Senior’s Guide to Medicare

senior guide to medicare cover

Senior’s Guide to Medicare

You will learn about:
  • Eligibility requirements to qualify for Medicare.
  • What each Medicare plan includes.
  • Additional options like VA Health Care.

64 min – Estimated reading time

Senior’s Guide to Medicare

Senior’s Guide to Medicare

senior guide to medicare cover

Medicare

Medicare is a federal program that provides health insurance to seniors and disabled individuals in the United States. Treatment is covered through a combination of individual fees and trust funds built up through employee taxes. It is managed by the Centers for Medicare & Medicaid Services (CMS), a federal department. 

Medicare is available for:

  • Seniors 65 years of age and older
  • Individuals with end-stage renal disease (ESRD)
  • Some younger individuals with disabilities

The coverage you receive through Medicare depends on what Medicare programs you are enrolled in. Refer to the “Medicare Parts A, B, C and D” section for information about covered services.

Seniors and Medicare

Individuals who are 65 years of age or older fall into the “senior” category, which is the primary population for Medicare. The program is split into four parts, each of which provides different services and coverage options. These are:

  • Medicare Part A (hospital coverage)
  • Medicare Part B (medical insurance)
  • Medicare Part C, otherwise known as Medicare Advantage Plans
  • Medicare Part D, otherwise known as Drug Coverage Plans

Medigap policies are plans that cover services that are not fully covered by Medicare. Medigap is not technically a component of Medicare, but rather a supplement that seniors may choose to add onto existing Medicare coverage.

Medicare Contact Information Directory

General Medicare Contact Information

1-800-633-4227
TTY: 1-877-486-2048

Mailing Address:
Medicare Contact Center Operations
PO Box 1270
Lawrence, KS 66044

Centers for Medicare & Medicaid Services Regional Office Contact Information
State/TerritoryRegional OfficePhone Number
AlabamaAtlanta Regional Office(404) 562-7500
AlaskaSeattle Regional Office(206) 615-2354
American SamoaSan Francisco Regional Office(415) 744-3501
ArizonaSan Francisco Regional Office(415) 744-3501
ArkansasDallas Regional Office(214) 767-6423
CaliforniaSan Francisco Regional Office(415) 744-3501
ColoradoDenver Regional Office(303) 844-1568
ConnecticutBoston Regional Office(617) 565-1232
DelawarePhiladelphia Regional Office(215) 861-4140
District of ColumbiaN/AN/A
FloridaAtlanta Regional Office(404) 562-7500
GeorgiaAtlanta Regional Office(404) 562-7500
GuamSan Francisco Regional Office(415) 744-3501
HawaiiSan Francisco Regional Office(415) 744-3501
IdahoSeattle Regional Office(206) 615-2354
IllinoisChicago Regional Office(312) 353-7180
IndianaChicago Regional Office(312) 353-7180
IowaKansas City Regional Office(816) 426-5233
KansasKansas City Regional Office(816) 426-5233
KentuckyAtlanta Regional Office(404) 562-7500
LouisianaDallas Regional Office(214) 767-6423
MaineBoston Regional Office(617) 565-1232
MarylandN/AN/A
MassachusettsBoston Regional Office(617) 565-1232
MichiganChicago Regional Office(312) 353-7180
MinnesotaChicago Regional Office(312) 353-7180
MississippiAtlanta Regional Office(404) 562-7500
MissouriKansas City Regional Office(816) 426-5233
MontanaDenver Regional Office(303) 844-1568
NebraskaKansas City Regional Office(816) 426-5233
NevadaSan Francisco Regional Office(415) 744-3501
New HampshireBoston Regional Office(617) 565-1232
New JerseyNew York Regional OfficeToll Free: (877) 449-5661Local: (212) 616-2222
New MexicoDallas Regional Office(214) 767-6423
New YorkNew York Regional OfficeToll Free: (877) 449-5661Local: (212) 616-2222
North CarolinaAtlanta Regional Office(404) 562-7500
North DakotaDenver Regional Office(303) 844-1568
Northern Mariana IslandsSan Francisco Regional Office(415) 744-3501
OhioChicago Regional Office(312) 353-7180
OklahomaDallas Regional Office(214) 767-6423
OregonSeattle Regional Office(206) 615-2354
PennsylvaniaPhiladelphia Regional Office(215) 861-4140
Puerto RicoNew York Regional OfficeToll Free: (877) 449-5661Local: (212) 616-2222
Rhode IslandBoston Regional Office(617) 565-1232
South CarolinaAtlanta Regional Office(404) 562-7500
South DakotaDenver Regional Office(303) 844-1568
TennesseeAtlanta Regional Office(404) 562-7500
TexasDallas Regional Office(214) 767-6423
UtahDenver Regional Office(303) 844-1568
VermontBoston Regional Office(617) 565-1232
VirginiaPhiladelphia Regional Office(215) 861-4140
U.S. Virgin IslandsNew York Regional OfficeToll Free: (877) 449-5661Local: (212) 616-2222
WashingtonSeattle Regional Office(206) 615-2354
West VirginiaN/AN/A
WisconsinChicago Regional Office(312) 353-7180
WyomingDenver Regional Office(303) 844-1568

Additional Contact Resources

You can find more contact information and resources by organization, state and/or by topic of interest at https://www.medicare.gov/contacts/

General Medicare Eligibility for Seniors

Seniors who are at least 65 years of age qualify for all types of Medicare. However, within each type, seniors may be eligible for certain perks or discounts. 

Eligibility for Medicare Part A

All seniors qualify for Medicare Part A, but only some can receive premium-free coverage. A premium is a payment made by an insured individual in exchange for having coverage. With premium-free Medicare Part A coverage, enrollees are exempt from making these payments.

Premium-free Medicare Part A coverage is available to seniors who:

  • Already receive retirement benefits from Social Security or the Railroad Retirement Board; or
  • Are eligible to receive retirement benefits from Social Security or the Railroad Retirement Board, but have not yet applied; or
  • Had (or have a spouse who had) Medicare-covered government employment and paid Medicare taxes for at least 40 work quarters; or
  • Are currently married with a spouse who is eligible for premium-free benefits; or
  • Are currently divorced but were married for at least 10 years and the ex-spouse is eligible for premium-free benefits; or
  • Are currently widowed but were married for at least nine months before the spouse died and the spouse was eligible for premium-free benefits.

