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The popularity of Medicare Advantage plans is growing at a rapid pace. In 2020, more than 36% of all Medicare beneficiaries were enrolled in Medicare Advantage health care plans. Whether you’re already in a Medicare Advantage plan, you’re curious about them, or you’ve never heard of them, this Medicare Advantage guide is for you. In this in-depth Medicare Advantage guide, we’ll provide a Medicare Advantage overview that will answer your frequently asked Medicare questions and cover the following topics: What is Medicare Advantage and who qualifies for it The different types of Medicare Advantage plans and how they work The difference between Original Medicare and Medicare Advantage What Medicare Advantage plans cover Who should consider getting Medicare Advantage How much Medicare Advantage costs Medicare Advantage and special scenarios Medicare Advantage plan ratings When to enroll in Medicare Advantage How to enroll in Medicare Advantage What Is Medicare Advantage? Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. The Medicare Advantage program is a way for beneficiaries to access their benefits and rights under Original Medicare, but through a private insurance company instead of the Federal Government. A Medicare Advantage plan is a contract between a private insurance company and the Medicare program. By law, every Medicare Advantage plan must cover everything covered by Original Medicare (Medicare Part A and Medicare Part B). This means that if you choose to enroll in a Medicare Advantage plan, you can be confident that you’ll receive all the benefits you’re entitled to under Original Medicare. Who Qualifies For Medicare Advantage? To qualify for Medicare Advantage, you must be enrolled in Original Medicare Parts A and B. You also must continue to pay your Part B premium in order to keep your Medicare Advantage coverage. There are no age restrictions for Medicare Advantage plans. 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.

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 Medicare 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.

Before the Medicare Part D program started in 2006, thousands of Medicare beneficiaries faced high price tags on drugs and had little help with curbing those costs. But now, Medicare Part D, also known as Medicare Prescription Drug Plans, give Medicare beneficiaries prescription drug coverage options. So if you’re soon becoming eligible for Medicare Part D plans, or thinking about switching your existing Medicare coverage, this Medicare Part D guide will cover all the basics and answer your questions, including: What is Medicare Part D? Who is eligible for Medicare Part D? When can you enroll in Medicare Part D? What does Medicare Part D cover? How does Medicare Part D work? How much does Medicare Part D cost? How can I get help with Medicare prescription drug costs? What is the Part D Senior Savings Model? Tips to shop for Medicare Part D plans What Is Medicare Part D? Medicare Part D is one of the four “parts” of the Medicare program. Under Original Medicare, also known as Medicare Parts A and B, only very limited drug coverage is provided. Any medications covered are generally restricted to medicines that must be administered by a doctor. So as we mentioned before, the Medicare Part D program was created to help combat the high cost of prescription drugs. Medicare Prescription Drug Plans (PDPs) are available through private insurance companies. These plans help Medicare beneficiaries with the cost of medications, and are available in 2 forms: Standalone Prescription Drug Plans (PDPs) Medicare Advantage Prescription Drug Plans (MAPDs) Standalone Medicare drug plans work with Original Medicare. You stay enrolled in Medicare Part A and/or B, and obtain your prescription drug coverage through a Part D plan from a private insurance company. An MAPD plan is an alternative to the Original Medicare program, and combines all the benefits of Medicare Part A and B with drug coverage. All these benefits are provided by a private insurance company. Many private insurance companies provide Medicare Part D drug plans, including large nationally known ones and smaller, local companies. You can get Medicare Part D drug coverage in all 50 States. Who Is Eligible For Medicare Part D? Medicare Part D eligibility depends on meeting two criteria. To be eligible, you must be either: 1) Enrolled in Medicare Part B, or entitled to Medicare Part A; and 2) Live in the plan service area. If you qualify for Medicare Part A or are actively enrolled in Medicare Part B, then you can sign up for a standalone Medicare Prescription Drug Plan. Note: You must have both Medicare Part A and B if you want to enroll in Medicare Advantage. Medicare PDPs are a great fit for those who are Medicare-eligible and don’t have other creditable drug coverage. Examples of other prescription drug coverage include: Employer or retiree coverage Union coverage Certain military coverage, like VA benefits or Tricare, may provide good drug coverage. But they may not meet the criteria of “creditable coverage." Medicare Part D Enrollment Periods Medicare Initial Enrollment Period You generally have an initial enrollment window when you first become eligible for Medicare Part D. This first enrollment window is known as your Initial Enrollment Period (IEP), which