A vast majority of Americans who have worked, or have been married at least ten years to a spouse who has worked, and paid into the social security system for at least ten years (40 quarters of work), are eligible for Medicare at age 65.  Individuals who have been entitled to Social Security disability benefits for at least 24 months as well as individuals with certain diagnosis are entitled to Medicare the first month of diagnosis.  Others, with special circumstances, such as being on kidney dialysis or a kidney transplant patient, become eligible for Medicare based on individual circumstances.

MEDICARE ELIGIBILITY IS NOT DEPENDENT ON FULL RETIREMENT AGE!  YOUR FULL RETIREMENT AGE MAY BE AT AGE 67 BUT YOUR MEDICARE ELIGIBILITY IS NOT AFFECTED BY FULL RETIREMENT AGE!

Initial sign-up for beneficiaries receiving retirement or disability benefits: If an individual has been receiving retirement or disability benefits for at least 4 months before your 65th birthday, you will automatically be enrolled into Medicare.  In a majority of these situations an eligible person will want to keep both Part A and Part B coverage.  Certain situations, such as having group coverage through an employer with 20 or more employees, could allow a beneficiary to delay Part B coverage.  Since Medicare Part B has a monthly premium many beneficiaries chose to delay Part B coverage if they are covered by a group health plan that has 20 or more participants. See the Medicare Costs section on this page to learn more about Medicare and associated premiums.  

Initial sign-up for beneficiaries not receiving benefits:  For a Medicare eligible beneficiary who is not receiving retirement benefits, there are several considerations when determining when to enroll and whether both Part A and Part B are needed. Signing up for Medicare when continuing group or union coverage (20 or more participants) that is as good as Medicare provides, would typically allow a beneficiary to sign up for Part A only.  An answers2medicare.com agent can be reached at 877-877-5085 or by clicking HERE to walk you through the details if this may impact you.

Another consideration is whether or not any contributions are being made to a Health Savings Account.  A Medicare beneficiary can no longer contribute pretax dollars to an HSA.  If a beneficiary delays their Part A enrollment and contributes to an HSA they will want to stop contributing 6 months before they plan on enrolling in Part A coverage so they do not incur a tax penalty.  This is because Part A coverage is retroactive up to six months before the enrollment month.

The initial sign-up period for Medicare begins 3 months before a Medicare eligible benefciary's 65th birthday and extends 3 months beyond their birthday month. If a beneficiary signs up in the months leading up to their birthday month coverage will start the month of their birthday.  (Unless you were born on the 1st!  In this case coverage starts a month early!)  Signing up on your birthday month or the three months following, coverage would start the month after signup. 

Signing up may be done online, over the phone or in person.  To schedule a phone or in-person appointment you can call 1-800-772-1213.  To sign up online, you need to have or create a "My Social Security" account.  To do this go to SSA.gov and select "sign in" on the menu bar.  Answers2medicare.com agents are trained to assist with online account setup and navigation.

Part B sign-up: If a beneficiary delays Part B coverage, there is a Medicare Part B Special Enrollment Period they may be able to use to enroll in Part B without penalty with coverage beginning as soon as the first of the month, the month after enrollment.  If you delayed Part B coverage due to group coverage you will want to provide proof of group coverage using CMS Form L564 along with your Part B enrollment.  You will not be penalized as long as you sign up for Part B within 8 months of losing group coverage.  Sign-up for Part B is typically done online or by submitting CMS Form 40B to Social Security by mail or fax.  Online enrollment applicants can submit their CMS L564 by uploading it online at SSA.gov.  Delayed Part B enrollment using this SEP can chose to have their Part B coverage start on the first of the month of the enrollment or on the first of the month up to 3 months after the enrollment month.

The GEP (General Enrollment Period) is for a Medicare beneficiary that has delayed Part B coverage and does not qualify for a Special Enrollment Period.  This period starts January 1st and ends March 31st with coverage begining the 1st of the month after you apply.  When a beneficiary utilizes the GEP they typically also incur a late enrollment period.

Medicare Advantage (Part C) Eligibility:  If you wish to get your Medicare benefits through a private insurer you must first be enrolled in both Medicare Part A and Part B and live in the plans service area.  Certain plans, such as those that cover individuals with low income or with certain chronic conditions, have additional eligibility requirements.