Those who do not qualify for premium-free Part A will be charged the following premiums in 2021:

  • Enrollees with less than 30 quarters of work credits: $471 monthly
  • Enrollees with 30-39 quarters of work credits: $259 monthly 

Learn more about Medicare Part A.

Eligibility for Medicare Part B

Eligibility for Part B coverage depends on whether a senior needs to pay Medicare Part A premiums. 

Seniors who get premium-free Part A are eligible for Part B as soon as they are entitled to Part A. Enrollment into Part B is automatic*. Seniors can choose to keep or refuse Part B coverage. If they refuse coverage and choose to enroll at a later time, they may be subject to a late enrollment fee and can only apply during certain enrollment periods.

*Seniors living in Puerto Rico who have Part A coverage will not automatically be enrolled in Part B; they must actively enroll in Part B with the Application for Enrollment – Medicare Part B (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf). 

Seniors who need to pay Part A premiums must meet all of the following requirements to enroll in Medicare Part B

  • Age 65 or older
  • U.S. resident and a U.S. citizen or a legal alien who has been lawfully admitted for permanent residence and has been living in the U.S. for five continuous years prior to the month of applying to Medicare

Learn more about Medicare Part B.

Eligibility for Medicare Part C

Seniors are eligible to enroll in a Medicare Part C plan if they:

  • Have Medicare Part A and Part B.
  • Are a U.S. citizen, U.S. national or are lawfully present in the U.S.
  • Live in the health plan’s service area.

Learn more about this on the Medicare Part C section. 

Eligibility for Medicare Part D

Seniors who have Part A and/or Medicare Part B can enroll in a Medicare Part D plan  if they do not have prescription drug coverage through another health insurance plan.

Seniors who are enrolled in a Medicare Part C plan may already have prescription drug coverage incorporated into the plan, so it is important for enrollees to check their coverage policies before enrolling.

Learn more about this on Medicare Part D section.

Eligibility for Medigap Policies

Medigap policies are designed to supplement Medicare Parts A and B coverage. In order to enroll in a Medigap health insurance plan, seniors must meet the following requirements:

  • Have Medicare Parts A and B
    • Seniors cannot enroll in a Medigap plan if they have Medicare Part C.
  • Pay the Medigap insurance provider a monthly premium
    • This premium is in addition to any premiums they must pay for Medicare Part B coverage.
  • Purchase a Medigap policy from a provider that is licensed in their state

Learn more about this on the Medigap policies section.

Medicare Parts A, B, C and D

senior man with doctor medicare parts

Medicare is divided into four categories:

  • Medicare Part A
  • Medicare Part B
  • Medicare Part C
  • Medicare Part D

Learn more about the services covered by these plans in the sections below.

Medicare Part A

Medicare Part A provides hospital-related coverage. All individuals who receive Medicare have Part A coverage. This encompasses:

  • Long-term hospital care
  • Inpatient hospital care
    • Semi-private rooms
    • Meals
    • General nursing
    • Medication
    • Other hospital services and supplies
  • Inpatient mental health care
    • General hospital admissions
    • Psychiatric facility admissions
  • Skilled nursing facility care
    • Semi-private room
    • Meals
    • Skilled nursing care
    • Physical therapy
    • Occupational therapy
    • Speech-language pathology services
    • Medical social services
    • Medication
    • Medical supplies and equipment
    • Ambulance transportation
    • Dietary counseling
    • Swing bed services
  • Nursing home care
  • Hospice care
  • Home health care
  • Part-time or “intermittent” skilled nursing care
    • Physical therapy
    • Occupational therapy
    • Speech-language pathology services
    • Medical social services
    • Part-time or intermittent home health aide services (personal hands-on care)
    • Injectable osteoporosis drugs for women

Costs and Coverage

In addition to premiums, Medicare Part A recipients may need to pay the following fees for services:

  • Deductibles: The amount of money an enrollee pays out-of-pocket for covered services before Medicare begins to pay.
  • Copayments: A fixed cost that the enrollee pays out of pocket for services, office visits or medications.
  • Coinsurance: The enrollee’s shared expense of a covered service. It is an agreed-upon percentage of costs that an enrollee pays out-of-pocket; the remaining cost is paid by Medicare.
Inpatient and Long-Term Hospital Care Service

Seniors who are admitted into a hospital are receiving inpatient care. Long-term hospital care is a type of inpatient stay that averages 25 days or longer.

Medicare Part A coverage has certain fees for inpatient services based on the length of stay during a given benefit period, which begins the first day a patient is admitted to the hospital and ends after they are discharged and have not been readmitted into a hospital for 60 consecutive days. There are no Medicare limits on benefit periods. This means that if a patient re-enters a hospital after their benefit period has ended, a new period begins. 

Medicare Part A covers up to 90 days of inpatient and long-term hospital care during each benefit period. Seniors who stay longer than 90 days are given 60 additional days of coverage, which are known as lifetime reserve days. While benefit periods reset after each 60-day period without a hospital admission, lifetime reserve days do not. Enrollees are only provided a total of 60 lifetime reserve days. Once they use all 60 days, they cannot receive more.

Seniors will be charged the following fees for inpatient and long-term hospital care service:

  • $1,484 deductible per benefit period
  • Days 1-60 of hospital admission: $0 coinsurance per day
  • Days 61-90 of hospital admission: $371 coinsurance per day
  • Days 91 and beyond of hospital admission: $742 coinsurance per lifetime reserve day 
  • Days after lifetime limit: Responsible for full cost of care
Inpatient Mental Health Care Service

Medicare recipients are covered for inpatient mental health care services provided at general hospitals and psychiatric facilities. These services are intended to treat mental health conditions such as depression and anxiety. Medicare covers the cost of:

  • Room and board
  • Meals
  • Nursing care
  • Lab tests
  • Medications
  • Therapy and treatment for the patient’s condition

Medicare will not pay for the following in an inpatient mental health admission:

  • Private duty nursing
  • Television or phone in the patient’s room
  • Personal items (i.e. toothpaste, socks, razors)
  • A private room (unless a doctor states it is medically necessary)

There is no limit to inpatient mental health care services provided at general hospitals. However, there is a lifetime limit of 190 days of inpatient care at psychiatric facilities. In both settings, patients can have multiple benefit periods. 