lasts for seven months that include: Three months before the month you become eligible for Medicare The month you become eligible for Medicare Three months after the month you become eligible for Medicare Note: Your IEP lasts for seven months, regardless of whether you’re entering Medicare because you turn 65, or if you will enter due to permanent disability. If you have other creditable drug coverage, like from an employer or spouse’s employer, then you can delay enrollment into Part D without being subject to a penalty. Be sure that your drug coverage is considered creditable though. If you enroll in Medicare Part D after your IEP and don’t have other creditable drug coverage, then you will be subject to a late enrollment penalty. You can be subject to this penalty for either of 2 reasons: You had no drug coverage at all after becoming eligible for Medicare. You had drug coverage from another source, but it wasn’t considered creditable by Medicare. Your late enrollment penalty will increase for each month that you go without creditable coverage. So it’s very important to get Medicare Part D drug coverage as soon as you’re eligible, or make certain that your non-Medicare drug plan will satisfy Medicare coverage requirements. Medicare Part D Special Enrollment Periods Beyond your IEP, you may qualify for a Special Enrollment Period (SEP) that will allow you to enroll in, or change, your Medicare Prescription Drug Plan. Generally, you’ll qualify for an SEP when you experience abrupt changes in your circumstances. Some common SEPs include: Moving out of your plan’s service area. Losing creditable drug coverage from your employer. Your Medicare Drug plan doesn’t renew its contract with the Centers for Medicare & Medicaid Services (CMS). During a Special Enrollment Period, you generally will only have one chance to enroll in a Medicare Part D drug plan. Medicare Annual Enrollment Period Everyone eligible for Medicare can enroll in or switch Medicare Part D plans during the Annual Election Period (AEP), also called the Medicare Open Enrollment Period. AEP runs from October 15 to December 7 each year. If you enroll in a plan during this window, your coverage will be effective on January 1 the following year. During the Medicare AEP, you can: Change from one Prescription Drug Plan to another PDP. Switch from a Medicare Prescription Drug Plan to a Medicare Advantage Prescription Drug Plan (MAPD). Switch from one Medicare Advantage Prescription Drug Plan to another MAPD. Switch from Original Medicare to an MAPD. Drop your MAPD plan and return to Original Medicare with the option to add a standalone drug plan. Medicare Advantage Open Enrollment Period If you’re enrolled in a Medicare Advantage plan, you have access to an additional enrollment window: the Medicare Advantage Open Enrollment Period (MA-OEP). The MA-OEP is from January 1 to March 31 each year. During the MA-OEP, you can: Switch from one Medicare Advantage plan to another with or without drug coverage. Drop MAPD and return to Original Medicare. You’ll get a chance to enroll in a standalone Medicare Part D plan if you do this. What Does Medicare Part D Cover? Medicare Prescription Drug Plans provide coverage for many prescription drugs. These Medicare PDPs are required to cover certain kinds of medications and prohibited from covering others. Generally, medications that are approved for therapeutic use are covered by Part D. It’s important to know, however, that Medicare Part D plans are not required to cover every drug that’s on the market. Instead, Medicare drug plans are allowed to choose which drugs they will cover. There are certain requirements that plans must use when they create their lists. The list of covered drugs is known as a formulary. Because of this freedom, each plan’s formulary is unique. Every Medicare drug plan formulary is organized into tiers. Each tier includes certain kinds of drugs in the following manner: Tier 1 – generic drugs Tier 2 – preferred brand name drugs Tier 3 – non-preferred brand name drugs Tier 4 – specialty drugs Medicare Part D Coverage For Vaccines Medicare Part D covers many vaccines, including: Hepatitis B (if you are not considered intermediate or high risk for Hepatitis B) Shingles Tdap (tetanus) boosters Note: While Medicare PDPs do not cover flu or COVID-19 vaccines, they are covered by Part B. How Does Medicare Part D Work? The amount you pay for a medication changes during the year, depending on your coinsurance, copay, and how much you and your plan have paid for prescriptions. Your costs change as you move through four coverage stages. The 4 stages are: Annual Deductible Stage – you pay full price until you’ve paid $445 (for 2021). Initial Coverage Stage – you pay a small copayment or coinsurance for each prescription until the amount you pay plus what your plan pays hits $4,130 (2021 amount). Coverage Gap Stage (also known as the Medicare donut hole) – you pay 25% of the total cost for both generic and brand name drugs. Catastrophic Coverage Stage – once your total costs, plus the value of manufacturer discounts exceeds $6,550, then you pay no more than 5% of the cost for any medications for the rest of the year. You begin each year at the first coverage stage and move through them as the year progresses. Note: Only drugs on your plan’s formulary count against these coverage stages, so it’s very important that