Prescription Drug Coverage (PDP) Eligibility:  "Stand alone" prescription coverage is typically purchased when a beneficiary gets their coverage through "Original Medicare."  To be eligible for prescription coverage through a Medicare Part D plan, a beneficiary must be enrolled in Medicare Part A and/or Part B and live in the plan's service area!

Medicare Advantage and Prescription Enrollment:  

INITIAL ENROLLMENT PERIOD:  3 months before a beneficiaries 65th birthday month, the month of and the 3 months after.  

ANNUAL ENROLLMENT PERIOD:  October 15th through December 7th of each year.  Medicare beneficiaries are able to change their Part C (Medicare Advantage) and Part D (Prescription) plans for the next calendar year

OPEN ENROLLMENT PERIOIOD:  January 15th through March 31st of each year.  Beneficiaries may switch between Advantage Plans or return to Original Medicare and enroll in a Precription (Part D) plan.

SPECIAL ENROLLMENT PERIOD:  A beneficiary has a window of opportunity, typically two months from the date of the qualifying event, to make a change in coverage.  Qualifying events may be, moving out of a plans service area, losing employer coverage, loss or gain of Medicaid or being part of a state pharmaceutical assistance program.  For a full list of SEP options, CLICK HERE!

MEDIGAP OPEN ENROLLMENT PERIOD:  6 month, one time, period beginning with the beneficiary's Part B effective date.  During this time a beneficiary may purchase a Medigap plan without the requirement to meet underwriting health requirements.  There are other limited "Guaranteed Issue" opportunities, some of which are state specific, that allow for the purchase of a Medigap policy without underwriting as well.

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Medicare can be confusing and understanding How Medicare Advantage plans fit into the Medicare puzzle can be difficult.  The state and even the county you live in can make a big difference in what plan you choose or even if an advantage plan is a good fit for your needs!

Background:  Before Medicare Advnatage legislation, Medicare beneficiaries were only able to purchase a Medigap plan to cover any expenses not covered by Medicare.  Becuse of the expense of this type of plan, many beneficiaries opted to not purchase a Medigap policy. In times of illness or as health declined, medical bills would often become unaffordable and with health isssues, a Medigap plan was not available because of health issues.  This often lead to a financial nightmare.  Medicare Advantage provided an answer to this problem by providing a lower cost alternative to Original Medicare but requiring that enrollment be limited to "enrollment periods."  (See the above section for more detail)

Since a Medicare Advantage Plan is an alternative to Original Medicare, it is important to note that while you have to keep paying your Part B premium, your coverage will be provided through a private insurer.  Now Medicare requires that the plan providers covers the same services as Original Medicare, however, each plan has its own summary of benefits.  

Medicare Advanatage Components:  Medicare Advantage Plans require consideration of 7 different key components:  Premium, Deductibles, Maximum Out-of-Pocket, Cost sharing (Co-pays and Co-insurances), extra benefits.  In addition to costs and benefits,  Medicare Advantage plans use a network of providers so provider networks and plan structures such as HMO's and PPO"s must also be considered.  See our section on "Enrollment and Eligibility" to learn more about Medicare advantage enrollment periods!

EXPLANATION OF BENEFITS:  This document describes the plan benefits and includes information of premiums, deductibles, max out of pocket costs, cost sharing and other plan benefits as well as infomation regarding whether you are required to chose a PCP (Primary Care Provider), get refferals to to see specialists, as well as what services may require prior authoirzation.

PREMIUM:  Medicare Advantage or "Part C" plans gerneally have lower premiums than the "Medigap" plans that are usually purchased when a beneficary stays on Original Medicare.  This is because you are agreeing to receive your care through the plan network and agree to pay the deductibles, copays and co-insurance as specified in the plan's explanation of beneifts.  Plan premiums may even be $0 but this does not mean they are "free" because Medicare pays a fixed monthly sum to the insurance carrier to provide for your care.  It is very important to note that Part C benefits typically change every year so it is very important to review plan information to see what changes will be in effect January 1 of the next year.  These changes are communicated through the plans ANOC, Annual Notice of Change.

