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FEATURED ARTICLE
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.
Medicare Resources
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 resources and our licensed insurance agents.
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
People often have questions about Medicare as they get close to age 65:
Does Medicare cover my prescription drugs?
Will my doctor accept my Medicare plan?
Does my Medicare plan cover dental, vision, and hearing?
These are questions we often hear, and we’re here to help get you these answers and more.
Let’s start by reviewing the basics of Original Medicare, including coverage and out-of-pocket costs. Then we’ll cover some options to reduce your Medicare costs and add valuable benefits to your coverage.
How Original Medicare coverage works
Original Medicare is split into two parts – Part A and Part B.
Medicare Part A
Covers some of the costs of care provided by the following facilities and providers:
Inpatient hospital care
Hospice Care
Home Health Care
Skilled Nursing Facility Care
Medicare Part B
Covers medically necessary services and supplies, including:
Doctor’s visits
Diagnostic tests (x-rays, blood work, MRIs, etc.)
Therapy visits (physical, occupational)
Some cancer treatments like chemotherapy
Outpatient surgeries like arthroscopic surgeries
Outpatient mental health visits
Durable medical equipment like bottled oxygen
How much does Original Medicare cost?
When you use your Medicare insurance, you will have to pay for some of the costs out of pocket. But the out-of-pocket costs are different for Parts A and B.
When you have a hospital stay, you’ll have to pay the Part A deductible which is $1,408 in 2020. You’ll pay this inpatient hospital deductible each time you are admitted to the hospital, provided you haven’t received hospital or skilled nursing facility services within the previous 60-day benefit period.
Meanwhile, Part B has three types of charges:
Part B deductible: $198 for 2020, which you only pay once each year. After that, Medicare will pay 80% of the cost, and you’ll pay 20% for every Medicare-covered Part B service or procedure you receive.
Part B coinsurance: 20% of the cost for each service or procedure
Part B excess charges: Up to 15% of the Medicare-approved charge if your doctor does not accept the Medicare-approved amount for a service (known as Medicare assignment).
For the most part, your out-of-pocket costs could be quite low if you’re healthy and don’t need many health care services. And if you get the flu or need some therapy for a sprained ankle, your 20% coinsurance could total a few hundred dollars for the entire year.
But your out-of-pocket costs could be very high if you suffer a major illness or need specialized surgery. Plus, Original Medicare does not cover prescriptions. So if you need medications, costs could be high.
One last point on costs: There’s no cap on your spending with Original Medicare. This means there’s no out-of-pocket maximum cap like you may have seen with your previous traditional, private health insurance plan. And this means your out-of-pocket costs could be extremely high if you require treatment for a chronic condition or illness.
Medicare Advantage may help control costs
Many Medicare beneficiaries choose to enroll in Medicare Advantage plans to curb out-of-pocket costs and get prescription drug coverage. Medicare Advantage (also known as Medicare Part C) is a contract between the Centers for Medicare and Medicaid Services (CMS) and a private health insurance company.
Medicare Advantage plans must cover everything that Original Medicare covers. When you join a Medicare Advantage plan, you may still pay for certain expenses including:
Monthly plan premium (if any): Many plans have a low-cost or $0 monthly premium. (You must continue to pay your monthly Part B premium).
Annual deductible (if any)
Copayments and/or coinsurance
Still, these costs are often lower than what you’d pay under Part A or B. One big benefit of a Medicare Advantage plan is that it includes an annual out-of-pocket maximum - so you’ll know your costs are capped, no matter what services or treatments you might need during a year.
Medicare Advantage provides extra benefits
Medicare Advantage can serve as a way to cover services that Original Medicare doesn’t. That’s because these plans often go beyond Original Medicare coverage offerings.
These extra benefits can vary by state and health plan, but they often include:
Chiropractic care and acupuncture.
Dental coverage: Sometimes for an additional premium.
Emergency coverage outside of the United States
Fitness benefits: Discounted or free gym memberships and silver sneakers programs.
Hearing coverage: Exams, and sometimes discounted hearing aids.
Prescription drug coverage: You’ll typically share the cost of your medications with your insurance company in the form of copayments or coinsurance for each prescription.
Transportation: To and from medical appointments.
Vision coverage: Exams, lenses, and the cost of frames.
An example of how it works
Let’s take vision coverage as an example. Original Medicare doesn’t cover basic vision services like eye exams and lenses. If you pay out of pocket, you can expect to pay (on average):
$114 for an eye exam
$113 for lenses
$238 for frames
Based on these averages, you could pay a total of $465 for an exam, lenses, and frames. While benefits vary by state and insurance company, many Medicare Advantage plans have exams and lenses for $0.
Many companies could also give you a credit towards the purchase of frames. And though you probably don’t buy new glasses every year, it’s unlikely that prices for lenses and frames will decrease. Getting frames from a Medicare Advantage plan can save you quite a bit of cash, especially given the relatively low (or $0) plan premiums they charge.