you find a Part D plan that covers your medications. How Much Do Medicare Drug Plans Cost? You pay a monthly premium to the insurance company for Medicare Part D coverage. In exchange, you pay less for many prescription drugs than if you paid cash at the pharmacy. You will likely pay some or all of these costs under Part D: Annual deductible Copayments Coinsurance If your plan has a Medicare Part D deductible, you’ll pay the full price for medications until you’ve met the deductible. For 2021, the maximum Part D deductible is $445. While many PDP plans don’t have an annual deductible, most do, and the average 2021 Medicare Part D deductible across all Part D plans is expected to be around $345. For those plans without deductibles, you would pay a copayment or coinsurance amount for medications starting with your first prescriptions. Premiums for higher-earning Medicare beneficiaries can be higher. Thanks to IRMAA (Income Related Monthly Adjustment Amount), you can expect to pay higher premiums for Medicare Part D coverage if you are single and have an adjusted gross income over $88,000, or if you file jointly and have gross income greater than $176,000. The additional cost of Part D coverage increases in several income bands: The first IRMAA band adds $12.30 per month to the cost of your Medicare Part D coverage. The highest band for single incomes over $500,000 and joint incomes above $750,000, adds an additional $77.10 per month to the cost of your Part D drug coverage. How To Get Help With Medicare Prescription Drug Costs While your Medicare drug plan can help with the cost of medications, you may still find prescriptions to be unaffordable. While there are several possibilities for obtaining lower-cost medications, the first place you should look is the Extra Help Program, also known as the Part D Low Income Subsidy program. Extra Help is provided and designed to help people with limited incomes pay for the costs of prescription drugs, including: Premiums Deductibles Coinsurance/copayments Extra Help benefits are available for those with limited means - both an overall asset or resource limit and an income limit. These limits depend on your marital status. The resource limit does not count the value of your personal residence, vehicles you own, or certain other assets. But the income limits are: $19,140 for single individuals $25,860 for married households Depending on the level of Extra Help you receive, you can expect to pay significantly less on prescriptions. At the full subsidy level, you’d pay no more than $3.70 for each generic drug filled, and no more than $9.20 for each brand name drug prescription filled. What Is The Part D Senior Savings Model? One of the 2021 changes to Medicare is the Part D Senior Savings Model. This program is a voluntary agreement between CMS and Medicare Part D plan sponsors. And it’s intended to bring down the cost of insulin for millions of Medicare beneficiaries. Not all Part D plans are participating, but there is at least one participating plan in every state. Enrollees in participating Medicare Part D plans, including both standalone drug plans, and MAPD plans, will pay no more than $35 for a one-month supply of many kinds of insulin. This is expected to save people an average of $446 per year. Tips To Shop For Prescription Drug Plans When finding Medicare prescription drug coverage, the first thing to understand is how you’re receiving your Part A and B benefits. As an example, if you’re enrolled in Original Medicare, combined with a Medicare Supplement plan, then you’ll want to look for standalone Prescription Drug Plans. But if you’re enrolled in a Medicare Advantage plan or will be, then you’ll want to look for MAPD plans. But it’s important to know that you typically can’t have a Medicare Advantage plan and a standalone Prescription Drug Plan at the same time, so make sure you know your circumstances. Once you know what kind of Medicare Part D drug plan you need, you can start to compare Part D plans. You should pay close attention to such details as: Monthly premiums Annual Part D deductibles Availability of the drugs you need on the plan formulary Tip: Every Part D plan has a different formulary, and two different plans can assign the same medication to two different tiers. So it’s important to look up your medications to get a feel for anticipated out-of-pocket costs for your medications. Also, if you take insulin, look for a Medicare Part D plan that participates in the Senior Savings Model. This alone can save you hundreds of dollars per year in insulin costs. Medicare Part D Guide Conclusion Medicare prescription drug plans are available to help lower the burden of prescription drug prices for Medicare beneficiaries. Some of our final Part D takeaways include: Be sure to sign up for a Medicare PDP during your Initial Enrollment Period or as soon as your creditable coverage ends to avoid a Part D penalty. Do plenty of research, whether you’re signing up for a Medicare Part D plan for the first time or considering switching during an open enrollment period. Look up all of your drugs to ensure they will be covered. If this seems daunting, you can get started by using our Medicare plan comparison tool to compare Part D plans and see if your drugs are covered. You can also call 800-620-4519 to get help from a licensed insurance agent and discuss your Part D options.

