LearningCenter

When you are eligible for Medicare, you have two primary options. One is Original Medicare, which includes Part A and Part B. The other option is Medicare Advantage, known as Part C.

You can’t have Part C and Original Medicare. When you choose Part C, you are choosing to get your Medicare Part A and B coverage through the Medicare Advantage plan.  That means you have to choose between them, which can be a challenge. This article will help you understand Original Medicare vs. a Medicare Advantage plan so you can choose the right one for your needs.


##Difference Between Original Medicare and Medicare Advantage

[Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) is administered by the government and it can be used at any doctor in the U.S. who accepts Medicare. Generally, most folks get [Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) for free and pay a monthly premium for [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b).

Original Medicare coverage will not vary depending on which state or area you live in. Your out-of-pocket costs, after your deductible, are generally 20% of the Medicare-approved costs for services. Original Medicare does not cover hearing, vision, or [dental care](https://medicare.healthinsurance.com/learning-center/article/does-medicare-cover-dental). If you want prescription drug coverage, you have to add [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) and pay a separate premium. 

[Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) is sold by private insurance companies who have a contract with the Federal government. Theremay be limitations on the medical providers you can use depending on where you live. Most Medicare Advantage plans include prescription drug coverage and additional benefits. You might be able to get vision coverage or a discount to a local health club.

Most importantly for many beneficiaries, Medicare Advantage has more predictable out-of-pocket costs. Instead of paying a percentage of the service cost, which is impossible to know in advance, you generally pay specific [deductibles and copayments](https://medicare.healthinsurance.com/learning-center/article/2021-changes-to-medicare). 

You can often get Medicare Advantage for the same cost as Original Medicare, although some Advantage plans cost more.

###Is Original Medicare Better Than Medicare Advantage?

Like any choice, there are pros and cons of Medicare Advantage plans vs. Original Medicare. For instance, Medicare Advantage plans can be better for those who want more predictable out-of-pocket costs or are looking for additional benefits. 

However, Original Medicare is better for those who travel frequently or use doctors who are not in the same medical network. You won’t need referrals to see specialists  and being able to see any doctor you choose can bring peace of mind. You can make Original Medicare out-of-pocket costs easier to manage if you add a [Medigap](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101) policy.

It’s important to think about your specific needs before you choose between Medicare Advantage and Original Medicare. Only you can decide which is best for your situation.

###Cost Difference Between Original Medicare and Medicare Advantage

When you have Original Medicare, you’ll pay a monthly premium for Part B  and there is also a deductible each year.  If you need prescription drugs, you may need Part D as well.. 

Once you reach the deductible for Part B, you’ll pay 20% of the Medicare-approved cost of the medical care you receive. There is no out-of-pocket maximum. For prescription drugs, after the deductible, there are specific copayments each time you need medication.

While Medicare Advantage may also have  a monthly premium, there are many plans with $0 premiums. Therefore, many plans won’t cost any more than you already pay for Medicare Part B, and they already include prescription drugs. 

Each Medicare Advantage plan has its own out-of-pocket costs, including deductibles, copayments, and coinsurance. You’ll want to compare plans before making your final decision. Most Medicare Advantage plans also have an out-of-pocket cost maximum each year, after which the plan covers 100%.

###Can You Switch From Medicare Advantage to Original Medicare?

You can switch from Medicare Advantage and Original Medicare in two different enrollment periods each year. The first is Open Enrollment, which is between October 15th and December 7th each year. You can make any changes to your Medicare plan that you like during this timeframe.

The second time you can switch plans is during the Medicare Advantage Annual Enrollment Period, which is between January 1st and March 31st each year. If you have a Medicare Advantage plan during this time, you can choose a different Medicare Advantage plan or switch from Medicare Advantage to Original Medicare. 

Some circumstances create a special enrollment period, where you can make changes to your Medicare coverage outside of the normal windows. For instance, if you move out of your Medicare Advantage coverage area, you have an opportunity to choose a new plan or switch to Original Medicare.

###Learn More About Original Medicare vs. Medicare Advantage

Understanding the differences between Medicare Advantage and Original Medicare is essential to making the right decision for your needs. However, it often helps to talk to a licensed insurance agent as well. If you have questions about your Medicare coverage and want to [compare plans](https://medicare.healthinsurance.com), contact us today!




Understand the difference between Original Medicare and Medicare Advantage so you can choose the plan that's right for your needs.

Original Medicare vs. Medicare Advantage: Which One is Right for You?

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Original Medicare Vs. Medicare Advantage

If you’re on Medicare and know that you may need more exercise, but aren’t sure how to go about it, the SilverSneakers program is a great way for you to get started with fitness or take your fitness goals to the next level.

In this guide to Medicare and SilverSneakers, we’ll review all the basics of the SilverSneakers program, including what it is, what it covers, how much it costs, and how it works with Medicare. We’ll also cover the wonderful benefits of fitness and exercise, especially for those who are [aging into Medicare](https://www.healthinsurance.com/learning-center/article/tips-for-aging-into-medicare) .


##What Is SilverSneakers? 

SilverSneakers is a complete fitness and wellness program focused on physical health for adults 65 and older. SilverSneakers programs are only available with certain Medicare plans. Classes and activities aim to improve the overall well-being of seniors at all levels and abilities.

Although SilverSneakers is traditionally known for offering access to gyms and health clubs, they have expanded to offer a complete range of fitness and wellness activities and programs. 

###What is Included in the SilverSneakers Program?

SilverSneakers currently offers:

- Free gym membership for seniors with <a href="https://tools.silversneakers.com/LocationSearch?_ga=2.13160816.615417601.1618407218-77505151.1618407218" target=" _blank">access to more than 17,000 gyms</a> across the U.S.
- Online classes
- On-demand classes
- FLEX community classes

The FLEX component of SilverSneakers has really brought their wellness offerings into the forefront of fitness for seniors. The FLEX community classes don’t resemble the gym at all. For people who don’t enjoy  gyms, or prefer alternatives to lifting weights or riding an exercise bike, FLEX is an intriguing option.

The FLEX program offers a <a href="https://www.silversneakers.com/learn/community-fitness/" target=" _blank">variety of senior workouts and fitness options</a> in friendly, no-stress settings including:

- Parks
- Recreation centers
- Churches

Activities and classes offered in the FLEX programs include:

- Tai Chi
- Yoga
- Boot camps

All classes are led by certified coaches and trainers. With FLEX, you can get out of your house, while staying out of the gym, and engage in any level of exercise you’d like. Plus, you still have access to all of the in-gym and online classes offered by SilverSneakers.

Something that isn’t included, though, is personal coaching or one-on-one training. All of the SilverSneakers classes and programs are geared either towards open-access gyms (you have the run of the gym) or group classes.

### Who Is Eligible For SilverSneakers?

The only eligibility requirement for SilverSneakers is that you’re covered by a participating Medicare plan. 
Although there’s a common assumption that you have to be 65 or older, SilverSneakers eligibility is not based on age. So if you’re in Medicare before age 65, rest assured that you can use SilverSneakers as long as your plan offers it. 


##How Does SilverSneakers Work?

For you as a user, SilverSneakers membership is very simple. If you qualify for it, you simply enroll online. Once you’re enrolled, you have access to 100% of the program and benefits offered by SilverSneakers.

For starters, you could look for a gym. This has historically been what SilverSneakers is known for. You can use their <a href="https://tools.silversneakers.com/LocationSearch?_ga=2.13160816.615417601.1618407218-77505151.1618407218" target=" _blank">fitness club locator</a> to find the gyms or facilities that are closest to you. 

You get the benefits of a gym membership, without having to pay for it. Instead, SilverSneakers has a payment arrangement with the gyms and facilities in their network. Wonderfully, you don’t have to be involved with those details.

You simply show up at the gym or facility of your choice and start working out. 

**Here are some things to keep in mind:**
- It might be a good idea to chat with the staff to see how the facilities are laid out.
- You might also want to ask the staff which classes and other privileges are included in your free membership. 
- One last thing to check is their COVID-19 policies regarding occupancy, masks, and other safety protocols. But you don’t need to complicate this. Simply sign up, get the necessary info, and then show up.

###Does SilverSneakers Pay for Gym Membership?

If you are eligible, some benefits of SilverSneakers include the use of gyms who participate in the program. Some plans cover the SilverSneakers program and members will be able to join select gyms. 


###SilverSneakers Classes Online

There are many other benefits of SilverSneakers besides the ability to use “in-person” facilities. This is especially true as a result of the [Coronavirus](https://www.healthinsurance.com/learning-center/article/what-is-coronavirus) pandemic. 
SilverSneakers has responded to the perils of quarantine and lock down by expanding their online offerings. The aim is to help counteract adverse health consequences due to isolation, immobility, and negative emotions. 

**SilverSneakers makes two kinds of online fitness content available:**

- Live classes via Zoom
- On-demand classes directly on the SilverSneakers website
- The live classes are just what they sound like: classes that you can take as they happen. SilverSneakers has a <a href="https://tools.silversneakers.com/Search/OnlineClasses" target=" _blank">schedule of upcoming classes</a> on their website. There is no additional fee for using the live classes.
- As for the on-demand classes, these are also viewed on the device of your choice using an internet connection. You can simply search for a class that interests you and play it whenever you want. You don’t have to wait for the class to go “live.”
- For the on-demand and live programs, you can find a great variety of offerings, including:
- Yoga
- Movement
- Cardio
- Strength training

###Does Medicare Cover SilverSneakers?

- Original Medicare, the basic government program, does not cover SilverSneakers. However, if you use a Medicare health  or Supplement plan offered by a private insurance plan contracted with the government, private insurance option, you might have access to the program.
- SilverSneakers is available to people who use either:
- [Medicare Advantage plans](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide), or
- Medicare Supplement Insurance (Medigap)

###SilverSneakers And Medicare Advantage

For Medicare Advantage plans, SilverSneakers will come as an “AdditionalExtra Benefit.” AdditionalExtra benefits are those offered by the plan beyond what’s covered by Original Medicare [Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) and [Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b). Other Medicare Advantage additional extra benefits often include vision and hearing coverage, rides to appointments, and dental coverage.

SilverSneakers is either included with your Medicare Advantage plan, or it’s not. You won’t be able to add SilverSneakers as an option. 

If using this benefit is important to you, you’ll want to specifically look for a Medicare Advantage Plan that offers SilverSneakers.

### Can I Join SilverSneakers if I Don’t Have a Medicare Advantage Plan?

Include 1 to 2 paragraphs to explain which forms of Medicare cover SilverSneakers. Can a user get it without Medicare Advantage?

###SilverSneakers And Medicare Supplement

[Medicare Supplement plans](https://www.healthinsurance.com/learning-center/article/medicare-supplement-101), which work with Original Medicare, sometimes offer SilverSneakers as an incentive for you to sign up. Once again, this isn’t an a la carte option; your plan either offers SilverSneakers, or it doesn’t. You can find out in advance whether or not a Medicare Supplement Insurance plan offers SilverSneakers.

**NOTE**: SilverSneakers is an additionalextra benefit. It is not a part of the core, required benefits of these plans. Insurance companies can change or eliminate extra benefits, including SilverSneakers. So make sure to choose your Medicare coverage based on other healthcare needs, too.


##Why Should I Take Advantage of SilverSneakers?

SilverSneakers is a great way to maintain a healthy lifestyle through physical activity. Studies show that even <a href="https://www.psychologytoday.com/us/blog/the-athletes-way/201505/very-small-amounts-exercise-can-reap-huge-benefits" target=" _blank">small amounts of exercise</a> can lead to better health and longevity. 
SilverSneakers eliminates one of the obstacles to physical health: the cost of a gym membership or private workout equipment. By making so many types of exercise for seniors available, SilverSneakers allows you to find an activity that appeals to you - making you much more likely to stick with it.

Among the many benefits of physical activity are:

- Reduced risk of dying from [coronary heart disease](https://www.healthinsurance.com/learning-center/article/cardiovascular-disease-cvd-medicare-coverage) 
- Reduced risk of developing diabetes, lung disease, and colon cancer
- Reduced symptoms of anxiety and depression, lifting overall feelings of well-being
- Can lower blood pressure
- Improves flexibility, reducing stiffness, and joint swelling
- As we age, we’re much more likely to be sedentary and inactive. SilverSneakers is an easy and affordable tool to combat these tendencies and stay vital, active, and healthy.


##How To Join SilverSneakers

If your Medicare plan offers SilverSneakers, you’ll want to use your Medicare plan’s insurance company’s member ID card to sign up. You’ll do this online at the SilverSneakers website.  If you’re not sure if your plan includes this benefit, you can <a href="https://tools.silversneakers.com/Eligibility/CheckEligibility" target=" _blank">check your eligibility</a> on their site as well.

**If your plan doesn’t offer SilverSneakers, you won’t be able to get it.** You can consider switching to a plan that does offer SilverSneakers. Keep in mind though that you probably can’t switch plans in the middle of the year.

Instead, you’ll want to take advantage of one of the enrollment periods allowed by Medicare. 
**For Medicare Advantage, you can use two enrollment periods:**
The Medicare Annual Election Period (AEP), and
The Medicare Advantage Open Enrollment Period (MA-OEP)

The [Medicare Annual Enrollment Period](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period) is from October 15th to December 7th of each year. If you switch to a new plan, your new coverage is effective on January 1st of the following year. 

The MA-OEP is from January 1st to March 31st of each year. Any changes to your coverage are effective on the first day of the month after your enrollment change.

NOTE: It’s important to make sure that any plan you switch to will meet your other healthcare needs. At a minimum, you’ll want to make sure that any Medicare Advantage plan covers your doctors and [medications](https://www.healthinsurance.com/learning-center/article/tips-to-reduce-your-prescription-drug-costs). Don’t switch just to get a fitness benefit.

Changing Medicare Supplement plans can be much more complicated. After your Medigap Open Enrollment Period, you usually have to apply for coverage, and you can be turned down, or charged more for pre-existing conditions. This makes choosing your first Medicare Supplement plan an important decision. 

**Here are some tips when choosing Medicare Supplement Insurance:**
If you’re shopping for coverage, try to find a Medigap plan that currently has SilverSneakers because you may not be able to switch Medigap plans later.

You can, however, move from [Medicare Supplement to Medicare Advantage](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap) during the Annual Election Period (AEP). If you do this, look for a new plan that has SilverSneakers coverage.

Remember that there are no age restrictions for SilverSneakers. So if you have a qualifying Medicare Insurance plan, you’re eligible for SilverSneakers.

To find a participating gym or facility in the SilverSneakers network, just use their <a href="https://tools.silversneakers.com/LocationSearch?_ga=2.13160816.615417601.1618407218-77505151.1618407218" target=" _blank">locator tool</a>.


##Additional SilverSneakers FAQs 

We've compiled some of the most frequently asked questions about Medicare and the SilverSneakers program with answers below.

###Is SilverSneakers Free?

SilverSneakers is available without any extra charge. In addition, the individual classes and services are free of charge. You pay a monthly premium for Medicare Advantage (some plans have $0 monthly premiums) and Medicare Supplement plans, though. And you must continue to   pay your Part B premium when you enroll in either of these plans.

###Who Pays For SilverSneakers?

Your Medicare health plan insurance company pays for SilverSneakers access.

###Can I Join SilverSneakers Without Insurance?

No. You must have a participating Medicare health insurance plan to get SilverSneakers.

###Does Tricare Cover SilverSneakers?

No. You must have a private Medicare plan like Medicare Advantage or Medicare Supplement Insurance[jla1] .

###Does Medicaid Cover SilverSneakers?

No, not by itself. If you have [Medicaid and a Medicare plan](https://www.healthinsurance.com/learning-center/article/whats-the-difference-between-medicare-and-medicaid) like Medicare Advantage or  Medicare Supplement, then you might be able to have access to SilverSneakers.