You will find that other extra benefits work in the same way. The hearing or dental coverage available from Medicare Advantage plans may not be completely comprehensive or free, but it’s often less expensive than what you can get from an individual policy.
How Medicare Supplements can help control costs
Medicare Supplement insurance is another way to lower your Medicare out-of-pocket costs. These policies are offered by private insurance companies and work with Original Medicare, paying for some or all of the costs that you’d normally pay.
The costs you have to pay with Original Medicare are known as “gaps in coverage.” Medicare Supplements help to fill these gaps - hence the name “Medigap” plans.
You’ll pay a premium directly to your insurance company for Medigap coverage. And Medigap can help with some or all of:
Part A deductibles
Part B deductibles
Part B coinsurance
Part B excess charges
Medicare Supplement plans come in standardized plans, with each plan paying a slightly different portion of the Original Medicare gaps. The standardized plans are known by letter: A, B, C, D, F, G, K, L, M, and N. Plans F, G, and N are among the most popular with people on Medicare.
Medigap plans offer a lot of freedom when it comes to choosing a doctor. Your coverage is portable all over the country, so you can see any doctor who accepts Medicare patients. You don’t have to deal with a network, or get a referral from a primary care physician.
As an added bonus: Many Medigap plans also cover you outside the United States, so you can have emergency coverage while you’re traveling as part of your retirement routine.
What Medigap plans don’t cover
There are a number of items that Medicare Supplement insurance doesn’t cover.
For starters, they don’t cover prescription drugs, so you’ll need to enroll in a stand alone prescription drug plan to help cover costs. These are also available from private insurance companies.
Medigap plans also don’t cover vision, hearing, or dental. While it’s possible that some Medigap plans offer discounts on these items, none provide comprehensive coverage. Medigap plans also provide no coverage for staying in a nursing home or other facility for long-term care.
Instead, you’ll have to purchase individual coverage from an insurance company to cover these items. Or, you may be able to purchase coverage for some of these items from your Medigap insurer in a separate supplemental policy.
With either option, you’d pay an additional premium for the coverage, but buying standalone vision or dental coverage from another company might be the more expensive option.
How to enroll in a Medicare Advantage or Medigap plan
The most important thing to know is that you’re not “stuck” in a Medicare plan: If you want to switch Medicare plans, you can do so during the Annual Enrollment Period, which is from October 15 to December 7 each year.
You can also switch from one Medicare Advantage plan to another, or go back to Original Medicare during the Medicare Advantage Open Enrollment Period, which is from January 1 to March 31 each year.
And if you want to learn how to reduce your out-of-pocket medical expenses in the meantime, you just need to get smart on maximizing your Medicare benefits.
Save time, learn more
Let us do the hard work for you, so you can save time and find the best Medicare plan for your needs. Working together, we can find and compare Medicare Advantage plans in your area to see if they work with your doctors and cover your medications.
Are you turning 65? Turns out, you’ll be joined by thousands of birthday buddies.
In fact, 10,000 Americans turn 65 every day - a real cause for celebration, whether it’s the milestone of retirement or your journey to the right Medicare coverage.
Still, many Americans are confused by Medicare: how to enroll, when their enrollment period is and what plan to even enroll in.
But the process doesn’t need to be so complex. Here’s your Medicare checklist for turning 65.
1. Make Sure You Qualify For Premium-Free Medicare Part A
Most people qualify for Medicare Part A because of their work history. If you’re a U.S. citizen or permanent legal resident, you qualify for premium-free Part A as long as you have paid payroll taxes for at least 10 years.
Call your local Social Security Office to see if you’re eligible for Medicare Part A. You may receive a paper statement from SSA [sample here] as a reference, or you can create an account online at ssa.gov.
What If You Didn’t Work Enough?
You may still qualify for Medicare Part A through your spouse if you don’t (or won’t) have 40 quarters of work history. You’re eligible if your spouse qualifies for premium-free Part A, and:
You have been married for at least one year and your spouse is eligible for Social Security benefits.
You're divorced and your former spouse is eligible for Social Security benefits. You must have been married at least 10 years, and you must be single now.
You’re widowed, but were married for at least nine months, and you are currently single.
If you don’t meet any of these criteria, you can either continue working until you’ve logged 40 quarters, or pay for Part A. For 2020, the Part A premium is $458 per month, but this amount may be reduced if you have some work history.
2. Figure Out When You’re Going To Need Part B
If you are currently employed and you are covered by an employer health plan, and your employer has more than 20 employees, you don’t have to sign up for Part B until you retire and give up your employer-based health coverage.
Many people can’t take full Social Security benefits until age 66, so it’s common to delay retirement by a year. You can delay Part B as long as your employer coverage meets Medicare’s minimum requirements.