DEDUCTIBLES:  Similiar to group and individual plan, some Medicare Advantage plans include a deductible that must be met before the plan coverage begins.  Many times basic services such as primary care visits and specialists may be exempted from the deductible.  Some advantage plans have a seperate drug deductible that should be considered though typically drug deductibles only apply to drugs that have a higher tier classification such as brand name or specialty drugs. 

MAX OUT OF POCKET: Medicare Advantage plans are required to have an "Out of Pocket Maximum" to protect against "run away" copay or co-insirance costs.  Each year Medicare sets the maximum in network and out of network cost-sharing that would be required from a plan for covered services.  AFter the Maximum out of pocket is met, the plan pays 100% of the charges for covered services.

COST SHARING:  Copays and co-insurance are considered cost sharing that a plan requires of the benefciary for covered services.  Copays are a set amount that the plan requires for a covered service where as co-insurance typically refers to a percentage of the total cost that the beneficary would be required to pay.    THe most significant copays and co-insurance costs are usually found with such services as "out-patient" procedures, hospital stays, advanced imaging, ambulance and Part-B medication.  Since PPO plans allow for beneficiaries to use out-of-network providers, care should be taken to consider the "out-of-network" cost sharing which can differ significantly from in-network cost sharing.  Out-of-network cost sharing can be significant, so just because a PPO plan allows for use of non-network providers, it may still be cost prohibitive. 

PRESCRIPTION COVERAGE:  Most Medicare Advantage or Part C plans are knows as MAPD (Medicare Advantage Prescription Drug) plans.  Some plans do not include prescription coverage.  It is important to note, if a benefciary selects a Part C plan that does not include coverage, they are not allowed to then purchase a stand alone prescription drug (Part D) plan and could incur a late enrollment penalty if they go more than 63 days without creditable drug coverage.

EXTRA BENEFITS:  Many Part C plans include extra benefits such as denatl vision and hearing coverage as well as gym memberships, allowances for over-the-counter purchses and healthy food allownaces.

NETWORK: Medicare Advantage plans utilize a network of doctors and hospitals.  HMO's (Health Management Organizations) are a type of network that typically require you to receive care from newtwork providers only, except in the case of an emergency.  Most HMO plans require you to chose a PCP as well as get referrals for specialists.  PPO (Preffered Provider Organizations) plans allow for care outside of the plan's network though often with moderatly higher to much higher out of pocket costs.  Though not available in many areas, there are also Medicare PFFS (Private-Fee-for-Service) plans.  These plans provide coverage based on their explanation of benefits and allow a beneficary to see any doctor who participates in Medicare.  The provider does have the option to not accept the terms and conditions of the plan. PFFS plans may or may not include prescription coverage but if it is not included you can opt to purchase a seperate "stand alone" Part D plan.

SPECIAL NEEDS PLANS (SNP):  These plans provide benfits and services for beneficiaries that have certain special circumstances.  Beneficiaries who are  "Dual Eigible" for Medicare and Medicaid, are eligible for a D-SNP (Dual Special Needs Plan).  Other plans are designed to serve the needs of those with verified chronic health conditions by providing additional services not normally privded in a typical Part C plan.

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HOW THE PLAN WORKS:  Unique to Medigap plans is that the coverage does not differ between companies - each plan is standardized by Federal law.  Three states: Minnesota, Massachusetts and Wisconsin have different plan structures.  To see the standardized plan grid CLICK HERE!

We will discuss the plan options (denoted by plan letter) below.  First, however, we will look at the way Medigap plans function.  When a beneficiary receives care from a service provider, and the benficiary is on Original Medicare, the provider will submit the claim to Medicare and Medicare will pay based on Medicare rules.  If the beneficiary has a Medigap plan, the bill then goes to that insurance provider who would pay based on the benefits of the plan letter chosen.  These plans are stadardized in every state except Minesota, Wisconsin and Massachusetts.  

