Understanding Medicare

Learn Medicare Basics

What Original Medicare (Parts A & B) Covers

 

Original Medicare is a federal health insurance program designed for people aged 65 or older and younger people with certain health conditions. It includes Parts A and B, which help pay for hospital, medical, and other healthcare costs.

 

 

Here's a side-by-side view of what each part covers:

 

Medicare Part A

 

 

Medicare Part B

 

 

Hospital stays

 

 

Doctor visits

 

 

Inpatient lab tests

 

 

Outpatient lab tests

 

 

Inpatient services and surgeries

 

 

Outpatient services and surgeries

 

 

Skilled nursing facility care

 

 

Preventive health appointments

 

 

Hospice

 

 

Certain medical equipment you use at home

 

 

Home healthcare, only after qualifying inpatient stay

 

 

Home healthcare, only if deemed "homebound"

 

What's Not Covered By Original Medicare?

 

Original Medicare doesn't cover everything. So, depending on your healthcare needs, you may want additional coverage. Original Medicare does not include benefits like these:

  • Most prescription drugs
  • Long-term hospital care
  • Most dental care including dentures
  • Eye exams
  • Routine physical exams

Overview Of Original Medicare Costs**

 

Original Medicare

 

 

Part A

 

 

Part B

 

 

Premium

 

 

$0

MONTHLY PREMIUM

 

(This applies only if you or your spouse had Social Security payroll deductions for at least 10 years.)

 

Your cost will be prorated if you haven’t made Social Security contributions.

 

 

$174.70

Each Month

 

(Could be higher depending on your income.)

 

Most people pay this with automatic deductions from Social Security.

 

 

Deductible

 

 

$1,632

Per inpatient Benefit Period

 

Starts when you’re admitted for inpatient care and ends 60 days after your release from a hospital or a skilled nursing facility.

 

 

$240

PER YEAR

 

 

Copays And Coinsurance

 

 

Hospital Stays

 

$0

Days 1-60 Hospitalized

 

$408/Day

Days 61-90 Hospitalized

 

$816/Day

Lifetime Reserve Days

 

Skilled Nursing

$0

Days 1-20

 

$204/Day

Days 21-100

 

 

You Pay
 

20%

Of Medicare-Approved Amount*


For the covered services you use, with no annual out-of-pocket maximum.
 

Medicare Pays

80%

Remaining Amount

*Some doctors may not accept the Medicare-approved amount for Original Medicare Part B (medical) costs, and can charge as much as 15% (only 5% in New York state) over what Medicare will pay, and will bill you the difference. You are responsible for paying these excess charges.

 

 

**Costs listed are based on 2024 rates.
Source: https://www.medicare.gov/basics/costs/medicare-costs 

Other Plan Types

 

More Coverage For Your Needs

 

Original Medicare might not be enough to meet your healthcare needs. If you take prescription medications regularly or want dental, vision, and hearing benefits, you should consider other plan options. Also, if you're managing a serious or ongoing health condition, out-of-pocket costs can add up. Extra coverage can help support your health and budget. Let us walk you through different plan types.

Smart Tip: At least 74% of people who have Original Medicare opt for additional coverage.1

Medicare Supplement Plans (Medigap)

 

You can add a Medicare Supplement plan to help pay for out-of-pocket costs like deductibles, copays, and coinsurance.

 

With these plans, you can go to any doctor or hospital in the U.S. that takes Medicare patients  – with no referral needed. This is a good choice if you travel or live in different places throughout the year.

 

You'll have to pay a monthly premium but it can help protect you from unexpected costs. Once you are enrolled, you must continue to pay your Original Medicare Part A and Part B monthly premiums. For most people, Part A is $0. Medicare Supplement plans don't include coverage for prescription drugs (Part D), dental, and vision. You may want to purchase plans for those benefits for an additional premium.

Smart Tip: If you miss your Medigap Open Enrollment Period, you may be denied coverage due to pre-existing conditions.

The best time to enroll in a Medicare Supplement plan is during the Medigap Open Enrollment Period. It is the six-month period beginning on the first day of the month you’re at least 65, and also enrolled in Medicare Part B.

