Navigating Medicare

Original Medicare does not provide prescription drug coverage. You must buy separate Part D prescription drug coverage if you have Original Medicare or a Medicare Supplement plan. Part D prescription drug plans help pay for the cost of prescription drugs and are sold through private companies.

Solution: If you want prescription drug coverage, there are two ways to get a Part D plan. You can purchase a Medicare Advantage plan with drug coverage (MAPD) or a stand-alone Prescription Drug Plan (PDP).

You may not be enrolled in a stand-alone PDP and also be enrolled in a Medicare Advantage Plan at the same time.*

*Exceptions: Medical Savings Account (MSA), Private Fee-for-Service (PFFS) or Cost Plans

Medicare Supplement plans are also known as Medigap plans. In general, Medicare Supplement (Medigap) plans only cover what Original Medicare covers. These plans are a supplement to Original Medicare and help to cover the Part A and Part B cost-sharing amounts, such as deductibles and coinsurance, for Original Medicare covered services. Medicare Supplement plans do not offer prescription drug coverage. Separate Part D prescription drug coverage must be purchased.

There are three types of Medicare Supplement plans offered in Massachusetts:

• Medicare Supplement Core
• Medicare Supplement 1
• Medicare Supplement 1A

All Massachusetts Medicare Supplement plans cover you for the same set of core benefits, including:

• Inpatient hospital care - cover the Medicare Part A coinsurance, plus coverage for 365 additional days after Medicare coverage ends
• Medical costs - cover the Medicare Part B coinsurance (generally 20% of Medicare-approved amount)
• Blood - cover the first 3 pints of blood each year
• Part A hospice coinsurance or copayment
• State-mandated benefits

With Medicare Supplement plans, you:

• Are covered throughout the US and US territories when you see a provider, doctor or hospital that accepts Original Medicare
• Are not required to have a primary care provider (PCP) or get a referral to see a specialist
• Are guaranteed renewal as long as you pay your premium
• Can switch Medicare Supplement plans anytime during the year

Medicare Supplement plans might not include additional benefits and extras such as dental, hearing, vision, fitness, etc.

Medicare Advantage plans are also known as Part C plans. These types of plans combine Part A and Part B, and usually offer Part D prescription drug coverage.

Medicare Advantage plans have to cover everything that Medicare Part A and Part B would cover. In addition, Medicare Advantage plans may provide coverage and benefits beyond those covered by Original Medicare, such as an annual physical, dental and fitness allowances, vision and hearing benefits, and health and safety items.

There are several types of Medicare Advantage (Part C) plans:

• HMO - Health Maintenance Organization
• HMO-POS - Health Maintenance Organization with a Point of Service Option
• PPO – Preferred Provider Organization
• SNP – Special Needs Plans
• PFFS – Private Fee-for-Service

Medicare Advantage plans:

• Are similar to employer group plans
• Have a set network of providers
• Have a set monthly premium (must continue to pay Part B premium)
• Have copays/cost-sharing when you use services (pay as you go)
• Protect your wallet with yearly out-of-pocket maximums
• May have built-in prescription drug coverage (depending on the plan)
• May offer emergency coverage when traveling worldwide
• Are easy to use 

Original Medicare (Part A and Part B) does not cover everything. It provides basic coverage, but there will be gaps in the coverage. You should expect to be responsible for a portion of your health care costs, including deductibles and coinsurance. This is why many people enroll in additional coverage options that help pay for costs and benefits not covered by Original Medicare. These options include Part C – Medicare Advantage plans and Medigap – Medicare Supplement plans.

Part A - Hospital Insurance

Provided by Federal Government
Coverage: Covers hospital and skilled nursing facility stays, home health care.
Deductible: Yes
Coinsurance: Yes
Premium: Most will not pay a premium

Part B - Medical Insurance

Provided by Federal Government
Coverage: Covers outpatient care, doctor services, physical and occupational therapy, mental health services, preventive care.
Deductible: Yes (Except for preventive services)
Coinsurance: Yes (20% or more of services)
Premium: Yes, monthly, dependent on adjusted gross income

Part C - Medicare Advantage

Provided by private health plans approved by Medicare
Coverage: Combines Part A and Part B and usually Part D. It generally offers extra benefits beyond Original Medicare.
Deductible: Varies by plan. ($0 deductible options may be available)
Coinsurance: Varies by plan
Premium: Yes. $0 premium options may be available.