##Final Thoughts On SilverSneakers

SilverSneakers is a versatile service that connects you to a multitude of fitness options. Using SilverSneakers can help reduce your risk for certain diseases and improve your mental well-being. Because of the lifestyle benefits, it’s worth [looking for a Medicare plan](https://www.healthinsurance.com/learning-center/article/10-medicare-frequently-asked-questions) that comes with SilverSneakers.

**Medicare Advantage plans may offer SilverSneakers, a way to work out at home or at participating fitness locations. <a href="https://tools.silversneakers.com/Eligibility/CheckEligibility?utm_campaign=2021aep_benefytt_resourcecenter|AEP21-B&utm_medium=referral&utm_source=benefytt" target="_blank">Click here</a> to check your eligibility, or call our licensed insurance agents at 1-800-620-4519 (TTY 711) to see if you qualify for a Medicare Advantage plan that may include SilverSneakers as a benefit.**



Learn how Medicare works with the SilverSneakers program. We’ll cover costs, eligibility, how to join, and more.

A Guide to Medicare and SilverSneakers

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Medicare and the SilverSneakers Program

Medicare Advantage, or Medicare Part C, often offers additional  benefits and sometimes savings on out-of-pocket costs. However, Medigap can also help you save on your costs and pay less for coinsurance, copayments, and deductibles.

It’s important to know the difference between Medicare Advantage and Medigap, along with the pros and cons of each. After that, you may be wondering, “Can I switch from Medicare Advantage to Medigap?” This article will help you understand if you can, and when it’s possible.


##What's the Difference Between Medicare Advantage and Medigap?

[Medicare Advantage, or Medicare Part C,](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) is an all-inclusive alternative to [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). It generally encompasses Medicare Parts A, B, and D. However, because your coverage is provided by a private insurer and not the government, there are limitations on your provider network. You can also expect different — and sometimes lower — copayments, deductibles, and coinsurance.

People choose Medicare Advantage because they enjoy getting additional benefits, such as low-cost health club memberships, vision and [dental coverage](https://medicare.healthinsurance.com/learning-center/article/does-medicare-cover-dental), and more. They also prefer the predictable out-of-pocket costs rather than a percentage coinsurance.

[Medigap](https://medicare.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap) is an add-on to Original Medicare and helps you pay for healthcare costs like your deductible, copayments, and coinsurance. There are several plans, lettered from A to N. However, some are not available to beneficiaries after a certain date.  Medigap is sold by private insurers, and the only difference between providers offering the same letter is cost — every Plan A will be the same as every other Plan A.

Medicare beneficiaries choose Medigap because it lowers or eliminates a lot of out-of-pocket costs. Medigap has to pay its share when Medicare covers its part. You can see any doctor in the U.S. that accepts Medicare, and you don’t need referrals for specialist appointments. 

In general, no one can sell you a Medigap plan if you have Medicare Advantage. In order to get Medigap, you have to disenroll from Medicare Advantage and return to Original Medicare.


##Switching From Medicare Advantage to Medigap FAQ

People have a lot of questions about switching from Medicare Advantage to Medigap. This section will answer some of the most frequently asked questions.

###Can You Switch From Medicare Advantage to Medigap Without Underwriting?

If you choose Medigap with Original Medicare during your initial enrollment period around your 65th birthday, you were guaranteed acceptance even if you had known health conditions. After that initial period, if you want to join a Medigap plan, they generally use underwriting to review your health risk before they decide to accept you.

If you want to avoid this underwriting, you’ll need a special enrollment period that has guaranteed issue rights. For instance, if you decide to switch out of a Medicare Advantage plan within the first 12 months, you can get Medigap without underwriting. 

Other times you can get Medigap without underwriting include:

- If you move out of your Medicare Advantage service area
- If you’re in one of four states that require Medigap to be freely available at certain times of year (Maine, Massachusetts, Connecticut, and New York)

###Can I Switch From Medicare Advantage to Medigap During Open Enrollment?

In order to switch to Medigap, you need to disenroll in Medicare Advantage and go back to Original Medicare. You can do this during two enrollment periods. 

The first is Open Enrollment, which occurs from October 15th-December 7th each year. During this time you can make any changes you’d like, including returning to Original Medicare and getting Medigap.

You might wonder about Medicare Advantage’s Annual Enrollment period, from January 1-March 31 each year. While you can leave your Medicare Advantage plan during that time and return to Original Medicare, you won’t be able to sign up for Medigap until the next Open Enrollment period. 

###Contact us to Learn More About Medicare Plans

Understanding your rights under Medicare can be challenging. It’s often easier when you speak to a licensed insurance agent about your situation. If you’d like to discuss your options and see whether Medicare Advantage or Medigap is better for you, we’re here to help. [Contact us today!](https://medicare.healthinsurance.com/)



If you're contemplating switching from Medicare Advantage to Medigap it's important to understand the pros and cons and differences between each plan. We answer these questions and more to help you make an informed decision.

Can I Switch From Medicare Advantage to Medigap

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Can You Change From Medicare Advantage to Medigap?

Individuals have an initial enrollment period available to them to first enroll in Medicare. However, Medicare also allows those in certain circumstances to enroll in Medicare Part B at a later point. 

In addition, Medicare also offers special enrollment periods to those already enrolled in Medicare. Each year, Medicare beneficiaries have a chance to change their Medicare plan choices during the [annual enrollment](https://medicare.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period) period (AEP). Those with [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) can also change their Medicare Advantage plan, or return to [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage), during the Medicare Advantage open enrollment period (MA OEP).

But what if you need to make a change to your Medicare plan outside of those dates? The government allows special enrollment periods (SEPs) for specific types of events where you will need immediate coverage before the next annual enrollment.

This guide will help you understand what SEPs are available and how each one works.


##Medicare SEP FAQ

It can be very challenging to keep up with which life events qualify for an SEP, especially if you’re in the middle of a move, job change, or other stressful situation. Plus, each SEP has its own rules. That’s why it’s important to know how each one works ahead of time, if possible.

###Medicare Special Enrollment Periods for Premium-Free Medicare Part A

Generally, you sign up for [Medicare Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) automatically when you turn 65.

Not everyone retires at or before age 65. If you’re still working after age 65 and are covered under a group health plan, you don’t have to sign up for Medicare right away. 

Once you retire and stop working, you have an eight-month special enrollment period to sign up for premium-free Medicare Part A, along with a drug plan (Part D) or Medicare Advantage (Part C) if you prefer.

If you qualify for premium-free Medicare Part A, . you can sign up for it anytime because you don’t pay a premium, although you may have a gap in coverage. 

However, if you have to pay a premium for Medicare Part A, you can only sign up during approved enrollment periods or if a special enrollment period is triggered. 

###Special Enrollment Period for Medicare Part B

[Medicare Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) carries a monthly premium, and if you sign up after your initial enrollment period you usually will face a penalty. There are exceptions, though, and many of them apply to events that cause a special enrollment period.

If you’re still working after age 65 and are covered under a group health plan, you may choose to delay signing up for Part B. Once you retire and stop working, you have an eight-month special enrollment period to sign up for Medicare Part B, along with a drug plan (Part D) or Medicare Advantage (Part C) if you prefer.

You get a special enrollment period for Part B if

- You have group health plan coverage
- You or your spouse (or a family member if you’re disabled) is working for the employer that provides your health coverage
- Generally, this SEP lasts for eight months from the above events.

###Special Enrollment Period for Medicare Advantage and Part D Plans

When you have a Medicare Advantage (MA)plan or a Prescription Drug Plan (also known as Medicare Part D), you can make changes during the normal annual enrollment period. However, there are times when you need to make immediate changes, and a special enrollment period can let you do that.

You can get a special enrollment period for an MA or Part D plan if:

- You lose group or union health coverage; this SEP lasts for two (2) months after that coverage ends.You move out of your plan's area, or to an area with new plan offerings; this SEP generally lasts from one month before your move until two months afterward
- You move back to the U.S. from abroad; this SEP lasts for two months after you return to the U.S.
- You move into or out of an institution; this SEP lasts as long as you live in the institution and for two full months afterward
- You are no longer eligible for Medicaid; this SEP lasts for three months from the date you’re notified or no longer eligible, whichever is later
- You are no longer eligible for a Special Needs Plan (SNP); this SEP lasts for three months after your disenrollment from the SNP
- You’re released from jail; this SEP lasts for two full months after you’re released
- If your MA or drug plan decides not to renew its contract for the next year, this SEP starts December 8th and ends on the last day in February of the following year
- You qualify for extra help with drug coverage - you qualify for an SEP every three months for the first 9 months of the year  

This is not an exhaustive list. If you have questions about Medicare enrollment or want to review your plan options, contact us today!

###Medicare Special Enrollment Period for a Disaster

If there is a Federal, State or locally declared emergency or disaster, the Center for Medicare Services (CMS) will designate a special enrollment period for those who missed their chance to enroll due to that event. 

The special enrollment period starts the date the declaration was made and continues for two full months following the end of the declaration.  This SEP also applies to those who don’t live in the affected area but rely on people in that area for help with healthcare decisions.


### Learn More About Medicare Special Enrollment Period (SEP)

There are a lot of life events that can impact your need for Medicare, and sometimes they happen outside of the normal enrollment timeframes. Special enrollment periods exist to help you get the coverage you need at the right time.

If you have questions about Medicare enrollment or want to review your [Medicare Advantage plan](https://medicare.healthinsurance.com) options, contact us today!


Understanding the Medicare special enrollment period is critical to know when and why you can make changes to your plan. We answer all your SEP questions in this guide.

Everything You Need to Know About Medicare Special Enrollment Periods

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Understanding Medicare Special Enrollment Period (SEP)

If you choose to have [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) with [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) added, you’ll receive prescription drug coverage through Medicare Part D. However, there can sometimes be a gap in the coverage of your prescriptions.

This gap is known as the “donut hole,” and it’s a period of time where you pay out-of-pocket for your medications. However, you don’t pay the full amount, and once your out-of-pocket costs hit a specific level Medicare will resume coverage.

What is the Medicare donut hole? This page will help you understand the donut hole and how to navigate it.


##How Does the Donut Hole Work in Medicare?

The Medicare donut hole is a period of time where you’ve reached the limit of your Medicare Part D coverage, but haven’t hit the “catastrophic coverage” level where Medicare resumes assisting you with your prescription drug coverage.

With Medicare Part D, the first portion of the year you’ll be paying toward your deductible. The deductible varies but can be up to $445 in 2021. Once you reach your deductible, your drug plan will kick in and you’ll pay your copayment or coinsurance for your medication.

If the amount you and your plan pay toward prescription drugs reaches a certain level, you’ll enter the donut hole. Keep in mind that not everyone gets to the prescription donut hole — the gap was designed to encourage Medicare recipients to seek out lower-cost drugs and generics. The Medicare donut hole in 2021 starts at $4,130. 

###When Does the Medicare Donut Hole End?

The coverage gap ends when you reach the catastrophic coverage limit for the year. In 2021, this amount is $6,550. 

The good news is that the donut hole essentially closed in 2020, so that even when you hit the coverage gap, you won’t pay more than 25% of the cost of prescription drugs. However, around 95% of the cost will count toward moving you out of the hole.


##Do Medicare Advantage Plans Cover the Donut Hole?

Medicare drug coverage — Part D — works the same in a Medicare Advantage plan as it does with a "Stand-alone” Part D plan. However, some [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) plans offer more generous benefits during the donut hole than a stand-alone Part D plan does.

Understanding your prescription drug coverage is essential so that you know if you’re likely to approach a coverage gap based on the price of your medication. If so, make sure you know what the costs will be during the donut hole period.

###Medicare Part D Plans Without the Donut Hole 

There are no Medicare Part D plans — including Medicare Advantage plans — without a coverage gap. However, some prescription plans have additional coverage options during the donut hole.

For instance, your Medicare Advantage plan might include coverage for some generic medications even in the gap. Or, they may offer some drugs at a lower cost than 25%. It all depends on your plan and provider.

The best way to avoid the donut hole is to work with your doctor to keep the cost of your medication low. If that’s not possible, the fact that you will pay no more than 25% of the full cost even in the coverage gap will help ease your mind.

###How Do I Get Out of the Medicare Donut Hole?

If you’re in the Medicare Part D donut hole, the only way to get out is to spend enough to reach the catastrophic coverage threshold. The good news is that while you’re paying no more than 25% of the cost of the medication, close to 95% of the cost of the drugs is going toward your spending total.

One way to manage the  coverage gap “donut hole” is to work with your doctor to find effective low-cost and generic medications that will help you maintain your physical health.

Here are some tips that can help:

- Use a generic or find a similar drug that has a generic
- Talk to your doctor about drug costs and whether specific prescriptions are really needed
- Shop around — different pharmacies offer different drug prices
- Compare Medicare plans each year to make sure you have affordable drug coverage


###Learn More About Medicare Costs and Plans

Medicare costs can be confusing, especially when there is the possibility of a coverage gap in the middle of the year. Fortunately, even during the Medicare donut hole, you don’t have to pay more than 25% of a prescription drug price, and you may even pay less. 

If you’re interested in comparing Medicare plans to make sure your drug coverage meets your needs, talking to a licensed insurance agent can help. Learn more about your options and [compare Medicare plans](https://medicare.healthinsurance.com/) today!


The Medicare donut hole applies to cost gaps for prescription drugs. Learn about how the donut hole works and what you can do to offset prescription drug costs.

What is the Medicare Donut Hole? 

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Everyone can enroll in Medicare in the seven-month period around their 65th birthday through the Medicare Initial Enrollment Period (IEP). It starts three months before your birth month, includes your birth month, and ends three months afterward. If you don’t enroll in Medicare (either Medicare Part A or Part B) during your IEP, you can enroll enroll in either during the General Enrollment Period that occurs annual from January 1 through March 31 of each year.  

After you enroll in Medicare when can you change your Medicare coverage options? 

There are three main enrollment periods that allow you to make changes to your coverage. Everyone with Medicare can make changes during the annual enrollment period (AEP).  If you have certain qualifying events happen in your life, you may also have a special enrollment period (SEP) to allow changes. And if you are enrolled in a Medicare Advantage (MA) plan, you will also have an opportunity to make changes during the MA open enrollment period (OEP) that happens at the beginning of the year. .

This article will cover these enrollment periods in more detail so you know exactly when you can make changes to your Medicare plan.


##Special Enrollment Period SEP for those enrolled in Medicare Advantage or Prescription Drug Plans

If you have special circumstances in your life, , you may qualify for a Medicare SEP to change your Medicare Advantage or Part D plan coverage. The special enrollment period options and length will be different for each circumstance. 

For example, you could qualify for an SEP if you:

- Retire from a job after age 65
- Move 
- Become eligible for Medicaid
- Have your Medicare plan terminated by the insurer
- Lose other medical or drug coverage

To learn more about Medicare SEPs, check out our guide on special enrollment periods.


## Medicare Advantage Open Enrollment (MA OEP) vs. Annual Enrollment (AEP)
Both Medicare annual enrollment period (AEP) and Medicare Advantage Open Enrollment  period (MA OEP) happen each year. However, there are some important differences. This will help you understand Medicare AEP vs Medicare Advantage OEP.

The Medicare annual enrollment period is between October 15th and December 7th of each year. During this time everyone with Medicare can join, switch, or drop any Medicare Advantage or Prescription Drug plan (“Part D). Your coverage will begin on January 1st, as long as you make your choice by December 7th. 

The Medicare Advantage open enrollment period applies only to those enrolled in Medicare Advantage plans. From January 1st to March 31st each year, you can switch to a different Medicare Advantage plan, or switch from Medicare Advantage to Original Medicare and join a separate drug plan. 