 

NOTE: Anthem does not sell Medicare Supplement plans in the state of New York

Prescription Drug Plans (Part D)

 

Medicare Part D standalone plans can be added to your Original Medicare or Medicare Supplement plan to help cover the cost of your prescription drugs. Most Medicare Advantage plans include prescription drug Part D coverage.

 

Part D Covers

 

 

Part D Does Not Cover

 

 

Brand name medications

 

 

Over-the-counter medications

 

 

Generic prescriptions

 

 

Vitamins

 

 

All recommended vaccines

 

 

Fertility drugs

 

 

Medical supplies for insulin injections

 

 

Medications for anorexia or weight control

 

Depending on your income, you may qualify for Extra Help , a federal program that helps pay for Medicare Part D costs.

 

Explore Anthem Medicare Part D Plans 

Smart Tip: If you don't enroll when you're first eligible, you might be charged a Part D late enrollment penalty.

Medicare Advantage Plans (Part C)

 

Medicare Advantage plans provide all-in-one coverage that includes Part A, Part B, and most include prescription drugs (Part D). They typically offer $0 or low monthly premiums and benefits such as routine dental, vision, and hearing care, as well as fitness memberships.

 

You could also receive a spending allowance to pay for things like over-the-counter health items, groceries, and utilities, all managed with one convenient prepaid benefits card. Not all plans offer these benefits.

 

 

HMO vs. PPO Plan Types

 

When selecting a plan, you may have a choice between a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). Consider these differences to help you decide which is right for you:

 

Medicare Advantage (Part C)

 

 

HMO

 

 

PPO

 

 

Premium

 

 

Lower premiums and copays

 

 

Higher premiums and copays

 

 

Network

 

 

Requires patients to use in-network doctors and hospitals

 

 

Allows patients to visit out-of-network doctors and hospitals

 

 

Referrals

 

 

May need referrals from their primary care physician (PCP) to see a specialist

 

 

No referrals for specialists

 

Before you select a Medicare Advantage HMO plan, make sure your doctor is in-network. Even if you’re thinking about a PPO, you should still check to see if your doctors are in-network. It might save you money if they are.

 

Explore Anthem Medicare Advantage Plans 

Smart Tip: Out-of-pocket costs can vary by plan, so make sure the plan you select is a good fit for your budget.

Medicare Advantage Special Needs Plans (SNPs)

 

Some Medicare Advantage plans provide coverage for people with limited incomes or specific health needs. You will need to qualify for these plans.

 

Dual Special Needs Plans (D-SNPs)

 

 

Chronic Special Needs Plans (C-SNPs)

 

 

Institutional Special Needs Plans (I-SNPs)

 

 

For people who qualify for both Medicare and Medicaid

 

 

For people living with:
  • Diabetes 

  • Lung disorders

  • Chronic heart failure

  • End-stage renal disease (ESRD)

 

 

For people living in:
  • A long-term care facility

  • A nursing home

  • Those requiring mid-level care lasting 90 days or longer

 

Smart Tip:  Special Needs Plans offer extra support, including a care coordinator to help you develop and maintain your care plan.

Choosing And Comparing Plans

 

Which Plan Should You Choose?

 

Here's a simple checklist you can refer to with important things to consider when selecting plans.

 

Consider these costs

 

 

Are these in-network?

 

 

What benefits do you need?

 

 

Premiums

 

 

Doctors

 

 

Vision care

 

 

Copays

 

 

Specialists

 

 

Dental care

 

 

Deductibles

 

 

Hospitals

 

 

Hearing care

 

 

Prescription drug prices

 

 

Healthcare facilities

 

 

Fitness programs

 

 

Maximum out-of-pocket

 

 

Pharmacies

 

 

Allowances for extras like over-the-counter items, groceries, and transportation.