ENROLLMENT PERIODS:  One significant distinctive of Medigap supplementsal policies is the 6 month "Open Enrollment" period.  According to "Medicare's Guide to Health Insurance," the best time to buy a Medigap policy is the 6 month period beginnning with the first month an individual's Part B is effective or if a beneficiary is already enrolled in Medicare part B previous to age 65, the 6 month period begins the first of the month in which they turn 65.  Certain states have restrictions on what plans are available if a beneficiary is under 65 and enrolling in a Medigap plan.   During the one-time Medigap Open Enrollment Period, the Medicare supplement company cannot ask you any medical questions and they cannot turn you down for any health conditions. During this time, a company cannot refuse a policy or charge you any additional amount due to health conditions, medications, or pre-existing illnesses. You will have your choice of Medicare supplemental plans.   Please note the Medicare Annual Enrollment Period in the fall does not apply to Medicare SUpplement Periods.  Beneficiarys may be required to answer health questions and be subjected to medical underwriting if they don't enroll in a Medigap policy during the Open period or during a "Guarenteed Issue" period as detailed below.

GUARANTEED ISSUE:  If a Medicare beneficiary delays enrollmet in a Medigap plan due to coverage with an employee group health plan, they have a 63 day guaranteed issue period in which they may enroll in a Medigap plan.  The plan selection is limited based on state regulations.  During the 63 day "GI" period enrollment can not be denied.  Certain other situations may also provide a guaranteed issue right, such as losing Medicaid,  moving out of a (MAPD) coverage area or moving back to Original Medicare and a Medigap policy within 12 months after a beneficiary first enrolled in an MAPD plan. Speaking with a licensed broker can help a beneficiary understand state specific regultions and company policies.  It is important to retain any documentation from the prior carrier that documents the loss of coverage and entitlement to a "Guaranteed Issue" right.

PLAN CHANGES:  State regualations and company policy oftern dictate how and when a plan may be changed to a different plan without the need to go through underwriting.  If, however, a beneficiary is able to answer health questions in a way that satisfies a carrier's enrollment requirements, plans may be changed at any time throughout the year.  Likewise, if a beneficiary was formerly in a Medicare Advantage plan or missed the 6 month "Open Enrollment Period," underwriting is typically required for enrollment though certain state regulations may allow for certain "Guaranteed Issue" rights.  Enrollment in a different Medigap policy does not automatically end the prior coverage so the beneficiary must contact the prior company and request cancellation.  Some states require cancellation requests to be made in writing.

COMPANY SELECTION: Since Medigap plans are based on federal regulations, plan benefits are not company specific though ceretain companies do provide certain "extra benefits" for those enrolled in their plans.  Some carriers offer household dicounts or offer multi-policy dicounts for bundling home or auto insirance.  Some states do not allow for this discount.  Be sure to check with a licensed agent for specific regulations that would apply to you.

Other considerations for company selection may include, initial premium, history of premium increases, quality of customer service and access to a local company agent or representative. 

COST:  Because most Medigap plans work with Medicare to cover nearly all Medically necessary care with little out-of-pocket costs such as deductibles or co-pays, they typically have significantly higher cost than that of a Medicare Advantage Plan.  Unlike Medicare Advantage Plans,  which is subsidized by Medicare, requires more out-of -pocket costs and also require use of a network of providers, Medigap plans are funded soley through enrollee premium payments, cover most Medicare cost sharing and utilize the full Medicare network.

PLAN BENEFITS: As mentioned earlier, plan beneifts are identified by specifc plan letters.  A plan G with one company is the same as plan G with another.  You can CLICK HERE to see a Medigap Grid but before chosing a plan it may be helpful to consult a licensed agent by calling 877-877-5085 or clicking the "Get a Quote" button at the beginning of this section.

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FACILITATION

The most basic distinction between using Orginal Medicare and a Medigap plan versus enrolling in a Part C (Medicare Advantage Plan) is the way the coverage is administrated.  Using Original Medicare means a beneficiary's providers will be billing Medicare and then, if they, the beneficiary, have a Medigap policy, the bill will be forwarded on to the company from which the beneficiary is receiving supplemental benefits.  Any cost sharing, which is typically limited will then be billed based on the benefits of the plan letter.

