Medicare Plans

  • A Medicare Advantage Plan is another option for getting Medicare Part A and Part B coverage.
  • Medicare Advantage Plans, also known as “Part C” or “MA Plans,” are provided by Medicare-approved private companies that must adhere to Medicare’s rules.
  • The majority of Medicare Advantage plans include prescription drug coverage (Part D).
  • In most cases, you will need to use health care providers who are part of the plan’s network. These plans limit your out-of-pocket expenses for covered services each year.
  • Several plans provide non-emergency coverage outside of the network, but at a higher cost. In many cases, your plan may require approval before covering certain drugs or services.
Medical Plans
  • Keep in mind that you must use your Medicare Advantage Plan’s card to obtain Medicare-covered services. Keep your Medicare card in a safe place in case you need it later.
  • You will still have Medicare if you join a Medicare Advantage Plan, but you will obtain most of your Part A and Part B coverage from your Medicare Advantage plan, not Original Medicare.
  • page 62

Types of Medicare Advantage Plans:

Health Maintenance Organization (HMO) Plans

A health insurance plan in which you can only visit doctors and hospitals that have agreements with this plan. In case of an emergency, you can go to any healthcare facility, even if it does not accept HMO plans. In most cases, you have to get a referral to see a specialist, but certain services, like yearly screening mammograms, do not require a referral.

HMO Point-of-Service (HMO-POS) Plans

These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.

Proffered Provider Organization (PPO) Plans

The Medicare Advantage Plan that allows you to pay less if you use hospitals or doctors that belong to the network in that regional area. If you use doctors and hospitals outside of the network, you will be charged an additional fee.

Private Fee-for-Service (PFFS) Plans

The Medicare Advantage Plan that allows you to visit any Medicare-approved doctor or hospital that agrees and accepts to treat you under the terms of the plan’s payment.

This is a fee-for-service plan that decides how much you must pay for services.

Special Needs Plans (SNPs) Plans

Medicare Special Needs Plans are a type of Medicare Advantage Plan for people who have both Medicare and Medicaid. Some Special Needs Plans are for people with chronic diseases and conditions, while others are for people who live in institutions such as nursing homes.

All SNPs must provide Medicare drug coverage (Part D).

Medicare Drug Coverage (Part D)

Part D is a separate Medicare drug plan that you can enroll in. You cannot join a separate Medicare drug plan if you are enrolled in a Health Maintenance Organization or Preferred Provider Organization Plan that does not cover drugs.

Coverage Gap

Medicare drug plans may have a “coverage gap,” also known as the “donut hole.”

This means that once you and your drug plan have spent a certain amount of money on covered drugs, you may have to pay more (until you reach the out-of-pocket threshold).

Catastrophic Coverage

You will pay a small coinsurance amount or a co-payment for the rest of the year for covered drugs. When you reach the Out of Pocket Threshold, you automatically receive this coverage (your spending on prescription drugs reaches a certain amount).

Brand – name Drugs

A brand-name drug is a medication researched and developed by a pharmaceutical company and then patented to protect it against other companies making copies and selling the drug.

Generic Drugs

According to the Food and Drug Administration (FDA) generic drug is a prescription drug with the same active ingredients as a brand drug with less cost.

Medicare Supplement Insurance (Medigap)

Medicare Supplement Insurance is sold by private companies that can help pay some of the health care costs like copayments, coinsurance, and deductibles that Original Medicare doesn’t cover.

What do Medicare Supplement Plans cover?

Besides covering healthcare costs like copayments, coinsurance, and deductibles that are not covered by Original Medicare, some Medicare Supplement Plans (MS) also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S.

If you have Original Medicare and you get a Medicare Supplement Plan (Medigap), Medicare will pay its share of the Medicare-approved amount for covered health care costs, after that your MS (Medigap) plan pays its share.

Important Things to Know about Medicare Supplement Plans (Medigap):

  • You must have Medicare Part A and Medicare Part B to be eligible to enroll.
  • A monthly premium paid to the private insurance company for the Medicare Supplement Plan (Medigap) is separate from the monthly Part B premium that you pay to Medicare.
  • If you have a Medicare Advantage Plan, you can apply for a Medicare Supplement Plan (Medigap), but make sure you can leave the Medicare Advantage Plan before your Medigap begins.
  • A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.
  • You can buy a Medigap policy from any insurance company that’s licensed in your state to sell one.
  • Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
  • Some Medigap policies sold in the past covered prescription drugs, but Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D).
  • It’s illegal for anyone to sell you a Medigap policy if you have a Medicare Medical Savings Account (MSA) Plan.

Extra Help

This qualifies you for the full low-income Medicare prescription drug subsidy.

Elderly Pharmaceutical Insurance (EPIC) Program

The Elderly Pharmaceutical Insurance Coverage (EPIC) program is a New York State program for seniors administered by the Department of Health. It helps more than 320,000 income-eligible seniors aged 65 and older to supplement their out-of-pocket Medicare Part D drug plan costs. Seniors can apply for EPIC at any time of year, but they must be enrolled or eligible to be enrolled in a Medicare Part D drug plan to receive EPIC benefits and maintain coverage.

Important Things to Know about Medicare Supplement Plans (EPIC):

  • EPIC provides secondary coverage for Medicare Part D and EPIC-covered drugs purchased after any Medicare Part D deductible is met. EPIC also covers approved Part D-excluded drugs once a member is enrolled in Part D.
  • EPIC helps pay the Medicare Part D drug plan premiums for members with income up to $23,000 if single or $29,000 if married. Higher income members are required to pay their own Part D premiums, but EPIC provides premium assistance by lowering their EPIC deductible.
  • EPIC has two plans based on income. The Fee Plan is for members with an income of up to $20,000 if single or $26,000 if married. The Deductible Plan is for members with incomes ranging from $20,001 to $75,000 if single, or $26,001 to $100,000 if married.
  • It is easy to join the program. Just complete the application and mail or fax it to EPIC. No documentation is required. EPIC verifies information with the Social Security Administration and the New York State Department of Taxation and Finance.
Elderly Pharmaceutical Insurance (EPIC) Program

TPMO disclaimer

“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact or 1-800-MEDICARE to get information on all of your options.”