An Overview of Your Optional Medicare Coverages

 Limitations of Original Medicare Parts A & B:

With Original Medicare, provided by the federal government, you’re covered for many hospital and medical expenses. However, there are some gaps in that coverage you may be required to pay for out-of-pocket, such as deductibles, co-payments, coinsurance, or non-covered services. The following examples illustrate how quickly these costs can add up for you:  

  • Medicare Part A has an upfront deductible for each hospitalization before your Medicare coverage begins.

  • If you stay in the hospital for more than 60 days, you begin paying a co-pay for each additional day.

  • After 90 days in the hospital, your daily co-pay increases even more.

  • After you pay your Part B annual deductible, you pay 20% of the cost for most doctors’ visits or outpatient services.  

  • You pay 100% for emergency or medical care received outside the U.S., except under limited circumstances.

  • Part A and Part B do not cover prescription drugs, vision, dental, or other types of coverage that may be important to you.  
     

With a Medicare Advantage, Medicare Supplement (Medi-Gap), and/or prescription drug (Part D) plan, offered by private insurance companies, you can fill these coverage gaps and significantly reduce the amount of money that you may be required to pay out-of-pocket.  

 Medicare Advantage Part C (replaces Parts A, B, & D):

Medicare Part C is also known as Medicare Advantage. Medicare Advantage plans combine Part A and Part B benefits into one plan, replacing the need to have Original Medicare Part A and B completely. Medicare Advantage Plans are offered by private insurance companies that are approved by Medicare and costs vary by plan. Although Medicare Advantage plans often have lower premiums and reduced out-of-pocket expenses, they utilize a coordinated care approach, so you are limited to seeing only the doctors and hospitals in your assigned network.  

 

All Medicare Advantage plans cover:

  • All the benefits of Part A (except hospice, which is still covered by Part A)

  • All the benefits of Part B

  • PLUS....Prescription Drugs Part D 
     

Depending upon the specific plan coverage offered by the insurance company, Medicare Advantage Plans may also offer additional benefits, such as:

  • Dental exams, cleanings, and x-rays

  • Eye exams, eyeglasses, and corrective lenses

  • Hearing tests and hearing aids

  • Wellness programs and fitness membership

 Medicare Supplement (Medigap Plans A, B, D, G, K, L, M, N): 

​​Medicare Supplement plans, also known as Medigap plans, are offered by private insurance companies to help pay some of the health care costs that Original Medicare doesn’t cover like co-payments, coinsurance and deductibles. These plans supplement, rather than replace, your Original Medicare benefits, so you still need to have Medicare Parts A and B. They also do not cover prescription drug expenses, so you may want to purchase Part D as well). See the chart below for a general illustration of some of the coverage available through Medicare Supplement Plans.

The federal government has standardized ten plans. Each is identified by a letter. All plans with the same letter offer the same benefits, with some of the standardized plans offering additional benefits so you can choose which one most effectively meets your needs. Not all the plans are available in every state. Medicare Supplement insurance helps with:

  • Part A and Part B deductibles

  • Co-payments and co-insurance

  • Excess charges by providers 

  • An additional 365 days of hospital care during your lifetime, beyond your Medicare lifetime reserve days

  • First 3 pints of Blood Transfusions

  • Foreign Travel Emergencies
     

What is typically not covered by Medicare Supplement plans:

  • Long-term care

  • Routine eye exams or eyeglasses

  • Routine hearing tests or hearing aids

  • Routine dental exams, cleaning or x-rays

  • Private duty nursing

  • Days in a skilled nursing facility beyond the 100 days covered by Part A.

The following chart provides a basic illustration of the types of coverage options available through the various Medigap plans.

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Medicare Part D (Prescription Drugs):

Once you have enrolled in Medicare Part A and/or Part B, you can get prescription drug coverage with a stand-alone Prescription Drug Part D plan, offered through an insurance company, or with a Medicare Advantage plan that includes prescription drug coverage.

You can enroll in Part D during the Initial Enrollment, a Special Enrollment (due to a change in life circumstances), or the Open Enrollment Period (October 15th to December 7th each year). If you want to add Part D at any other time, you must pay a penalty for late enrollment.  There is a monthly premium, yearly deductible, and co-payments/ coinsurance throughout the year, depending upon the plan that you purchase.

Prescription Drug Part D plans cover:

  • The types of drugs most commonly prescribed for Medicare beneficiaries as determined by federal standards

  • Specific brand name drugs and generic drugs included in the formulary or list of drugs

Premiums for Prescription Drug Part D plans:

Each insurance company that provides Part D coverage has scheduled rates for their plans.  In addition, based on an individual's prior income, an additional fee may be required.  See chart below.​

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What isn’t covered by Part D:

  • Drugs not on the plan formulary

  • Drugs prescribed for anorexia, weight loss, or weight gain

  • Drugs used to promote fertility

  • Erectile dysfunction drugs

  • Drugs used for cosmetic purposes or hair growth

  • Prescription vitamins and mineral products

  • Non-prescription drugs

  • Drugs received while an inpatient (these may be covered by Part A)

 

What Pharmacy Can I Use?

  • Some plans have a network of pharmacies for you to choose from, while others offer nationwide coverage.

  • Plans may also offer mail-order services.

Hospital Staff
Medical Team
Filling Out Prescriptions
Pharmacist at Work