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  • Overview
  • Basic options
  • Medicare Advantage
  • Part D
  • Medicare Supplement
  • Compare options
  • Costs

Medicare options

Basic coverage (Original Medicare)

Part A
Hospital Insurance

Part B
Medical Insurance

Enhance your coverage with optional plans

Part C Plans (Medicare
Advantage Plans)

Covers all the benefits included in Medicare Parts A and B—and more.

May cover additional benefits such as Part D prescription drug medications, routine vision care and hearing services, hearing aids, dental care, wellness programs and worldwide emergency care



or

Part D Plan (PDP)
(Prescription drug coverage plans)
Covers certain prescription medications only
and/or
Medicare Supplement Insurance (Medigap) Plans

Fills in the gaps left by Original Medicare

Medicare consists of different parts, and each part provides different coverage. So, it’s important to think about what type of coverage you would like, and what type of coverage you may need now and in the future.

With Medicare, you can receive basic coverage or you can enhance that basic coverage with optional plans.

If you decide that you would like more coverage than Original Medicare alone provides, you have options. There are plans that will cover some or all of the out-of-pocket costs you are responsible for with Original Medicare, leaving you with little to no out-of-pocket costs. There are also plans that cover the items and services that Original Medicare does not cover, like routine vision and hearing services and prescription drugs. Keep in mind that you have to be enrolled in both Medicare Parts A and B to receive coverage from most of these options.



To learn more about your coverage options, click the gray tabs above.

Basic Medicare options: Original Medicare

Let’s look at Medicare’s basic coverage options—Parts A and B, also known as Original Medicare.

Part A: Hospital Insurance

Medicare Part A helps pay for your inpatient care in hospitals, skilled nursing facility stays, hospice care and some home health care.

Part B: Medical Insurance

Medicare Part B helps pay for medically necessary services like doctor office visits and outpatient hospital care. It also covers some preventive services like screenings and flu shots.

What's covered by Part A What's covered by Part B
Hospital care Annual wellness exam
Skilled nursing facility stays Ambulance rides and services
Home health care Behavioral health care
Hospice Lab tests and X-rays
Medical equipment
Orthotics and prosthetics
What's not covered by Parts A and B
• Most dental care, including routine cleaning and exams
• Hearing aids
• Routine hearing exams
• Routine foot care
• Routine vision care
• Most prescription drugs
• Worldwide emergency care


Important notes about Original Medicare

  • You receive coverage directly from the Medicare program, not a private health plan.
  • You may see any provider, anywhere, who accepts Medicare and you as a patient.
  • You do not have to elect a primary care provider (PCP).
  • Referrals are not required, in most cases.
  • You have to pay a portion of the cost for most covered services.
  • Most people pay premiums for Part B, and some people pay premiums for Part A.

Other options: Medicare Advantage Plans (Part C)

Medicare Advantage Plans, also called Part C Plans, are offered by private health insurance companies that are contracted with the Medicare program. These plans provide all the coverage offered through Medicare Parts A and B, plus more, like: worldwide emergency coverage, routine hearing exams, routuine vision care and fitness benefits. In many cases these plans also provide drug coverage offered through Part D (prescription drug coverage). Members of these plans are often responsible for monthly plan premiums and may be responsible for deductibles, copayments and/or coinsurance.

Things to keep in mind about Medicare Advantage Plans

  • These plans offer similar coverage and cost-sharing structure as many traditional insurance plans offered by employers.
  • One insurance card (health plan provides Medicare benefits).
  • Offers all the coverage of Original Medicare—plus more.
  • There are different types of plans like:
  • Health Maintenance Organization (HMO) plans
  • Health Maintenance Organization plan with a Point-of-Service (HMO-POS) option
  • Preferred Provider Organization (PPO) plans
  • Special Needs Plans (SNP)
  • If you are enrolled in a Medicare Advantage Plan, you cannot be enrolled in a Medicare Supplement (Medigap) Plan or a Part D Plan at the same time.

Other options: Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plans are offered by private health insurance companies that are contracted with the Medicare program. These types of plans provide coverage for your prescription medications only. Both you and the plan share the cost of prescription drugs. Members of these plans are often responsible for monthly plan premiums and may be responsible for deductibles, copayments and/or coinsurance. Your out-of-pocket costs are determined by the coverage stage you are in during any particular time.

Here’s a look at how a standard Part D Plan may work—what’s covered and what you will have to pay at each stage of coverage.

Coverage stage

What is this stage?

Your costs for 2017

Deductible When you pay the full cost of your drugs until your deductible is met

Full cost of your drugs

Deductibles vary by plan and can be up to $400

Initial coverage

When you and your plan share the total cost of your drugs

Copayments/coinsurance until your yearly drug costs—paid by you and your plan—reach $3,700

Coverage gap (“donut hole”)

When you pay most of the plan's negotiated price for your drugs. The plan pays a little.

Until your out-of-pocket costs reach $4,950, you pay 40% of the cost (plus a portion of the dispensing fee) for brand-name drugs and 51% of the cost for generic drugs

Catastrophic coverage

When the plan pays most of the cost of your drugs for the remainder of the calendar year

You pay the greater of:

  • A $3.30 copayment for generic or preferred brand drugs, and a $8.25 copayment for all other drugs, or
  • 5% coinsurance

Things to keep in mind about Part D Plans

  • Only cover prescription medications.
  • Usually have two health insurance cards (Medicare card and Part D Plan card).
  • Your out-of-pocket costs could include a monthly plan premium, a deductible and/or copayments or coinsurance.
  • Part D Plan formularies vary. Check to make sure that the drugs you take are covered by the specific Part D Plan that you are considering.