But if you work for a small company with less than 20 employees, you’ll probably need to enroll in Part B when you’re first eligible. Be sure to talk about this with your employer before your 65th birthday. There’s no reason to pay the Part B premium until you’ll actually need Medicare.
3. Decide When You’re Taking Social Security
There are a few nuances to receiving Social Security and how it impacts when you can enroll in Medicare Parts A and B:
If you take Social Security at age 65, your enrollment in Medicare will be automatic.
If you pass on Social Security at age 65, but want to sign up for Medicare, you’ll have to apply for it separately.
You can use ssa.gov to enroll if you choose to enroll before your 65th birthday.
If you wait until after you’re 65, you’ll have to visit a Social Security office to sign up for Medicare.
4. Know Which Doctors You Want To See When You Have Medicare
Make sure the doctors you see, or want to see, accept Medicare. Finding out ahead of time can help you avoid surprises.
If you plan to move during your retirement, it’s wise to get recommendations for doctors in your new hometown and see if they accept Medicare patients.
5. Get A Firm Understanding Of Your Medications
When it comes to medications and aging into Medicare, there are 3 steps to take:
You should always know your medications and their doses.
Talk to your doctor about generic versions of your prescriptions to reduce costs.
Find out if your doctor thinks you might need a new or different medication in the future.
6. Understand The Gaps In Original Medicare
Medicare doesn’t cover 100% of your health care costs. Instead, you’ll pay a portion out of your own pocket. The costs you pay for Part A differ from what you’ll pay for Part B.
Gaps In Medicare Part A
Part A will cover you for inpatient type of events, like:
Hospital stays
Home health care
Hospice
Skilled nursing facilities
When you have a hospital stay, you’ll have to pay the Part A deductible. For 2020, the deductible is $1,408. You’ll pay this inpatient hospital deductible each time you are admitted to the hospital, provided you haven’t received hospital or skilled nursing facility services within the previous 60-day benefit period.
Gaps In Medicare Part B
Part B of Original Medicare covers the services you’d receive in an outpatient setting, including:
Doctors and therapy appointments
Lab work and diagnostic imaging
Outpatient surgeries
Medical equipment like oxygen machines
Some cancer treatments like chemotherapy
When you use Part B coverage, you can expect to pay out of pocket for each service. Your share of cost can include:
Part B deductible: $198 for 2020 (you only pay the Part B deductible once each year).
Part B coinsurance: 20% of the cost for each service or procedure.
Part B excess charges: Up to 15% of the Medicare-approved charge if your doctor does not accept the Medicare-approved amount for a service (known as Medicare assignment).
The biggest Part B expense is the 20% coinsurance, which you’ll pay throughout the year. There are other costs you can expect to pay out of pocket with Original Medicare, including things like dental care, eye exams, hearing aids, and more.
Keep in mind that there is no cap on how much you can spend out of pocket with Original Medicare.
How To Find The Right Plan For You
Make sure any Medicare plan you consider:
Covers the doctors you want to see
Covers the medications you need
Has a premium you can afford
You can also narrow your choices down further by asking yourself:
Do I intend to split my time between two or more States?
Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?
If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re comfortable with a particular HMO-type medical group and plan to live in one place, then Medicare Advantage could be right for you.
Your Options Beyond Original Medicare
There are Medicare plans available that help close the coverage gap of what Original Medicare doesn’t cover. They include:
Medicare Advantage
Medicare Part D (Prescription Drug Plans)
Medicare Supplement (Medigap)
Medicare Advantage Plans
Medicare Advantage plans, also known as Medicare Part C, is a contract between a private insurer and Medicare. These plans must cover everything that Original Medicare covers.
Medicare Advantage plans work like traditional private health insurance, so you may see certain out-of-pocket costs with Medicare Advantage, including:
Monthly premium: Many Part C plans don’t have a monthly premium.
Annual deductible: Most plans don’t have a deductible.
Copayments or coinsurance for services and procedures.
Medicare Advantage plans also offer a number of added benefits, which vary by state and health plan. Some benefits include:
Fitness programs like Silver Sneakers or free memberships to local gyms.
Vision coverage for exams, lenses, and sometimes frames.
Hearing coverage for exams and discounted hearing aids.
Dental coverage for basic dental services.
Transportation to and from medical appointments
Prescription drug coverage (some plans)
Medicare Advantage plans can also provide emergency coverage outside the United States. With the international coverage, out of pocket maximum protection, and a wide range of extra benefits, you can see why many people choose Medicare Advantage plans.
Prescription Drug Plans
Prescription Drug plans (PDPs or Medicare Part D) help with the cost of prescription drugs. Each company creates their PDPs differently, but you can expect to pay these costs for coverage:
Monthly premium, which varies based on income
Annual deductible (although many plans don’t have a deductible)
Copayment or coinsurance per filled prescription
The copayments and coinsurance costs increase as the total amount your plan pays rises above certain thresholds, also known as coverage stages:
Coverage Stage 1 – Deductible Stage: You pay full price until you’ve spent $435 (for 2020).