The Medicare Annual Enrollment Period (AEP), sometimes called Medicare Open Enrollment or the Medicare Annual Election Period, starts on October 15. If you’re eligible for Medicare, you’ll probably receive lots of information over the next few weeks and throughout AEP. And this information can be overwhelming. But we’re here to help you with this useful Medicare guide. So let’s dive into the Medicare Annual Enrollment Period, what it is, how to prepare, and what you can do during AEP. Then, we’ll cover some tips for choosing the right Medicare plan for your healthcare needs. What is the Medicare Annual Enrollment Period? The Medicare Annual Enrollment period happens each year from October 15 to December 7. During this time period, you have the option to make changes to your Medicare coverage. Your new coverage would then take effect January 1. But if you’re satisfied with your current Medicare coverage, you don’t have to take any action during Medicare AEP. There are no penalties involved if you do nothing. Medicare plan details can change annually, though, so it’s wise to review your Medicare coverage each year. We’ll cover more on this shortly. What’s the Difference Between Medicare AEP and the Medicare General Enrollment Period? The Medicare Annual Enrollment Period is sometimes confused with the Medicare General Enrollment period, which is January 1 to March 31 each year. It’s important to understand the differences between the two enrollment periods. The Medicare General Enrollment Period is for Medicare beneficiaries who didn’t sign up for Medicare Part A) or Part B when they first became eligible and aren’t eligible for a Medicare Part B special enrollment period. The AEP, however, is for beneficiaries who are already enrolled in Medicare and want to change their Medicare coverage. What Changes Can I Make During the Medicare Annual Enrollment Period? The first thing to know is that you cannot use the Medicare Annual Election Period to enroll in Medicare Part A or Part B for the first time. But if you’re enrolled in Medicare Part A and Part B and you’d like to change your Medicare coverage, here are some things you can do during the Medicare Annual Election Period: 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. 5 Tips to Prepare for the Medicare Annual Enrollment Period There are many Medicare insurance carriers and plan options, but there are several steps you can take to be a savvy shopper and choose the right plan for your unique needs. 1. Mark Your Calendar This may seem like an obvious tip, but it’s worth mentioning: Mark your calendar for October 15 through December 7 if you’d like to make a change to your Medicare plan. You might even set aside a few hours to research and compare Medicare Advantage plans and Prescription Drug plans ahead of October 15. These plans announce their benefits for the next year starting on October 1. Writing down these Medicare AEP dates and to-dos will help you to commit to these priorities. 2. Review Your Medicare Annual Notice of Change You’ll receive lots of information over the next month or so, so if you’re currently enrolled in a Medicare Advantage or Prescription Drug Plan, the Annual Notice of Change (ANOC) is one piece of mail you’ll want to read. Your Medicare plan will mail your Annual Notice of Change letter to you by September 30. The ANOC letter will inform you of most changes to your Medicare health plan, including coverage and benefits that will take effect on January 1, 2021. Each year, your Medicare health plan sets the amounts it will charge you for premiums, deductibles and other services. Medicare doesn’t set these rates - but your insurance company does. With this in mind, the amounts you pay could change each year. While evaluating your current Medicare plan, you may want to ask yourself questions like: Did the plan cover the services I needed? Did I use out-of-network providers? Did I spend more out of pocket than I originally anticipated? Has something changed with my health (new diagnosis, new prescriptions, etc.)? The ANOC will also provide a side-by-side comparison of your current plan and next year’s plan benefits, costs and other changes (if any). Moral of the story: Don’t toss this piece of mail aside. Always review your ANOC to ensure your plan continues to meet your needs on an annual basis. And if you don’t receive your ANOC by September 30, contact your Medicare insurance company. 