Advantage plans, on the other hand, are facilitated through private insurance carriers.  The plan administrator receives monthly payment from Medicare to subsidize the cost of the plan.  Plan providers also require beneficiaries to use a network of doctors, may require referrals for specialists, and facilities and require cost sharing based on the plans explanation of benefits.  

REGIONAL DIFFERENCES:

There are significant regional differences that need to be considered when assesing benefits of Medicare Advantage and Medigap plans.  Often times a client will discuss with us a plan their relative in another state has and desire to enroll in something similar.  Sometimes this is possible but some regions, usually defined by county lines, where there are a limited number of plans, and no similar plans are offered.  Advantage plans differ state to state and county to county and the number of plans and the level of benefit differ greatly.  Some areas may offer 50 or more plans while in other areas there are a very limited number of plans avialable.Medigap plans are standardized through out the country except in the states of Minessota, Wisconsin and Massachusetts.  These states have unique plan structures and do not have plan designations such as PLan G and Plan N.  

ENROLLMENT DIFFERENCES:

Before we break these components down, lets make a quick review of the enrollment eligibility.  Anyone who lives in a plan's service area and has a viable enrollment period may enroll in a MA (Medicare Advantage) plan.  There are certain types of MA plans, however, that are restricted to those with certain special needs.  Medigap plans, though not restricted by enrollment periods, may require the applicant to answer health questions unless they are in their one time Medigap Open Enrollment Period or are eligible for Guaranteed Issue.  

BENEFITS:  Original Medicare along with a Medigap policy provides coverage that is based on federal regulation and does not change based on plan year.  Advantage plans have very diverse plan benefits.  Plan benefits vary by county, by company and the plan itself.  Reviewing these plans with a licensed agent can allow for clarity in this review process.  Advantage plan benefits are explained in each plans "Explanation of Benefits."  When exploring plans benefits, deductibles (including drug deductibles), copays and co-insurance, max-out-of-pocket costs, as well as precription coverage,  should be considered. 

Deductibles:  Original Medicare includes deductibles for services covered under both Part A (Hospital) and Part B (Doctor).  The most popular Medigap plans cover the Part A deductible and beneficiaries who were eligible for Medicare before January 1st of 2020, were eligible for a Medigap plan that also covered the Part B deductible.  Beneficiares with eligibility on or after January 1st of 2020 would be responsible for the Part B deductible.  This deductibles typically sees slight increases each year.  The 2024 Part B deductible is $240.  Most Medicare Advantage Plans do not have a deductible, though some may include a deductible that must be met before certain services are covered.  Most Medicare Advantage plans also include prescription drug coverage and seperate consideration must be given to consider if the plan has a seperate drug deductible.  Since Medigap plans do not have Prescription coverage, the drug deductible a beneficiary would consider in comparison to a Medicare Advantage plan, would be the seperate prescription coverage and corresponding deducitbles of a stand alone Part D plan.

Cost Sharing:  Copays and Co-insurance differ significanlty between the two types of plans.  The most popular Medigap plans cover all costs not covered by Original Medicare.  For example, a Plan G will cover any Medicare co-insurances or copays for all Part A and Part B Medicare covered services, while a plan N covers all PArt A and Part B covered services except for up to a $20 office visit copay and a $50 Emergency Room Copay if the ER visit doesn't result in an inpatient stay.  Plan G also covers rarely charged Part B excess charges while Plan N does not.  Make sure you view the BENEFIT GRID or call 877-877-5085 to discuss plans in detail with a licensed agent.  Advantage plans have copays or co-insurance for most covered services.  Each plan coverage is based on the published "Explanation of Benefits" or EOB.  This EOB details copay and co-insurance information 

Maximum Out-of-Pocket Costs (MOOP):  The MOOP feature prevents "run away" copay and co-insurance costs.  When a beneficiary's deductibles, copays and co-insurance expenses meet the maximum amount allowed by the plan, all covered services are covered at 100% for the rest of the plan year.  While the advantage plan MOOP is a comparison to make for every advantage plan, the most popular Medigap plans don't include a maximum out of pocket because the cost sharing is very limited.  Several plans, Plan K and Plan L, do include a maximum out of pocket because they do have cost sharing for many of the Medicare covered services.