Seniors are charged for inpatient mental health care based on their length of stay during any given benefit period:

  • $1,484 deductible per benefit period
  • Days 1-60 of hospital admission: $0 coinsurance per day
  • Days 61-90 of hospital admission: $371 coinsurance per day
  • Days 91 and beyond of hospital admission: $742 coinsurance per lifetime reserve day 
  • Days after lifetime limit: Responsible for full cost of care
  • 20 percent of Medicare-allowed cost for mental health services received from doctors while they are inpatients
Skilled Nursing Facility Service

Skilled nursing care is any health care treatment or service that can only be provided by a registered nurse or doctor. Seniors receive this type of care at skilled nursing facilities (SNF) certified by Medicare. Medicare only covers SNF services if all of the following criteria are met:

  • The enrollee has a qualifying hospital stay
    • Before entering a SNF, the enrollee must be admitted to a general hospital for a period of at least three days. 
    • If the enrollee leaves the SNF and re-enters within 30 days, he or she does not need another three days of inpatient care.
  • The enrollee enters the SNF within 30 days of the qualifying hospital stay
  • The enrollee has days left in his or her benefit period
  • A doctor determines skilled nursing care is necessary for the treatment of a medical condition that:
    • Was treated during the qualifying hospital stay, even if it was not the reason for admission; or
    • Started while the enrollee was receiving care in a SNF for a hospital-related medical condition

Seniors will be charged the following fees for SNF care:

  • Days 1-20: $0
  • Days 21-100: $185.50 coinsurance per day
  • Days 101 and beyond: Responsible for full cost of care

Hospice Care

Medicare Part A enrollees pay nothing for hospice care, otherwise known as end-of-life care for terminal illnesses. However, they may need to pay a $5 copayment per medication prescribed to them during this time. 

Seniors may need to pay a portion of the cost for respite care, which is when the patient’s caregiver needs rest. If the patient is admitted into an inpatient facility while the caregiver rests, he or she may be responsible for up to 5 percent of the Medicare-allowed amount (the total amount a doctor or provider accepts for services). 

Medicare does not cover the cost of room and board. Hospice patients who receive care in their homes or in facilities in which they live (such as nursing facilities) are responsible for paying their own costs for food, shelter and utilities. However, if a hospice coordinator determines that an enrollee needs short-term care in a hospice facility, Medicare will cover the cost of the stay. 

Home Health Care

Medicare Part A enrollees pay nothing for home health care services, which refers to any services or treatments provided in the enrollee’s home by skilled health care professionals. However, those who require durable medical equipment (DME) may need to pay 20 percent of the Medicare-approved cost. DME is any equipment ordered by a doctor for use in the home, such as a cane, walker, wheelchair or hospital bed. Learn more about DME in the “Durable Medical Equipment” section.

To receive home health care, a doctor must certify that the enrollee is homebound (cannot leave the house). Medicare pays for the following home health care services:

  • Part-time/intermittent skilled nursing care
    • Unlike skilled nursing care provided in a skilled nursing facility, this type of care is given less than seven days per week and less than eight hours per day. 
  • Physical, occupational and speech-language therapy
  • Part-time/intermittent home health aide services
    • This type of care is personal, hands-on services such as help bathing, dressing and changing medical equipment or dressings.
  • Medical social services
  • Injectable osteoporosis drugs

Medicare will not pay for the following services provided at home:

  • Round-the-clock (24/7) care
  • Meal delivery services
  • Homemaker services (when this is the only care the enrollee needs)
    • This means shopping, cooking and cleaning.
  • Personal care (when this is the only care the enrollee needs)

Medicare Part B

senior woman with nurse and walker medicare part b

Medicare Part B is a voluntary coverage option for seniors that covers medically necessary and preventative treatment as well as outpatient care in hospitals. Outpatient care refers to treatments and services that do not require patients to get admitted into a hospital. Medicare Part B coverage always requires the enrollee to pay monthly premiums. 

Part B coverage encompasses: 

  • Clinical research 
    • Diagnostic tests
    • Surgical treatment
    • Medicine
    • New types of patient care 
  • Ambulance services
    • Ground ambulance transportation
    • Emergency air transportation
    • Medically necessary non-emergency ambulance transportation
  • Durable medical equipment (DME)
    • Blood sugar monitors
    • Blood sugar test strips
    • Canes 
    • Commode chairs
    • Continuous passive motion devices 
    • Continuous Positive Airway Pressure (CPAP) devices
    • Crutches
    • Hospital beds
    • Infusion pumps and supplies
    • Lancet devices and lancets
    • Nebulizers and nebulizer medications
    • Oxygen equipment and accessories
    • Patient lifts 
    • Pressure-reducing support surfaces
    • Suction pumps
    • Traction equipment
    • Walkers
    • Wheelchairs and scooters
    • All other applicable equipment 
  • Mental health care
    • Inpatient
    • Outpatient
      • One depression screening per year
      • Individual and group psychotherapy
      • Family counseling
      • Psychiatric evaluation
      • Medication management
      • Certain prescription drugs that are not self-administered
      • Diagnostic tests
      • A one-time “Welcome to Medicare” preventive visit
      • A yearly “Wellness” visit
    • Partial hospitalization
  • Limited outpatient prescription drugs
    • Part B primarily covers drugs that are typically not self-administered. For instance, vaccinations, injections and intravenous medication. 

Costs and Coverage

Seniors with Part B coverage are required to pay the following fees for treatment.

Medicare Part B Premiums

Unlike Part A, all Medicare recipients must pay monthly premiums for Part B coverage. Seniors who receive benefits checks through Social Security, the Railroad Retirement Board or the Office of Personnel Management will have their monthly premium payments automatically deducted from their check. All other enrollees will receive bills for premium payments. 

The standard premium amount in 2021 is $148.50 per month. However, some seniors with higher incomes may be required to pay higher monthly Part B premiums. This is based on the modified adjusted gross income, or MAGI. Your MAGI is calculated by finding your total income for the entire year and adding back any tax-exempt interest or deductions.