Coverage Stage 2 – Initial Coverage Stage: You pay small copayments or coinsurance for each prescription.
Coverage Stage 3 – Coverage Gap Stage: Also known as the Medicare “Donut Hole.” Once your total drug costs (what you’ve paid plus what your plan has paid) exceed $4,020, you hit the coverage gap. You’d then pay 25% of the cost of prescriptions.
Coverage Stage 4 – Catastrophic Stage: Once your total drug costs (excluding what your plan has paid) exceed $6,350, you pay no more than 5% for medications
These coverage stages reset on January 1 each year. But it’s important to know that there is no out-of-pocket cap on drug costs under Part D.
Medicare Supplement Insurance
Medicare Supplement Insurance, also known as Medigap, is designed to fill the gaps in Original Medicare. Medigap supplements Original Medicare by paying some or all of the expenses that you’d normally have to pay out of pocket.
Medigap policies are issued in 10 standardized plans: A, B, C, D, F, G, K, L, M, and N. Each of these plans cover a slightly different portion of the Original Medicare gaps.
Plan G is a popular Medigap option that covers every gap except for the Part B deductible. If you have Plan G, you can expect to pay for the first $198 in Part B expenses (like doctor’s visits). Plan G will then cover every penny of any Medicare-approved service or procedure.
Several Medicare supplements provide some international coverage, including plans C, D, F, G, M, and N.
Medigap plans also give you maximum flexibility, so you can see any doctor or use any facility that accepts Medicare patients, anywhere in the United States. You’re not bound to a network, or reliant upon referrals.
Medicare Supplement Insurance plans don’t cover prescription drugs, so you’ll need to enroll in a stand alone Prescription Drug plan to get drug coverage.
Considerations Before Choosing A Plan
Make sure any Medicare plan you consider:
Covers the doctors you want to see
Covers the medications you need
Has a premium you can afford
You can also narrow your choices down further by asking yourself:
Do I intend to split my time between two or more States?
Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?
If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re fine with HMO-type medical groups and plan to live in one place, then Medicare Advantage could be right for you.
As you approach age 65, it’s important to start your research sooner rather than later. Make sure you know what plans your doctors will accept, and which plans cover your medications.
Comparing Medicare plan features and costs doesn’t have to be complicated though. You can find and compare Medicare quotes or enroll in a plan through our site. We also have licensed Medicare agents available to help answer any questions you may have.
Medicare spending is trending upward. In 2018, Medicare benefit payments totaled $731 billion - an increase from $462 billion in 2008.
And Medicare-aged people can sometimes have chronic conditions and limitations, which can lead to costly medical services and treatment - all while living on a modest income. So it might be important for you to know the cost of an impending medical procedure to treat your condition.
But finding the true cost of a medical procedure can be tricky, so we used Medicare's procedure price lookup tool to find rough costs of every procedure covered under Medicare.
It's not a perfect science though: The average costs found on Medicare's procedure price lookup tool are based on Original Medicare. That said, the prices do not account for physician fees and Medicare Advantage or Supplemental plans. Still, the tool can give you a ballpark estimate for medical procedures so you can plan ahead and budget accordingly.
With this in mind, let's take a look at five common procedures for Medicare recipients and the costs associated with each procedure.
(Note: All costs are based on Medicare's procedure price lookup tool. Current Procedural Terminology (CPT) is a medical code used to report medical, surgical and diagnostic procedure codes for tracking and billing purposes.)
1. Cataract surgery
Cataract surgery is a common surgery procedure designed to correct blurry vision and reduce glare from lights. During the procedure, an ophthalmologist removes the lens of your eye and replaces it with an artificial lens.
How much does cataract surgery cost?
According to Medicare’s tool, the average out-of-pocket cost of cataract surgery is between $51 and $101 for CPT 66821, but the treatment may involve more than one procedure so the final cost could be more. And there may be additional costs from the facility where the procedure is performed.
Who typically needs cataract surgery?
The need for cataract surgery increases with age. In fact, one in five people ages 65 and up need the procedure, and that ratio increases to three in five people by age 80.
Not everyone with cataracts will need surgery to correct the problem, though. Only those having trouble doing everyday activities because of their cloudy, blurred vision will need the surgery.
Is cataract surgery covered by Medicare?
Yes.
2. Upper GI endoscopy
An upper GI endoscopy involves inserting a small camera into the esophagus, so your doctor can see the inside of your stomach and small intestine. This procedure is often performed to diagnose the cause of persistent heartburn.
If abnormalities are found, additional procedures may be performed at that time or scheduled for a later date.
How much does an upper GI endoscopy cost?
The average cost to the patient for this procedure is between $57 and $112 for CPT 50572, depending on the type of facility used.
Who typically needs an upper GI endoscopy?