Part D - Prescription Drug Coverage

Provided by private health plans approved by Medicare
Coverage: Covers prescription drugs.
Deductible: Varies by plan.
Coinsurance: Varies by plan
Premium: Yes, if bought separately; often combined with medicare Advantage Plans.

Medicare Supplement (Medigap)

Provided by private health insurance companies
Coverage: May cover Part A and Part B cost sharing (deductible and coinsurance) for Original Medicare covered services.
Deductible: Varies by plan.
Coinsurance: Varies by plan
Premium: Yes, monthly.

Original Medicare Costs Explained Further

Part A Deductible: If you only have Original Medicare (the red, white and blue card), you will have to pay your Part A deductible if you are admitted to a hospital or skilled nursing facility.

Solution: A Medicare Advantage or Medicare Supplement plan may cover this deductible.

Part B Deductible: If you only have Original Medicare, you will have to pay your Part B deductible when you use your Original Medicare card for outpatient services, such as doctors’ visits, labs, X-rays, etc.

Solution: A Medicare Advantage or Medicare Supplement plan may cover this deductible.

Part B Coinsurance and Copayments: If you only have Original Medicare, you will be responsible for 20% of the Medicare-approved amount of all medical bills after your Part B deductible is met.

Solution: Medicare Supplement plans typically pay for this cost. Medicare Advantage plans carry their own copayments, which can be less expensive than the 20% of the cost of a medical bill (i.e., $15 copay for a doctor visit vs. 20% of the total bill amount).

Premiums: Original Medicare charges a monthly Part B premium, which is calculated based on your adjusted gross income. It is important to know that, if you choose a Medicare Advantage or a Medicare Supplement plan, you must continue to pay your Medicare Part B premium in addition to the premium for the Medicare Advantage or Medicare Supplement plan.

Original Medicare is the federal health insurance program for people who are age 65 or older and for people younger than 65 with certain disabilities. Original Medicare helps to cover the cost of hospital and medical expenses. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). When you sign up for Original Medicare, you receive coverage over your lifetime as long as you pay your monthly premium.

With Original Medicare, you may be responsible for deductibles, coinsurance and copayments, and will have limitations on what is covered. For instance, routine vision, dental, hearing and prescription drugs may not be covered.

Original Medicare only provides basic coverage. There will be gaps in coverage and you will be responsible for a portion of your health care costs. This is why many people enroll in additional coverage (Medicare Advantage or Medicare Supplement), which helps pay for costs and offers benefits not covered by Original Medicare.

To learn more about Medicare, visit medicare.gov.

The Medicare Prescription Payment Plan will be initiated in 2025 to help members that have high prescription drug costs early in the year to spread payments across the full year. Click here to learn more about the program.

You can generally join a Health New England Medicare Advantage plan if:

• You are entitled to Medicare Part A and are enrolled in Medicare Part B
• You live in our service area: Berkshire, Franklin, Hampden and Hampshire counties in Massachusetts
• You can enroll in a Medicare Advantage plan during a valid election period: 
  
  • Initial Coverage Enrollment Period - Timing varies based on when you turn 65
  • Annual Enrollment Period - October 15 – December 7 each year
  • Open Enrollment Period - January 1 – March 31 each year
  • Special Election Period - Timing varies based on circumstances:
    • If you move out of your plan’s service area
    • If you have both Medicare and Medicaid
    • If you qualify for Prescription Advantage or Extra Help to pay for your prescription drug costs
    • If you live in an institution (like a nursing home)
    • If you lose employer group coverage

You can join a Health New England Medicare Supplement plan:

• If you reside anywhere in Massachusetts.
• If you are entitled to Medicare Part A, are enrolled in Medicare Part B, and you continue to pay your Medicare Part B premium.
• You may also be eligible if you are under the age of 65 and have a disability other than end-stage renal disease.

You can enroll anytime during the year, because most Massachusetts Medicare Supplement plans have a continuous open enrollment.