The table below outlines monthly premium amounts for seniors with incomes higher than $88,000 (or $176,000 for joint tax returns) as shown on their income tax return documents two years prior to when they applied for Medicare. 

Individual Tax ReturnJoint Tax ReturnMarried And Separate Tax ReturnsMonthly Premium (2021)
Between $88,000.01 and $111,000Between $176,000.01 and $222,000N/A$207.90
Between $111,000.01 and $138,000Between $222,000.01 and $276,000N/A$297
Between $138,000.01 and $165,000Between $276,000.01 and $330,000N/A$386.10
Between $165,000.01 and $499,999.99Between $330,000.01 and $749,999.99Between $88,000.01 and $411,999.99$475.20
$500,000 and greater$750,000 and greater$412,000 and greater$504.90

Deductibles and Coinsurance

Medicare Part B enrollees have an annual deductible, which is a set amount of money they pay out of pocket before Medicare pays. The current annual deductible in 2021 is $203 per year. 

Once an enrollee meets this deductible, they are responsible for coinsurance, which is a percentage of healthcare costs that the enrollee pays. The current coinsurance amount is 20 percent. Medicare pays the remainder of the cost.

Seniors typically pay coinsurance for the following services:

  • Doctor visits
  • Outpatient therapy
  • Durable medical equipment (DME)

Clinical Trials

Medicare enrollees can participate in clinical trials or research studies to test new equipment, medication or procedures. Patients must pay 20 percent of the Medicare-approved amount for all clinical trials in which they participate. Depending on the type of trial, the Part B deductible may also apply. 

Ambulance Services

Medicare Part B covers ambulance transportation to the nearest appropriate hospital, skilled nursing facility (SNF) or critical access hospital. Medicare will only pay when the ambulance is used for medically necessary services and transportation in another vehicle (like a car) would endanger the health of the individual. 

Medicare may also pay for transportation via helicopter or airplane if ground transportation is not accessible or fast enough. Enrollees are required to pay 20 percent of the Medicare-approved amount for all types of ambulance services. The Part B deductible also applies, which means if the enrollee has not met the annual deductible, he or she will pay out-of-pocket up to the annual deductible amount.

Durable Medical Equipment

senior woman diabetes pen Durable Medical Equipment

Seniors can receive durable medical equipment (DME) that is medically necessary to treat their condition, illness or symptoms. DME must be prescribed by a doctor for use in the enrollee’s home. Examples of DME include: 

  • Blood sugar monitors
  • Blood sugar test strips
  • Canes 
  • Commode chairs
  • Continuous passive motion devices 
  • Continuous Positive Airway Pressure (CPAP) devices
  • Crutches
  • Hospital beds
  • Infusion pumps and supplies
  • Lancet devices and lancets
  • Nebulizers and nebulizer medications
  • Oxygen equipment and accessories
  • Patient lifts 
  • Pressure-reducing support surfaces
  • Suction pumps
  • Traction equipment
  • Walkers
  • Wheelchairs and scooters 

Medicare will only pay for DME if the enrollee’s doctor and equipment supplier participate in Medicare. If they do not participate, Medicare will deny the claim and the enrollee will be responsible for the full cost of the DME. Medicare-participating doctors and suppliers are contracted by Medicare to accept assignment, which means they can only charge enrollees coinsurance and the Part B deductible for the cost that is approved by Medicare. 

Seniors pay a coinsurance of 20 percent for DME. They may apply their deductible to the payment. Enrollees may need to rent or buy the equipment, depending on the item and their medical needs. 

Limited Outpatient Prescription Drugs

Seniors must pay 20 percent of the Medicare-approved amount for medication received in a doctor’s office or pharmacy. 

In a hospital outpatient setting, patients are charged a 20 percent copay for prescription drugs. If the patient’s hospital participates in the 340B Drug Pricing Program, he or she will be charged 20 percent of the lower price in most cases. The 340B program requires drug manufacturers who participate in Medicaid to sell outpatient drugs at discounted prices to healthcare organizations that primarily serve uninsured and low-income patients. Because health care organizations are receiving discounts, they can provide these drugs to patients at a lower cost.

Patients who receive drugs that are not covered by Medicare Part B must pay 100 percent of the drug cost unless they have prescription drug coverage through Medicare Part D or another plan. Learn more about Part D coverage in the “Medicare Part D” section. 

Outpatient Mental Health Care Service 

While Medicare Part A covers inpatient mental health care (care received while admitted into a hospital or psychiatric facility), Part B covers outpatient mental health services provided at doctors’ offices or other office settings outside of a hospital. Outpatient settings are those that do not require admissions or overnight stays. Coverage includes any services used to diagnose, treat or resolve mental health conditions. 

Medicare Part B covers the following outpatient mental health services:

  • One free yearly depression screening provided by a primary care doctor
    • Medicare only pays when the doctor or health care facility participates in Medicare.
  • Individual and group psychotherapy with a doctor or licensed therapist
    • Otherwise known as “talk therapy,” this service involves interacting with others in an effort to overcome obstacles and change certain behaviors.
  • Family counseling
  • Psychiatric evaluations and testing
  • Medication management
  • Some prescription drugs that are not “self-administered”
    • For example, drugs that need to be injected.
  • Diagnostic tests
  • Partial hospitalization
    • Unlike inpatient care, an overnight stay is not required. It is more intensive than standard outpatient care and is typically provided in outpatient wings at hospitals.
  • Treatment for substance and alcohol abuse

Enrollees are required to pay 20 percent of the Medicare-approved amount for outpatient mental health services. They may apply their deductible to the payment.

Medicare Part C

Medicare Part C, also known as Medicare Advantage, is the option to receive Medicare coverage through a private insurance company. Part C plans are offered through private companies who have been approved by Medicare. These plans include all benefits that are offered in Plan A and Plan B, and frequently include Part D benefits as well. 

They may include greater coverage than standard Medicare offers, including vision, hearing and dental coverage. 

Like a standard health insurance plan, Medicare Part C recipients must stay within a plan’s network to receive benefits. In exchange, they receive more thorough coverage with a lower copayment than standard Medicare treatment typically charges. 

There are many different types of Medicare Part C plans available.