Other options: Medicare Supplement Plans (Medigap Plans)

With Medicare Supplement Insurance Plans—or Medigap Plans—you will be covered for all the items and services offered through Original Medicare, and maybe more. These types of plans are offered by private health insurance companies and cover most deductible and coinsurance costs associated with Original Medicare. Medicare Supplement Plans also offer flexibility by allowing members to receive care from any provider who accepts Medicare and you as a patient.

In Massachusetts, there are two types of Medicare Supplement Insurance Plans—Supplement Core and Supplement One. The type of plan you choose determines the costs that will be covered, and the costs that you may be responsible for.

Things to keep in mind about about Medigap Plans

  • Usually have to use two health insurance cards when receiving care (Medicare card and Medicare Supplement card).
  • Covers most out-of-pocket costs, like deductibles and copayments/coinsurance, that you would have to pay with Medicare Parts A and B.
  • Some plans offer more benefits than you would receive with Original Medicare alone (e.g., routine vision care, fitness benefits, etc.).
  • Does not cover most prescription drugs. You may want to purchase a Part D Plan.
  • You can't be a member of a Medicare Advantage Plan and a Medicare Supplement (Medigap) Plan at the same time.

Compare your options

Original Medicare

Medicare Advantage
(Part C)

Original Medicare +
Medicare Supplement (Medigap)

Original Medicare +
Medicare Prescription Drug Plan (Part D)

Original Medicare +
Medicare Supplement + Medicare Prescription Drug Plan (Part D)

Includes Medicare Parts A and B

Yes

Yes

Yes

Yes*

Yes

Includes prescription drug coverage (Part D)

No

Typically, but not always

No

Yes

Yes

Includes extra benefits (for example: routine hearing and vision care)

No

Typically, but not always

Typically, but not always

No

Typically, but not always

Must choose a Primary Care Provider

No

Yes for HMO and HMO-POS plans

Usually no for PPO plans

No

No

No

Must get referrals to see specialists

No

Typically, but not always, for HMO and HMO-POS plans

No for PPO plans

No

No

No

Ability to see any provider who accepts Medicare

Yes

No for HMO plans

Typically, but not always, for PPO and HMO-POS plans (out-of-network rules may apply)

Yes

Yes

Yes

* With the Original Medicare + Medicare Prescription Drug Plan (Part D) option, you may have Medicare Parts A and/or B.

How much does it cost?

Depending on what Medicare option you choose, you may be responsible to pay a monthly plan premium to your plan, and you must continue to pay any premiums due to Medicare. You may also have to pay some out-of-pocket costs, such as a deductible or copayments/coinsurance, for certain services you receive.

Original Medicare costs

The chart below is an example of some costs you will pay for specific covered services, with Original Medicare as your only coverage.

Medicare coverage option

2017 monthly plan premium

Other out-of-pocket costs

Cost to you per benefit period in 2017

Part A

$0 for most people*

$227/month for those who worked between 7.5 and 10 years

$413/month for those who worked less than 7.5 years

  • Deductible
  • Coinsurance
  • Copayments

Hospital stays

  • $1,316 deductible for days 1-60
  • $329 per day for days 61-90
  • $658 per day for days 91 and beyond**

Skilled Nursing Facility stays (after a qualifying 3-day hospital stay)

  • $0 a day for days 1-20
  • $164.50 a day for days 21-100
  • 100% of the costs for days 101 and beyond

Part B

$109-$134***

  • Deductible
  • Coinsurance
  • $183 annual deductible
  • 20% coinsurance for Medicare-covered services, like doctor office visits, lab tests and X-rays

Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) costs

Premiums, deductibles, copayments, coinsurance and benefits may vary by plan. Be sure to get cost details from any Medicare Advantage or Part D Plan you may be considering.

Medicare Supplement (Medigap) costs

In Massachusetts, there are two types of Medicare Supplement Insurance Plans—Supplement Core and Supplement One. The type of plan you choose determines the costs that will be covered, and the costs that you may be responsible for.

* You will pay a $0 Part A monthly plan premium if you or your spouse worked and paid into Social Security for at least 10 years.
**After you are in the hospital for 90 consecutive days, you may begin to receive coverage using your "lifetime reserve days." Under Original Medicare, you have 60 reserve days that you are able to use over your entire lifetime.
*** You will pay a higher monthly Part B plan premium if you are single and your income is $85,000/year or more, or if you’re married and your combined income is $170,000/year or more.

A deductible is a set dollar amount that you must pay out of pocket for health care or prescriptions before a plan begins to pay.

Coinsurance is an amount you are required to pay as part of your share of the cost for services. For example, if you have Medicare Part B, and you see your doctor because you don’t feel well, you are responsible to pay for 20% of the cost for that doctor office visit.

A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t received any inpatient hospital or SNF care for 60 days in a row.


Fallon Health is an HMO/HMO-POS plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Senior Plan and NaviCare depends on contract renewal.

NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS.


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The information on this page was last updated on 3/24/2017