3. Make A List of What’s Important To Your Health Keeping a list of what’s important to your health is an invaluable way to prepare for the Medicare Annual Enrollment Period. Start by writing down all of your doctors, preferred health care facilities and hospitals, and prescription drugs, if you take any. We also recommend making a list of value-added benefits that may fit your health, lifestyle and budget. For example, you may be someone who likes to keep active and have social interaction. So a fitness program like SilverSneakers, which gives you access to a network of gyms and other programs, might be a good fit for you. A Medicare Advantage plan may provide these types of fitness or wellness programs. Another thing to consider is whether or not you have an elective surgery planned for 2021. If so, you’ll want to check your hospital-specific benefits under your current Medicare Advantage plan. 4. Check Your Plan’s Drug Formulary Your Medicare plan’s drug formulary will not be included in your Annual Notice of Change, so be sure you call your insurance customer service representative to see if your prescription drugs will be covered for the 2021 plan year. If your prescription drugs aren’t covered, it’s wise to use the Medicare Annual Enrollment Period to find a plan that does cover them. 5. Talk To Your Doctor Another “Medicare must-do” is to make sure all of your doctors and healthcare facilities will remain in network with your current Medicare plan. If they aren’t, you may want to take advantage of the Medicare Annual Enrollment Period. So be sure to ask your doctor if he or she plans on changing health plan affiliations over the next year. What Are The Benefits of A Medicare Advantage Plan? Understanding your Medicare plan options - starting with a Medicare Advantage plan - is a smart first step to take because you can switch, enroll into or disenroll from Medicare Advantage plans during AEP. Medicare Advantage plans, otherwise known as “Medicare Part C” or “MA Plans,” bundle Original Medicare (Parts A and B) services into one plan. While Original Medicare offers you a number of benefits, it may not cover health and medical services you might need. Medicare Advantage plans might be an attractive option because some plans include extra benefits that could save you money. These benefits may include: $0 monthly plan premiums Prescription drug coverage Dental, vision and hearing coverage Access to fitness programs Rides to medical appointments Help managing certain chronic conditions (congestive heart failure, COPD, diabetes) Medicare Advantage plans may also cover a number of in-home services to keep you safe and healthy at home, especially during these uncertain times due to the coronavirus pandemic. These benefits may include: Telemedicine services (also known as telehealth) Home-delivered meals Home-delivered prescriptions Private home aides Another potential perk of Medicare Advantage plans is that they include annual out-of-pocket maximums, which means your costs will be capped. But it’s important to note that Medicare Advantage plans vary by county and zip code. One way to compare Medicare Advantage plans and get Medicare quotes is through our easy-to-use quoting tool. Just enter your zip code to see Medicare Advantage plans that are available in your area. More Medicare Options for People With Kidney Failure One major change happening for the 2021 plan year is that people with End Stage Renal Disease (ESRD), also known as kidney failure, will now have the option to enroll in a Medicare Advantage plan. The Centers for Medicare & Medicaid Services (CMS) estimates that more than 80,000 people living with ESRD will enroll in a Medicare Advantage plan by 2026 - a significant increase of 63%. Medicare Advantage plans may provide ESRD patients with better coverage compared to Original Medicare. Many Medicare Advantage plans include access to coordinated care, which helps ensure all your doctors are on the same page regarding your treatment. What Are Medicare Advantage Special Needs Plans? Medicare beneficiaries also have access to Medicare Advantage plans designed for unique needs. These are called Special Needs Plans (SNPs). Like other types of Medicare