To summarize the Medicare annual enrollment period vs Medicare Advantage open enrollment period:

Dates: Oct 15 - Dec 7 for AEP, Jan 1 - March 31 for Medicare Advantage OEP
Costs: None beyond your plan’s monthly premiums
Eligibility to Enroll: AEP — any Medicare beneficiary; OEP — Medicare Advantage enrollees only
Form of Medicare Available: AEP — any; MA OEP — Change Medicare Advantage plans or Medicare Advantage to Original Medicare

###Medicare Enrollment Periods Chart

This chart can help you understand Medicare open enrollment vs annual enrollment, along with special enrollment periods.
<br>
<table>
  <tr>
    <th></th>
    <th>Medicare Annual Enrollment (AEP)</th>
    <th>Medicare Advantage Open Enrollment (OEP)</th> 
    <th>Medicare Advantage & Part D Special Enrollment (SEP)</th>
  </tr>
  <tr>
    <td>Start Date</td>
    <td>October 15th</td> 
    <td>January 1st</td>
    <td>When a qualifying even occurs</td>
  </tr>
  <tr>
    <td>End Date</td>
    <td>December 7th</td> 
    <td>March 31st</td>
    <td>Varies</td>
  </tr>
  <tr>
    <td>Notes</td>
    <td>Any Medicare beneficiary can make any changes</td> 
    <td>Medicare Advantage enrollees only, limited changes</td>
    <td>Details depend on the qualifying event</td>
  </tr>
</table>
<br>
###Learn More About Medicare Enrollment Periods

Now that you understand the different enrollment periods, you might decide you want to make a change. Making the right choice for your needs is easier when you talk to a licensed insurance agent. Contact us today for any questions about enrollment periods or [comparing Medicare plans](https://medicare.healthinsurance.com)!



Between OEP, AEP, and SEP, Medicare enrollment periods can be confusing. Learn about the different enrollment windows and what you need to do to qualify for Medicare benefits.

Understanding Medicare Enrollment Periods

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[Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) offers important prescription drug coverage and is part of both Original Medicare and Medicare Advantage. As a result, it’s important to understand the Medicare Part D phases that occur each year.

There are four Medicare Part D stages. Depending on your drug costs, you may not reach all four in a given year. However, it’s still vital to know what to expect in case your prescription drug needs increase over time.

Here’s what you need to know.


##What are the 4 Stages of Medicare Part D?

What are the Medicare Part D stages of coverage? As we mentioned, there are four of them. They start with the deductible period, then initial coverage, followed by the donut hole, and then catastrophic coverage. We’ll go in-depth into each stage so that you can fully understand how they work for you.

###Deductible Period

During the deductible period, you pay the full price of your prescription drugs until you meet your Medicare Part D deductible. The deductible may vary from one plan to another, but Medicare does set a maximum limit. 

####Medicare Part D Deductible 2021

In 2021 the deductible limit for Medicare Part D is $445. 

Some plans have a $0 deductible, meaning that you skip the first of the Medicare Part D payment stages and move straight into initial coverage.

Other plans have a deductible that only applies to certain tiers of medications, while other medications are covered right away. For instance, generic medications may be covered immediately while name-brand medications have a deductible. 

Make sure you review the Medicare Part D deductible when you compare plans each year so you can choose the plan that’s best for your needs.

###Initial Coverage

Once your deductible is met, you move into initial coverage. This is where your Medicare Part D plan covers your medication, and you only pay a copayment or coinsurance each time. Each plan will have a different list of covered medications and different out-of-pocket costs, so be sure to carefully review the details of your plan.

The initial coverage period lasts until you hit $4,130 in total drug costs, which includes both the amount you have paid during the year and the amount your plan paid. Depending on your medical needs, you may not hit the limit, but if you do, you enter the coverage gap known as the Medicare donut hole.

###Medicare Part D Donut Hole

Once you hit the Medicare Part D initial coverage limit, you enter a gap in coverage known as the donut hole. In the past, you had to pay a significant amount of your drug costs during this gap. The coverage gap for all drugs essentially closed in 2020, meaning your share of costs in the “donut hole” is limited to 25% of the drug cost (both brand-name and generic).

This percentage will replace the copayment or coinsurance you were paying during the initial coverage period. S For a generic drug that costs $100, you would pay $25 for that drug during the donut hole.  For brand-name drugs, even though you only pay 25% of the cost, around 95% of the cost will count toward your out-of-pocket total to move you out of the coverage gap.

Once you have paid $6,550 in out-of-pocket costs for prescription drugs, you’ll exit the donut hole and enter catastrophic coverage.

###Medicare Part D Catastrophic Coverage

The final stage of Medicare Part D is catastrophic coverage. What is catastrophic coverage in Medicare Part D? It’s a phase designed to help those who have especially high prescription drug costs.

During catastrophic coverage, you’ll pay significantly lower copayments or coinsurance for your remaining prescriptions for the year. For Medicare Part D catastrophic coverage in 2021, you’ll pay 5% of the cost of drugs, and the plan pays for the remainder. 


##Does Medicare Part D Have an Out-of-Pocket Maximum?

There is no out-of-pocket maximum for Medicare Part D, but once you hit catastrophic coverage, your out-of-pocket costs drop significantly. Generally, you’ll pay a a minimum of $9.20 for brand-name medication and $3.70 for generic drugs, or 5% of retail costs, whichever is higher.  

###Learn More About Medicare Part D Coverage Stages

Medicare Part D is important coverage for many Medicare beneficiaries. That’s why it’s vital to understand the various Part D phases and whether you will enter them in a specific year. Comparing plans is easier with a licensed insurance agent by your side. Contact us to learn more or use our [plan comparison tool](https://medicare.healthinsurance.com/) to learn about plans in your area.




Understanding the stages of Medicare Part D can help you determine how much you will pay for prescription drugs. Learn more about the four coverage stages.

The 4 Phases of Medicare Part D 

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what are the phases of medicare part d?

Medicare Part D Phases 

Not all Medicare beneficiaries can afford to pay their premiums, copayments, and coinsurance. If you have a lower income, it’s possible that you’ll qualify for a Medicare Savings Program to help with your out-of-pocket expenses.

Are you asking, “Do I qualify for a Medicare Savings Program?” If so, this article will help. This page is designed to help you understand the Medicare Savings Program income limits and other requirements.

Read on to find out if you qualify.

##What Does the Medicare Savings Program Cover?

There are four different Medicare Savings Programs that you may qualify for. Each one has different requirements and benefits. In general, there are income limits and resource limits to qualify for each program, and they may help pay your premiums, deductibles, copayments, and coinsurance.


###Qualified Medicare Beneficiary

The first program is known as the “Qualified Medicare Beneficiary” program. If your income is 100% of the <a href="https://www.healthcare.gov/glossary/federal-poverty-level-fpl/" target="_blank">Federal Poverty Level</a> or below and you are below the resources threshold, you can qualify for assistance with Part A premiums (if applicable), Part B premiums, deductibles, copayments, and coinsurance. Providers are not allowed to bill you for services or items covered by Medicare, and you pay very little for prescription drugs as well.

###Specified Low-Income Medicare Beneficiary

You may be eligible for the Specified Low-Income Medicare Beneficiary (SLMB) program if you make less than 120% of the Federal Poverty Level and are below the resources threshold for the program. 

This program covers your [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) premium but does not cover any other out-of-pocket expenses from Medicare. You will still be responsible for your deductible, copayments, and coinsurance. 

However, you will qualify for Extra Help with prescription drugs under [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) automatically, which will help you save money on needed medication.

###Qualified Individual Program

The Qualified Individual (QI) program is state-based and helps pay Part B Medicare premiums for those with Medicare Part A and limited resources. This limited program is available on a first-come, first-serve basis and has limited spots each year. You also need to reapply each year.

You can qualify for the QI program if you make 135% or less of the Federal Poverty Level income and are below the resources limit for the program.

###Qualified Disabled Working Individual

If you qualified for Medicare due to a disability but recently returned to work, you may no longer be able to get <a href="https://medicare.healthinsurance.com/learning-center/article/medicare-part-a">Medicare Part A</a> premium-free. You can qualify for this assistance if you make as much as 400% of the Federal Poverty Limit if your income is from working. 

The Qualified Disabled Working Individual (QDWI) program may help you if the following apply:

- **You’re a disabled working person under 65**
- **You lost Social Security benefits and premium-free Medicare Part A due to returning to work**
- **You’re not getting medical assistance from your state through Medicaid**
- **You meet the income and resource requirements set by the state**

QDWI will help pay your Medicare Part A premiums.


##Who Qualifies for the Medicare Savings Program?

There are two qualifications for the Medicare Savings Programs. One is based on your income, and the other is your resources. The requirements may vary depending on the state you live in, and whether any of your income comes from working. Let’s take a deeper look.

###What is the Income Limit for the Medicare Savings Program?

The Medicare Savings Program income limit varies by location; most states base it on a percentage of the Federal Poverty Limit, which shifts slightly each year.

In 2021, here are the monthly income limits for each program. Limits for Hawaii and Alaska are slightly higher.

- Qualified Medicare Beneficiary: Individual $1,094 and Married Couple $1,472
- Specified Low-Income Medicare Beneficiary: Individual $1,308 and Married Couple $1,762
- Qualified Individual: Individual $1,469 and Married Couple $1,980
- Qualified Disabled Working Individual: Individual $4,379 and Married Couple $5,892

There are also resource limits for each program. Counted resources include stocks, bonds, and money in your checking or savings account. The resource limit for the QMB, SLMB, and QI programs is $7,970 for an individual and $11,960 for a married couple.

For the QDWI program, the resource limit is $4,000 for an individual and $6,000 for a married couple.

###What Counts as Income for Medicare Savings Program?

When looking at your income, how do you know what counts? The good news is that if you are working, around half of your working income is excluded. Worker’s compensation and disability benefits are also excluded.

If your income, after these adjustments, is close to the limit, it’s worth applying for the program. If approved, you could save a considerable amount of money on out-of-pocket expenses. Contact your <a href="https://www.medicare.gov/talk-to-someone" target="_blank">state’s Medicaid office</a> if you have questions about your eligibility.


##Medicare Savings Program vs. Medicaid

The Medicare Savings Program is administered by each state, often through the Medicaid office. However, it is not the same as Medicaid. 

[Medicaid](https://medicare.healthinsurance.com/learning-center/article/whats-the-difference-between-medicare-and-medicaid) is specifically designed for low-income families and individuals and covers medical care with little to no out-of-pocket expenses. There is no monthly premium to be on Medicaid, you qualify based on your income and assets. 

The Medicare Savings Program is designed to help Medicare beneficiaries, who are disabled or over 65, pay for their out-of-pocket costs with Medicare. This may include your Part B premium, your Part A premium (if any), and other costs. 

It is possible to be eligible for both Medicare and Medicaid at the same time. These folks are known as “Dual Eligible,” and generally qualify for a Medicare Savings Program automatically, along with Extra Help for prescription drugs.


##Learn More About the Medicare Savings Program

If you’re ready to learn more about Medicare and the Medicare Savings Program, it’s helpful to talk to a licensed insurance agent. Contact us to learn more and [compare plans](https://medicare.healthinsurance.com/) to find the one that’s right for you.

Medicare Savings Programs help individuals pay for premiums, deductibles, copays, drug costs, and more. Learn more about coverage and who qualifies in this guide. 

What is the Medicare Savings Program?

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For most Americans, enrollment in Medicare is automatic around the time you turn 65. If you’re already receiving retirement benefits from Social Security or the Railroad Retirement Board, you will automatically start receiving Medicare benefits on the first day of the month you turn 65.

But what if you’re still working, or you don’t want to sign up for Medicare right away? Is it mandatory to go on Medicare when you turn 65? This page will help you understand your options.

##Do You Automatically Get Medicare When You Turn 65?
If you are already receiving Social Security retirement benefits, you will automatically get Medicare at age 65 if you qualify for premium-free Medicare Part A. If you have to buy [Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a), you will need to sign up manually online or by contacting your local Social Security office.

You’ll know if you were automatically enrolled because you’ll receive a “Welcome to Medicare” package in the mail. This package includes details about Medicare Part A and Part B, along with your Medicare card. It will also help you answer the question, “How much will I have to pay for Medicare when I turn 65?” If you are uncertain or have questions about your Medicare eligility, you can contact Social Security direction, either via phone, online or visiting a local SSA office.  

You have the option to reject Medicare [Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) if you don’t want it. However, if you change your mind and enroll later, you may have to pay a late enrollment penalty.

##What Happens If You Don't Sign Up For Medicare At 65?
Do you have to sign up for Medicare when you turn 65? Unless you are covered by an employer group or union health insurance plan, if you don’t and enroll later, you will have to pay higher premiums. So while you don’t “have” to sign up, it will likely cost you more if you delay.

If you’re not automatically enrolled and you also decide not to enroll for Medicare during your initial enrollment period near your 65th birthday, you won’t have coverage. If you change your mind, you will need to manually enroll in Medicare Part A and Part B by contacting your local Social Security office. And you may have to pay higher premiums if you didn’t enroll when you were first eligible.  Again, unless you were covered by your employer or union group coverage.  

If you qualify for premium-free Medicare Part A, you can enroll in that coverage anytime. However, for Medicare Part B, you can only enroll during specific enrollment periods. The General Enrollment Period (GEP) for Medicare occurs every January - March 31 and is an opportunity for individuals to apply for Medicare Part A or B if not automatically enrolled in Medicare or missed their Initial Enrollment Period. Enrollments during the GEP are effective July 1. If you don’t get Part B when you are first eligible, you could have to pay a late enrollment penalty. 

##Do You Have To Sign Up For Medicare At 65 If You Are Still Working?
If you have medical coverage under a group health insurance plan offered by an employer or a spouse’s employer, you generally do not have to sign up for Medicare at age 65. You are able to delay your enrollment until your group coverage ends, without paying a penalty. Medicare gives you a special enrollment period that lasts eight months after the group coverage ends. The exception is for employers with less than 20 employees, so check with your employer or Social Security because if you don’t enroll in medicare, your employer might pay less or not at all.  

You can also sign up for Medicare Parts A and B while you’re still working, if you choose to. As long as you were previously covered by a group health insurance plan, you won’t have to pay a penalty.

If you have Medicare Part B and return to work after the age of 65, you can drop Part B, as long as you have coverage under your employer’s group plan. When the group plan coverage ends, you can sign up for Part B again without paying a penalty.

###Understanding Your Medicare Option
Knowing exactly when to enroll in Medicare can be confusing, especially if you’re still working or not receiving retirement benefits. Also, it’s important to understand all of your options and decide whether [Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) is right for you or if you want a different plan. 

The best way to find out is to talk to a licensed insurance agent. Contact us to find and compare plans today!


For a lot of people, Medicare used to start with retirement at 65. With more people working past 65, you may be wondering if Medicare is mandatory.

How to Sign Up for Medicare at Age 65 | HealthInsurance.com

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How to Sign Up for Medicare at Age 65

Medicare is important health insurance coverage for many Americans, and it pays to fully understand the coverage you have. When there are a variety of parts, all with different letters, it can be a challenge. What are Parts A and B and which one do you need?

Fortunately, we can help. Medicare Part A and Part B are both elements of [Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). They cover your health costs in different situations. Here’s what you need to know.

##What Is Medicare Part A And B?

###Medicare Part A
[Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) is known as hospital insurance because it helps cover the costs when you are hospitalized. Part A pays for inpatient care, hospice care, skilled nursing, and some home health care services. 

Medicare Part A generally does not cover 100 percent of costs. There is usually a copay or deductible that you are responsible for. Also, in order to qualify for coverage, the services must be deemed medically necessary. 

###Is Medicare Part A Premium Free? 
Medicare Part A can be premium-free for many Americans. In order to qualify for this, you have to be receiving Social Security or the Railroad Retirement Board, and you need to have a qualifying work history. This means that you or your spouse have worked a specific number of quarters while paying FICA taxes. 

