Medicare is a federal health insurance program for people who are 65 and over, for some younger people with disabilities, and for people with end-stage kidney disease.
You may have a choice of how you get your health care in Medicare. You can always choose the Original Medicare Plan, open to everyone with Medicare. Or, you may be able to choose a Medicare Advantage Plan. Medicare Advantage Plans are health plans offered by private insurance companies that provide you your Medicare benefits. You can also choose a Medicare Drug Plan to help reduce the costs of your prescription medications.
The Medicare plans include:
- The Original Medicare Plan, sometimes called the “traditional” plan
- Medicare Advantage Plans, such as:
- Medicare Health Maintenance Organizations (HMOs)
- Medicare Preferred Provider Organizations (PPOs)
- Medicare Private-Fee-for-Service (PFFS) Plans
- Medicare Prescription Drug Plans
Remember:
- You can always choose the Original Medicare Plan.
- No matter which Medicare plan you choose, you will still be in the Medicare program.
- All Medicare plans must provide at least the same benefits offered by the Original Medicare Plan.
- You can change your health plan at any time for any reason, as long as the plan is accepting new members.
- If you are now in the Original Medicare Plan and you’re happy with what you have, you don’t need to change.
The Original Medicare Plan
The Original Medicare Plan is a fee-for-service health plan. This means that your doctor, hospital or other health care provider gets paid for each service you receive. Under this plan, you can go to almost any doctor or hospital in the country that accepts Medicare.
In the Original Medicare Plan, Medicare pays its share of the doctor or hospital bill, and you pay your share. The Original Medicare Plan pays for many heath care services and supplies, but it doesn’t pay all of your health care costs. For this reason many people with Original Medicare also purchase a Medigap policy and enroll in a Medicare prescription drug plan.
Medicare Advantage Plans
There are three main types of Medicare Advantage Plans: HMOs, PPOs, and PFFSs. They are offered by private insurance companies. These plans provide all of the benefits of Original Medicare and generally provide additional benefits and lower copayments. However, there may be a limit on where you can get your care, which doctors you can see, and how often you can see them.
Medicare HMOs and PPOs
These plans pay for the same health care as the Original Medicare Plan. Some plans also offer other benefits that the Original Medicare Plan doesn’t cover. These benefits can include prescription drug coverage, check-ups, vision care, and hearing aids. However, be aware that these plans can change their benefits from year to year.
In a Medicare HMO, you can only go to doctors, specialists, and hospitals in the plan’s network. You usually need to choose one doctor, such as a family doctor or internist, to be your main or primary care doctor. Your primary care doctor will coordinate all of your health care and send you to a specialist when you need one (such as a cardiologist for a heart problem). Your primary doctor can also admit you to the hospital.
Some Medicare HMOs offer a Point of Service (POS) option. This allows you to go to other doctors and hospitals that are not part of the plan’s network, but you may pay more. This option has some similar features to a Medicare PPO.
A Medicare PPO also has a network of doctors, specialists and hospitals. However, in a PPO, you can go to doctors, specialists and hospitals outside the plan’s network, but you will pay more for your care.
Since prescription drug coverage is usually included in HMOs and PPOs, you may not need to select a separate Medicare prescription drug plan.
Medicare Private Fee-for-Service (PFFS) Plans
You can choose any doctor or hospital that accepts the plan’s payment. The insurance company pays its share of your doctor and hospital bills, and you pay your share. However, the private insurance company, not Medicare, decides how much you pay for your care. This means you might pay more for your health care than if you were in the Original Medicare Plan. Under the PFFS Plan, you may get extra benefits.
Some PFFS Plans include prescription drug coverage and some do not. Unless your prescription drugs are covered through the PFFS Plan or elsewhere, you may need to select a Medicare prescription drug plan.
Medicare Prescription Drug Plans
Everyone needs to make a decision about prescription drug coverage. If you have Original Medicare, you may need to select a Medicare prescription drug plan. You may not need to purchase a drug plan if you have a Medicare Advantage Plan. Drug coverage is generally included in Medicare HMO and PPO Plans.
Be aware that drug plans vary considerably in coverage and costs. Compare plans carefully to find the best plan for your individual health needs.
You may not need to purchase additional coverage if your prescription drug purchases are covered elsewhere (for example, Medicaid, employer, union).
Where Medicare Plans are Available
- The Original Medicare Plan is available everywhere in the country and to everyone who signs up for Medicare.
- Medicare Advantage Plans are available in some parts of the country and not in others. Some areas have more than one Medicare Advantage Plan, other areas don’t have any.
- Medicare Prescription Drug Plans are available everywhere in the country, however plans may vary by region.
Signing Up for a Medicare Plan
The Original Medicare Plan:
If you are getting Social Security or Railroad Retirement benefits, you automatically get the Original Medicare Plan (Parts A and B) when you turn 65. You’ll receive a packet of information on Medicare, including your Medicare card. If you want to join a Medicare Advantage Plan, you need to follow the instructions in your packet.
If you are not getting Social Security or Railroad Retirement benefits, you need to sign up for Medicare yourself by calling or visiting your local Social Security office. In this case, you tell Medicare which Medicare plan you want.
Medicare Advantage Plans:
If you want to join a Medicare Advantage Plan (HMO, PPO or PFFS), you must have both Medicare Part A and B and live in the service area of the plan you want to join. People with End-Stage-Renal Disease are not eligible to enroll in a Medicare Advantage Plan.
Medicare Prescription Drug Plans:
If you want to join a Medicare drug plan, you can contact the individual company directly and ask for an enrollment package. You can also call Medicare at 1-800-633-4227 or visit Medicare.gov to get information about signing up for a plan.
Changing Plans
Generally, you can choose to switch your current plan to a new plan from November 15 to December 31 of each year. Enrollment is generally for the calendar year. In certain cases, such as if you move or enter a nursing home, you can switch plans at other times.
If you decide to switch plans you can:
- Write or call your plan,
- Call Medicare at 1-800-633-4227, or
- Contact the Social Security Administration
After you request to switch, your plan will let you know, in writing, the date your coverage begins. If you don’t get a letter, call the plan and ask for the date.
Before Switching Plans
If you have other health care coverage, such as Medicaid or retiree health insurance from an employer or a union, find out how these plans work with each Medicare plan. You will also want to find out all the facts about your coverage before dropping your extra insurance or switching between the different types of Medicare plans. If you drop your additional insurance when you change plans, you may not be able to get the same Medigap policy or your retiree health insurance back if you later want to return to Original Medicare.
AARP Resources
AARP on Medicare
A series of articles from AARP to help you better understand your Medicare options.
Medicare Prescription Drug Coverage
This series of articles will help you sort through your drug coverage choices.
Additional Resources
Medicare Personal Plan Finder
Information on costs, benefits, doctor choice and quality of the Medicare plans in your area.
Medicare Prescription Drug Plan Finder
Learn about the program and find and compare prescription drug plans that meet your personal needs.
State Health Insurance Assistance Program (SHIP)
SHIP is an important Medicare partner that offers free one-on-one health insurance counseling to people with Medicare. Search using the “Organization” search engine.