 

Compare Coverage By Plan
(Offered By Anthem)

 

Included

 

 

Original Medicare

 

 

Medicare Advantage (Part C)

 

 

Medicare Part D

 

 

Hospital and medical insurance

 

 

yes

 

 

yes

 

 

no

 

 

Prescription drugs

 

 

no

 

 

yes

 

 

yes

 

 

Limited annual out-of-pocket costs

 

 

no

 

 

yes

 

 

no

 

 

Dental, vision, hearing coverage

 

 

no

 

 

yes

 

 

no

 

 

Extra benefits

 

 

no

 

 

yes

 

 

no

 

 

$0 or low monthly premiums

 

 

 

 

yes

 

 

 

 

Access any doctor or hospital in the U.S. that accepts Medicare patients

 

 

yes

 

 

no

 

 

no

 

 

Network of providers and pharmacies

 

 

no

 

 

yes

 

 

yes

 

For Prescription Drug Plans (Part D) you must be enrolled in Original Medicare Part A and/or Part B, and continue to pay your Part A and/or Part B monthly premiums.

Smart Tip: Once enrolled in Medicare Advantage, you must continue to pay your Original Medicare Part A and Part B monthly premiums. For most, Part A is $0.

Eligibility And Enrollment

 

Are You Eligible For Medicare?

 

To be eligible for Medicare, you must be a U.S. citizen or legal permanent resident. Legal permanent residents must live in the U.S. for at least five continuous years prior to the month they apply for Medicare. You must also meet at least one of the following requirements:

  • Age 65 or older
  • Younger than 65 with a qualifying disability
  • Any age with a diagnosis of end-stage renal disease (ESRD) or Lou Gehrig's Disease (ALS)

Read Our Article About Medicare Eligibility 

Smart Tip: You must sign up for Parts A and B before you can choose a Medicare Advantage (Part C) plan.

Working After 65

 

You can enroll in all or part of Medicare even if you're still working. A Medicare plan could offer valuable benefits at no cost to you. Here are a few things to consider if you’re still working:

  • You don't have to enroll in Medicare when you turn 65 if you work for a company with 20 or more employees. Make sure you have adequate coverage through your employer if you are delaying enrollment.
  • If you work for a company with fewer than 20 employees or have an individual or family plan, you are required to enroll in Medicare at age 65 or face penalties.
  • You can no longer contribute to a Health Savings Account (HSA) if you enroll in any part of Medicare while you're still working. If you delay Medicare enrollment until after you turn 65, you’re required to stop contributing to your HSA at least six months before you enroll in Medicare.
  • You may be eligible for a Special Enrollment Period if you decide to wait to enroll in Medicare once your employer coverage ends.
  • You should always check with your employer's health plan administrator before making any changes to your coverage.

Smart Tip: If you have an individual policy, sign up for Original Medicare when you turn 65 to avoid a monthly Part B late enrollment penalty.

Where Do You Enroll?

 

For Original Medicare (Parts A & B)

 

Sign up for Original Medicare through the Social Security Administration. Here are three ways to enroll:

 

Online:

 

     Visit the official government website 

 

By Phone:

 

     1-800-772-1213 (TTY: 1-800-325-0778)

 

In-person:

 

     Find your nearest Social Security office 

 

 

For Anthem Medicare Plans

 

Once you've enrolled in Original Medicare, you can sign up for additional coverage, including Medicare Advantage (Part C) or Prescription Drug (Part D) plans. We’re here to help.

Smart Tip: If you’re receiving Social Security or Railroad Retirement Board benefits four months prior to your 65th birthday, you’ll be automatically enrolled in Original Medicare (Parts A and B).

When Can You Enroll?

 

You can sign up or change your Medicare coverage at different times, based on your situation. It's important to understand these enrollment periods, so you don't miss your opportunity to get the healthcare coverage you need.

 

Enrollment Periods

 

 

Time Frames

 

 

Action You Can Take

 

 

Initial Enrollment Period (IEP)

 

 

7 months

 

Starts 3 months before your 65th birthday month and ends three months after it

 

 

You can enroll

 

 

Annual Enrollment Period (AEP)

 

 

Oct. 15 - Dec. 7

 

 

You can add or change plans

 

 

General Enrollment Period (GEP)

 

 

Jan. 1 – March 31

 

 

You can enroll

 

 

Special Enrollment Period (SEP)

 

 

Based on life changes, like moving to a new area

 

 

You can add, drop, or change plans

 

 

Plan-Specific Enrollment Periods

 

  

  

 

Medicare Advantage Open Enrollment Period (OEP)

 

 

Jan. 1 - March 31

 

 

You can change or drop your Medicare Advantage plan one time only.

