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When you first enroll in Medicare and during certain times of the year, you can choose how you get your Medicare coverage. There are 2 main ways to get your Medicare coverage—Original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C). Some people need to get additional coverage, like Medicare drug coverage or Medicare Supplement Insurance (Medigap).Use this information to help you compare your coverage options and decide what coverage is right for you.
Original Medicare Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance).If you want drug coverage, you can join a separate Medicare drug plan (Part D).You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
If you choose Original Medicare, you can also decide to: Join a separate Medicare drug plan (Part D) if you want drug coverage. Add other insurance (like Medicare Supplement Insurance (Medigap), Medicaid, or employee or union coverage), to help pay your out-of-pocket costs (like your 20% coinsurance).
Note :
If you don’t get Medicare drug coverage or Medigap when you’re first eligible, you may have to pay more to get this coverage later. This could mean you’ll have a lifetime premium penalty for your Medicare drug coverage.
Medicare Advantage (Also Known As Part C)
• Medicare Advantage is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D.
• Plans may have lower out-of-pocket costs than Original Medicare.
• In many cases, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs.
• Most plans offer extra benefits that Original Medicare doesn’t cover—like vision, hearing, dental, and more.
Medicare Drug Coverage Part D
All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
You’ll make these payments throughout the year in a Medicare drug plan:
• Premium
• Yearly deductible
• Copayments or coinsurance
• Costs in the coverage gap
• Costs if you get Extra Help
• Costs if you pay a late enrollment penalty
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HMO (Health Maintenance Organization)
You usually have to use the doctors and other providers in the plan’s network. In an HMO with point-of-service option (HMOPOS), you may be able to go out-of-network for certain services. If you want drug coverage, the HMO Plan you join must include drug coverage.
PPO (Preferred Provider Organization)
These plans have a network of doctors and other providers, but you can use providers outside their network. You’ll usually pay less if you get services from in-network providers. If you want drug coverage, the PPO Plan you join must include drug coverage.
PFFS (Private Fee-for-service)
You can see any doctor or other provider that accepts the plan’s payment terms and agrees to treat you. Not all providers will, even if you’ve seen them before. If you join a PFFS Plan that doesn’t include drug coverage, you can also join a separate Medicare drug plan (Part D).
MSA (Medical Savings Account)
These are high-deductible plans that deposit money into a savings account that you can use to pay health care costs before you meet the deductible. You can see any doctor or provider. Once you’ve used the amount of money in the account, you’ll pay all costs until you meet the deductible. These plans don’t include drug coverage, but you can also join a separate Medicare drug plan.
Cost Plan
These plans are only available in some states. You can see any doctor or other provider that works with Medicare. If you go to a provider outside the network, Original Medicare covers those services. You’ll pay the Part A and Part B deductibles and coinsurance, usually 20% of the Medicare-approved amount, for those services.
You can join a Cost Plan without drug coverage anytime the plan’s accepting new members. You can also join a separate Medicare drug plan during an enrollment period.
If you want to join a Cost Plan with drug coverage, you can only join during an enrollment period.
MMP (Medicare-Medicaid Plan)
These plans are only in some states. You can join if you have Medicare, are getting full Medicaid benefits, and meet other criteria by the state. All MMPs include drug coverage.
Special Needs Plans
You can join this type of plan if you:
• Have both Medicare and Medicaid
• Have a specific disease or condition (like diabetes)
• Live in an institution (like a nursing home)
These plans tailor their benefits, provider network, and drug formularies to best meet the needs of the people they serve. All SNP Plans include drug coverage.
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