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  • Overview
  • Original Medicare
  • Medicare Advantage
  • Part D Plans
  • Medicare Supplement
  • Compare plans
  • 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 services and items like: Part D prescription drugs, routine vision care, hearing services, hearing aids, dental care, wellness programs and worldwide emergency care.



or

Part D Plan (PDP)
Prescription drug coverage
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 vision and hearing services and prescription drugs. Keep in mind that you have to be enrolled in Medicare Parts A and B to receive coverage from the options described on the following pages.



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

Medicare coverage options - Original Medicare

With Medicare, you can receive basic coverage or you can enhance that basic coverage with optional plans. First, let’s look at Medicare’s basic coverage options—Parts A and B, also known as Original Medicare.

Basic coverage (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 Lab tests and X-rays
Hospice Medical equipment
Behavioral health care
Orthotics and prosthetics
What's not covered by Parts A and B
• Most dental care
• Hearing aids
• Routine hearing exams
• Routine foot care
• Routine vision care
• 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.
  • Original Medicare does not cover everything. Some examples of items and services that are not covered:
  • Most prescription drugs
  • Preventive dental services, like cleanings and exams
  • Routine eye exams and glasses
  • Routine hearing exams and hearing aids

Optional Coverage: Medicare Advantage Plans (Part C)

Medicare Advantage Plans, also called Medicare 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, hearing exams, vision care and fitness benefits. In many cases these plans also provide the coverage offered through Medicare Part D (prescription drug coverage) Plans.

What is covered with Medicare Advantage (Part C) Plans?

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Do you have Medicaid?

If you do, you are eligible for even more coverage options! Depending on the type of care you want or need, you could be eligible for a Senior Care Options (SCO) Plan, Special Needs Plan (SNP) or a Program of All-Inclusive Care for the Elderly (PACE).

To learn more, contact:

Fallon Health
1-877-255-7108 (TTY: 711)

Medicare
1-800-MEDICARE
(1-800-633-4227)
TTY: 1-877-486-2048

Things to keep in mind about Medicare Advantage Plans

  • These plans are often the most familiar to enrollees as they offer a similar coverage and cost-sharing structure as many other non-Medicare plans.
  • 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 Point-of-Service (HMO-POS) option
  • Preferred Provider Organization (PPO) plans
  • Although you can't be a member of a Medicare Part D Plan and a Part C (Medicare Advantage) Plan at the same time, you may get coverage for Medicare Part D prescription drugs through a Medicare Advantage Plan.
  • You can't be a member of a Medicare Part C (Medicare Advantage) Plan and a Medicare Supplement (Medigap) Plan at the same time.

Optional Coverage: 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, meaning that 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 typical Medicare 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 2016

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 $360.

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 $3,310

Copayments/coinsurance differ by plan and medication.

Coverage gap (“donut hole”)

When you pay most of the plan's negotiated price for your drugs and your plan pays a small amount

Discounted costs for brand-name drugs

58% of the cost for generic drugs until your yearly out-of-pocket costs reach $4,850

 

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 $2.95 copayment for generic or preferred-brand drugs, and a $7.40 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.

Optional Coverage: Medicare Supplement policies (Medigap Plans)

With Medicare Supplement Insurance policies—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.

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

  • The best time to join a Medicare Supplement (Medigap) Plan is during your Initial Enrollment Period or during Medicare's Annual Enrollment Period. During these enrollment periods, health plans will have to allow you to join their plan, even if you have health problems.
  • 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, 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., vision care, fitness benefits, etc.).
  • Does not cover most prescription drugs. You may want to purchase a Medicare Part D Plan.
  • You can't be a member of a Medicare Part C (Medicare Advantage) Plan and a Medicare Supplement (Medigap) Plan at the same time.

Compare your choices

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

Yes

Typically, but not always

No

Typically, but not always

Must choose a Primary Care Provier

No

Yes for HMO and HMO-POS plans

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

Monthly plan premium for 2015

Other out-of-pocket costs

Cost to you per benefit period in 2015

Part A

$0 for most people*

$224/month for those who worked between 7.5 and 10 years

$407/month for those who worked less than 10 years

  • Deductible
  • Coinsurance
  • Copayments

Hospital stays

  • $1,260 deductible for days 1-60
  • $315 per day for days 61-90
  • $630 per day for days 91-150

Skilled Nursing Facility stays

  • $0 a day for days 1-20
  • $157.50 a day for days 21-100
  • 100% of the costs for days 101 and beyond

    Note: You are covered only after a qualifying 3-day hospital stay.

Part B

$104.90** in 2015, but changes annually

  • Deductible
  • Coinsurance
  • $147 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.
** 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 before any medical services are paid by your health insurance carrier.

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 6/24/2015.