###Medicare Part B

[Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) is medical insurance. It covers services such as doctor’s visits, preventive care, mental health, physical therapy, and other outpatient care. In order to use Medicare Part B, the provider must accept Medicare insurance and the items and services must be medically necessary.

Like Medicare Part A, Part B does not cover 100 percent of costs. If you have Original Medicare, you will be responsible for 20% of the Medicare-approved amount for each service or item. You may also have a deductible.

###Is Medicare Part B free?

Medicare Part B is not free. Most Americans have to pay a monthly premium for Part B. If you are lower-income, you may be eligible for programs that help you pay for your Part B premium. 


##Who Is Eligible For Medicare A And B?

Eligibility for Medicare A and B is generally limited to Americans and permanent residents who are 65 years of age or older. You may also qualify if you are under age 65 and have a qualifying disability or end-stage renal disease.

Many people get Medicare Part A and B automatically when they turn 65, but some people need to sign up. If you are already receiving Social Security benefits when you turn 65,  you will automatically get Medicare Parts A and B.  However, be sure to check our your eligibility requirements if you have more questions or need for more information.

###Learn More About the Differences Between Medicare Part A and B

It’s important to fully understand your Medicare options so that you can choose the right plan for your needs. Medicare Parts A and B are just the beginning. You can also qualify for additional coverage that may lower your out-of-pocket costs.

To learn more about your Medicare options, talk to a licensed insurance agent and [compare plans](https://medicare.healthinsurance.com/) today!




If you are wondering what the difference between Medicare Part A and Part B is, we define each here and highlight their similarities and differences.

What’s the Difference Between Medicare Part A & Part B? | Healthinsurance.com

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What's the Difference Between Medicare Part A and Part B

You might be asking yourself, “I am 64, when should I apply for Medicare?” 

Like most health insurance plans, Medicare has specific sign-up periods each year. The first one occurs when you’re about to turn 65 and lasts seven months. Then, there’s an annual enrollment period each year where you can evaluate, compare, and change your plan. 

Some people are automatically enrolled in Medicare Part A and B when they are eligible, while others have to take specific steps to apply. If you’re wondering when to enroll in a Medicare Advantage plan, you can do so during any enrollment period.

Here’s what you need to know about when to enroll in Medicare.

## Medicare Enrollment
If you’re already receiving Social Security benefits, you’ll generally be enrolled in Medicare A and B automatically when you’re eligible. Keep in mind that you’ll receive [Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) — if you want a different plan, you’ll need to sign up for that during the [enrollment period](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period).

If you have to sign up manually, you’ll need to know when to enroll in Medicare. The answer to “When should I enroll in Medicare?” is based partly on which parts of Medicare you’re considering.

###When Should I Apply For Medicare Part A And B?
[Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) and [Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) are Original Medicare. Part A is hospital insurance, and Part B is medical coverage for doctor’s visits and other care. You should get Medicare Part A and B during the first enrollment period when you turn 65.

If you qualify for Medicare Part A premium-free, you can sign up for it anytime, regardless of enrollment periods. If you have to pay for Part A, you need to sign up as soon as you are initially eligible. If you receive Social Security payments, you’ll automatically be enrolled during the timeframe that you turn 65.

In general, if you are receiving Social Security payments, you will also be automatically enrolled in Part B.  However, if you are not getting those payments, you will need to sign up for Medicare Part B if you want it during the first enrollment period around your 65th birthday. If you don’t, you could face a late-enrollment penalty. 

You can choose to defer enrollment in Medicare Part B if you’re currently employed and have a group health insurance plan. When your group insurance plan ends, you’ll be granted a special enrollment period to sign up for Medicare Part B without a penalty.

Once your initial enrollment time frame is over, you can sign up for Part B or change your Medicare plan only between January 1 and March 31 each year.

###When Should I Apply For Medicare Part C And D?

[Medicare Part C](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) is known as Medicare Advantage. It is a full replacement plan for Original Medicare (Parts A and B) and often includes additional benefits, like vision, hearing, dental, and prescription drugs.

[Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) is prescription drug coverage. You can buy a stand-alone Medicare Part D plan to go with Original Medicare if you choose not to enroll in a Medicare Advantage plan.

You can only sign up for Medicare Advantage or Medicare Part D plans during regular enrollment periods. That includes the seven months around your 65th birthday and during the annual open enrollment that runs from Oct 15  - December 7 of each year.  Those enrolled in Medicare Advantage can also make changes during Medicare Advantage Open Enrollment between January 1 - March 31 of each year.

Sometimes you can qualify for special enrollment periods, such as if you lose other health coverage, return from overseas, or move outside the coverage area of your current plan.

###Learn More About When to Apply for Medicare
Understanding when to apply for Medicare is important, but you should also learn about the various options. We’re here to help make things easier. Talk to a licensed health insurance agent and [compare plans](https://medicare.healthinsurance.com/) to make the right choice for your needs!


Applying for Medicare on time can be confusing. Let us help you schedule when you should apply, learn about the enrollment period, and more.

When Should I Apply For Medicare? | Healthinsurance.com

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When Should I Apply For Medicare?

As you age, you may begin having issues with your teeth. This may lead you to wonder, “How do I get dental coverage with Medicare?” 

The truth is that most dental procedures are not covered by [Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage), although you may be able to get coverage through [Medicare Advantage](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide). This page will help you understand what’s covered and what’s not covered by Medicare when it comes to dental care.

##What Dental Services Are Covered By Medicare?
There are some dental services you may need as you get older. This includes cleanings, cavity fillings, and even dental surgery. Let’s take a look at each one.

###Does Medicare Pay For Dental Bone Grafts?
Original Medicare does not cover dental bone grafts unless they are performed while you are an inpatient in the hospital and it’s medically necessary. However, if you have a Medicare Advantage plan, you may have coverage.

###Does Medicare Pay For Dental Cleanings?
Dental cleanings are not covered by Original Medicare. If you want to have dental coverage for cleanings, consider a Medicare Advantage plan.

###Does Medicare Cover Dental Crowns?
Dental crowns are generally not covered by Medicare unless you are admitted to the hospital and it’s medically necessary. If you have a Medicare Advantage plan, you may be able to get coverage.

### Does Medicare Cover Dental Surgery?
Dental surgery is not covered by Original Medicare unless it’s medically necessary while you are in the hospital. You may have coverage for dental surgery with some Medicare Advantage plans.

##What Medicare Plans Cover Dental?
Medicare has a variety of parts, each with its own specific coverage. Do any Medicare plans cover dental? Let’s take a look.

###Does Medicare Part A Cover Dental?
[Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a), or hospital insurance, may cover certain dental procedures if you’re an inpatient at the hospital. It must be deemed medically necessary. 

Medicare Part A may also pay for the hospital portion of your stay if you have to be an inpatient specifically for a dental procedure, although the procedure itself will not be covered.

### Does Medicare Part B Cover Dental?
[Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b), or doctor’s insurance, doesn’t cover dental procedures or appointments.

###Does Medicare Part C Cover Dental?
Medicare Part C, also known as Medicare Advantage, is an entire replacement plan for Original Medicare. Many Medicare Advantage plans do include dental coverage. You’ll want to review the details and costs before you make a decision on a Medicare Advantage plan.

### Does Medicare Advantage Cover Dental?
As we mentioned earlier, many, but not all, Medicare Advantage plans include some amount of dental coverage. You’ll want to compare plan prices and see what procedures are covered. Don’t forget that you may have out-of-pocket costs, like deductibles or copayments, as well.
If you want dental coverage through Medicare, Medicare Part C is the way to go.

###Does Medicare Part D Cover Dental?
[Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide), which provides coverage for prescription drugs, does not include dental care coverage.

Medicare Advantage is the best way to get dental coverage with Medicare.

H2: Understanding Your Options for Medicare and Dental Procedures
It’s important to ensure you’re getting the care you need with Medicare. If dental coverage is a concern, you’ll want to carefully consider which plans are available that provide coverage for dental procedures. 

It’s best to talk to a licensed agent who can help you learn more about Medicare. Contact us to [compare plans](https://medicare.healthinsurance.com/) today!


Learn what you need to know about Medicare and dental coverage. Which plan covers dental procedures and more.

Does Medicare Cover Dental? | Healthinsurance.com

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Does Medicare Cover Dental?

If you’re approaching your 65th birthday or caring for an older relative, you may be wondering how to apply for Medicare. Do you have to apply specifically, or is coverage provided automatically? What form(s) do you need? The answer depends on your unique situation and medical needs.

In this article, we’ll help you understand how to apply for Medicare in a variety of situations.

##How To Apply For Medicare Part A and B?
[Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) is hospital insurance, while [Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) is medical insurance. For most Americans with sufficient work history, there’s no monthly premium associated with Part A coverage. There is a monthly cost for Medicare Part B. Curious how to apply for Medicare Part A? You may not need to!

You’ll receive Medicare Part A and B automatically without applying if you’re receiving Social Security or Railroad Retirement Benefits (RRB) for at least four months before you turn 65. If you’re not receiving Social Security benefits before you turn 65, you’ll have to enroll with Social Security to get the coverage you need. 

If you’re still working and have a group health insurance plan when you become Medicare-eligible, you can choose to delay enrollment in Medicare Part B without later paying a penalty when you enroll. When your group health insurance plan ends, you can apply online or by using the Part B enrollment form.

If you have qualifying disabilities and you’re under 65, you’ll receive Part A and Part B automatically after you’ve received Social Security disability benefits for 24 months. If you have ALS (Lou Gehrig’s Disease), you’ll automatically get Medicare Parts A and B the month your disability benefits begin.

Finally, if you have End-Stage Renal Disease, Medicare benefits are optional. If you want them, you will need to sign up by contacting Social Security.

##How To Apply For Medicare Part C & D
[Medicare Part C](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide), also known as Medicare Advantage, is an all-in-one replacement for Original Medicare and includes additional benefits. For instance, most Medicare Advantage plans include prescription drug coverage, and some include vision, dental, and other benefits.

You can purchase Medicare Advantage plans directly from private insurance companies. The plans vary in terms of price, benefits, and medical network. That’s why it’s important to get multiple quotes and [compare your options](https://medicare.healthinsurance.com/) before you make a decision. 

[Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide)is an optional add-on that you can have in addition to Parts A and B. Part D, also known as a Medicare drug plan, provides prescription drug coverage and costs an additional monthly premium. 

###How to Apply for Medicare Part D
You can apply for Medicare drug plans using the Medicare Plan Finder tool or by calling the provider directly.

##Applying For Medicare FAQs
As you review your Medicare options, you may find that you have a few questions. Here are some of the most common concerns we hear.

###What Documents Do I Need To Apply For Medicare?
If you’re automatically enrolled in Medicare Part A and B, you won’t need any additional documentation. However, if you enroll yourself, you will need to provide your date and place of birth and information on any current health insurance, whether that’s Medicaid, private coverage, or group coverage from your employer.

###How Do I Sign Up For Medicare Online?
Signing up for Medicare online is the easiest option if you aren’t automatically enrolled. [Find and compare Medicare plans online](https://medicare.healthinsurance.com/). 

###Learn More About How to Apply for Medicare
With its various parts and enrollment dates, navigating Medicare can be a challenge. We’re here to make it easier for you. Contact us to speak to a licensed insurance agent who can answer all of your Medicare application questions.


If you are ready and eligible to sign up for Medicare, learn how you can apply and compare plans today!

How Do I Apply for Medicare?

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Medicare was originally designed for individuals who had retired from the workforce. As a result, the standard was set that you qualify for Medicare when you’re 65 years old. However, there are now additional ways to qualify for Medicare. Younger people with qualifying disabilities can also be eligible, along with individuals with end-stage renal disease. If you meet certain qualifications, you can get Medicare Part A for free, but Medicare Part B comes with a monthly premium.

It’s important to understand who is eligible for Medicare Part A and Part B and who is not eligible for Medicare so you get the benefits you understand your medical benefits and costs.

##Medicare Eligibility Requirements
There are a variety of requirements to be eligible for Medicare, especially if you want Part A with no monthly premium. Below are some of the more specific details on Medicare eligibility requirements.

To qualify for Medicare you need to:
- Be a U.S. citizen or permanent legal resident who has been in the U.S. for at least five years
- Be 65 or older
- You can qualify for Medicare if you’re under 65 but have a qualifying disability or end-stage renal disease

###Who Qualifies for Premium-Free Medicare Part A?
You can get Medicare Part A without a premium if:

- You are 65 or older and you or a spouse worked and paid Medicare taxes for at least 10 years
- You receive benefits from Social Security or the Railroad Retirement Board
- You or your spouse had government employment that was Medicare-covered

##Who Can Apply For Medicare Part A and Part B?
Anyone who meets the eligibility requirements can apply for Medicare coverage. Your initial enrollment period begins three months before your 65th birthday and lasts seven months. If you sign up during the first three months of your enrollment period, your Medicare coverage will go into effect the first day of the month you turn 65.

If you qualify for premium-free Medicare Part A and you are receiving Social Security benefits when you become eligible for Medicare, your Part A coverage will begin automatically when you turn 65.  . If you’re not receiving benefits, you can still get Medicare Part A on time by enrolling online or contacting Medicare directly.  While Part A may be automatic for some, all individuals must apply to enroll in Part B.  You can sign up for Part B during your initial enrollment period that occurs around your entitlement to Part A, and then generally only between January 1 and March 31 of each year (unless you have delayed because you continue to work). .  

If you don’t apply for Medicare Part B when you’re eligible, you’ll most likely have to pay a late enrollment penalty.

If you have to pay for Medicare Part A, it follows the same rules as Medicare Part B. You can only enroll at specific times, and you have to sign up. 

###Who can Apply for Medicare Online? 
Any qualifying individual can apply for Medicare online, however,  you can only sign up during the initial enrollment period and then between January 1 and March 31 of each year. 


##Medicare Eligibility FAQs
Here are a few common questions we hear about Medicare eligibility:

###Can I Get Medicare at 62?
Some people begin to claim retirement benefits from social security at age 62 and might wonder if they can also get Medicare benefits at that time. Generally, the answer is no. You can only get Medicare before age 65 if you have been on Social Security disability for at least two years, have ALS (Lou Gherig’s disease), or suffer from end-stage renal disease.

###Can You Get Medicare If You’ve Never Worked?
If you haven’t worked, you can still qualify for Medicare, but you may have to pay a monthly premium for both Medicare Part A and Part B. You may still be able to get Medicare Part A premium-free if your spouse worked, or if you have specific disabilities or medical conditions. 

###Who Can Get Premium-Free Medicare Part A?
You can qualify for premium-free Medicare Part A if you qualify for Original Medicare and have the appropriate work history as described above (i.e. paid Medicare taxes for 10 years). Generally, you have to pay a premium for Medicare Part B, but there are options for those with limited income and limited assets. 

The Medicare Savings Program (MSP) can help pay your Medicare Part A and B premiums if you qualify. 

###Learn More About Medicare Eligibility Requirements
If you’re curious about your Medicare eligibility and want to talk to a licensed insurance agent, we’re here to help. Simply give us a call at 1-866-955-0898 (TTY 711) or visit our website to review your options today!


Find out if you qualify for Medicare, eligibility requirements, and more. All of your Medicare eligibility FAQs answered by our experts.

Who Qualifies for Medicare?

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Who Qualifies for Medicare? 

Medicare is a health insurance program provided by the federal government. Medicare is provided for individuals who are 65 and older, as well as younger people with disabilities or end-stage renal disease.

 Medicare includes several parts, each of which provides coverage for specific medical needs. Original Medicare includes Part A (hospital coverage), Part B (medical coverage), and Part D (prescription medication coverage). Medicare Part C is known as Medicare Advantage.