People who suffer from acid reflux. Their symptoms often include abdominal pain, difficulty swallowing, nausea, or stomach bleeding.
Is an upper GI endoscopy covered by Medicare?
Yes.
3. Colonoscopy and biopsy
Like an endoscopy, a colonoscopy involves inserting a small camera attached to a tube into the intestinal tract — in this case into the colon. The main purpose of a colonoscopy is to check for colon cancer.
During this procedure, it’s not uncommon to find polyps, which are removed and sent for a biopsy. A biopsy is a lab test to determine whether tissue is cancerous.
How much does a colonoscopy cost?
It can be tricky to calculate the cost of a colonoscopy because there are several variables involved. For example, there's no need for a biopsy if polyps aren't found. But if something else is found, like a tear in the lining of the colon, an on-the-spot procedure might be performed.
Generally, the patient cost for a colonoscopy with no complications is between $100 and $195 for CPT 45380. And there may be additional costs from the facility where the colonoscopy is performed.
Who typically needs a colonoscopy?
Colonoscopies are recommended for anyone with a family history of colon cancer or over the age of 50, making this one of the most common procedures for seniors.
Your doctor is likely to order a colonoscopy if you have such symptoms as:
Rectal bleeding
A change in bowel habits including constipation or diarrhea
Narrow or thin stools
Abdominal discomfort including gas pain and bloating
Chronic fatigue
Unexplained weight loss
Unexplained anemia
Is it covered by Medicare?
Yes.
4. Arthroplasty knee (knee replacement)
”Arthroplasty knee” is a fancy way of saying “knee replacement.” No matter the term you use, this procedure repairs worn knee sockets, which can include complete or partial knee replacement.
Two out of three seniors will need knee replacement surgery at some point, making this the most common medical procedure for those over 65.
How much does a knee replacement cost?
It can be difficult to estimate the exact cost in advance because the surgeon may not know exactly what's needed until taking a look inside the joint. The cost can also vary depending on whether the knee replacement is performed in a hospital or at an ambulatory surgical center.
In many instances, knee replacement procedures might cost less in a hospital setting. The costs for arthroplasty knee surgery range from $524 to $1,364 (CPT 29879) when performed as a hospital outpatient. But it may be higher if it's performed in a clinical setting. Look into costs associated with the facility where the knee replacement will be done.
That's because hospital outpatient departments must cap Original Medicare patient costs at $1,364.
Who typically needs knee replacement?
Osteoarthritis is the most common reason for knee replacements, but other factors may lead to the deterioration of the knee joints, including:
Rheumatoid arthritis
Gout
Knee injuries
Knee deformities
Hemophilia
Bone disorders
Is it covered by Medicare?
Yes.
5. Total or partial hip replacement
A hip replacement, also known as hip arthroplasty, is a surgical procedure in which a damaged hip joint is removed and replaced with an artificial joint, often made of titanium and ceramic. During the procedure, the entire hip joint is surgically opened to remove the damaged head of a thigh bone and replace it with man-made materials, which eventually fuses with the bone. At the same time, the eroded lining of the hip socket is also removed and replaced, restoring mobility and resulting in pain-free movement.
Hip replacements are typically caused by osteoarthritis, a degenerative condition that erodes the surface of a joint. More than 10 million American seniors suffer from osteoarthritis.
How much does a total or partial hip replacement cost?
As with any medical procedure, pricing varies by your location and provider. On average, the patient's cost of a total hip replacement ranges from $548 to $1,139 for CPT 29862.
But remember: If a surgery like this is performed in a clinic setting, the Original Medicare cap of $1,364 doesn’t apply — which could increase the cost to you. Always look into costs associated with the facility where the hip replacement will be performed.
Who typically needs a hip replacement?
People over age 60 with osteoarthritis or other degenerative joint conditions of the hip.
Is it covered by Medicare?
Yes. Both partial and full hip replacement surgery is covered under Medicare.
Don't get surprised by medical procedure costs
Remember: Though the projected costs of these common medical procedures may help you prepare your wallet for the given procedure, they're just ballpark figures. Procedure costs can vary by your location, so it's always wise to check with your Medicare provider to get additional procedure cost estimates.
It's also worth noting that your doctor may order tests or additional procedures that may not be covered by Medicare. And if your procedure requires a hospital stay, there are plenty of ways to avoid costly hospital bills.
Also keep in mind that you may need additional services after your procedure, such as physical therapy, so you may need to factor rehabilitative services into the equation.
Choosing a Medicare plan
Having a general idea how much common medical procedures cost is a good first step to be prepared for them. But choosing the optimal Medicare plan for you is also important because coverage for some procedures may depend on whether you have Original Medicare or Medicare Advantage.
Medicare Advantage and Medicare Supplement are two common ways to replace or supplement Original Medicare, but they serve different purposes:
Medicare Advantage plans also known as Part C usually cover Parts A, B, and D with one bundled insurance policy for all Medicare coverage.
