Looking For More Information?

Whether you choose Original Medicare or a Medicare Advantage plan, take the time to consider your options.

The resources listed below can help answer questions you may have and provide additional information on eligibility and coverage.

To determine Medicare eligibility and to enroll in Medicare, contact the Social Security Administration at
(800) 772-1213, Monday through Friday, from 7 a.m. to 7 p.m., or visit www.ssa.gov.
TTY users call 1-800-325-0778.

To find out more about Original Medicare, call 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, seven days a week, or visit www.medicare.gov.
TTY users call 1-877-486-2048.

Click here to download a PDF of the government handbook Medicare and You that includes information on costs, coverage, health plans and enrollee rights.

Learn More About
Peoples Health

To learn more about Peoples Health Medicare Advantage plans, click here or call (800) 978-9765 to speak with a plan representative, 8 a.m. to 8 p.m., Monday through Friday. TTY users may call 711.

What is Medicare?

Medicare is a federally funded health insurance program that provides healthcare benefits to individuals age 65 and older, younger people with certain disabilities, and people of any age who have permanent kidney failure or end-stage renal disease (ESRD) and require dialysis or a kidney transplant.

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What are the different parts of Medicare?

Medicare has four parts. Each part covers specific services or benefits.

Part APart A: Hospital insurance covers inpatient hospital services, blood, skilled nursing facility care, home health and hospice care. Most people do not pay a premium for Part A services. For some services (e.g., inpatient hospital stays) they will need to pay a $1,156 deductible (for 2012) before Medicare coverage begins.

Part BPart B: Medical insurance covers doctor, outpatient hospital, home health and preventive services, as well as other services Part A does not cover. You can choose if you want to enroll in Part B. Most people must pay a monthly premium to receive coverage. (This premium may be paid by other individuals or organizations if the Medicare beneficiary qualifies.) The premium amount may change from year to year and is based on annual income.

Part CPart C: Private insurance programs, also known as Medicare Advantage programs, allow individuals to enroll in a private plan that Medicare pays to provide healthcare coverage. To be eligible to enroll in Part C, beneficiaries must be enrolled in parts A and B. Part C is optional.

Part DPart D: Outpatient prescription drug coverage is optional coverage provided by private health insurance plans that contract with Medicare. Part D covers prescription drug costs and can be received by itself through a prescription drug plan (PDP) or through a Medicare Advantage prescription drug plan. Depending on the health plan, there may be a premium associated with Part D prescription drug coverage. Plans can offer a “standard” benefit defined by law (or an equivalent benefit), which has a deductible, coinsurance payments and “the coverage gap” (also called “the doughnut hole”). Plans may also offer enhanced Part D coverage, which means there may be no deductible, drug costs may be lower or it may offer partial coverage in the coverage gap. 2010 healthcare reform changes Part D drug coverage and will eliminate the coverage gap over time.

Please note: Medicare does not pay for custodial long-term care services, preventive dental care, dentures, routine vision care, eyeglasses, routine hearing exams or hearing aids.

Regulatory History of Medicare

19971997 Balanced Budget Act (BBA): Since the 1970s, private insurance plans have had the option to offer insurance coverage to Medicare beneficiaries. Under the BBA, these plans were officially renamed “Medicare + Choice” plans, and Medicare was granted the right to contract with these plans to provide Medicare coverage to beneficiaries on Medicare’s behalf. These plans were renamed “Medicare Advantage” plans in 2003 with the passage of the Medicare Prescription Drug Improvement and Modernization Act.

20032003 Medicare Prescription Drug Improvement and Modernization Act (MMA): Provided a prescription drug benefit (Medicare Part D) and more benefits under Medicare. The MMA also established a late enrollment penalty (LEP) for beneficiaries who do not enroll in Medicare Part D when they are originally eligible. The MMA created a coordinated enrollment process, or enrollment periods, for all plan types. The current annual enrollment period is October 15 through December 7 each year to enroll in a plan for the following year.