Advantage plans, SNPs vary based on location. You may be able to switch to a Special Needs Plan during the Medicare Annual Enrollment Period if one of these situations apply: You’ve been diagnosed with a serious medical condition by a doctor. There are SNPs for certain chronic conditions, such as kidney and heart failure, diabetes and dementia. Services are tailored to the specific condition the plan covers. You need or have received skilled nursing care for at least 90 days at your home or at an institution, such as a nursing home or long-term care facility. You qualify for both Medicare and Medicaid. Medicaid eligibility is based on your income and assets. If you qualify, Medicaid will pay most of the costs for your Medicare Special Needs Plan. Special Needs Plans include all the same benefits as regular Medicare Advantage plans, plus some expanded coverage. For example, all Special Needs Plans must include prescription drug coverage, which is usually tailored to the specific condition the plan covers. Although most regular Medicare Advantage plans include prescription drugs, some do not. Some SNPs also provide a care coordinator to help you stay on track with your doctor appointments and treatment plan. What If My Income Has Changed in 2020? The coronavirus crisis has affected the financial well-being of many Americans, including those on Medicare. If you’ve experienced a decrease to your income or assets, the Medicare AEP 2020 season is a great time to switch to a more affordable plan. If you have limited income, you might qualify for extra savings on Medicare costs through these programs: Medicare Savings Programs. These programs help pay for some of your Medicare Part A and Part B out-of-pocket costs, such as copays, deductibles and premiums. Most programs are for Medicare beneficiaries who also qualify for Medicaid. And as mentioned, Medicaid covers the majority of your costs when you join a Medicare Advantage Special Needs Plan. You can check if you qualify through your local Medicaid office. Medicare Extra Help. Extra Help reduces your Medicare prescription drug plan costs. You should contact Social Security to check your eligibility for Extra Help if you have an existing Medicare drug plan or you join one during AEP. How To Enroll During the Medicare Annual Enrollment Period To enroll in an eligible plan during the Medicare Annual Enrollment Period, you can visit Medicare plan comparison websites like healthinsurance.com or Medicare.gov. Or, you might prefer to talk to a licensed insurance agent to get help enrolling in Medicare. Whatever option you choose, be sure to have 3 items handy before you enroll in a plan or make changes to your current plan during AEP: Your Medicare card Your list of doctors, prescriptions and what is important to your health Pen and paper to take notes More on Medicare Eligibility Medicare is a federal health insurance program developed in 1965. To be eligible for Medicare you must meet one of the following criteria: You are age 65 or older You are under age 65, disabled, and have been receiving Social Security disability benefits for at least 24 months. You have End Stage Renal Disease or Lou Gehrig’s Disease (also known as Amyotrophic Lateral Sclerosis or ALS). You can visit Medicare.gov to see if you’re eligible for Medicare and calculate your estimated premiums for certain plans. How To Find A Medicare Advantage or Prescription Drug Plan You don’t have to go it alone when choosing a Medicare Advantage plan or Prescription Drug Plan. We’re here to help you navigate the Medicare Annual Enrollment Period through a number of ways, including: Our Medicare plan comparison tool Our online Medicare resources You can also call 800-620-4519 to speak to a licensed insurance agent about your options. You can also read through some of our articles to learn more about Medicare. Medicare 101 Guide Top Medicare Frequently Asked Questions Understanding Original Medicare vs. Medicare Advantage

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: Medicare Supplement Insurance (Medigap): You must have both Part A and B through the Original Medicare program. Medicare Part D (Prescription Drug Plans): You can add separate Part D drug coverage to Original Medicare Part A and/or Part B. 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.