  • Health Maintenance Organization (HMO) Plans — These plans provide coverage within the company’s network except in the case of emergencies. Typically, you must get a referral to see a specialist. If you see a doctor or practice outside of the network, you will pay a higher cost — in many cases, the full cost — compared to the in-network costs. 
  • Preferred Provider Organization (PPO) Plans — Like HMO plans, PPO plans request that you stay in-network to receive coverage. However, you may still receive coverage for treatment outside of the network albeit with a higher cost to you. Referrals are not generally required to see a specialist. 
  • Private Fee-For-Service (PFFS) Plans — PFFS plans are more similar to standard Medicare than other Medicare Advantage plans. You can seek treatment from any Medicare-approved provider that accepts the terms of the plan. Some PFFS plans have networks with lower costs, while others do not. In some cases, PFFS plans may not provide prescription drug coverage. You can enroll in Medicare Part D if your PFFS plan through Medicare Advantage does not include prescription coverage. 
  • Special Needs Plan (SNP) — These plans are designed for Medicare recipients with specific illnesses or limited incomes. Like HMOs and PPOs, you are generally limited to receiving care within a network. You typically must have a primary care doctor or care coordinator to address treatment plans. SNPs must include Part D coverage. In order to qualify for an SNP, you should meet one of the following requirements:
    • You have a chronic illness
    • You live in an institution or need nursing care at home
    • You qualify for both Medicare and Medicaid
  • Medicare Savings Account (MSA) Plans — MSA plans allow you to use a medical savings account combined with a high-deductible plan to receive coverage. If you use MSA, you generally must join a Part D plan as well, unless you already have a Medigap policy with drug coverage. 

The availability of Medicare Part C plans depends on the area in which you live. Some areas may offer all, some or none of these types of Part C plans. In addition, there may be several plans available in your area within the same category. 

Visit medicare.gov/plan-compare and enter your ZIP code to see the plans that are available in your area.

Costs and Coverage

Medicare Part C plans provide the same benefits as Parts A and B. However, costs vary by plan. HMO, PPO, PFFS and SNP plans may charge a monthly premium. All plans will have different co-pays depending on the plan you select. 

In addition to the costs associated with your Part C plan, you are still required to pay your Part B premiums. Some Part C plans cover the cost of your Part B premiums or may charge a $0 premium. If you enroll in a MSA plan, you must also pay your Part B premium, but you will not be charged any additional premiums for your Part C plan. 

Medicare Part D

Medicare Part D, also known as a “drug coverage plan,” provides prescription drug coverage that supplements Original Medicare (Parts A and B) plans. Because prescription drugs are not covered under Medicare Parts A or B, seniors can choose to enroll in a Medicare Part D plan to be covered for a variety of prescription medications. Medicare Part D is not required; enrollees may choose to enroll in this type of plan if they do not have drug coverage from any other insurance plan.

Like Medicare Part C, drug coverage plans vary in availability based on the area in which an enrollee lives. Part D plans are offered by private insurance companies that work with Medicare to provide drug coverage to Medicare recipients. An enrollee’s insurance costs, drug costs and plan options vary depending on where he or she lives.

Although plans differ, all Medicare Part D insurance companies must meet certain drug class coverage options set by Medicare. This means that all plans must cover medications in the following drug classes: 

  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • Cancer drugs
  • HIV/AIDS drugs
  • Immunosuppressants

Each insurance company that offers Medicare Part D has its own drug formulary, or a list of prescription medications it will cover. Drugs in the formulary are typically divided into tiers based on cost and specialization. For example, a Part D plan may have a formulary that categorizes covered drugs into tiers based on generic medications, brand-name medications and specialized medications. In general, generic prescription drugs are the lowest-cost drug option in Part D plans. 

Medicare requires Part D plans to carry at least two versions of a drug in its formulary. This way, if a specific brand of drug is not available, a generic or other equivalent drug will be covered by the plan.

Costs and Coverage

Medicare Part D recipients must pay a monthly premium for coverage. Premium amounts vary depending on the plan. Seniors with a higher income will have to pay an additional cost tied to their incomes in addition to the premium. This is called the Part D-Income Related Monthly Adjustment Amount.

The 2021 Part D-IRMAA is as follows: 

If filing an individual tax returnIf filing a joint tax returnIf married and filing separate tax returnsYour monthly IRMAA cost
$88,000 or less$176,000 or less$88,000 or lessYour plan premium
above $88,000 up to $111,000above $176,000 up to $222,000not applicable$12.30 + your plan premium
above $111,000 up to $138,000above $222,000 up to $276,000not applicable$31.80 + your plan premium
above $138,000 up to $165,000above $276,000 up to $330,000not applicable$51.20 + your plan premium
above $165,000 and less than $500,000above $330,000 and less than $750,000above $88,000 and less than $412,000$70.70 + your plan premium
$500,000 or above$750,000 and above$412,000 and above$77.10 + your plan premium

Medigap Policies

health insurance policies medigap

Medigap policies are insurance policies designed to cover healthcare services and treatments not completely covered by standard Medicare. They can also cover expenses like copayments, coinsurance and deductibles. Medigap health insurance policies are offered by individual health insurance companies rather than the federal government.

Medigap policies can only be assigned to one person. There are no group, family or spousal Medigap plans. If a married couple wishes to have Medigap coverage for both spouses, each individual must purchase his or her own policy.

Medigap insurance plans do not include prescription drug coverage*. Seniors who want or need drug coverage can purchase a separate Medicare Part D plan. Refer to the “Medicare Part D” section for more information about drug coverage options.

*Some Medigap policies sold before January 1, 2006 include prescription drug coverage, but all policies sold thereafter do not.

Medigap policies are standardized. This means it is easier to compare plans from different insurance companies because they all offer the same basic benefits. For example, two different health insurance providers selling the same Medigap policy are required to provide the same benefits.  However, the costs can vary between companies for the same policies. 

Comparing Medigap Policies

In all states except Massachusetts, Minnesota and Wisconsin, Medigap policies are standardized the same way. Like Medicare plans, Medigap policies are also categorized by letter.

The following Medigap plans are available: 

  • A
  • B
  • C*
  • D
  • F*
  • G
  • K
  • L
  • M
  • N

Each insurance company is responsible for determining which type of Medigap plan(s) it wants to sell. All insurance providers must adhere to the following requirements when selling Medigap policies:

  • Companies do not need to offer every Medigap plan.
  • Companies must offer Medigap Plan A if they offer any Medigap policy. 
    • If they offer any plan in addition to Medigap Plan A, they must also offer Plans C or F. 