Prescription Coverage:  Medigap plans sold on or after January 1, 2006 do not include prescription drug coverage (Part D).   The appropriate comparison when considering a Medigap plan or a Medicare Advantage plan would be to compare Advantage Plan prescription coverage to a "stand-alone" prescription drug plan purchased when a beneficiary gets their Medicare coverage through Original Medicare.  Both Advantage plan coverage and "stand-alone" prescription coverage benefits includes deductibles, copays and co-insurance, pharmacy networks, drug tiers and maximum out of pocket costs.

Extra Benefits:  Medicare Advantage plans often offer additional benefits over and above what is provided by Orginal Medicare.  These benefits could include dental, vision and hearing coverage, gym memberships, grocery and over-the-counter benefits, travel benefits, home safety devices, even meals after an in-patient hospital stay.  Advntage plans will sometimes even provide "give back" of a portion of the Part B premium.  These benefits are not availabe with Medigap plans though a few select companies may provide gym memberships and vision and/or dental discounts.

NETWORKS: One of several key considerations with any plan is the availability of providers that are participating in the plan's network.  In the "Medicare Advantage Plans" section, we discussed the different types of advantage plan networks such as HMO's and PPO's.  Since Medigap plans work with Original Medicare, these plans are accepted nationally, anywhere Medicare is accepted.  

PLAN STRUCTURE:  By now it should be clear that the plan structures of Medicare Advantage and Medigap policies vary greatly.  It is usually helpful to talk to a licensed agent to help you understand the differences in structure and benefits of both ways to receive Medicare benefits.  One important note, when you enroll in a Medicare Advantage plan:  Medicare will no longer pay caims submited on behalf of a beneficiary that is enrolled in an advantage plan.  All care must billed to the plan provider.  

PREMIUM:  Medicare Advantage plans, because they are subsidized by Medicare and because they have copays and co-insurance for most services, have a significanlty lower premium than a Medigap policy.  Medigap, on the other hand, is fully funded by enrollee premium payments.  Because of this, and the limited cost sharing, generally results in significantly higher premium costs.

A NOTE ABOUT PFFS:  Private Fee for Service Plans are available when there is a limited number of Advantage Plans available.  These plans don't have a network and are able to be used wherever Medicare is accepted as long as the provider agrees to accept the terms and conditions of the plan.

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Medicare Part D is a federal program that provides Medicare beneficiaries help with prescription drug costs. Beneficiaries had to pay the majority of prescriptions costs out of pocket before this program was instituted in 2006..  While Part D is a federal program the plans are provided through private insurance companies.  Medicare beneficiares that chose to stay with Original Medicare typically enroll in a stand alone prescription plan.  While enrollment in part D is voluntary, delaying enrollment may cause a late enrollment penalty (LEP) to be assesed.  If a beneficiary is covered by a group plan that provides creditable prescription coverage then no LEP will be assessed.

Stand alone prescritpion plans most often purchased when a Medicare beneficiary receives their coverage through original Medicare.  When an individual has a Medicare supplement or is Dual - Eligible for Medicare and Medicaid their prrescription coverage must be obtained through a stand alone plan.

Selection of a presciption plan is dependent upon several considerations: prescription utilization, plan formularies, pharmacy networks, premium, deductibles, copays and co-insurance.  

PRESCRIPTION UTILIZATION:  Part D plans are required to cover at least two drugs in each of the thereputic categories and are required to cover almost all drugs within these protected classes: antipsychotics, antidepressants, anticonvulsants, immunosuppressants, cancer drugs, and HIV/AIDS drugs.  Selection of a Part D plan that covers all of your medication is important for several reasons.  First, instead of paying the full cost of the prescription you only pay the plans stated copay or co-insurance.  Another reason this is important is because only the cost of prescriptions on a plan's formulary count toword the 2025 $2000 maximum out of pocket.

PLAN FORMULARIES:  Each prescription plan has a list of covered drugs.  This list is called the plan formulary.  As was mentioned above, Medicare sets requirements that each plan formulary must meet.  The plan's formulary lists the covered drugs and also what tier each drug is on.  The tier level helps determine how much a certain prescription will cost and if the plan has a drug deductible, whether the decutible applies.