20082008 Medicare Improvements for Patients and Providers Act (MIPPA): In 2008, Congress enacted MIPPA. The bill maintained payment rates for physicians providing Medicare services, set higher regulatory standards for Medicare Advantage plans, increased Medicare benefits for low-income beneficiaries and eliminated the LEP for low-income beneficiaries.

20102010 Patient Protection and Affordable Care Act (PPACA): Effective in 2011, PPACA eliminated the open enrollment period (OEP) for Medicare Advantage plans. PPACA also established the Annual Disenrollment Period (ADP), which allows beneficiaries to disenroll from a Medicare Advantage plan and return to Original Medicare within 45 days of their enrollment.

What is the coverage gap?

Most Medicare drug plans have a coverage gap, also called the “doughnut hole.” This means that after beneficiaries and their plans have spent a certain amount of money for covered drugs, the beneficiary may have to pay 100 percent of the costs out-of-pocket for prescription drugs.

Here’s how it works:

During Phase 1 of prescription drug coverage, a standard copay is paid by the beneficiary and the prescription drug plan pays the remainder of the cost of each covered drug until the total combined drug costs reach $2,930*.

During Phase 2, the beneficiary is considered to be in the doughnut hole and must pay higher costs for many or all drugs. The Medicare Coverage Gap Discount Program pays for 50 percent of the cost for most brand-name drugs. The coverage gap does not end until the beneficiary spends a total of $4,700*, including his or her copays from phase 1.

The final phase, Phase 3, begins after the beneficiary’s expenses have exceeded $4,700*. The plan then pays most or all of the costs for covered drugs and the beneficiary pays reduced copays.

The prescription drug cycle starts over again on January 1 of every year.

*These amounts reflect the drug coverage cycle for 2012.

2010 Coverage Gap Reform

Healthcare reform measures will eventually eliminate the coverage gap. On June 10, 2010, Medicare began issuing $250 rebate checks to beneficiaries currently in the coverage gap. In 2011, beneficiaries who entered the gap received a discount (7 percent or more) on generic prescription drugs and a larger discount (50 percent or more) on brand-name drugs. The discounts will continue to increase until the coverage gap is completely closed by 2020.

What is medicare supplemental insurance or a Medigap policy?

Supplemental insurance helps fill in the “gaps” for medical care that may not be covered by Original Medicare. It assists beneficiaries with coinsurance, copays and deductible for services. There is usually an additional premium associated with supplemental insurance.

What is a Medicare Advantage plan?

Medicare Advantage plans are health plans offered by private insurance companies that provide Medicare-covered benefits and often coverage for additional benefits.

Medicare Advantage plans cover all benefits covered by Original Medicare. Medicare Advantage plans are an alternative means for people eligible for Medicare to receive coverage for healthcare services. Medicare Advantage plans are regulated by the Centers for Medicare & Medicaid Services (CMS). While Original Medicare allows beneficiaries to go to any healthcare facility and see any doctor who accepts Medicare, Medicare Advantage plans give their members a specific network of providers and hospitals from which to receive services.

Members of a Medicare Advantage plan still pay their Medicare Part B premium, and they may pay a premium for the Medicare Advantage plan. Not all Medicare Advantage plans have a premium.

Who is eligible to join a Medicare Advantage plan?

To enroll in a Medicare Advantage plan, a person must:

  • Be entitled to Medicare Part A and enrolled in Medicare Part B
  • Live in the plan’s service area
  • Not have end-stage renal disease (ESRD). However, there are certain instances where an individual who has or has had ESRD can still enroll.
How do Original Medicare and Medicare Advantage plans work together?

Medicare Advantage plans work with Original Medicare to provide coverage for healthcare
benefits to beneficiaries. They must follow rules and standards set by Medicare. The federal government pays Medicare Advantage plans to provide all Medicare-covered benefits. If there is a difference between the amount an Medicare Advantage plan is paid by Medicare and their actual cost to provide benefits to beneficiaries, the plan must use any savings to provide additional benefits or reduce beneficiary costsharing. This is how some Medicare Advantage plans provide coverage for benefits such as vision and dental, which are not covered by Original Medicare.