Did you know Medicare has the high rate of satisfaction among Medicare beneficiaries? In fact, they ranked both Original Medicare and Medicare Advantage highly according to a 2019 survey. Still, it can be a difficult task to pick the best Medicare plan for your needs. Let's simplify the process by looking at Original Medicare, then discussing how Medicare Part C (Medicare Advantage) plans and Medicare Supplement (Medigap plans) work. What Is Medicare? Medicare is health insurance for: People who are 65 and over. People under 65 years old who are disabled and have been receiving Social Security Disability benefits for at least 24 months. People suffering from End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease. Medicare Part A Costs Original Medicare is broken into two parts: Part A (for hospitalization) and Part B (for medical services). In most cases, there is no cost for Medicare Part A. But you would have to pay a $471 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $259. Medicare Part B Costs Medicare Part B premiums are determined by your modified adjusted gross income. If your income for 2021 was less than or equal to $87,000 for a single or $174,000 for a married couple filing jointly, you will pay the standard Medicare Part B rate, which is $148.50 a month in 2021. Part B premiums rise to a maximum of $504.90 a month if your income exceeds $500,000 for an individual or $750,000 for a couple filing jointly. Many people are automatically enrolled in Medicare Part A and Part B when they turn 65 and begin to receive Social Security retirement benefits. But you might be in a situation where you have other health insurance besides Medicare, like a plan through your employer. In this case, you can delay your enrollment in Part B without being penalized and save paying the monthly premium. However, you would have to pay a $458 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $252. How To Enroll In Original Medicare If you don’t receive Social Security benefits at age 65, you need to sign up on your own. There are three ways to enroll: Go online to www.SocialSecurity.gov. Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Visit your local Social Security office in person. The seven-month Initial Enrollment Period (IEP) for Medicare begins three months before you turn 65, continues during your birthday month, and runs for three months after you turn 65. If you don’t enroll in Medicare during this timeframe, you could face penalties for not complying with Medicare rules. There’s also a Medicare annual enrollment period each year after your initial enrollment, which allows you to make changes to your coverage for the following year. What Are The Different Types Of Medicare Plans? Medicare Part A is hospital insurance. It helps cover inpatient care, skilled nursing facility care, hospice care, and home healthcare. In most cases, there is no cost for care, but there is a deductible of $1,484 in 2021. Medicare Part B is medical insurance. This plan helps cover doctor visits, outpatient care, home healthcare, durable medical equipment, and many preventive care services. Monthly premiums vary based on your income, and there is a deductible of $203 in 2021. Medicare Part C is Medicare Advantage. Medicare Advantage plans combine Medicare Part A and Part B into a health plan. Many Medicare Advantage plans may include prescription drug coverage and extra benefits. (More on this below). Medicare Part D is prescription drug coverage. Medicare Part D helps cover the cost of prescription drugs. The standard maximum deductible is $445 in 2021. Medicare plans A-N is Medicare Supplement coverage. Medicare Supplement, also known as Medigap, have several different plans, which help cover benefits that Original Medicare may not cover. Medigap prices vary by plan benefits, not income. Note that Plans C, E, F, H, I, and J are no longer sold to new enrollees. So, the big question is: Should you consider Medicare Advantage, or enroll in Original Medicare and get a Medicare Supplement instead? And the short answer is: It depends. You have to evaluate your healthcare needs and how much you can afford to pay out-of-pocket for health insurance. What is Medicare Advantage (Medicare Part C)? Medicare Advantage provides all of your Part A (hospital) and Part B (medical) coverage. A majority of Medicare Advantage plans offer extra coverage, such as vision (78%), hearing, dental care (67%) or wellness programs (72%). Most include Part D prescriptions drug coverage (90%). Those with Private Fee For Service (PFFS) plans that do pay a drug premium pay $65 a month on average. As a Medicare beneficiary, you have a choice between selecting Original Medicare or choosing a Medicare Advantage plan (also known as Part C), which is provided by private health insurance companies. How Much Does Medicare Advantage Cost? Medicare Part C premiums vary by the plan (many plans have $0 premiums). And each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get medical services. For example, most insurance companies require Medicare Advantage plan participants to get pre-approved before they can have a procedure done, but another insurance company might not have that requirement. Do Medicare Advantage Plans Cover Pre-existing Conditions? Yes, your acceptance is guaranteed. This includes coverage for people with