##Who Qualifies for Medicare? 
As we mentioned above, an individual[ who qualifies for Medicare](https://www.healthinsurance.com/learning-center/article/who-qualifies-for-medicare) if he or she is 65 or older. Younger individuals can qualify for Medicare if they are permanently disabled or diagnosed with end-stage renal disease. 

##What Is The Purpose Of Medicare?
Medicare is available to make health coverage accessible to older Americans age 65 and over, including those who are traditionally retired and no longer have access to employer-based health insurance.

Medicare also provides coverage to those under 65 with certain disabilities to cover their health needs and associated expenses. These Americans often cannot work and don’t have access to employer coverage or other health insurance.

##Types of Medicare 
Medicare is divided into several parts, labeled from A to D:

- [Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) is known as hospital insurance. It offers coverage for inpatient hospital care, lab tests, and surgery, as well as home health care and skilled nursing facilities. These services must be deemed medically necessary to be covered by Medicare. You may have to pay a deductible or coinsurance
- [Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) is used for medical visits to a doctor. Medicare covers medically necessary services and preventive services. Each Medicare participant pays a monthly premium for Medicare Part B and there may also be deductibles and coinsurance that apply, depending on the care you receive
- [Medicare Part C](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) is known as Medicare Advantage. This isn’t part of Original Medicare but instead is an all-in-one replacement plan. Medicare Advantage plans include hospital coverage and doctor’s visits, along with prescription drug coverage. Many also offer additional benefits Original Medicare doesn’t cover, such as vision and dental care. However, you will often need to use medical professionals within the provider’s network. You’ll pay different copayments and deductibles with Medicare Advantage than with Original Medicare, which may allow you to save money. You may also have an additional monthly premium
- [Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) is prescription drug coverage. It helps you pay for both brand-name and generic drugs, depending on your needs. The drug plans for Medicare are offered by insurance companies and other approved private companies. If you choose Medicare Part D, you will have a separate Part D premium each month 

##Medicare FAQ
In addition to the different types of Medicare, qualified individuals, caregivers, and loved ones often have questions about Medicare coverage. Here are some additional Medicare FAQ and answers. 

###What Does Medicare Cover?
Medicare covers a wide variety of healthcare services. The specific coverage depends on the Medicare policy you choose. Services covered by Medicare include:

- Ambulance services
- Anesthesia
- Artificial eyes & limbs
- Bariatric surgery
- Blood processing & handling
- Cardiac rehabilitation programs
- Cardiovascular disease screenings
- Cervical & vaginal cancer screenings
- Chemotherapy
- Depression screenings
- Diabetes prevention programs
- Diagnostic tests (laboratory and non-lab)
- Eye exams (routine)
- Eyeglasses & contact lenses
- Flu shots
- Foot care
- Hearing aids
- Hepatitis B and HIV screenings
- Inpatient hospital care
- Kidney transplants
- Lung cancer screenings
- Mammograms
- Mental health care (inpatient and outpatient)
- Occupational therapy
- Opioid use disorder treatment services
- Organ transplants
- Pain management
- Prescription drugs (outpatient)
- Preventive & screening services
- Radiation therapy
- Sexually transmitted infections screenings & counseling
- Sleep studies
- Surgery
- Urgently needed care
- X-rays
- Yearly "wellness" visits

###Do I Need Medicare if I Already Have Health Insurance?
Whether or not you need Medicare if you already have health insurance depends on your individual medical needs. You may need Medicare even if you already have other health insurance if your current plan doesn’t meet the minimum coverage requirements.

Most plans offered by employers meet these standards. So if you have insurance through your job, you probably don't need Medicare. However, by staying on an employer plan, you can delay enrolling in Part B without a penalty and avoid paying Part B premiums.

An important note: When you have Medicare plus additional insurance policies, each provider becomes a "payer." The policy that pays for your specific medical services first depends on the coordination of benefits rules for your plans.

In other words, the primary payer will pay what it owes on your medical bills first, then the provider will send the remaining amount to the secondary payer to pay the rest.

###What is the Difference Between Medicare and Medicaid?
Medicare is a federal health insurance program for older Americans and those with disabilities regardless of income. Medicaid is a state-based health insurance program for lower-income Americans that need help paying for medical care.

 To learn more about costs, eligibility, and coverage, visit this guide to [Medicare vs. Medicaid](https://www.healthinsurance.com/learning-center/article/whats-the-difference-between-medicare-and-medicaid).

###Who Do You Call for Medicare Questions?
If you have additional questions about Medicare and what it covers, you can call 1-866-955-0898 (TTY 711) to speak with one of our licensed insurance agents. 

Agents are available Monday - Friday from 8am - 9pm and Saturday - Sunday 10am - 5pm ET.

###Where Can I Get Free Medicare Advice?
For information on Medicare coverage, open enrollment, the different types of Medicare, and more, [visit our Medicare learning center](https://medicare.healthinsurance.com/learning-center). For specific Medicare questions, contact us to speak with a licensed insurance agent.  

##Learn More About Medicare
Medicare is a valuable way to cover your healthcare costs if you are older or disabled. To compare your options and find the right Medicare plan in your area, visit our [Medicare plans](https://medicare.healthinsurance.com) page today!


What is Medicare? A government-lead healthcare program people 65 and over and others with qualifying disabilities can count on. Learn about the purpose of Medicare, coverage types, and more.

What is Medicare?

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As we age, we grow more vulnerable to chronic and seasonal illnesses. And many times these illnesses can hit hard and fast, sometimes making it difficult to recover. But taking preventative measures against illnesses, like getting vaccines, is a safe course of action. 

To help accomplish this, Medicare beneficiaries have access to comprehensive benefits for routine vaccinations. In this guide to Medicare vaccine coverage, we’ll review which vaccines and immunizations are covered by Original Medicare and the various private Medicare insurance plans on the market.

## The Importance Of Vaccines For Adults Over 65

It’s much easier to avoid getting sick with some illnesses than it is to treat, recover or survive them. This is especially true for those [ages 65 and up](https://www.healthinsurance.com/learning-center/article/tips-for-aging-into-medicare): Illnesses such as the flu, pneumonia, and COVID-19 can take a heavy toll on this population.

And since most of these illnesses are seasonal by nature, they’re perfect candidates for vaccines. In fact, the CDC recommends that <a href="https://www.cdc.gov/flu/highrisk/65over.htm" target=" _blank">adults ages 65 and over</a> have annual vaccination against the flu.

Studies have shown that seniors who are vaccinated are more likely to avoid seasonal illnesses and have <a href="https://www.cdc.gov/flu/prevent/vaccine-benefits.htm" target=" _blank">fewer severe symptoms</a>, including a decreased chance of:

- Doctor’s visits
- Hospitalizations
- Death

However, there are non-seasonal vaccinations for adults over age 65. These may include:

- Varicella / Shingles
- Tdap
- Pneumococcal
- Hepatitis A and B

**Quick Medicare Tip: Be sure to check with your doctor for advice on which vaccines to get and how frequently you should receive them. This is especially important because of the potential for interactions with existing health conditions.**

## What Vaccines Does Medicare Cover? 

Medicare vaccination coverage depends on how the specific vaccines are categorized. 
In other words, vaccines can be covered by [Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b). But in other cases, vaccines are covered by [Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) drug plans.

##Medicare Part B Vaccine Coverage

Medicare Part B covers outpatient medical care, broken down into two groups of services:

- Medically necessary services, and
- Preventative services

You’ll use Part B for routine healthcare like doctor’s visits and lab work. Unlike [Part A of Original Medicare](https://www.healthinsurance.com/learning-center/article/medicare-part-a), you’ll probably have to pay a monthly premium to have Part B coverage.

Medicare Part B covers vaccinations under the preventive services category. And many recommended elderly immunizations are included in Medicare Part B vaccine coverage. 
The following vaccines are among the most important.

###Does Medicare Coverage My Flu Shot? 

Medicare Part B covers influenza vaccinations. Medicare will cover one flu shot per person, per flu season. And <a href="https://www.medicare.gov/coverage/flu-shots" target=" _blank">you will pay nothing</a> as long as you receive your flu shot from a doctor or other qualified health care worker who accepts Medicare “assignment.” This means that they agree to accept Medicare’s payment as payment in full. 

Most doctors and health care practitioners take Medicare Assignment.

###Will Medicare Pay for Hepatitis B Shots?

Medicare Part B vaccine coverage for the Hepatitis B vaccine is a little more complicated. Part B will cover it, **but only if you’re at moderate or high risk.** 

You’re considered to have medium or high risk if <a href="https://www.medicare.gov/coverage/hepatitis-b-shots" target=" _blank">any of these apply to you</a>: 
- You have hemophilia
- You have End Stage Renal Disease (ESRD)
- You have diabetes
- You live with someone who has Hepatitis B
- You’re a healthcare worker and frequently exposed to bodily fluids

If you meet these criteria and receive the shot from a practitioner who accepts Medicare assignment, you’ll pay nothing. The Hepatitis B vaccine may be given as a series of two or three injections, depending on which vaccine is used.

###Does Medicare Pay for Pneumococcal Shots?

Medicare Part B will cover a total of two pneumococcal shots for seniors. 

You can get the first shot at any time, and Part B will cover the second shot as long as you receive it at least one year after your first injection. Like other instances of Medicare vaccine coverage, you’ll pay nothing out of pocket if you get the pneumococcal shots from a qualified practitioner who takes Medicare assignment.

###Does Medicare Pay for COVID-19 Vaccine?

As the newest and most urgently needed vaccine on the block, Medicare Part B will cover the COVID-19 vaccine. We’ll review some of the specifics of COVID-19 Medicare Part B vaccination coverage shortly. For now, COVID-19 vaccine coverage through Medicare Part B is all available for no out-of-pocket cost.

**Quick Medicare Tip: Need more help understanding Medicare Part B? Visit our [Guide to Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) to learn how Medicare Part B coverage works.**


##Medicare Part D Vaccine Coverage

[Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) is the prescription drug program for Medicare beneficiaries. Drug coverage is not available as part of the Original Medicare Fee-for-Service program. Instead, it’s offered by private insurance companies. 

Medicare Part D drug coverage is available as 2 types of plans:

- Standalone Prescription Drug Plans (PDP), and
- Medicare Advantage Prescription Drug (MAPD) Plans.

Whether you get prescription drug coverage from a standalone plan or a [Medicare Advantage plan](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide), the drug coverage works the same. In both cases, your insurance company helps pay part of the cost of your medications. Unlike Medicare Part B vaccine coverage, you’ll generally have to pay some share of the cost for Medicare Part D vaccination coverage.

The formal list of drugs and vaccines covered is known as a Medicare Part D formulary. The formulary is an exclusive list. Two things to know:

- If a drug or vaccine isn’t on the formulary, then the plan doesn’t cover it. 
- If you receive medications of vaccines that aren’t on your plan’s formulary, then the plan won’t cover it and you’ll pay full price.

That said, it’s important to make sure that you only use medications or vaccines that are on your plan’s formulary.

With Part D drug coverage, you’ll usually pay a copayment or coinsurance amount for each drug or vaccination you receive. But this amount can change during the course of the calendar year as you move through the <a href="https://medicare.healthinsurance.com/learning-center/article/phases-medicare-part-d">four coverage stages</a> of Medicare Part D.

Part D drug plans cover vaccines that <a href="https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b" >are not covered by Medicare Part B</a>. Generally speaking, these vaccines are considered to be less necessary than the vaccines covered by Part B. 

And since Medicare Part D vaccine coverage is provided by a private insurance plan, you don’t have to worry about whether your practitioner accepts Medicare assignment. As long as they accept your Part D plan, you’ll only pay the required copayment or coinsurance.

### Is Shingles Vaccine (Zoster) Covered by Medicare? 

The shingles vaccine is covered by Medicare Part D plans. The CDC recommends that people over age 65 receive two doses of this vaccine.

###Is the Shingrix Vaccine Covered by Medicare?

Shingrix, another shingles vaccine, is covered through standalone Medicare Part D plans.

###Will Medicare Cover MMR Vaccine?

Private Part D drug plans cover the Measles, Mumps, and Rubella vaccine in one or two doses if you were born after 1957.

###Does Medicare Cover Tdap Vaccine?

The tetanus, diphtheria, and pertussis vaccine is eligible to be covered by Medicare Part D plans. The CDC recommends that you receive a new shot every ten years. A more frequent dose may be required in response to <a href="https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fschedules%2Fhcp%2Fadult.html#note-tdap# target=" _blank">some wound care situations</a>.

###Does Medicare Cover Tetanus Shots?
Medicare will cover a tetanus shot, however, the specific part of Medicare that provides the coverage depends on the reason you need the shot.

- Medicare Part B covers tetanus shots following an injury or illness
- Medicare Part D covers the regular tetanus booster
- Medicare Part C (Medicare Advantage) covers both scenarios


Again, your vaccine costs will vary based on your individual plan formulary as part of Medicare Part D vaccine coverage. To find out how much you’ll pay, you’ll need to contact your Part D plan.

If you have trouble affording medications including Part D covered vaccinations, you may be able to get assistance through the <a href="https://www.ssa.gov/benefits/medicare/prescriptionhelp/" target=" _blank">Extra Help program</a>.

Extra Help is available to people who meet certain income and asset requirements. If you qualify, you’ll [pay less for your medications](https://www.healthinsurance.com/learning-center/article/tips-to-reduce-your-prescription-drug-costs), and you may even get help paying for your Medicare Part D premium. You will have to recertify for Extra Help each year, but the savings are worth the effort.

**Quick Medicare Tip: Visit our [Guide to Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) to read more about how Part D coverage works.**

###How Does Medicare Cover The Coronavirus Vaccine?

As we covered earlier, adults ages 65 and up are more vulnerable to [coronavirus](https://www.healthinsurance.com/learning-center/article/what-is-coronavirus) than other age demographics. And COVID-19 has definitely taken its toll on this age group.

That’s why it’s especially key that Medicare beneficiaries take advantage of their Medicare benefits, including Medicare coverage for COVID-19. Under a provision of the <a href="https://www.kff.org/global-health-policy/issue-brief/the-coronavirus-aid-relief-and-economic-security-act-summary-of-key-health-provisions/?gclid=Cj0KCQiAhP2BBhDdARIsAJEzXlEH9JUVP7NzFFua3ONpoOFw2X7H4QdoBiLJvxDEMkd_zP0PmoMlyeIaAuKREALw_wcB" target=" _blank">2020 CARES Act</a>, any FDA-approved coronavirus vaccine will be covered by Medicare Part B. This includes both two-shot vaccines and single dose COVID-19 vaccines.

As long as the coronavirus vaccines are FDA-approved, Medicare will cover the costs. 

Also, since Medicare Advantage is required to have the same coverage [as Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage), Medicare Advantage plans also cover the coronavirus vaccine.

Other key things to know about Medicare coverage for coronavirus includes:

- Medicare covers COVID-19 testing.
- Medicare covers <a href="https://www.medicare.gov/coverage/coronavirus-disease-2019-covid-19-antibody-test" target=" _blank">COVID-19 antibody tests</a>.
- Medicare covers all medically necessary hospitalizations, including hospital stays for COVID-19 treatment and quarantine requirements.
- [Medicare Advantage plans](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) can’t charge deductibles, copayments and coinsurance for tests that detect or diagnose COVID-19.
- Medicare Advantage plans may offer additional benefits like [telemedicine](https://www.healthinsurance.com/learning-center/article/talk-to-a-doctor-online-versus-in-person) to keep you out of the waiting room and get non-emergency care at home.

##Does Medicare Cover Travel Vaccines?

As a general rule, Medicare does not cover vaccinations for international travel. However, some Part D drug plans may offer coverage for vaccinations necessary for travelling outside the U.S. 

Be sure to contact your [Medicare Part D plan](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) to see if this is the case. Otherwise, you’ll need to pay out of pocket for your travel immunizations.

