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I am eligible for Medicare. What are my options?

Original Medicare

Here are the basics you’ll need to know to get started:

  • Government funded program
  • Includes Part A and Part B coverage
    • Medicare Part A is also known as “hospital insurance.” Part A usually includes coverage for inpatient hospital stays, home healthcare and skilled nursing facility services
    • Medicare Part B is also known as “medical insurance.” Part B includes coverage for medical services such as doctors’ visits, lab services, outpatient hospital services and other medically necessary services
  • May require premiums (for Part B) and may have deductibles and coinsurance requirements for doctor’s appointments and hospital stays
  • You will not need a referral from a primary care physician (PCP to see a specialist.
  • Does not include coverage for prescription drugs. However, you can enroll in a separate stand-alone Part D Prescription Drug Plan through a private insurer
  • You can purchase a Medicare Supplement insurance plan through a private insurer to help cover your out-of-pocket costs

Medicare Advantage

Learn about additional options. Here are the basics:

  • Plans sold by private insurance companies
  • Also known as Part C
  • Must offer at least the same benefits as Original Medicare
  • Plans usually include additional benefits such as prescription drug coverage, dental, vision, hearing coverage, fitness and wellness programs
  • Three common types of Medicare Advantage plans: HMO, PPO and PFFS
  • Plans use a combination of deductibles and copays to pay for healthcare services, so you have more predictable costs that are easier to budget
  • Many include prescription drug coverage AND health coverage together all in one plan
  • No supplement (“Medigap”) coverage is needed
  • Plans include worldwide coverage for emergency care

PPO

PPO (Preferred Provider Organization) is one type of Medicare Advantage plan. Here are the basics:

  • Type of Medicare Advantage plan that includes all the benefits of Original Medicare and is offered by a private insurance company
  • PPO plans usually include prescription drug coverage and other extras
  • Includes a network of physicians, hospitals, and specialists that have agreed to offer services at a reduced fee
  • No referral from a primary care physician is required to see a specialist
  • Allows the freedom to choose any doctor or hospital that accepts Medicare, but you generally pay less out-of-pocket for services received from in-network providers
  • Provides coverage for annual screenings at no charge
  • Emergency coverage when you travel outside the United States

HMO

HMO (Health Maintenance Organization) is another type of Medicare Advantage Plan. Here are the basics:

  • Type of Medicare Advantage plan that includes all the benefits of Original Medicare and is offered by a private insurance company
  • HMO plans usually have out-of-pocket costs that are lower and more predictable than with other types of plans
  • HMO plans usually include prescription drug coverage and other extras
  • There is a network of physicians, hospitals, labs and other healthcare facilities offering services at a reduced fee
  • You must choose a primary care physician (PCP) in the plan’s network to help coordinate your care. In most HMO plans, this doctor must provide a referral for you to see an in-network specialist
  • No coverage for providers outside of the HMO network of physicians, hospitals, and specialists -- meaning you’re charged the full fee if you choose to visit an out-of-network provider (with the exception of medical emergencies)
  • Emergency coverage when you travel outside the United States

PFFS

PFFS (Private Fee-for-Service) is an additional Medicare Advantage plan option. Here are the basics:

  • Type of Medicare Advantage plan includes all the benefits of Original Medicare and is offered by a private insurance company
  • PFFS plans usually include prescription drug coverage and other extras
  • You have the freedom to visit any provider who is able to receive payment from Medicare and agrees to the terms and conditions of the PFFS plan. However, providers have the right to decide if they will or will not accept the terms and conditions of your plan each time you visit
  • Many PFFS plans now have a network of providers that have agreed to see that plan’s members for the duration of their contract.
  • If your plan doesn’t have a contracted network of providers, you may have to pay more to visit doctors outside of the plan’s network.
  • Emergency coverage when you travel outside the United States

“Your Guide to Medicare Private Fee-for-Service Plans,” Centers for Medicare and Medicaid Services, (accessed 18 Mar. 2013)
“What People on Medicare need to know about Private Fee-for-Service plans” Humana-Medicare.com, (accessed 18 Mar. 2013)

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