A Medicare supplement plan (also known as a Gap plan) is to cover some of the out-of-pocket costs not paid by Medicare Parts A and B, like deductibles, copays and coinsurance. Each of the standardized plans provides benefits for different out-of-pocket costs.
Medicare Supplement, Part D and Medicare Advantage
This is the perfect time to gain a little bit more information about Medicare because at this point you have some choices to consider!
Which types of plans will you be a candidate for?
- Choosing to remain on Original Medicare and adding a Medicare Supplement plan + Prescription Drug coverage
- Choosing to go to a Medicare Advantage plan
- Choosing to add only Part D to Original Medicare
Please read through the information provided in this portion of The Self Guided Tour to determine what might be the best fit for you and your health care. If you are not sure what would be appropriate for your health care, the next step will put you in touch with an Essential Solutions Representative who will be able to work with you and assist in this matter.
Medicare Supplement Information
Medicare supplement insurance (Medigap) helps pay some of the out-of-pocket health care costs that Original Medicare (Parts A and B) doesn’t pay. It isn’t a government benefit, like Parts A and B. Plans are offered through private insurance companies. It’s your decision whether to buy a plan or not.
What Does Medicare Supplement Insurance Cover?
Each standardized plan with the same letter must offer the same basic benefits, no matter which insurance company sells it. For example the basic benefits of one company’s Plan F are the same as the basic benefits of another company’s Plan F. The only difference between Medicare supplement plans with the same letter sold by different insurance companies is the premium.
What Does Medicare Supplement Insurance Cost?
This shows costs you may have with a Medicare supplement insurance plan. You need to look at individual plans to understand their specific costs.
Premium
Plan premiums can vary from company to company, even for exactly the same coverage. You continue to pay the Part B premium to Medicare as well.
Deductible
You may pay Part A and Part B deductibles with some Medicare supplement plans. The high-deductible Plan F has an annual plan deductible.
Co-payment
You may pay a set co-payment for covered Part B services with some Medicare supplement plans. Co-insurance You may pay part of the co-insurance amount for covered Part B services with some Medicare supplement plans.
How Medicare Supplement Insurance Works
Each standardized Medicare supplement insurance plan covers different types of out-of-pocket costs. So what you pay in out-of-pocket costs will depend on what services you use and which plan you have.
Depending on which Medicare supplement insurance plan the person has some or all of their out-of-pocket costs could be covered. In general, plans that cover more costs have higher premiums.
Enrolling in a Medicare Supplement Insurance Plan
You have a specific enrollment period for Medicare supplement insurance called Medicare Supplement Open Enrollment Period. This period:
- Begins the first month that you are age 65 or older and enrolled in Medicare Part B
- Lasts for 6 months
- Guarantees your right to buy a plan (You cannot be denied coverage if you apply during this period.)
Even if you miss your open enrollment period, you may apply for Medicare supplement insurance at any time. You could be denied coverage, or charged a higher premium based on your health history. Some states have additional Medicare supplement open enrollment periods, including for beneficiaries under age 65.
Medicare Advantage Information
Medicare Advantage (Part C) combines Part A & Part B coverage into one plan. Many come with built-in prescription drug coverage. Select plans that don't have drug coverage allow you to add a standalone Part D plan.
When you choose a Medicare Advantage there are things that you should know first:
1. Medicare Advantage plans are required to include the same benefits that you get from Original Medicare and often provide more benefits beyond.
2. Medicare Advantage plans can provide additional benefits like dental and vision, fitness memberships, transportation to doctor's appointments, and more. Review your plan's Summary of Benefits and Evidence of Coverage to know all of the benefits available to you in your Medicare Advantage plan.
3. There is a difference between Medicare Advantage Prescription Drug plans (MAPD) and Medicare Advantage (MA) only plans. MAPD offers a prescription drug plan attached and the MA does not! MA plans typically exist for veterans who receive prescriptions from the VA hospital.
4. It is not typical at all, however if a Medicare Advantage plan receives 5 stars, it can be enrolled into throughout the year! If you have a 5-star rated plan available in your zip code and want to enroll into it, call us to help you through enrollment.
5. Medicare Advantage plans can change from year to year, so it's very important that you review the updated Summary of Benefits and Evidence of Coverage, to be aware of how these changes will affect you.
6. There are two other types of Medicare Advantage plans. Chronic Special Needs Plan (CSNP): a Medicare Advantage plan for people with chronically disabling conditions of the heart, of the lungs (only some states) and or have diabetes. The other type is called Dual Special Needs Plan (DSNP): a Medicare Advantage plan for people who are dually eligible for Medicare and Medicaid. If you believe you may qualify for a CSNP or DSNP plan, reach out and discuss with your local Essential Solutions advisor as you may have a Special Enrollment Period to work with!
Medicare Part D
Medicare Part D is prescription drug coverage. It helps pay for the medications your doctor prescribes. Original Medicare (Parts A and B) does not cover prescription drugs. Many people who choose Original Medicare add a prescription drug (Part D) plan or choose a Medicare Advantage plan that includes Part D.
In general, you may enroll in a Part D plan if you are entitled to Medicare Part A or if you are enrolled in Medicare Part B. In addition, you must live in the service area of a Part D plan.
What Does Medicare Part D Cover?
Medicare Part D Plans are required to cover certain common types of drugs, but each plan may choose which specific drugs it covers. The drugs you take may not be covered by every Part D plan. You need to review each plan’s drug list, or formulary, to see if your drugs are covered.
Medicare Part D covers certain prescription drugs
- The federal government sets guidelines for the types of drugs Part D plans must cover.
- Each Part D plan decides which specific drugs it will cover and what premium members will pay.
- When comparing Part D coverage, check each plan's formulary (drug list) to make sure your drugs are included.
Prescription drug plans do not cover:
- Drugs that are not on the plan’s drug list
- Drugs that are covered under Part A or Part B
- Drugs that are excluded by Medicare
Medicare Prescription Drug Plans (Part D)
You don’t get prescription drug coverage with Medicare Parts A & B alone. Learn about Part D prescription drug plans and when you should enroll to avoid Medicare’s late enrollment penalty.
What Does Medicare Part D Cost?
The insurance companies that offer Medicare Part D drug plans and Medicare Advantage (Part C) plans with drug coverage set their own prices, but the types of costs they include are similar. The table below shows the types of costs that plans may apply. Part D plan premiums and cost sharing can vary widely, even for similar coverage. You need to review plan details carefully.
Premium
Per month (Plan premiums vary. You still pay the Part B premium to Medicare and the Part A premium, if you have one).
Deductible
Per year (Some plans charge an annual deductible, and some don’t).
Co-Payment
Most new prescriptions and refills (Some plans charge co-pay each time you fill a prescription).
Co-insurance
Some new prescriptions and refills (Some plans charge a percentage of the cost when you fill a prescription).
How Medicare Part D Cost Sharing Works
Medicare Part D has different stages of cost sharing until you reach a set limit on out-of-pocket costs for the year. The limit is $5,100 in 2019. After that, your plan pays most of the cost of your drugs for the rest of the year.
Co-pays, co-insurance amounts and your plan deductible, if any, count as out-of-pocket costs. Premium payments do not.
Part D cost-sharing stages are explained below. The costs shown are for 2019. You may not go through every stage in any given year. If you get (Extra Help) from Medicare for Part D costs, the coverage gap stage doesn’t apply to you.
We do not offer every plan available in your area. Currently, we represent 10 organizations that offer 115 products in your area.
Please contact Medicare.gov, 1–800–MEDICARE, or your local State Health Insurance Program to get information on all of your options.