## Conclusion: Does Medicare Cover Immunizations and Vaccines 

Vaccines aren’t just for kids - they’re an important way for all ages to keep healthy and prevent illnesses.

And Medicare vaccine coverage gives those ages 65 and up the support needed to get access to crucial vaccines. After all, preventing infection is much easier than treating certain illnesses, especially those that affect the respiratory system like COVID-19, flu, and pneumonia. 

Through Medicare Part B of Original Medicare and Medicare Part D drug plans, you can be sure that necessary vaccines will be covered at the optimal doses and frequency.

But just because a vaccine is recommended for most people and covered by Medicare doesn’t mean that you should run out and get it. Some vaccines may not be suited to you based on your individual health status and history. For this reason, it’s critical that you speak with your doctor about the vaccines you should and shouldn’t receive.

You can also learn more about Medicare coverage for vaccines on the benefits provided by your Medicare insurance plan. Just remember: Part D plans change their formularies every year, so the costs of Medicare Part D vaccines may change. Always review your coverage during the [Medicare Open Enrollment Period](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period), and consider switching to a plan that better suits your needs if necessary.

If you’d like to get help finding a Medicare plan, **call 800-620-4519** to speak with one of our licensed insurance agents, or click to try our [Medicare plan comparison tool](https://medicare.healthinsurance.com/) to find Medicare Advantage or Prescription Drug Plans near you.

___________________________________________________________________________________________________________

*The above information does not constitute medical advice. Always consult with a medical professional regarding your health needs. If you are experiencing a health emergency, contact your local emergency health services immediately or visit the nearest emergency room or urgent care.*


Learn which vaccines and immunizations are covered by Medicare in this guide from our insurance experts.




What Vaccines are Covered by Medicare: A Guide to Shots and Medicare

Medicare Vaccine

Healthinsurance.com A Guide To Medicare Vaccine Coverage

What Vaccines Are Covered by Medicare: A Guide to Medicare and Immunizations

Retirement should be a time of joy and freedom, but too often these years can unfortunately be tainted by battles with chronic illnesses. And one of the most common is cardiovascular disease (CVD), often called heart disease. In fact, heart disease is <a href="https://www.cdc.gov/heartdisease/index.htm" target=" _blank">the leading cause of death in the United States</a>. 

That’s why February marks American Heart Month - a way to bring awareness to heart disease and help spread tips on heart disease prevention.

And to help celebrate American Heart Month, we’ll review some of the facts about cardiovascular disease, along with tips to combat it. Then we’ll dive into how your Medicare coverage can help you prevent, treat or manage cardiovascular diseases. 

## What Is Heart Disease?

Heart disease, also known as cardiovascular disease CVD is <a href="https://www.mayoclinic.org/diseases-conditions/heart-disease/symptoms-causes/syc-20353118" target=" _blank">a broad term</a> for several different medical conditions. 

But generally speaking, heart disease is an illness that affects the heart or circulatory system. The illnesses that fall under the heart disease category include: 

- Coronary artery disease (CAD)
- Heart rhythm problems
- Congenital heart disease
- Infections of the heart tissue
- Heart valve disease

## Cardiovascular Disease Risk Factors

Many of the biggest risk factors of cardiovascular disease are lifestyle related. And while there’s a general assumption that these factors are the sole cause, many people are actually born with heart disease. It can be congenital and hereditary.

But those with lifestyle risk factors have control over heart disease prevention. The <a href="https://www.cdc.gov/heartdisease/risk_factors.htm" target=" _blank">main risk factors</a> and causes of heart disease include:

- Obesity
- High cholesterol
- Diabetes
- Smoking
- High blood pressure
- And these causes of heart disease can be directly tied to such behaviors as: 
- Poor diet
- Poor physical activity
- Too much alcohol
- Tobacco use
- Genetics or heredity

Simply put, the lifestyle habits (good or bad) that we form are what lead to the major risk factors for cardiovascular disease. Genetics and heredity may then play a role in whether or not we actually develop heart disease.

## 4 Tips To Prevent Cardiovascular Disease CVD

As we mentioned above, the fact that so many of the risk factors for CVD are lifestyle related can be a silver lining, meaning we can make smart choices and avoid unhealthy behaviors to protect our hearts. 

Now let’s walk through some healthy habits to maintain good heart health.

### #1. Stop Smoking

Quitting smoking is almost universally hailed as the biggest step to reduce your risk of heart disease. Smoking is considered the most easily avoidable lifestyle factor that leads to cardiovascular disease. So if you currently smoke, make an attempt to stop now. Quitting smoking will also save you money, making this heart disease prevention tip a no-brainer.

### #2. Eat Healthy

Diet also plays a big role in the health of your heart. A poor diet multiplies and compounds risk factors, but a smart, healthy diet can reduce your risks and get your heart in great shape.
 
You should always speak with your doctor about nutrition and heart healthy diet options. But generally speaking <a href="https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations" target=" _blank">a heart healthy diet</a> may include:

- Fruits and vegetables
- Whole grains
- Low-fat dairy products
- Skinless poultry and fish
- Nuts and legumes

In addition to eating these nutritious foods, another suggested tip is to limit your saturated fat, sodium, and sugar intake. This type of diet fits into the DASH (Dietary Approaches to Stop Hypertension) eating plan.

### #3. Stay Active

There’s no getting around the fact that an active lifestyle is a healthy one. But you don’t have to jump right in and overdo it. In fact, gentle but steady exercises can be great way to help prevent heart disease, including:

- Walking 30 minutes per day
- Cycling
- Swimming

The main point is to pick an activity that you enjoy. So if you have a scenic path, beach, or lake nearby, consider talking walks or riding your bike there. You should also have a backup plan for poor weather or to keep safe and healthy during COVID-19. Research home workout apps or programs on platforms like YouTube or you Smart TV. 

But just remember: If you over-commit to exercise and activity, you may fall off the wagon completely. Instead, start small, and add time and distance gradually. If you make it a firm part of your routine, you’ll stick to it.

Again, always be sure to consult your doctor before developing an exercise or activity regimen for heart health.

### #4. Stay Informed About Your Cardiovascular Disease CVD Risks

One of the most important heart disease prevention tips is to stay proactive and empowered about your own personal health. This is especially true if you have a family history or genetic predisposition. Here are some key strategies: 

- Don’t miss or delay your doctor’s appointments. 
- If recommended, make sure you get cardiovascular screenings and tests. 
- If you’re on heart disease medications, be sure to consistently take them and follow your treatment plan. 
- Ask questions and be proactive when it comes to your health and wellbeing.

## How Does Medicare Cover Cardiovascular Disease CVD?

If you’re on Medicare or [aging into Medicare](https://www.healthinsurance.com/learning-center/article/tips-for-aging-into-medicare),and cardiovascular disease prevention and treatment is important to you, you’re in luck. All aspects of the Medicare program cover heart disease related measures. This includes Medicare cardiovascular screening, treatment, and healthy lifestyle tools.

Heart disease prevention and treatments are covered by:

- Original [Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a)
- Original [Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b)
- [Medicare Part D drug plans](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide)
- [Medicare Advantage plans (Part C)](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide)
- [Medicare Supplement Insurance (Medigap plans)](https://www.healthinsurance.com/learning-center/article/medicare-supplement-101)

In the most basic sense, Medicare will cover all the stages of cardiovascular disease, including:

- Annual screenings (covered by Part B)
- Doctor’s visits, both primary and specialists (covered by Part B)
- Heart condition medications (covered by Part D)
- Cardiovascular tests and procedures (covered by Part B)
- Hospitalizations (when admitted as an in-patient, covered by Part A)

When you use Medicare Part B under Original Medicare, you can expect to pay:

- Part B deductible ($203 for 2021)
- Part B coinsurance (20% of the Medicare-approved charges)
- Part B excess charges (up to 15% of the Medicare-approved charges if you use providers who don’t agree to Medicare’s prices)
- When you use [Part A coverage](https://www.healthinsurance.com/learning-center/article/medicare-part-a) under Original Medicare, your costs may include:
- Part A deductible ($1,484 per benefit period)
- Part A coinsurance of $0 per day (after you pay the deductible) for hospital stays of up to 60 days
- Part A coinsurance of $371 per day for hospital stays over 60 days

### Medicare Cardiovascular Screenings

Medicare covers <a href="https://www.medicare.gov/coverage/cardiovascular-disease-screenings" target=" _blank">cardiovascular screenings</a>, which involves a blood test once every five years.

But if your doctor orders more frequent cardiovascular screenings and tests, Medicare will cover them. However, you’ll pay your share of costs as we outlined above.

### Medicare Cardiac Rehabilitation Programs

Medicare Part B will cover part of the costs for cardiovascular disease rehabilitation programs. These covered programs include exercise, education, and counselling designed to maintain your heart health. 

**Note: Medicare Part B will cover <a href="https://www.medicare.gov/coverage/cardiac-rehabilitation" target=" _blank">these cardiac rehabilitation programs</a>, only if any of these scenarios apply to you:**

- You’ve had a heart attack in the last 12 months. 
- You’ve had heart bypass surgery.
- You’re experiencing stable angina or chronic heart failure.
- You’ve had a heart of lung transplant.
- You’ve had a valve or artery repair or replacement.

Once again, you’ll pay your standard 20% coinsurance if you use these cardiac rehab programs under [Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b).

### Cardiac Tests Covered By Medicare

Beyond standard cardiovascular disease screenings and rehabilitation programs, Medicare will cover medically necessary cardiac tests ordered by your doctors. These types of heart tests may include:

- Blood tests
- Echocardiograms (ECG)
- Exercise stress tests
- MRI or x-rays
- 
Just as with the other services, you’ll pay 20% cost-sharing under Part B of Original Medicare.

## Cardiovascular Medications

Most prescription drugs are [not covered by Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). But you may be able to get heart and cardiovascular prescription drug coverage through a Medicare Part D plan.

The 2 types of Medicare plans that offer Part D:
- Standalone Prescription Drug Plans (PDP) and
- Medicare Advantage plans that include Prescription Drugs (MAPD)

It’s important to note that not all drugs are covered by all [Medicare Part D drug plans](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide). However, all Part D plans must cover at least two drugs in every therapeutic category, including heart disease or cardiovascular disease.

**Tip: You can use our [prescription lookup tool](https://medicare.healthinsurance.com/prescriptions) to see if your drugs are covered under Medicare Part D.**

### Medicare Chronic Condition / Disease Management Programs

If you have more than one chronic condition, you can qualify for special disease management programs. 

These are also covered by Original Medicare, but you’ll still be responsible for your standard cost sharing. You may also have to pay <a href="https://www.medicare.gov/coverage/chronic-care-management-services" target=" _blank">a monthly fee</a> to participate in these chronic care management services.

Under these management programs, you’ll work with your healthcare professionals to craft a comprehensive health plan tailored to your heart condition. A chronic care management plan may include:

- Goal setting and health evaluations
- Working with all of your specialists
- Managing your medications

## Cardiovascular Disease And Private Medicare Plans

So far, we’ve reviewed your coverage and costs under Original Medicare. But if you choose a private plan option like [Medicare Advantage or Medigap](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap), these plans will cover your cardiovascular health as well.

If you enroll in a Medicare Supplement plan, your plan will pay part of the costs you’d normally pay out of pocket. If you [enroll in a Medicare Advantage plan](https://medicare.healthinsurance.com/), you’ll likely pay small copayments - similar to what you’d pay under Original Medicare. 

But with Medicare Advantage, you’ll have out-of-pocket spending protection, since these plans put a cap on your annual health spending.

Most Medicare Advantage plans and some Medigap plans also offer access to non-Medicare health and wellness benefits. These can include gym memberships, SilverSneakers or other health programs that can help you lower your risks of cardiovascular disease.

## Conclusion: Medicare & Cardiovascular Disease Coverage

With lifestyle and healthy habits, you can control many of the factors that may lead to cardiovascular disease. And if you currently have heart disease, you can manage your condition with a healthy lifestyle and tests, specialists, and medications covered by Medicare.

To make the most of your private Medicare coverage (Part C or Part D):

- Check to ensure your medications are covered by the plan you’re considering.
- Make sure you’ll remain in-network with your doctors and specialists.

And if you want help choosing a Medicare plan, you can work with a licensed insurance agent who can help you find Medicare plans and give you [free Medicare quotes](https://medicare.healthinsurance.com/) (with no obligation to enroll in a plan).

Just **call 1-800-620-4519** to speak with one of our licensed insurance agents, or use our [Medicare plan comparison tool](https://medicare.healthinsurance.com/) to find Medicare plans in your area.

**Note: This article is for general education purposes and does not replace the advice of a medical professional. Always seek the guidance of your physician or a medical professional for medical advice, diagnosis, and treatment.**


Learn about Medicare coverage for heart disease and find cardiovascular disease treatment and prevention tips.







Medicare and Cardiovascular Disease (CVD) 

Heart Month

Healthinsurance.com Medicare & Cardiovascular Disease (CVD)

Does Medicare Cover Heart Disease?

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. When you enroll in a Medicare Part C plan, your benefits are offered and administered by a private insurance company and these private insurance companies must comply with many rules and regulations set by the Medicare program. So whether you’re already in a Medicare Advantage plan, curious about them, or you’ve never heard of them, this in depth guide is for you.


## Who Qualifies For Medicare Advantage?

To qualify for Medicare Advantage, you **must be enrolled in Original [Medicare Parts A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) and [Medicare Part B](https://www.healthinsurance.com/learning-center/article/medicare-part-a)**. 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.

###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 interested in signing up for a Medicare Advantage plan, there are three ways to do it. You can sign up for Medicare Advantage during your initial enrollment period around your 65th birthday, or during an annual enrollment period afterward. If you’re enrolled in Medicare Advantage and want to change to a different MA plan, you can take advantage of the Medicare Advantage open enrollment period.

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](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-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.

 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.

###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.

##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 are the Advantages and Disadvantages of Medicare advantage Plans?

What are the benefits and drawbacks of Medicare Advantage? There are pros and cons to having this type of plan. Let’s take a look at them:

<strong>Advantages of Medicare Advantage:</strong>

- There’s a maximum cap on out-of-pocket costs for each year
- Most MA plans include prescription drug coverage
- There are often additional benefits included, such as vision and dental coverage, health club discounts, and more
- You have more clarity on your out-of-pocket costs because MA plans generally have copayments rather than coinsurance percentages like Original Medicare
- Some MA plans are available at no additional cost above your Part B premium

<strong>Disadvantages of Medicare Advantage:</strong>

- Plans may have a limited network of doctors focused in a single geographic area
- You may have to coordinate your care through a primary care physician and get referrals to specialists
- There may be no insurance coverage for doctors outside the plan’s network, including when you travel
- You may not be able to combine your health coverage from retirement benefits with MA, and choosing an MA plan may cause you to lose other coverage and be unable to get it back


## What is the Difference Between Original Medicare and Medicare Advantage Plans?

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.


## 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](https://www.healthinsurance.com/learning-center/article/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](https://www.healthinsurance.com/learning-center/article/2021-changes-to-medicare) will explore Medicare Advantage plans providing hospice benefits. 

### Medicare Part B Services

[Medicare Part B services](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) 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](https://www.healthinsurance.com/learning-center/article/does-medicare-cover-cancer-treatment), including chemotherapy

As mentioned, Medicare Advantage plans cover all of these services with the exception of hospice care.

### Medicare Part D Services

Most Medicare Advantage plans offer [prescription drug coverage](https://www.healthinsurance.com/learning-center/article/tips-to-reduce-your-prescription-drug-costs). These plans are also known as Medicare Advantage Prescription Drug Plans (MAPDs), and they include [Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide). 

### Medicare Advantage Extra Coverage

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. 