Medigap Benefits by Policy

Medigap policies are categorized into 10 plans, each of which offers different benefits to Medicare recipients. The table below shows the benefits provided by each type of Medigap plan in all states except Massachusetts, Minnesota and Wisconsin. For information about Medigap policies in these states, refer to the “Medigap Policies in Massachusetts, Minnesota and Wisconsin” section of this guide.

Medigap BenefitsMedigap Planscolspancolspancolspancolspancolspancolspancolspancolspancolspan
ABCDF*G*KLMN
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are usedYYYYYYYYYY
Part A hospice care coinsurance or copaymentYYYYYY50%75%YY
Part A deductibleNYYYYY50%75%50%Y
Part B coinsurance or copaymentYYYYYY50%75%YY***
Part B deductibleNNYNYNNNNN
Part B excess chargesNNNNYYNNNN
Blood transfusions per year (first 3 pints)YYYYYY50%75%YY
Skilled nursing facility care coinsuranceNNYYYY50%75%YY
Foreign travel exchangeNN80%80%80%80%NN80%80%
Out-of-pocket limit for 2021**N/AN/AN/AN/AN/AN/A$6,220$3,110N/AN/A

Medigap Policies in Massachusetts, Minnesota, and Wisconsin 

In Massachusetts, Minnesota and Wisconsin, Medigap policies are standardized in a different way. Continue reading the sections below to learn more about Medigap in these three states.

Medigap Policies in Massachusetts

All Massachusetts Medigap policies must cover the following basic benefits: 

  • Part A coinsurance
  • Part A hospice cost sharing
    • Provides gap coverage for some Medicare Part A enrollees who are required to pay for hospice care or services.
  • 365 days of additional Part A hospital coverage after Part A Medicare coverage ends
  • Part B coinsurance
  • First 3 pints of blood for transfusions per year

Beneficiaries in Massachusetts can choose from three types of Medigap plans:

  • Core Plan
  • Supplement 1 Plan
  • Supplement 1A Plan

Core Plan

The core plan covers the following: 

  • Basic benefits
  • 60 inpatient days in a mental health treatment facility per year
  • State-mandated benefits (yearly pap smears and mammograms)

Supplement 1 Plan

The Supplement 1 Plan covers everything that the Core Plan covers in addition to the following:

  • Part A inpatient hospital deductible
  • Part A skilled nursing facility coinsurance
  • Part B deductible
  • Foreign travel emergency costs
  • 120 inpatient days for mental health treatment per year

Supplement 1A Plan

The Supplement 1A Plan covers everything that the Core Plan covers in addition to the following:

  • Part A inpatient hospital deductible
  • Part A skilled nursing facility coinsurance
  • Foreign travel emergency costs
  • 120 inpatient days for mental health treatment per year

Medigap Policies in Minnesota

All Minnesota Medigap policies must cover the following basic benefits

  • Part A coinsurance
  • Part B coinsurance
  • Part A hospice care cost sharing
    • Provides gap coverage for some Medicare Part A enrollees who are required to pay for hospice care or services
  • Parts A and B home health services and supplies cost sharing
  • First 3 pints of blood for transfusions per year

There are two plans in Minnesota

  • Basic Plan
  • Extended Basic Plan

Basic Plan

The Basic Plan covers the following:

  • Basic benefits
  • Part A skilled nursing facility (SNF) coinsurance
    • Provides 100 days of care in a SNF
  • 80 percent of foreign travel emergency
  • 50 percent of outpatient mental health care costs
  • Medicare-covered preventive care
  • 20 percent of physical therapy costs
  • State-mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, immunizations)

Extended Basic Plan

The extended basic plan covers: 

  • Basic benefits
  • Part A inpatient hospital deductible
  • Part A skilled nursing facility (SNF) coinsurance
    • Provides 120 days of care in a SNF
  • Part B deductible
    • Except newly eligible Medicare recipients. As of January 1, 2020, anyone who is new to Medicare cannot have the Part B deductible covered by Medigap. 
  • 80 percent of costs associated with a foreign travel emergency**
  • 50 percent of outpatient mental health
  • 80 percent of usual and customary fees**
  • Medicare-covered preventive services
  • 20 percent of physical therapy
  • State-mandated benefits (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, immunizations)

Medigap Policies in Wisconsin

All Wisconsin Medigap policies must cover the following basic benefits: 

  • Part A inpatient hospital coinsurance
  • Part A hospice cost-sharing
    • Provides gap coverage for some Medicare Part A enrollees who are required to pay for hospice care or services
  • Part B coinsurance
  • First 3 pints of blood for transfusions per year

Wisconsin has one type of Medigap plan known as the Basic Plan. However, insurance companies have more flexibility in defining the Basic Plan. They can choose to add on certain benefits to the standard coverage options.

All companies offering the Basic Plan cover the following:

  • Basic benefits
  • Part A skilled nursing facility (SNF) coinsurance
  • 175 days of inpatient mental health care after the Medicare inpatient mental health care limit is reached
  • 40 home health care visits in addition to the Medicare allowed number of visits
  • State-mandated benefits

Wisconsin has other Medigap plan options that vary in cost and benefits. The 50% and 25% cost-sharing plans are similar to standardized Medigap Plans K and L, which are outlined in the table found in the “Medigap Benefits by Policy” section.  Insurance companies can offer Medigap Basic plans with a high deductible of $2,370 in 2021. Additionally, companies also have the option to include the following benefits in their Medigap policies: 

  • 50% Part A deductible
  • Part B deductible
    • Except newly eligible Medicare recipients. As of January 1, 2020, anyone who is new to Medicare cannot have the Part B deductible covered by Medigap. 
  • Part B copayment or coinsurance 
  • Part B excess charges
  • Additional home health care
    • Provides 365 visits, including those paid by Medicare
  • Expenses related to a foreign travel emergency

Information and Documents Needed to Apply

couple filling out form Information and Documents Needed to Apply

During the Medicare application process, you will need to provide certain information and documents that verify your eligibility for the program. 