Medicare supplement insurance is not comprehensive medical coverage. Instead, it provides extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t cover. These plans, also known as Medigap, can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits. Additionally, a standalone prescription drug plan must be purchased to get prescription drug coverage.
If you need help choosing the right Medicare plan for your specific medical needs, you can find and compare Medicare plans through our plan comparison tool or by contacting one of our licensed Medicare insurance agents.
We've also put together Medicare FAQs for more information.
Cancer statistics are telling: The median age for a cancer diagnosis is 66, and the highest age category for diagnosis is between ages 65-74 (27.6%), with men being diagnosed more frequently than women. But the good news is the rate of new cancer diagnoses and death are trending down.
Still, a cancer diagnosis can be life-changing. And the last thing you want to think about is how your health insurance will cover your diagnosis - whether it’s for surgery or treatment.
In a study by Fidelity Investments, a 65-year old couple retiring in 2019 can expect to spend $285,000 on health care and medical expenses throughout retirement unless a critical illness occurs or the wrong insurance plan is selected.
Rest assured, your cancer treatment costs will be covered, but the coverage depends on the type of Medicare plan you have - standalone Medicare coverage (Part A, Part B, and Part D), Medicare coupled with a Medicare supplement plan, or a Medicare Advantage (also known as Part C) plan.
What Original Medicare Covers
Original Medicare is a combination of Part A (hospitalization) and Part B (medical) and Part D (prescription coverage). It provides cancer benefits if you're diagnosed before you age into Medicare or after you have enrolled.
Relating to cancer, here’s what Original Medicare covers:
Part A
You pay your Part A deductible for common cancer treatments like:
Up to 150 days of inpatient hospital care (on day 61 you begin to pay a daily copay)
Inpatient surgeries related to cancer
Skilled nursing for cancer recovery
Home health services
Short-term nursing home care
Hospice, also known as End of Life care
Part B
You pay your Part B deductible and 20% of outpatient medical services for treatments like:
Visits to your oncologist and other physicians
Second opinion consultations
Outpatient surgery in a doctor’s office
Diagnostic imaging
Chemotherapy
Radiation
Durable medical equipment
Physical therapy and rehabilitation
Participation in clinical trials for experimental treatments through clinical studies
Part D
You’re responsible for your prescription drug copays until you reach the catastrophic coverage limit, which will then cover 95% of your prescription costs, including:
Medications for chemotherapy
Medications to ease side effects, such as prescriptions to treat nausea
Original Medicare pays for a broad spectrum of covered cancer services but it can have its limits. Let’s look at an example:
In 2020, Medicare Part A pays the full cost for a semiprivate room and board, general nursing and miscellaneous services up to 60 days in the hospital. Up to that point, you are only responsible for a $1,408 deductible. The rest of your hospitalization costs are covered.
However, if you are in the hospital for 61-90 days, Medicare payments are reduced, and you have to pay $352 a day for treatment. If you’re in the hospital for more than 91 days, the benefits are further reduced and you’re responsible for paying $704 a day.
What Original Medicare Doesn’t Cover
While Medicare has extensive coverage for cancer treatment, there are a few benefits that are not covered by Medicare which include:
Room and board in assisted living facilities.
Adult daycare.
Long-term nursing home care.
Food or nutritional supplements (except enteral nutrition equipment).
Services outside of skilled care that help you with activities of daily living (like cooking or eating).
As a reminder, if you have standalone Original Medicare with no supplemental coverage, you're also responsible for your deductibles and coinsurance, which is a set percentage you have to pay for hospital stays, medical treatment and prescription drugs.
What Medicare Advantage (Part C) Covers
Medicare Advantage is required to cover the same amount as Original Medicare, but can offer extra benefits and services. Medicare Advantage plans are offered through private health insurance companies - most plans have deductibles, copays and out-of-pocket limits. Once you've reached your out-of-pocket pocket limit, your Medicare Advantage plan will cover all additional medical costs during your plan year.
Keep in mind, you could be limited to doctors within a specific HMO or PPO network, which can be a problem if you are in the middle of a medical regimen or often travel out-of-state. So if you like your current cancer doctors providing your treatment, this may be a downside.
You’re also required to get a referral to see a specialist, which means you are required to pay for two doctor visits instead of just one.
Two important things to note about Medicare Advantage:
You must enroll in Original Medicare and obtain a Medicare number before you can enroll in a Medicare Advantage plan.
Medicare Advantage plans cannot be paired with a Medicare supplement plan.
If you have cancer, it’s wise to shop around for Medicare Advantage plans and compare plan benefits with Original Medicare to determine what your out-of-pocket costs will be under each plan.