- 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.**


##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)


## 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](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap). 
- 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 many plans do not have them. If they do, these premiums tend to be low. 

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.


## Medicare Advantage Plans

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 <a href="https://togetherhealth.com/" target=" _blank">licensed insurance agent</a> who may be able to guide you to the right plan for your needs. You can also try our [online Medicare plan comparison tool](https://medicare.healthinsurance.com/home).

This guide to Medicare Advantage will help you learn what Medicare Part C is, how Part C works, and its advantages and disadvantages.




















What is Medicare Advantage? | Healthinsurance.com

Medicare Advantage

Healthinsurance.com Guide to Medicare Advantage (Part C)

What Is Medicare Advantage And How Does It Work?

Confused about medicare drug coverage? Learn what Medicare Part D is and what drugs are covered by Medicare Part D.








What is Medicare Part D? | Healthinsurance.com

Medicare Part D

Healthinsurance.com Guide To Medicare Part D

What Is Medicare Part D And What Drugs Are Covered?

Original Medicare provides basic hospital and medical insurance coverage to Medicare enrollees. 
Depending on your healthcare needs, this could leave you with coverage gaps. But there are two primary ways to close them: through a [Medicare Advantage plan](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) or through Medicare Supplement Insurance (also known as Medigap). 

In this Medicare Supplement guide, we’ll review all of the Medigap basics, including:

- What is Medigap insurance?
- What services and benefits are covered under Medicare Supplement?
- Who is eligible for Medigap?
- Medicare Supplement costs
- When are the Medicare Supplement enrollment periods?
- How does Medigap work with other insurance plans?
- Medicare Supplement and special scenarios
- What’s the difference between Medicare Advantage and Medicare Supplement?
- Advantages and Disadvantages of Medigap plans

##What is Medigap Insurance (Medicare Supplement)?

Medicare Supplement, also known as Medigap, is a category of Medicare insurance products offered by private insurance companies. 
Medigap plans are designed to work with Original Medicare, and they can close some, or all, of the [gaps in your Original Medicare coverage](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). In other words, these plans are designed to reduce your out-of-pocket spending in Medicare.

##Types of Medigap Insurance Plans

There are 10 standardized Medigap plans, each identified by letters: A, B, C, D, F, G, K, L, M, and N. There are also high-deductible versions of plans F and G. Each Medigap plan covers a different mix of your out-of-pocket costs under Original Medicare.

Medicare Supplement benefits are standardized across 47 states: Minnesota, Wisconsin, and Massachusetts have their own regulations. That said, this Medicare Supplement guide will focus on the 10 standardized Medigap plans. 
Below is a breakdown of what each Medigap plan covers.

### Medigap Plan A

The most basic Medigap plan is Plan A, which covers your:

- Part A coinsurance/copay for an additional 365 days in the hospital (beyond Original Medicare)
- Part B coinsurance/copayments
- First three pints of blood
- Part A hospice care coinsurance/copay

### Medigap Plan B

Plan B offers a little more coverage, including everything offered by Plan A, plus the Part A deductible.

### Medigap Plan C

Plan C covers what Plans A and B do, plus the following:

- Skilled nursing facility coinsurance/copayments
- Part B deductible
- Emergency foreign travel

**Plan C is no longer available for people who became eligible for Medicare after 12/31/2019. But if you became eligible for Medicare before that date, Plan C remains available to you.**

### Medigap Plan D

Plan D covers everything covered by Plan C, except for the Part B deductible.

### Medigap Plan F

Plan F is the most comprehensive Medicare Supplement Insurance plan available. It closes many gaps, covering everything Plan C covers, plus Part B excess charges. 

**But like Plan C, Plan F isn’t available to those who became eligible for Medicare after 12/31/2019.**

### Medigap Plan G

Plan G is the next-most comprehensive plan. Plan G covers all of the gaps except for the Part B deductible.

### Medigap Plan K

Plan K has an unusual structure, covering 50% of many of the gaps. Plan K covers:

- 100% of Part A coinsurance/copays for up to 365 additional hospital days
- 50% of Part B coinsurance/copays
- 50% of the cost of your first three pints of blood
- 50% of Part A hospice care coinsurance/copays
- 50% of Skilled Nursing Facility care coinsurance
- 50% of the Part A deductible
- Out-of-pocket maximum of $6,220 (2021 amount)
- Plan K does not cover:
- Part B deductible
- Part B excess charges
- Foreign travel

### Medigap Plan L

Plan L covers 75% of a range of items (i.e. Part A deductible, Part B coinsurance, first three pints of blood, Part A hospice copayment, Part A skilled nursing coinsurance). Plan K, by comparison, covers those same items, but only at 50%. The out-of-pocket maximum for Plan L is $3,110 in 2021.

### Medigap Plan M

Medigap Plan M covers everything that Plan D covers, except that Plan M only covers 50% of the Part A deductible.

### Medigap Plan N

Medigap Plan N covers everything plan D does, with the exception of a copayment of up to $20 for Part B services and up to $50 for emergency room visits (this is waived if you’re admitted as an inpatient).

## What Services Are Covered Under Medigap?

All of the [services and procedures](https://www.healthinsurance.com/learning-center/article/common-medical-procedures-and-costs-for-seniors) covered by Original Medicare are covered by Medicare Supplement, depending on which standardized plan you choose.

### Original Medicare Part A

All Medicare-approved services and procedures covered by [Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) are eligible, including:

- Inpatient hospital stays 
- Skilled nursing care (non-custodial only)
- Hospice care
- Home health care

### Original Medicare Part B

Medicare Supplement insurance can help pay for your share of costs under [Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b), including:

- Doctor’s visits
- Lab work and diagnostics
- [Vaccines](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-and-vaccines) 
- Durable medical equipment
- Physical therapy
- Some [cancer treatments](https://www.healthinsurance.com/learning-center/article/does-medicare-cover-cancer-treatment) 

### Extra Benefits Provided By Medigap Plans

Some Medicare Supplement insurance plans offer [additional benefits beyond what Original Medicare covers](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage).

However, these benefits are not guaranteed and can change from year to year. Some of the most common extra Medigap benefits include:

- Gym memberships and fitness programs like SilverSneakers
- Discounts on vision, hearing, and prescription drugs
- Access to nurse hotlines

**Note: Insurance companies are not required to offer extra benefits, so some do not.**

## Who Is Eligible For Medicare Supplement?

As a basic rule, you must be eligible for Medicare Parts A and B in order to qualify for Medigap plans. However, Medicare Supplement eligibility is also subject to federal and state laws. This means that the federal government imposes basic regulations, and some states add additional requirements.

For instance, federal law requires that Medicare Supplement insurance plans offer coverage to [people age 65](https://www.healthinsurance.com/learning-center/article/tips-for-aging-into-medicare) and older. However, some states require Medicare Supplement insurers to allow people younger than age 65 to enroll, if they’re eligible for Medicare.

We’ll be reviewing some of the costs of Medicare Supplement in the next section, but for now, know that Medigap coverage is usually better for those age 65 and up because premiums for people under age 65 can be expensive.

Since Medigap is designed to work with Original Medicare, you must remain enrolled in Part A and Part B at all times.

## Medigap Costs

While Medicare Supplement insurance is designed to lower your out-of-pocket spending, there are certain costs that you’ll still have to pay. Your specific costs will vary based on which standardized plan you choose, but you can expect to pay some or all of Medicare Supplement costs:

- Part B premium (paid to Social Security regardless of which Medigap plan you choose)
- Monthly premium for Medigap coverage (paid to your insurance company and can increase over time)
- Deductibles (Part A and/or B, or some percentage of the Part A deductible)
- Coinsurance (whatever amount your Medigap plan doesn’t cover)

**Example:** Let’s say you have Medicare Supplement Plan G. Your monthly premium at age 65 might be $135 per month, in addition to your Part B premium of $148.50. You go to the doctor in January and have bloodwork, imaging (x-ray, or MRI), and a minor outpatient surgery performed. And your total Medicare-approved costs are $600. 

Since Mediare Supplement Plan G doesn’t cover the Part B deductible, you must pay the first $203 for Part B expenses. Your Medigap plan will then cover the rest of your bills. And you won’t pay out of pocket for any other Medicare-approved services for the rest of the year.

## When Can I Enroll in Medigap?

There are **two types of enrollment** into Medicare Supplement plans:
- Guaranteed issue
- Medically underwritten
(We’ll cover these more in depth in a bit). 

You’ll get a Medigap Open Enrollment Period when you meet these two criteria:

- You are age 65, and
- You are enrolled in Medicare Part B

Your Medicare Supplement insurance open enrollment period won’t start until both of these conditions are true. So if you work beyond age 65 and delay enrollment in Part B, your Medigap Open Enrollment Period won’t begin until you actually enroll in Part B, even if it’s after your 65th birthday.
On the other hand, if you enter Medicare before you turn 65 (say, due to disability), your open enrollment period doesn’t begin until you actually turn 65.

Whenever your Medicare Supplement Open Enrollment Period begins, it will last for six months. You can enroll in any Medicare Supplement insurance plan available in your state during this time, and your enrollment is guaranteed.

**Note: Your Medigap Open Enrollment Period is not the same as the [Medicare Open Enrollment Period](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period).**

## Medicare Supplement Guaranteed Issue

With Medicare Supplement guaranteed issue, you can’t be declined coverage, charged a higher premium based on your health status, or be subject to a waiting period.

You may have the opportunity to get Medigap coverage (or switch from one plan to another) on a guaranteed issue basis in other limited situations, including when: 

- You permanently move out of your plan’s service area.
- You leave your first Medicare Advantage plan after trying it out for 12 months or less (Trial Right).
- Your Medicare Advantage plan loses, or fails to renew, its contract with CMS.
- You lose certain employer or retiree coverage.

If you don’t qualify for guaranteed issue, you’ll have to apply for a medically-underwritten Medigap policy.

### Medical Underwriting

If you apply for Medicare Supplement insurance outside of your Open Enrollment period and you don’t qualify for a guaranteed issue period, you’ll be subject to medical underwriting. This means that you’ll answer questions about your health on your application.
It also means you can be declined coverage for health reasons, or you can be charged a higher premium. A plan can also impose a waiting period for services relating to a pre-existing condition. This waiting period can be up to six months.

For these reasons, you are better off getting Medigap when you’re first eligible, during your Open Enrollment Period.

## How Does Medigap Work with Other Insurance Plans?

Medicare Supplement insurance is designed to work with Original Medicare. You cannot combine Medigap coverage with a [Medicare Advantage plan](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide).

However, you can get drug coverage from a standalone [Medicare Part D](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) Prescription Drug Plan.

## Medicare Supplement & Dual Eligibility

If you’re on [Medicare and Medicaid](https://www.healthinsurance.com/learning-center/article/whats-the-difference-between-medicare-and-medicaid) at the same time (often called dual eligibility), you may <a href="https://www.medicare.gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigap/illegal-medigap-practices" target=" _blank">not be able to get Medicare Supplement Insurance</a>, except in very limited circumstances.

## What’s The Difference Between Medicare Advantage And Medicare Supplement Plans?
While both of these Medicare plan types are offered through private insurance companies, [they have several major differences](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap). 

Medicare Advantage plans are an alternative to Original Medicare. Meanwhile, Medigap plans are designed to work with Original Medicare. You’ll stay in Parts A and B, and Medigap supplements your coverage by paying for some or all of your out-of-pocket costs. Here is a helpful resource to learn more about the [differences between Medigap and Medicare Advantage.](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap)

Many Medicare Advantage plans offer prescription drug coverage. But no modern Medicare Supplement plan (after 2006) provides drug coverage. Instead, you’ll need to combine your Medigap coverage with a Prescription Drug Plan.

Most Medicare Advantage plans are either HMOs or PPOs that use a network of doctors and facilities. Medicare Supplement insurance, though, retains all of the flexibility of Original Medicare. This means you can see any provider in the nation that takes Medicare patients. There are no plan networks, and you generally don’t need a referral to see specialists.

## Advantages and Disadvantages of Medicare Supplement Plans?

Medicare Supplement plans are very useful for lowering your out-of-pocket Medicare costs, but they’re not for everyone. Here are some pros and cons.

### Pros of Medicare Supplement Insurance

- Maximum flexibility (no network or referral restrictions).
- More comprehensive plan with less out-of-pocket expenses than Original Medicare or Medicare Advantage (depending on which Medigap policy you choose).
- More likely to provide coverage while you’re travelling outside of the United States.

### Cons of Medicare Supplement Insurance

More expensive than Original Medicare or Medicare Advantage (initial premiums are usually higher, and they rise over time).
You must also get drug coverage in a separate Prescription Drug plan, which adds costs. 

## Medicare Supplement Plan Comparison Chart

<a href="https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies" target=" _blank">Click here</a> to compare 2021 Medicare Supplement plans and get a complete breakdown of benefits, coinsurance costs, and deductible amounts.

###Compare Medigap Plans

In this Medicare Supplement guide, we’ve reviewed the basics of coverage and given examples of how Medigap plans work. Overall, Medicare Supplement plans can be a great way to lower or eliminate your out-of-pocket healthcare costs under Original Medicare. And these plans are especially good for those who can comfortably afford the premiums, don’t want network or referral restrictions, or travel outside of the U.S. frequently.

If you’re looking for [Medicare coverage](https://medicare.healthinsurance.com) that offers more flexibility, we can help you find the right Medicare Supplement Insurance plan to fit your lifestyle. 

**Call 800-620-4519 (TTY 711) to speak with one of our licensed insurance agents about your Medicare Supplement plan options.**



Confused about Medigap? Our comprehensive Medicare Supplement Guide can help. Learn about what Medigap is, how it works, discover plans & more.



What is Medigap (Medicare Supplement Insurance)?

Medigap

Healthinsurance.com Medicare Supplement Guide

What is Medicare Supplement Insurance (Medigap)?

The transition from 2020 to 2021 offers many opportunities for people on Medicare. Whether you use [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage), (Medicare Advantage)[https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide], or (Medicare Supplement Insurance)[https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101], 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](https://www.healthinsurance.com/learning-center/article/politics-economy-and-healthcare-during-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](https://medicare.healthinsurance.com/learning-center/article/what-is-the-medicare-donut-hole]” was essentially closed for [Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) drug plans.
- Medicare expanded access to [telehealth/virtual doctor appointment](https://www.healthinsurance.com/learning-center/article/telemedicine-for-coronavirus-treatment) 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 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.

###How Much Does Medicare Pay for 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 <a href="https://www.medicare.gov/Pubs/pdf/11579-medicare-costs.pdf" target="_blank">2021 Medicare Costs guide</a> from Medicare.gov for a complete breakdown of [Medicare Part B premiums](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b).


## Medicare Advantage Plan Changes For 2021

Many of the most exciting and notable 2021 changes to Medicare encompass [Medicare Advantage plans](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide). 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 <a href="https://www.ahip.org/medicare-advantage-what-is-changing-for-beneficiaries-with-end-stage-renal-disease-esrd-in-2021/" target="_blank">End Stage Renal Disease</a> (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, <a href="https://hospicenews.com/2020/09/25/53-medicare-advantage-plans-to-offer-hospice-in-2021-palliative-care-to-grow%EF%BB%BF/" target="_blank">53 Medicare Advantage plans</a> 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](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). Examples may include:

- (Dental coverage)[https://medicare.healthinsurance.com/learning-center/article/does-medicare-cover-dental]
- 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 <a href="https://www.cms.gov/newsroom/press-releases/trump-administration-announces-historically-low-medicare-advantage-premiums-and-new-payment-model#:~:text=In%202021%2C%20about%20730%20plans,primarily%20health%20related%20under%20a" target="_blank">will be $21 per month</a>. 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 <a href="https://www.diabetes.org/blog/how-medicares-new-senior-savings-model-makes-insulin-more-affordable" target="_blank">Part D Senior Savings Model</a>. This model program, which is essentially a five-year test, will cap the price of a 30-day supply of many insulins at $35. 