To apply for Medicare Parts A and B, you will need to provide the following information:

  • Your date and place of birth
  • Your Medicaid number and start date, if applicable
  • Your current health insurance information.

If you are applying for Medicare Parts A or B as a spouse of someone eligible for Medicare, you will also need to provide the following information:

  • Your marriage and divorce information
    • Name of current spouse
    • Name of previous spouse, if previous marriage lasted for more than 10 years or ended in death
    • Spouse’s or spouses’ date(s) of birth and SSN(s)
    • Beginning and end date(s) of marriage(s)
    • Place(s) of marriage(s)
  • Names and dates of birth of children who became disabled before the age of 22, who are under 18 and unmarried or who are 18 or 19 and attending school full time
  • U.S. military service history, including:
    • Branch served in
    • Position held
    • Start and end dates
  • Employer details for last three years, if not self-employed
    • Employer name
    • Start and end dates
  • Self-employment details for last three years, if self-employed
    • Business type
    • Total net income
  • Bank account information for direct deposit

To apply for Medicare Parts C or D, you will need to provide the following information found on your Medicare card:

  • Your Medicare number
  • The date(s) that your Medicare Parts A and/or B coverage began 

How to Apply for Medicare Parts A and B

You can apply for Medicare Parts A or B in the following ways:

  • Online
  • By phone
  • In person

How to Apply Online for Parts A and B

Follow the steps outlined below to apply online:

  1. Visit the Social Security website here: https://www.socialsecurity.gov/medicare/apply.html
  2. Scroll down and select “Apply for Medicare Only.”
    The link will bring you to the “Apply for Benefits” online portal on the Social Security website.
  3. Enter all required information.
    Refer to the “Information and Documents Needed to Apply” section for a complete list. The application may take between 10 and 30 minutes.
  4. Click “Submit Now”.
    Once you submit the form, you will receive a receipt and an application number which you should keep for future reference. The Social Security Administration (SSA) will process your application and mail you their decision.

How to Apply by Phone for Parts A and B

Enroll in Medicare Parts A and B by calling 1-800-772-1213

How to Apply in Person for Parts A and B

Enroll in Medicare Parts A and B by visiting your local Social Security office. Search for an office near you using the locator tool here: https://secure.ssa.gov/ICON/main.jsp 

How to Apply for Medicare Part C

Since Medicare Part C plans are offered by private insurance companies rather than the federal government, the ways you can enroll may differ. Depending on your provider, you may be able to enroll in the following ways:

  • Online
    • Visit your provider’s website to see if there is an online application available.
  • By phone
    • Call your provider directly to apply or learn more about your application options.
    • Call the national Medicare line at 1-800-633-4227
  • By mail or in person
    • All Medicare Part C plans must offer a paper enrollment form. Some providers may allow for mail-in applications while others require you to return the forms in person. Contact your plan for more information. 

To enroll in a Medicare Part C plan, you must first find a plan that is available in your area. Use the plan finder here:https://www.medicare.gov/plan-compare/ 

How to Apply for Medicare Part D

Before enrolling in a Medicare Part D plan, you must find a plan that is available in your area. Use the plan finder here: https://www.medicare.gov/plan-compare/. Once you find a Part D plan that works for you, you can enroll in the following ways:

  • Online
  • By phone
    • Call your provider directly to apply or learn more about your application options.
    • Call the national Medicare line at 1-800-633-4227
  • By mail or in person
    • All Medicare Part D plans must offer a paper enrollment form. Some providers may allow for mail-in applications while others require you to return the forms in person. Contact your plan for more information. 

Program of All-Inclusive Care for the Elderly (PACE) 

PACE is a joint Medicare and Medicaid program that helps elderly individuals seek medical care in their communities, rather than requiring them to go to a nursing home or other long-term care facility. 

Seniors and PACE

Seniors who enroll in PACE receive a team of health care professionals dedicated to coordinating their treatment. PACE covers all treatments covered by Medicare and Medicaid that are deemed medically necessary by a team of health care professionals.

These treatments and services include:

  • Adult day primary care
  • Dentistry
  • Doctor visits
  • Emergency services
  • Home care
  • Hospitalizations
  • Laboratory/X-ray services
  • Meals
  • Medical specialty services
  • Nursing home care
  • Nutritional counseling
  • Occupational therapy
  • Physical therapy
  • Prescription drugs
  • Preventive care
  • Social services
  • Social work counseling
  • Transportation

PACE Contact Information Directory 

Because it is not a federal program, PACE is not available in all states. Instead, individual PACE programs are available to serve limited areas. There are currently 135 PACE programs with 272 centers across 31 states. 

Currently, a PACE program is only available in the following states: 

  • Alabama
  • Arkansas
  • California
  • Colorado
  • Delaware
  • Florida
  • Indiana
  • Iowa
  • Kansas
  • Louisiana
  • Maryland
  • Massachusetts
  • Michigan
  • Nebraska
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • Tennessee
  • Texas
  • Virginia
  • Washington
  • Wisconsin
  • Wyoming

Because PACE programs are location-specific, you may not have access to a program, even if it is available in your state. 

Use the PACE program locator tool to see if there is a PACE program near you: https://www.npaonline.org/pace-you/pacefinder-find-pace-program-your-neighborhood 

General PACE Eligibility for Seniors 

In order to be eligible for PACE, you must meet the following requirements: 

  • Be 55 years of age or older
  • Live within the service area of a PACE organization
  • Require a nursing home level of care, as certified by your state
  • Be able to live in your community with PACE care

Information and Documents Needed to Apply

PACE programs are administered by individual organizations in each state. Therefore, the information and documents you will need to apply will vary. Generally, you will need to prove that you meet the eligibility requirements listed in the previous section. You may need to provide:

  • Proof of age, such as a birth certificate 
  • Proof of residency, such as utility documents, lease agreements or mortgage information
  • Medical information verifying your need for nursing home level care

How to Apply for PACE

To enroll in PACE, you must determine if there is a program in your area. Use the PACE program locator tool to see if there is a PACE program near you: https://www.npaonline.org/pace-you/pacefinder-find-pace-program-your-neighborhood 

Since PACE is operated individually, the application process differs. If there is a PACE program in your area, contact the program to learn how to apply.

