help ESRD patients in 2 different ways: Moving from Original Medicare to Medicare Advantage Moving from Medicare Supplement Insurance to Medicare Advantage In the first case, you can take advantage of the out-of-pocket spending cap that a Medicare Advantage plan can offer. The out-of-pocket cap could be a real benefit for ESRD patients since it’s not only dialysis treatments that could count against the Medicare out-of-pocket maximum (OOPM). All spending on Medicare-approved services and procedures count towards the OOPM, so an ESRD patient might “max out” their spending during 2021 and get substantial relief the rest of the year. On the other hand, if you have ESRD and are currently covered by a Medigap (Medicare Supplement) plan, you might be able to save money on your monthly premium by switching to Medicare Advantage. And you might save money or come close to breaking even by switching from Medigap to Medicare Advantage, depending on the premiums and out-of-pocket maximums for plans in your area. Just be sure you run the numbers before making this move. Note: It can be difficult to get Medicare Supplement insurance coverage back after you move away from it. You might have to go through medical underwriting, which means you may be declined coverage as an ESRD patient with a pre-existing condition, unless you qualify for a guaranteed issue period. Due to the complexities of Medigap coverage, it’s a great idea to talk to a licensed insurance agent to see if switching to Medicare Advantage is a good idea. Get Help With Medicare If you still have questions about 2021 changes to Medicare and how they impact you, call 800-620-4519 to get help from one of our licensed insurance agents. Or you can try our free Medicare plan comparison tool to find Medicare plans in your area. There is no obligation to enroll in a plan.
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