Consider the pain point of having to see different doctors if you’re required to stay within a specific Medicare Advantage network. In the end, nothing is permanent. If you enroll in one plan and find it’s not working for you, you can switch to a different coverage during the open enrollment period on October 15 - December 7 each year.
What Medicare Supplement (Medigap) Covers
Medicare supplement plans, also referred to as Medigap plans, fill gaps in coverage that Original Medicare doesn’t pay for, such as a Part A deductible or Part B coinsurance. Medicare supplements also help pay for extended sickness and treatments for diseases like cancer.
Medigap plans and cancer coverage:
Medigap policies don’t cover long-term care, or in-home health care with a private nurse.
Medigap policies only cover one person so you and your spouse cannot share a Medigap plan. You must each purchase separate supplemental plans.
Medigap supplement plans do not offer prescription drug coverage like Medicare Advantage plans. You must enroll in Part D to get drugs covered.
There are 11 different Medigap Plans to choose from (in most states), but some plans are no longer available for new enrollments as of 2020. Still, it’s important to compare Medicare supplement plans because different insurance companies can charge different amounts for the same plan.
For example, some plans might only cover 50% of Medicare Part B coinsurance, resulting in a lower monthly premium, while other plans will pay the entire amount of coinsurance, and have a higher monthly premium.
Cost is usually the only difference between Medigap policies with the same letter sold by different insurance companies. So it comes down to what you can afford to pay on a monthly basis and what out-of-pocket costs you can afford for your cancer treatment.
Medicare Enrollment Dates and Timelines
If you have cancer and are aging into Medicare, it’s important to start the application process early. You have a seven-month period to enroll, which includes:
Three months before your 65th birthday
The month of your 65th birthday
Three months after your 65th birthday
Many people will automatically be enrolled in Medicare Part A and Part B - especially if they’re receiving Social Security retirement benefits when becoming eligible for Medicare coverage.
If you’re still working and receive health insurance through an employer, it’s a good idea to enroll in Part A to receive extra benefits through Medicare in addition to your employer health insurance. You can enroll in Part B after you’ve retired.
If you’re already on Medicare and want to change your coverage, you have some options.
Medicare Open Enrollment (October 15 - December 7)
You can sign up, switch, or leave Medicare Advantage and Part D prescription drug plans..
General Enrollment Period (January 1 - March 31)
You can enroll in Parts A, B, or both.
Medicare Supplement Enrollment
You’re eligible to enroll in a supplemental plan for exactly six-months after your Part B coverage begins with guaranteed coverage.
For example, you have until November 30 to enroll in a Medicare supplement plan if your Medicare Part B coverage began on June 1. If you miss this six-month window, the insurance company has the right to ask medical questions on its application and can deny you coverage if your health conditions make you ineligible.
If you enroll during the enrollment period and are approved, the insurance company can refuse to cover out-of-pocket costs for any pre-existing health problem for up to six months. It is known as a “pre-existing condition waiting period.” After six months, the Medigap policy will cover the pre-existing condition.
You generally don’t need to renew coverage each year, no matter what type of Medicare plan you have. But benefits may change, so it’s still smart to review your plan each year to make sure it’s the best. For example, a pharmacy or provider network may change, causing your costs to increase.
Questions?
Need more information about Medicare and cancer? We have licensed Medicare agents available to walk you through your plan options that may cover your specific cancer treatment and care.
“Medicare for All” has been a popular phrase as Obamacare and rules surrounding the health insurance landscape continue to shift. But why is it such a popular topic?
For starters, Medicare has the highest rate of satisfaction among its users. In fact, enrolled 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. 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 up into two parts: Part A (for hospitalization) and Part B (for medical services). In most cases, there is no cost for Part A.
But 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.
Medicare Part B costs
Part B premiums are determined by your modified adjusted gross income. If your income for 2019 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 $144.60 a month in 2020.
Part B premiums rise to a maximum of $491.60 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, so you can delay your enrollment in Part B without being penalized and save paying the monthly premium as long as you’re on that plan.
Enrolling in 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?
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 $1,408 in 2020.
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 $198 in 2020.
Part C is Medicare Advantage. Medicare Advantage combines Medicare Part A and Part B into a health plan and many of these include Part D and additional health benefits. (More on this below).
Part D is prescription drug coverage. Part D helps cover the cost of prescription drugs. The standard maximum deductible is $435 in 2020.
Plans A-N is Medicare supplemental coverage. Also known as Medigap, there are a host of differences between the plans, which help cover benefits that Medicare Part A and Part B 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 supplemental plan 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 Part C (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 except for people who suffer from End State Renal Disease (ESRD) until that changes in 2021. Other than that, 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 supplements 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.
Medicare Advantage vs. Medicare Supplement: What’s the difference?
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%.
Other services may be covered based on the supplemental plan you pick.
Shopping tips
Choosing between a Medicare Advantage plan or a Medicare supplement plan on to your Original Medicare coverage depends on your situation. 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. Get Medicare quotes, compare plans, or contact us today.