End State Renal Disease (ESRD), which is a 2021 change to Medicare. Medicare Advantage plans have zero coverage restrictions, and you’re not required to complete any medical history forms. What Is A Medicare Supplement (Medigap) Plan? Medicare supplement plans (Medigap) plans provide extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t pay. These plans can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits. It’s important to note that you can’t have more than one Medicare supplement plan. And though Medicare supplement plans may have higher monthly premiums than Medicare Advantage plans, you may want to consider buying a Medicare supplement insurance plan if: You’re likely to have numerous hospital stays during a year. You have regular doctor visits and/or medical services. You live in different places during the year and cannot be confined to a local network. You frequently travel outside the U.S. and want insurance coverage for emergency medical care overseas, which Medicare Part A and Medicare Part B may not provide. Note: Some Medicare supplement plans provide international travel coverage. A Medicare supplement plan may also be a good fit if you want to visit a specific top-tier medical facility like the Mayo Clinic. You wouldn’t qualify for an in-network check-up with a Medicare Advantage plan, but you’d have the ability to see a Mayo Clinic doctor with a Medicare supplement plan, with coverage for a large chunk of your services. How Much Do Medigap Plans Cost? Pricing for Medicare Supplement plans are based on the plan you select (high/low benefits), your age at time of enrollment, your state of residence, and the health insurance company you select. That’s why it is important to compare when you shop from plan to plan or even between the same company’s plan differences before choosing a Medicare supplement plan. What's The Difference Between Medicare Advantage and Medigap? Medicare Advantage offers more choice and covers more medical services than Medicare, while still following all of Medicare’s rules. Meanwhile, Medicare Supplement insurance was created to help Original Medicare recipients cover more of their out-of-pocket expenses. Remember: Medicare Advantage acts as an alternative to original Medicare, while Medicare Supplement plans are additions to Original Medicare coverage.   Medicare Advantage Medicare Supplement Coverage In most cases, copayments (a fixed amount of money you pay) are required. In most cases, it can cover deductibles, copayments, and coinsurance that isn’t covered by Part A and Part B. Cost Many times $0 or a low monthly cost. Higher monthly cost based on state, gender, and age. Travel Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay. Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay. Prescription Drugs Typically included with coverage. Not covered. You must enroll in a Part D plan for drug coverage. Routine dental, vision, hearing coverage May be covered depending on the plan selected. Not covered. Copayments and coinsurance Usually have copayments and/or coinsurance. Typically pays for copayments and coinsurance. Network Medicare Advantage plans have different networks: HMO, PFFS, and PPO. It’s important to understand the rules about going out of network for your healthcare. No network. See almost any doctor or medical facility that accepts Medicare. Medicare Advantage and Medigap plans may provide benefits for the following services (but check your plan details for specific benefits): Hospitalization: Medicare limits the number of days you can spend in the hospital. If you pass the maximum number of days, supplemental insurance pays the copayment that Medicare does not cover. Skilled Nursing Facility: Depending on the plan you select, Medicare supplement covers skilled nursing services that Medicare does not cover. Blood: If you need blood, Medigap coverage could pick up the tab on a few pints. Hospice care: Medicare pays for everything but copayment and coinsurance. Medicare supplement could pay the copayment and coinsurance. Inpatient or outpatient hospital medical expenses: Medicare generally pays 80% of all expenses, and a Medigap plan generally pays the remaining 20%. Note: Medicare supplement plan benefits are subject to state rules and regulations. Benefits described here encompass common Medigap plans available in the marketplace. Other services may be covered based on the supplemental plan you pick. Please check your insurance policy documents or talk to a customer service representative for more information. How To Find Medicare Advantage and Medigap Plans Choosing between a Medicare Advantage plan or adding a Medicare Supplement plan on to your Original Medicare coverage depends on your situation. To start, ask yourself these types of questions: Do I travel outside of the United States regularly? Do I live in a different state for a portion of the year? Do I want to see any doctor and not be limited to a network? Is my budget more important than my health benefits? Are extra benefits like dental and vision coverage important to me? But you don’t have to go it alone: We can answer your questions about Medicare and help you find the best Medicare plan for your needs. Just try our Medicare Advantage plan comparison tool to get Medicare quotes online, or call 800-620-4519 to get help from a licensed insurance agent.