 

Smart Tip: Once you're enrolled in a Medicare plan, you are automatically renewed every year as long as your plan continues to be offered and you pay your premiums.

When Does Your Coverage Start?

 

Depending on the plan you choose and when you sign up, your benefits will begin at different times.


Plan Type


If You Signed Up...


Your Coverage Starts

 

Original Medicare

 

  

  

  

 

During your Initial Enrollment Period before your 65th birthday

 

 

The first day of your 65th birthday month. If your birthday comes on the first of the month, your coverage begins the first day of the previous month.

 

 

During your Initial Enrollment Period after you turn 65

 

 

The first day of the next month

 

 

Medicare Advantage and Part D

 

  

  

 

During Your Initial Enrollment Or Special Enrollment Period

 

 

Your birthday month or the first day of the next month

 

 

During Medicare Advantage Open Enrollment Period

 

 

The first day of the next month

 

 

During Annual Enrollment Period

 

 

January 1

 

 

Medicare Advantage Dual Special Needs Plan (D-SNP)

 

  

  

 

When you're first eligible

 

 

The first day of the next month

 

 

Once a quarter

 

 

The first day of the next month

 

 

Annual Enrollment Period

 

 

January 1

 

 

Medicare Supplement Plans

 

  

  

 

During your Initial Enrollment or Medigap Open Enrollment Periods

 

 

Your birthday month or the first day of the next month

 

 

Anytime

 

 

The first day of the next month

 

Ready to Enroll?

 

Talk one-on-one with a licensed agent: tel.

Employer To Medicare

 

 

Review these common considerations when moving from employer-provided coverage to Medicare.

 

Medicare And Your Health Savings Account (HSA)

 

If you have an HSA, stop adding to it six months before you enroll in Medicare to avoid a tax penalty. After enrolling in Medicare, you can use the money left in your HSA to pay for Medicare premiums, copays, deductibles, and coinsurance.

 

 

Medicare And Your Health Reimbursement Arrangement (HRA)

 

You can use an HRA to pay some medical expenses and Medicare premiums. However, be aware that your account won't be accessible once you stop working for the employer providing the HRA.

 

 

COBRA – Continuation Of Coverage

 

If you have COBRA, your coverage will stop when you become eligible for Medicare. Sign up during your Initial Enrollment Period  to avoid any gaps in coverage.

 

 

Coverage For Military Personnel (TRICARE)

 

If you are an active service member, at 65, you can sign up for Medicare during the Initial Enrollment Period and keep your TRICARE coverage into retirement.

 

 

If you're considering a Medicare Advantage plan, choose one without prescription drug coverage. Your TRICARE prescription drug coverage will likely be better.

Get More Resources And Support

Take a deeper dive into detailed information about plans, benefits, eligibility, and more.

Our plan recommendation tool will help you find a plan that’s right for you.

Need Help Or Ready To Shop?

Enter your Zip code below to find plans available in your area.

Have questions? Talk to a licensed agent:

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Original Medicare: Part A (Hospital Insurance) and Part B (Medical Insurance). 

 

1For example, 74% of Medicare beneficiaries were enrolled in Prescription Drug (Medicare Part D) coverage in 2019. Source: Assistant Secretary for Planning and Evaluation (ASPE) Office of Health Policy https://aspe.hhs.gov/sites/default/files/documents/f81aafbba0b331c71c6e8bc66512e25d/medicare-beneficiary-enrollment-ib.pdf

 

Anthem BlueCross BlueShield is a Medicare Advantage plan with a Medicare contract. Anthem BlueCross BlueShield Is a SNP plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Anthem BlueCross BlueShield depends on contract renewal.

 

Anthem BlueCross is a Medicare Advantage plan with a Medicare contract. Anthem BlueCross Is a SNP plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Anthem BlueCross depends on contract renewal.

 

Anthem does not sell Medicare Supplement plans in the state of New York.