What Is Medicare? Coverage, Parts & Basics

What Is Medicare?

Medicare is federal health insurance. Most people qualify at age 65. Some younger people qualify because of a disability or certain health conditions.

It helps pay for covered hospital care, doctor visits, preventive services, and prescription drugs. Your costs and what’s covered can change based on the plan you choose.

What Are The Four Parts Of Medicare?

Medicare has four main parts. Original Medicare includes Part A and Part B. Part C, also called Medicare Advantage, is another way to receive your Medicare benefits. Part D helps cover prescription drugs.

What Is Original Medicare?

Original Medicare is the traditional Medicare program provided by the federal government. It includes Part A, also called Hospital Insurance, and Part B, also called Medical Insurance.

With Original Medicare, you can visit any doctor or hospital in the United States that accepts Medicare. Original Medicare helps pay for many covered services, but it does not cover everything.

What Does Medicare Part A Help Cover?

Medicare Part A helps cover inpatient and facility-based care when you are formally admitted to a hospital or qualifying health care facility. You may have costs to pay, like a deductible and a share of the bill. Your costs can also change based on how long you get care.

• Inpatient hospital stays
• Skilled nursing facility care after a qualifying hospital stay
• Hospice care
• Some home health care

Most people pay a $0 monthly premium for Part A.

What Does Medicare Part A Not Cover?

Part A does not cover most outpatient or routine medical services. These may include doctor office visits, most routine dental, vision, and hearing services, most prescription drugs taken at home, and long-term custodial care.

Some of these services may be covered by Part B, Part D, Medicare Advantage, or other coverage options.

What Does Medicare Part B Help Cover?

Medicare Part B helps cover medically necessary outpatient services and preventive care. Most people pay a monthly cost for Part B. You may also pay a deductible each year and pay part of the cost when you get care.

• Doctor and specialist visits
• Outpatient hospital services
• Preventive care, screenings, and vaccines
• Mental and behavioral health services
• Durable medical equipment, such as wheelchairs or walkers
• Some diagnostic tests and ambulance services

What Does Medicare Part B Not Cover?

Part B does not cover every health care need. It generally does not cover routine dental care, routine vision exams, hearing aids, long-term custodial care, or most prescription drugs taken at home.

Original Medicare also does not include an annual out-of-pocket maximum, which is why some people choose additional coverage.

Why Are Medicare Part A and Part B Important?

Part A and Part B form Original Medicare and are the foundation for many other Medicare choices.

• Medicare Advantage (Part C): You must have Part A and Part B to join.
• Medicare Supplement (Medigap): You must have Part A and Part B to buy a policy.
• Part D prescription drug coverage: You must have Part A and/or Part B to enroll in a standalone drug plan.
• Dual-Eligible Special Needs Plans (D-SNPs): You must have Part A and Part B to join a D-SNP that coordinates Medicare and Medicaid benefits.

What Is Medicare Part C (Also Called Medicare Advantage)?

Medicare Part C, also called Medicare Advantage, is another way to receive your Medicare Part A and Part B benefits through a private insurance company approved by Medicare.

Medicare Advantage plans must cover the same services you need to diagnose or treat a health problem as Original Medicare. Many plans also include prescription drug coverage and additional benefits, such as dental, vision, or hearing coverage.

Plans can be different depending on where you live. For example, each plan may have different doctors you can use, different benefits, and different costs.

What Are the Different Types of Medicare Advantage Plans?

There are several types of Medicare Advantage plans. These are the most common:

• Health Maintenance Organization (HMO) plans: You usually use doctors in the plan’s network. You may need a referral to visit a specialist.
  
  
• Preferred Provider Organization (PPO) plans: You can visit doctors outside the network, but it might cost more. Referrals are usually not needed.
  
  
• Chronic Condition Special Needs Plans (C-SNPs): This Medicare Advantage plan is for people with certain long-term health conditions, like diabetes, heart disease, lung disease, or other ongoing issues. It will include extra support for that condition. 
  
  These plans are for people with certain long-term health problems, like diabetes, heart disease, or lung disease.
  
  
• Dual-Eligible Special Needs Plans (D-SNPs): This Medicare Advantage plan is for people who have both Medicare and Medicaid. It helps keep your benefits and care in one place.
  
  These plans are for people who have both Medicare and Medicaid. They help make sure the two programs work together.

What Is Medicare Part D Prescription Drug Coverage?

Medicare Part D is optional prescription drug coverage offered by private insurance companies approved by Medicare. It helps pay for covered prescription medications that are not covered under Original Medicare.

Part D coverage is available in two main ways:

• Standalone Part D plans, also called PDPs, that work with Original Medicare.
• Medicare Advantage plans with drug coverage, also called MAPD plans.

Part D plans use a list of drugs the plan helps pay for called a formulary. Costs and coverage rules vary by plan.

Anthem does not offer standalone Part D plans but nearly all our Medicare Advantage plans include prescription drug (Part D) coverage.

What Is Medicare Supplement (Also Called Medigap)?

Medicare Supplement insurance, also called Medigap, is private insurance that helps pay some out-of-pocket costs not covered by Original Medicare. These costs may include deductibles, copayments, and coinsurance.

Medigap works with Original Medicare. To buy Medigap, you must have Medicare Part A and Part B.

• Medigap can help lower your share of certain Original Medicare costs.
• You can see any provider that accepts Medicare.
• Plans are standardized by letter in most states, though availability and price vary.
• Medigap does not include prescription drug coverage, so you may need a separate Part D plan for medications.

What’s Next – Applying and Enrollment?

Ready to take the next step? Learn how to apply for Medicare and find out when you can enroll in Medicare. Understanding your enrollment options can help you avoid gaps in coverage and choose a plan that fits your needs.