Note: Medicare supplement plan benefits are subject to state rules and regulations. Benefits described here encompass common Medigap plans available in the marketplace. Please check your insurance policy documents or talk to a customer service representative for more information.
Coronavirus disease is making headlines, so many of us have immunity on the mind. Not to mention: Cases of the flu hit many parts of the United States every year.
Though the coronavirus and the flu are two completely different threats, the likeliness of contracting either illness is higher for older Americans:
Coronavirus: At least 50% of the U.S. coronavirus cases were in people who are 50 and older (as of Feb. 7, 2020).
Flu: Over 60% of seasonal flu-related hospitalizations occur in people who are 65 and older.
There’s currently no vaccine for coronavirus, but there is a flu vaccine that can help immunize you against the flu. And the good news is: The flu vaccine is covered by Medicare, along with other vaccinations you may need.
Of course, you’ll want to talk with your doctor about which vaccines are appropriate for you and your health. Once you know what you need, you might ask: “Will Medicare cover my vaccine?”
Let’s take a look at how Medicare Part B and Medicare Part D cover some common vaccines.
Medicare Part B
Medicare Part B is medical insurance that covers 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 $198 in 2020.
Medicare Part B coverage is included in Original Medicare and Medicare Advantage.
What Vaccines Does Medicare Part B Cover?
Flu shots: Part B covers one flu shot per flu season.
Hepatitis B shots: Part B coverage depends. You pay nothing for Hepatitis B vaccines if you’re at medium or high risk for Hepatitis B. You may also pay nothing if your doctor or other qualified healthcare provider accepts assignment. Always consult with your doctor first.
Pneumococcal shots: This is a series of two shots: Part B covers the first shot. Part B will cover the second shot if you receive it at least one year after the first. You may also pay nothing if your doctor or other qualified healthcare provider accepts assignment.
Shingles shots: Not covered by Part B.
Tdap shots: Not covered by Part B, but your Medicare Part D plan may cover them.
Part B may also cover vaccines directly related to treatment of an injury or direct exposure to a disease.
Still, your vaccines may not be covered if you don’t use the right provider. If you have Original Medicare, make sure your healthcare provider accepts Medicare. If you have Medicare Advantage, see a healthcare provider within your plan’s network.
Medicare Part D + How It Works
Medicare Part D is prescription drug coverage that supplements Part B. Medicare Part D covers a limited number of prescription medications and vaccines.
Part D can help with the cost of prescription drugs and many recommended vaccines.
Medicare Part D is offered only through private insurers, but all Part D plans must offer a standard level of coverage set by Medicare. Your Part D plan's formulary will determine what prescription drugs and vaccines are covered.
What Vaccines Does Medicare Part D Cover?
Part D plans cover all commercially available vaccines when reasonable and necessary to prevent illness, with exception to those vaccines that are already covered by Medicare Part B. Covered vaccines may include:
Hepatitis B shots: Part D may cover Hepatitis B vaccines if you are not considered intermediate or high risk for Hepatitis B, in which case this vaccine is covered by Part B.
Shingles shots: Part D generally covers the shingles (herpes zoster) vaccine.
Tdap shots: Part D plans typically cover Tdap shots, which is the booster for tetanus, diphtheria and pertussis (also known as whooping cough).
Your out-of-pocket costs will depend on your Part D plan formulary and where you get the vaccine (doctor’s office vs. a walk-in clinic). Other factors that impact costs include whether or not you’ve met your plan deductible, your plan’s coinsurance (if you have one), and your plan’s copayment amounts.
In 2020, no Medicare drug plan can have a deductible that exceeds $435.
Example Vaccine Costs with Medicare Part D
Let’s look at two examples of what your cost for a vaccine could be with Part D (based on Healthcare Bluebook's price breakdown):
A Hepatitis B vaccine in Miami could cost around $67 at a walk-in clinic and $145 at a doctor’s office. Part D plans in Miami (33101) cover this vaccine as a tier 3 (preferred brand drug) and the beneficiary would pay a copay ranging from $26 to $47.
A Tdap vaccine in Miami may cost $67 at a walk-in clinic and $36 at a physician’s office. Part D plans in Miami (33101) cover this vaccine as a tier 3 (preferred brand drug) and the beneficiary would again pay a copay ranging from $26 to $47.
Your Part D plan may have prior authorization and could require a copayment for certain vaccines. In some cases, you may be required to pay for the vaccine upfront, up to your plan’s allowable charge. You would then submit a claim to your Part D plan for reimbursement.
Check your plan policy to see what's covered under Part D before you get a vaccine.
Which Medicare Plan is Right for You?
It can be difficult to navigate Medicare, the various plans, and what they cover. But we’re here to help make Medicare easy.
Whatever Medicare questions you have, we can help you find, compare and enroll in Medicare plans. Get a
complimentary consultation today.
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