Medicare issues quality ratings for the plans administered by Medicare Advantage organizations. Medicare surveys Medicare Advantage plan beneficiaries to measure the overall quality of plans, including quality of care, beneficiaries’ ability to access care, plan responsiveness and beneficiary satisfaction. Individual Medicare Advantage plans are rated on a scale of one to five stars, with five stars being the highest score. Ratings are posted on Medicare’s website.

What is a Medicare Advantage prescription drug plan?

A Medicare Advantage prescription drug plan is a Medicare Advantage plan that
offers Medicare Part D prescription drug coverage in addition to healthcare coverage.

Medicare Advantage and Medicare Advantage Prescription Drug Plan Models

There are a variety of different Medicare Advantage/Medicare Advantage Prescription Drug plan models, which are listed below:

Health Maintenance Organization
A health maintenance organization (HMO) provides care through a specific network of
physicians, hospitals and healthcare facilities. Members in HMOs generally must use these
specified healthcare providers. Each member in an HMO has a primary care physician who oversees the coordination of the member’s care.

Point of Service Plan
Some HMOs have a point of service (POS) option, which allows plan members to see providers who are not in the plan’s network. Out-of-network services will be at a higher cost to the member. Some services may require prior approval.

Preferred Provider Organization
A preferred provider organization (PPO) is similar to an HMO because it offers a network of physicians, hospitals and healthcare facilities to plan members. Members of PPOs have the option to see providers who are out of network, although out-of-network services may be at a higher cost to the member. Out-of-network services do not require prior approval.

Special Needs Plan
A special needs plan (SNP) addresses the healthcare needs of individuals who meet one or more of the following:

  • Are living in a long-term care facility or skilled nursing facility
  • Have severe or disabling chronic conditions
  • Are dually eligible for both Medicare and Medicaid

Employer Group Waiver Plan
An employer group waiver plan (EGWP) is an employee (or retiree) benefit plan established or maintained by an employer, an employee organization (such as a union) or a church group that provides medical care to employees and their dependents directly.

A private-fee-for-service (PFFS) plan is administered by an independent insurance agency. A PFFS plan differs from the other plans listed above because it allows plan members to go to any healthcare provider or hospital anywhere in the United States that agrees to accept the terms of the PFFS payment agreement. The member does not need a referral from the primary care physician to see a specialist. However, the member must make sure a provider accepts the plan's payment terms prior to receiving any treatment.

Can I enroll in a Medicare Advantage plan if I have ESRD?

ESRD is a chronic condition resulting from temporary or permanent damage to the kidneys. This damage results in loss of function to the kidneys that can eventually lead to renal failure.

People with ESRD are eligible for Original Medicare.

Under federal law, a Medicare Advantage plan cannot accept anyone who has ESRD unless the individual:

  • Can submit documentation that he or she is the recipient of a successful kidney
    transplant and no longer requires dialysis
  • Began dialysis treatment for ESRD but recovered natural kidney function
    and no longer requires a regular course of dialysis to live
  • Developed ESRD while a member of a health plan offered by a Medicare Advantage
  • Developed ESRD after he or she signed the enrollment form but before the
    effective date of coverage
  • Is currently a member of a commercial health plan offered by the Medicare Advantage
    organization and wants to switch to another Medicare Advantage plan

An individual with ESRD who was a member of a health plan that was terminated or not
renewed for the individual’s service area can make one election to enroll in a new Medicare Advantage plan. An individual who develops ESRD while enrolled in a Medicare Advantage plan may continue to be enrolled in that plan.

What makes Medicare Advantage plans different from Original Medicare?

Medicare Advantage plans are simply another way to receive Medicare healthcare benefits. Many Medicare Advantage plans have no additional premium beyond the Medicare Part B premium, and often they provide additional benefits, such as:

  • Prescription drug coverage
  • Fixed low copays for doctor visits and hospital stays
  • Specialist doctor visits without referrals
  • Coverage for preventive dental and routine vision services
  • Coverage for health club memberships, health and wellness seminars, workshops and screenings

Additionally, some Medicare Advantage prescription drug plans offer coverage for drugs not normally covered by Medicare Part D, as well as the option to have 90-day supplies of prescription drugs delivered to the beneficiary’s home.