Medicare Basics

Whether you're new to Medicare, or just want to brush up on your Medicare information, we've laid out some key elements for you.

What Is Medicare Advantage (Part C)?

  • As a Medicare recipient, you are eligible for additional health plan choices, such as Medicare Advantage. This type of plan, sometimes referred to as "Part C", combines health insurance with health services. The benefits include all of Part A (hospital insurance) and Part B (medical insurance), and certain plans may also include Part D (prescription drug coverage).

Medicare coverage is broken up into parts and cover specific services.

Medicare Part A (hospital insurance) includes:

  • Hospital and inpatient care
  • Nursing facilities, hospice, and home health care

Medicare Part B (medical insurance) includes:

  •  Doctors' services, hospital outpatient care, and home health care
  • Preventive services

Medicare Part D (prescription drug coverage) includes:

  •  Prescription drug coverage through Medicare-approved insurance companies
  • Discounts on prescription drugs

MEDICARE ADVANTAGE: Each health insurance company must follow the guidelines set by Medicare. However, there are no set rules regarding out-of-pocket costs or how a member receives services (referrals, in-network vs. out-of-network). These rules vary according to health insurance carrier and may change each year.

MEDICARE PPO: With Medicare PPO plans, members can see any provider of their choice and do not need a referral when going to a specialist. This plan type includes the flexibility and freedom to see any doctor a member chooses, however, out-of-network doctors will have higher fees.

MEDICARE HMO: Medicare HMO plans include a list of in-network providers that all members must select from. Each member has a primary care physician who oversees all of their health care, including referrals to all other doctors and specialists. This type of plan is often called managed health care for this reason.

MEDICARE SNP: Medicare Special Needs plans are for individuals with either certain chronic diseases and/or conditions or who are eligible for both Medicare and Medicaid. These plans offer coverage for Medicare Part C (medical care) and Part D (prescription drugs).

Medicare Advantage Is Ideal For People Who Prefer:

  • A less expensive alternative to Medigap.
  • Coordinated care with a network of providers to choose from.
  • Less insurance paperwork.

It is also ideal for individuals with pre-existing conditions for which a waiting period may be a hardship.

Am I Eligible?

Anyone who is entitled to Part A and enrolled in Part B, lives within the plan service area, and does not have end-stage renal disease (ESRD), with limited exceptions, is eligible for enrollment in a Medicare Advantage plan. There are specific times when you can sign up for these plans, or make changes to coverage you already have. In addition to the Initial Enrollment Periods described below, there is also an Annual Enrollment Period (AEP) that begins on October 15 and ends on December 7 in which you can enroll in, or disenroll from, a Medicare Advantage plan.

If you're newly eligible for Medicare because you turn 65, you can enroll in a Medicare Advantage plan during the 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

If you're newly eligible for Medicare because you're disabled (under 65), you can enroll in a Medicare Advantage plan during the 7-month period that starts 3 months before your 25th month of getting Social Security or Railroad Retirement Board (RRB) disability benefits and ends 3 months after your 25th month of getting disability benefits.