Under this new program for 2021, beneficiaries will have access to about 1,700 MAPDs [(Medicare Advantage plans with Part D drug benefits)](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) and stand alone [Prescription Drug Plans](https://www.healthinsurance.com/learning-center/article/tips-to-reduce-your-prescription-drug-costs) 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](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-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 <a href="https://innovation.cms.gov/innovation-models/part-d-savings-model#:~:text=As%20a%20result%2C%20beneficiaries%20who,their%20average%20cost%2Dsharing%20today." target="_blank">more than $400 per year</a> 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](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap), 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](http://medicare.healthinsurance.com/) 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](http://medicare.healthinsurance.com/)** to find Medicare plans in your area. There is no obligation to enroll in a plan.

Find out how Medicare costs, premiums, and deductibles have changed in 2021 and what you need to do to get the best coverage.








Medicare Coverage in 2021 | Healthinsurance.com

2021 Changes

Healthinsurance.com Summary of 2021 Changes to Medicare

Medicare in 2021: Costs, Premiums, & Deductibles

Need help understanding Medicare Part B? Our Medicare medical insurance guide addresses what’s covered, who’s eligible, how to enroll, premiums & more. 

What Is Medicare Part B? | Guide to Coverage, Costs & More

Medicare Part B

Healthinsurance.com Guide To Medicare Part B

What Is Medicare Part B: Complete Guide To Coverage, Costs, and Eligibility

Some Medicare beneficiaries have concerns about their out-of-pocket expenses. In particular, it can be intimidating to face 20% coinsurance after your deductible is met. That can get expensive! 

Both Medicare Advantage and Medigap can address these concerns, in different ways. Understanding the difference between Medicare Advantage and Medigap can help you choose the right plan for your needs. This article will help you understand Original Medicare, Medicare Advantage, and Medigap

Did you know Medicare has the highest rate of satisfaction among Medicare beneficiaries? In fact, they ranked both Original Medicare and Medicare Advantage highly <a href="https://www.insurance.com/health-insurance/health-insurance-plan-ratings" target="_blank">according to a 2019 survey</a>.

Still, it can be a difficult task to pick the [best Medicare plan](https://medicare.healthinsurance.com/) 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 and take a closer look at the difference between Medigap and Medicare Advantage.


<h2>What Is Medicare?</h2>

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.


<h2>Medicare Part A Costs</h2>

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](https://www.healthinsurance.com/learning-center/article/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.


<h2>Medicare Part B Costs</h2>

[Medicare Part B](https://www.healthinsurance.com/learning-center/article/understanding-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](https://www.healthinsurance.com/learning-center/article/tips-for-aging-into-medicare) 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.


<h2> How to Enroll in Original Medicare</h2>

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 <a href="https://www.elderlawanswers.com/turning-65-what-you-need-to-know-about-signing-up-for-medicare--8968" target="_blank">face penalties</a> 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. 


<h2> What are the Different Types of Medicare Plans?</h2>

- **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](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) 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](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) 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](https://www.healthinsurance.com/learning-center/article/medicare-supplement-101), have several different plans, which help cover benefits that [Original Medicare may not cover](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). 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. 


<h2> What is Medicare Advantage (Medicare Part C)?</h2>

Medicare Advantage provides all of your Part A (hospital) and Part B (medical) coverage. A majority of Medicare Advantage plans offer <a href="https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2019/" target="_blank">extra coverage</a>, such as vision (78%), hearing, dental care (67%) or wellness programs (72%). Most include [Part D prescriptions drug coverage](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) (90%).  

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.

<h3> How Much Does Medicare Advantage Cost?</h3>

[Medicare Part C](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) 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. 

<h3>Do Medicare Advantage Plans Cover Pre-existing Conditions?</h3>

Yes, your acceptance is guaranteed and you're not required to complete any medical history forms. This includes coverage for people with End State Renal Disease (ESRD), which is a [2021 change to Medicare](https://www.healthinsurance.com/learning-center/article/2021-changes-to-medicare). 


<h2> What is a Medicare Supplement (Medigap) Plan?</h2>

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.

<h3> How Much Do Medigap Plans Cost?</h3>

Pricing for [Medicare Supplement plans](https://www.healthinsurance.com/learning-center/article/medicare-supplement-101) 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. 


<h2> What's the Difference Between Medicare Advantage and Medigap?</h2>

[Medicare Advantage offers more choice](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) and covers more medical services than Medicare, while still following all of Medicare’s rules. One of the biggest differences between the two is the difference in cost. Medigap plans Generally have a higher premiums than Medicare Advantage plans, but in some cases, Medicare Advantage can cover less expenses than Medigap. This means that despite a lower initial cost, you may end up paying *more* in out-of-pocket expenses with Medicare Advantage than with Medigap.

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.**


<h2>Do I Need Medigap or Medicare Advantage?</h2>

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?

Answering these questions will help you determine if Medigap or Medicare Advantage is a better fit for you.

<h3>Can You Switch From Medicare Advantage to Medigap?</h3>

Switching from Medicare Advantage to Medigap means you need to go back to Original Medicare. Instead of having coverage under Medicare Part C (Medicare Advantage), you’ll have coverage under Medicare Part A and Part B, with Medigap added on.

This can only be done during open enrollment periods. The Annual Election Period is between October 15th and December 7th of each year. The Medicare Advantage Open Enrollment Period is between January 1st and March 31st each year.

Keep in mind that usually if you switch from Medicare Advantage to Original Medicare with Medigap, you may pay a higher price for your Medigap plan because you won’t have guaranteed issue rights. Guaranteed issue rights give you the ability to buy any Medigap plan without paying more due to your health status.

To switch from Medicare Advantage to Medigap with guaranteed issue, you need to:
- Have purchased your Medicare Advantage plan when you were first eligible, but decided within the first year to switch.
- Lose your Medicare Advantage plan because you moved out of the service area or the plan stopped operating in your area. 

These temporary guaranteed issue opportunities may not include all Medigap plans — it will depend on the rules in your state. 


<h2>Compare Medigap and Medicare Advantage</h2>

The chart below offers a side-by-side comparison of costs and coverage to help you understand the difference between Medigap and Medicare Advantage.
<br><br>
<table class="table--comparison">
    <thead>
      <tr>
        <th style="padding: 1em; background: #005cb9; vertical-align: middle">&nbsp;</th>
        <th style="padding: 1em; background: #005cb9; vertical-align: middle; font-weight: bold; color: #fff;">Medicare Advantage</th>
        <th style="padding: 1em; background: #005cb9; vertical-align: middle; font-weight: bold; color: #fff;">Medicare Supplement</th>
    </tr>
    </thead>
  <tbody>
    <tr>
        <td style="padding: 1em;"><strong>Coverage</strong></td>
        <td style="padding: 1em;">In most cases, copayments (a fixed amount of money you pay) are required.</td>
        <td style="padding: 1em;">In most cases, it can cover deductibles, copayments, and coinsurance that isn’t covered by Part A and Part B.</td>
    </tr>
    <tr>
        <td style="padding: 1em;"><strong>Cost</strong></td>
        <td style="padding: 1em;">Many times $0 or a low monthly cost.</td>
        <td style="padding: 1em;">Higher monthly cost based on state, gender, and age.</td>
    </tr>
    <tr>
        <td style="padding: 1em;"><strong>Travel</strong></td>
        <td style="padding: 1em;">Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay.</td>
        <td style="padding: 1em;">Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay.</td>
    </tr>
    <tr>
        <td style="padding: 1em;"><strong>Prescription Drugs</strong></td>
        <td style="padding: 1em;">Typically included with coverage.</td>
        <td style="padding: 1em;">Not covered. You must enroll in a Part D plan for drug coverage.</td>
    </tr>
    <tr>
        <td style="padding: 1em;"><strong>Routine dental, vision, hearing coverage</strong></td>
        <td style="padding: 1em;">May be covered depending on the plan selected.</td>
        <td style="padding: 1em;">Not covered.</td>
    </tr>
    <tr>
        <td style="padding: 1em;"><strong>Copayments and coinsurance</strong></td>
        <td style="padding: 1em;">Usually have copayments and/or coinsurance.</td>
        <td style="padding: 1em;">Typically pays for copayments and coinsurance.</td>
    </tr>
    <tr>
        <td style="padding: 1em;"><strong>Network</strong></td>
        <td style="padding: 1em;">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.</td>
        <td style="padding: 1em;">No network. See almost any doctor or medical facility that accepts Medicare.</td>
    </tr>
</tbody>
</table>

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.**

<h3>Find & Compare Medicare Advantage and Medigap Plans</h3>

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.

Healthinsurance.com can help you discover the difference between Medigap and Medicare Advantage and determine which program is best for you.

Medicare Advantage vs. Medigap | What's the Difference?

Medicare 101

Medicare Advantage vs. Medigap: What's the Difference?

Medicare Advantage vs. Medigap: What is the difference? 

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](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) 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](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) plans to curb out-of-pocket costs and get [prescription drug coverage](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide). 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):

- <a href="https://health.costhelper.com/eyeglasses.html" target="_blank">$114 for an eye exam</a> 
- <a href="https://valuvision.com/how-much-are-eyeglasses-without-insurance/" target="_blank">$113 for lenses</a> 
- <a href="https://valuvision.com/how-much-are-eyeglasses-without-insurance/" target="_blank">$238 for frames</a>

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.

<a href="https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap" target="_blank">Medigap plans</a> 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. Just **call 800-620-4519** to reach one of our licensed insurance agents or you can <a href="http://medicare.healthinsurance.com" target="_blank">find and compare Medicare Advantage plans</a> in your area to see if they work with your doctors and cover your medications.


Medicare coverage can be confusing. Learn about what Medicare covers, Medicare costs, and more.




What Does Original Medicare Cover? | Healthinsurancecom

How to Fill the Gaps of What Original Medicare Doesn't Cover

Medicare Coverage and Costs

Are you turning 65? Turns out, you’ll be joined by thousands of birthday buddies.

In fact, <a href="https://arc.aarpinternational.org/countries/united-states" target="_blank">10,000 Americans turn 65</a> 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 <a href="https://www.ssa.gov/myaccount/assets/materials/SSA-7005-SM-SI%20Wanda%20Worker%20Young.pdf" target="_blank">[sample here]</a>  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](https://www.healthinsurance.com/learning-center/article/understanding-medicare-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 <a href="https://www.ssa.gov/" target="_blank">ssa.gov</a> 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 Medicare 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 <a href="https://medicare.healthinsurance.com/" target="_blank">close the coverage gap</a> 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](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) 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](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap) 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)](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) 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 get Medicare quotes <a href="http://medicare.healthinsurance.com" target="_blank">through our site</a>. Or you can **call 800-620-4519**  to reach one of our licensed Medicare agents who can guide you through your Medicare plan options. 

10,000 Americans turn 65 every day but many are confused about Medicare. We share 6 important tips that anyone aging into Medicare should be aware of. 

6 Tips for Seniors Aging into Medicare | HealthInsurance.com

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Healthinsurance.com 6 Tips for Aging into Medicare

Aging Into Medicare & Medicare Planning for Retirement

Medicare spending is <a href="https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing" target="_blank">trending upward</a>. 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 <a href="https://www.medicare.gov/procedure-price-lookup/"  target="_blank">procedure price lookup tool</a> to find rough costs of every procedure covered under <a href="https://www.healthinsurance.com/learning-center/article/medicare-supplement-101">Medicare</a>.

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](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) 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. <a href="https://www.verywellhealth.com/what-are-cpt-codes-2614950"  target="_blank">Current Procedural Terminology (CPT)</a> 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 <a href="https://www.mayoclinic.org/tests-procedures/cataract-surgery/about/pac-20384765"  target="_blank">removes the lens of your eye</a> 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 <a href="https://www.nei.nih.gov/learn-about-eye-health/resources-for-health-educators/eye-health-data-and-statistics/cataract-data-and-statistics"  target="_blank">three in five people</a> 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 <a href="https://www.niddk.nih.gov/health-information/diagnostic-tests/upper-gi-endoscopy"  target="_blank">inserting a small camera into the esophagus</a>, 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 <a href="https://www.mayoclinic.org/tests-procedures/colonoscopy/about/pac-20393569"  target="_blank">polyps</a>, 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. 

<a href="https://www.consultant360.com/articles/total-knee-replacement-very-elderly"  target="_blank">Two out of three seniors</a> 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?
<a href="https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925"  target="_blank">Osteoarthritis</a> 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 <a href="https://www.healthinsurance.com/learning-center/article/how-to-avoid-costly-hospital-bills">avoid costly hospital bills</a>.
 
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 <a href="https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap">serve different purposes</a>:

- 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](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) must be purchased to get prescription drug coverage.

If you need help choosing the right Medicare plan for your specific medical needs, you can compare Medicare plans through our <a href="https://medicare.healthinsurance.com/">online Medicare plan finder</a> or by **calling 800-620-4519** to reach one of our licensedd insurance agents.

We've also put together <a href="https://www.healthinsurance.com/learning-center/article/10-medicare-frequently-asked-questions">Medicare FAQs</a> for more information.

We took a look at five common medical procedures for Seniors, their cost and whether Medicare covers them or not. Click to read about these procedures. 

Medicare and Common Senior Medical Procedures

medical

5 Common Medical Procedures and Costs for Seniors

5 Common Medical Procedures for Seniors

Cancer statistics are telling: The <a href="https://seer.cancer.gov/statfacts/html/all.html" target="_blank">median age for a cancer diagnosis</a> 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 deaths 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. 

###What is the Average Out-of-Pocket Cost for Cancer Treatment?

[In a study](https://www.ebri.org/docs/default-source/ebri-issue-brief/ebri_ib_506_savingstargets-28may20.pdf) by the Employee Benefit Research Institute (EBRI), a 65-year old couple retiring in 2020 can expect to spend $325,000 on health care and medical expenses throughout retirement unless a critical illness occurs or the wrong insurance plan is selected.

###How Much Will Medicare Pay for Cancer Treatment?

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 Cancer Treatments Original Medicare Covers

Original Medicare is a combination of Part A (hospitalization) and Part B (medical) and [Part D (prescription coverage)](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide). 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: 
 
### Cancer Treatment Covered by Medicare Part A

You pay your [Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-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
 
###Cancer Treatment Covered by Part B

If you’re wondering does Medicare part B pay for cancer treatment, the answer is yes, Part B does provide partial coverage for some treatments, consultations, and medical equipment.

You pay your [Part B deductible](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) 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
 
###Cancer Drugs Covered by Medicare Part D

Are cancer drugs covered by Medicare? Here's how Medicare Part D works with cancer medications.

You’re responsible for your prescription drug copays until you reach the <a href="https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/catastrophic-coverage" target="_blank">catastrophic coverage limit</a>, 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 for Cancer Treatment
 
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.
 

##Does Medicare Advantage (Part C) Cancer Treatment?

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](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide):

- 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 <a href="https://medicare.healthinsurance.com/">shop around for Medicare Advantage plans</a> 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 Cancer Treatment Costs Does Medicare Supplement (Medigap) Cover?

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. <a href="https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap">Medicare supplements</a> 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 <a href="https://medicare.healthinsurance.com/">compare Medicare supplement plans</a> 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](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) 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 About Medicare and Cancer Treatment 

Need more information about Medicare and cancer? **Call 800-620-4519** to speak with one of our <a href="https://togetherhealth.com/">licensed Medicare agents</a> to learn more about your plan options that may cover your specific cancer treatment and care.



Cancer treatment costs can be expensive and Medicare coverage varies by plan. We analyzed different Medicare types to find out what cancer treatments and costs each one covers.