VA Health Care for Senior Veterans

The Department of Veterans Affairs (VA) provides several types of benefits for senior veterans, including health care. Through the VA, senior veterans can receive treatment and services at locations around the country. 

The following basic services are covered through VA health care:

  • Preventive care
  • Inpatient hospital services
  • Urgent and emergency care services
  • Mental health services
  • Prescriptions
  • Medically-necessary tests
    • Medically-necessary means that a doctor believes the treatment or service is required to diagnose or treat a specific condition.
  • Medically-necessary rehabilitation and therapy services
  • Prosthetics
  • Hearing aids
  • Radiation
  • Routine eye exams 

VA health care benefits also provide coverage for senior veterans who require assisted living, residential health care or home health care services. This type of coverage is known as geriatrics and extended care (GEC) services.

Geriatrics and Extended Care

senior man in wheelchair with nurse Geriatrics and Extended Care

During the Medicare application process, you will need to provide certain information and documents that verify your eligibility for the program. 

To apply for Medicare Parts A and B, you will need to provide the following information:

  • Your date and place of birth
  • Your Medicaid number and start date, if applicable
  • Your current health insurance information.

If you are applying for Medicare Parts A or B as a spouse of someone eligible for Medicare, you will also need to provide the following information:

  • Your marriage and divorce information
    • Name of current spouse
    • Name of previous spouse, if previous marriage lasted for more than 10 years or ended in death
    • Spouse’s or spouses’ date(s) of birth and SSN(s)
    • Beginning and end date(s) of marriage(s)
    • Place(s) of marriage(s)
  • Names and dates of birth of children who became disabled before the age of 22, who are under 18 and unmarried or who are 18 or 19 and attending school full time
  • U.S. military service history, including:
    • Branch served in
    • Position held
    • Start and end dates
  • Employer details for last three years, if not self-employed
    • Employer name
    • Start and end dates
  • Self-employment details for last three years, if self-employed
    • Business type
    • Total net income
  • Bank account information for direct deposit

To apply for Medicare Parts C or D, you will need to provide the following information found on your Medicare card:

  • Your Medicare number
  • The date(s) that your Medicare Parts A and/or B coverage began

VA Health Care Contact Information Directory

VA Health Care – Department of Veterans Affairs (VA)

1-877-222-8387

General VA Health Care Eligibility for Seniors 

Senior veterans interested in health care coverage from the VA must must meet the following  standard eligibility requirements:

  • Served in the active military, naval, or air service
    • Former members of the Reserves or National Guard must have been called to active duty by a federal order and completed the full period for which they were called or ordered to active duty. Veterans who had active-duty status for training purposes only do not qualify for VA health care.
  • Did not receive a dishonorable discharge
  • If  they enlisted after September 7, 1980 or entered active duty after October 16, 1981:
    • Must have served 24 continuous months or the full period for which they were called to active duty, unless:
      • They served prior to September 7, 1980, or
      • They were discharged for a disability that was caused (or made worse) by active-duty service, or
      • They were discharged for hardship or “early out.”

Seniors who meet the requirements listed above may also qualify for geriatrics and extended care (GEC) services if they meet all of the following requirements:

  • Signed up for VA health care
  • Need a specific service to help with ongoing treatment and personal care as determined by the VA
  • The service (or space in the care setting) is available in their location

Information and Documents Needed to Apply

To apply for VA health care, you will need to provide the following information and documents:

  • Full name
  • Date of birth 
  • Your most recent tax return
  • Social Security Numbers (SSN) for yourself and any qualified dependents
  • Account numbers for any current health insurance you already have (like Medicare, private insurance or insurance from your employer)
  • Copy of your military discharge papers (DD-214 or other separation documents)
  • Financial information for yourself and any qualified dependents

How to Apply for VA Health Care

Regardless of the services or benefits you need from the VA, you must first apply for general VA health care. Once your application is approved, you can apply for specific services such as geriatric and extended care (GEC) services. 

You can apply for VA health care in the following ways:

  • Online
  • By phone
  • By mail
  • In person

How to Apply Online

  1. Visit the Apply for Health Care online portal on the VA’s website here: https://www.va.gov/health-care/apply/application/id-form
    • Log into your VA.gov account before starting the application so you can save your progress and complete it at a later time if necessary.
  2. Gather all required information and documents.
  3. Complete all steps in the online application form.
    • Once you submit the application, you will receive a confirmation message.
  4. Receive a determination in the mail within one week of applying.
    • If more than a week has passed, call the VA at 877-222-8387.

How to Apply by Phone

Call the VA at 1-877-222-8387 Monday through Friday between 8 AM and 8 PM ET.

How to Apply by Mail

  1. Complete the Application for Health Benefits (VA Form 10-10EZ).
  2. Sign and date the form. 
    • If you are using a power of attorney (someone who has written consent to sign official forms and documents on your behalf), you must submit a copy of the Power of Attorney form along with your application. Download the form here: https://www.va.gov/geriatrics/docs/vha-10-0137-fill-2-26-20.pdf 
    • If you sign with an “X,” two people you know must witness your signature. They will also need to sign and print their names on the Application for Health Benefits form.
  3. Mail the completed application to:
    Health Eligibility Center
    2957 Clairmont Road, Suite 200
    Atlanta, GA 30329

How to Apply in Person

  1. Complete the Application for Health Benefits (VA Form 10-10EZ).
  2. Sign and date the form.
    • If you are using a power of attorney (someone who has written consent to sign official forms and documents on your behalf), you must submit a copy of the Power of Attorney form along with your application. Download the form here: https://www.va.gov/geriatrics/docs/vha-10-0137-fill-2-26-20.pdf
    • If you sign with an “X,” two people you know must witness your signature. They will also need to sign and print their names on the Application for Health Benefits form.
  3. Bring the completed application to your local VA office.
  4. Use the locator tool here to search for an office near you: https://www.va.gov/find-locations/

How to Apply for Geriatric and Extended Care (GEC) Services

Once your VA health care application is approved and you are enrolled in health coverage, you can apply for the GEC services you need. To access GEC services, you must either:

  • Contact your VA social worker, or
  • Call the VA hotline at 877-222-8387 Monday through Friday between the hours of 8 AM and 8 PM ET. 

The VA will determine whether you meet the qualifications for GEC services.

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