PHARMACY NETWORKS:  Another consideration when chosing a prescription plan is whether the pharmacy or pharmacies you want to utilize are in the plan's network.  Many plans have certain pharmacies that are considered "preffered" or "In-network" or "out-of-network."  Typically the lowest cost sharing will be found at preferred pharmacies.  Any prescriptions filled at an out-of-network pharmacy will not be covered by the plan and the beneficiary will be responsible for the full cost of the medication.  Prescriptions costs incured at an out-of-network pharmacy will not be included in the 2025 $2000 maximum out of pocket.

PREMIUMS:  The monthly cost associated with any insurance plan is called the premium.  Stand alone prescription plan premium costs vary greatly.  Typically,  less expensive plans include higher deductibles and have higher cost sharing than more expensive plans.  Additionally, more expensive plans may carry additonal drugs on their drug formulary than a less expensive plan.

DEDUCTIBLES:  Many stand-alone prescription plans include Deductibles.  Deductibles must be met before the plan begins to cover prescription costs.  Most plans do not apply the deductible to Tier 1 and Tier 2 drugs but it is important to understand the explanation of benefits for specific underdstanding of each plan.  

COPAYS AND CO-INSURANCE: Stand alone prescription drug plans often require a copay or co-insurance payment for each prescription.  Copays and Co-insurances typically differ based on whether the selected pharmacy is a preferred pharmacy or simply in-network. 

Prescription Payment Plan:  New for 2025 is the Prescription Payment plan.  This is a voluntary program that allows deductibles, copays and co-insurances to be spread out over the entire year so a beneficiary is able to better manage their out-of-pocket costs.

LIS/Extra Help:  Certain Medicare beneficiaries qualify for Low Income Subsidy or Extra Help based on income and certain assets.  Eligibility for these benefits can be reviewed and subsidies applied for at:  https://www.ssa.gov/medicare/part-d-extra-help  

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WHAT CAN I EXPECT TO PAY?

•    Original Medicare

                       Part A:  Typically premium free with qualifying* work history

                                     $505 (2024) monthly without a qualifying work record

                                               *a qualifying work record includes 10 years (40 work

                                                 quarters) of earings

                       Bart B:  Standard Part B premium is $174.70 (2024)

                                     Income related adjustment may be made for households with

                                     income above certain thresholds.  for more infomation on IRMAA

                                     CLICK HERE

              In addition to possible Part A and Part B premium a Medicare benificiary     

          planning on staying on Original Medicare will likely also need to budget for a 

                                         Medigap plan and Prescription Drug PLan.

Medicare Beneficiaries who opt for a Medicare Advantage (Part C) plan may need to

vv budget for a premium expense for that as well though many areas have $0 plans.

•    FEDERAL ASSISTANCE for Medicare beneficiaries is provided through "Extra

                 Help" that provides assistance with Part D (or the part D part of a 

                  Medicare Advantage premium).   This assistance also limits prescription

                  copays as well.  Income and asset limits apply.

•     STATE ASSISTANCE is provided through Medicare Savings Programs 

                  administrated by state Medicad agencies:

                                  -  Qualified Medicare Beneficiaries (QMB) receive help with Part B

                                       premium costs as well as Medicare copays and deductibles in 

                                       addition to help with Part D premiums and copays

                                  -  Specified Low-Income Beneficiaries (SLMB) recieve help with 

                                      Part B premium costs as well as Part D premiums and co-pays

                                  - Qualified Individuals (QI)receive help with Part B premiums and

                                      as well as help with Part D premiums and co-pays.  There are 

                                      income and asset limit differences between SLMB and QI.  SLMB

                                      also alows for some retroactive coverage for Part B premiums. 

                                  -  Qualified Disabled Working Individuals (QDWI) receive help with 

                                       Part A premium after having been on disability long enough to 

                                       become eligible for Medicare and having returned are no

                                       longer eligible for premium free part A.  

                                  -   State Pharmecutical Assistance Programs (SPAP) provide help

                                        with Part D costs.  Usually the eligibility requirements for SPAP's

                                       are more lenient than the  Federal Extra Help program.

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