Medicare is the U.S. government's health insurance program for people age 65 or older. Some people under age 65 can qualify for Medicare, too. They include those with disabilities, permanent kidney failure, or amyotrophic lateral sclerosis.

Medicare helps with the cost of health care. It does not cover all medical expenses or the cost of most long-term care. The program has four parts:

• Part A is hospital insurance
• Part B helps pay for medical services that Part A doesn't cover
• Part C is called Medicare Advantage. If you have Parts A and B, you can choose this option to receive all of your health care through a provider organization, like an HMO.
• Part D is prescription drug coverage. It helps pay for some medicines.

Medicare is the federal health insurance program for:

• People who are 65 or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

The different parts of Medicare help cover specific services:

• Medicare Part A (Hospital Insurance)
  Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
• Medicare Part B (Medical Insurance)
  Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
• Medicare Part D (prescription drug coverage)
  Helps cover the cost of prescription drugs (including many recommended shots or vaccines).

Most people don’t pay a monthly premium for Part A.

You usually don't pay a monthly premium for Part A if you or your spouse paid Medicare taxes while working for a certain amount of time. This is sometimes called "premium-free Part A."

If you don't qualify for premium-free Part A, you can buy Part A.

If you aren't eligible for premium-free Part A, you may be able to buy Part A. You'll pay up to $499 each month in 2022 ($506 in 2023). If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $499 ($506 in 2023). If you paid Medicare taxes for 30–39 quarters, the standard Part A premium is $274 ($278 in 2023).

Part A (Hospital Insurance) costs

Part A costs:	What you pay in 2022:
Premium	$0 for most people (because they or a spouse paid Medicare taxes long enough while working - generally at least 10 years). If you get Medicare earlier than age 65, you won’t pay a Part A premium. This is sometimes called “premium-free Part A.” Do I qualify for premium-free Part A? If you don’t qualify for premium-free Part A: You might be able to buy it. You’ll pay either $274 or $499 each month for Part A ($278 or $506 in 2023), depending on how long you or your spouse worked and paid Medicare taxes. Remember: You also have to sign up for Part B to buy Part A. If you don’t buy Part A when you’re first eligible for Medicare (usually when you turn 65), you might pay a penalty.
Deductible	$1,556 ($1,600 in 2023) for each inpatient hospital benefit period , before Original Medicare starts to pay. There’s no limit to the number of benefit periods you can have in a year. This means you may pay the deductible more than once in a year. How do benefit periods work?
Inpatient stay	Days 1-60: $0 after you pay your Part A deductible. Days 61-90: $389 copayment each day ($400 in 2023). Days 91-150: $778 copayment each day while using your 60 lifetime reserve days ($800 in 2023). After day 150: You pay all costs. What's not covered? What will I pay if I get mental health services as an inpatient?
Skilled nursing facility stay	Days 1-20: $0 copayment. Days 21-100: $194.50 copayment each day ($200 in 2023). Days 101 and beyond: You pay all costs.
Home health care	$0 for covered home health care services. 20% of the Medicare-approved amount for durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
Hospice care	$0 for covered hospice care services. You may also pay: A copayment of up to $5 for each prescription drug and other similar products for pain relief and symptom control while you're at home. What if my hospice care doesn't pay for my drug? 5% of the Medicare-approved amount for inpatient respite care . What's not covered?

Everyone pays a monthly premium for Part B.

Most people will pay the standard Part B premium amount. The standard Part B premium amount in 2022 is $170.10 ($164.90 in 2023). If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

Part B (Medical Insurance) costs

Part B costs:	What you pay in 2022:
Premium	$170.10 each month ($164.90 in 2023) (or higher depending on your income). The amount can change each year. You’ll pay the premium each month, even if you don’t get any Part B-covered services. Who pays a higher Part B premium because of income? You might pay a monthly penalty if you don’t sign up for Part B when you’re first eligible for Medicare (usually when you turn 65). You’ll pay the penalty for as long as you have Part B. The penalty goes up the longer you wait to sign up.
Deductible	$233 ($226 in 2023), before Original Medicare starts to pay. You pay this deductible once each year.
General costs for services (coinsurance)	Usually 20% of the cost for each Medicare-covered service or item after you’ve paid your deductible (and as long as your doctor or health care provider accepts the Medicare-approved amount as full payment – called “accepting assignment”).
Clinical laboratory services	$0 for covered clinical laboratory services.
Home health care	$0 for covered home health care services. 20% of the Medicare-approved amount for durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment).
Inpatient hospital care	20% of the Medicare-approved amount for most doctor services while you’re a hospital inpatient.
Outpatient mental health care	$0 for your yearly depression screening. 20% of the Medicare-approved amount for visits to your doctor or other health care provider to diagnose or treat your condition. If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional amount to the hospital.
Partial hospitalization mental health care	After you meet the Part B deductible: 20% of the Medicare-approved amount for each service you get from a doctor or certain other qualified mental health professional Coinsurance for each day of partial hospitalization services you get in a hospital outpatient setting or community mental health center
Outpatient hospital care	Usually 20% of the Medicare-approved amount for doctor and other health care providers’ services. You’ll also pay a copayment to the hospital for each service you get in a hospital outpatient setting (except for certain preventive services). In most cases, your copayment won’t be more than the Part A hospital stay deductible amount. This additional hospital copayment means you may pay more for an outpatient service you get in a hospital than you’d pay if you got the same service in a doctor’s office.

Get help with Part A & Part B costs
If you have limited income and resources, you may be able to get help from your state to pay your premiums and other costs.

With Medicare, you have options in how you get your coverage. Once you enroll, you’ll need to decide how you’ll get your Medicare coverage. There are 2 main ways:

Original Medicare

Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You pay for services as you get them. When you get services, you’ll pay a

deductible

at the start of each year, and you usually pay 20% of the cost of the Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D).

Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like copayments, coinsurance, and deductibles. Some Medigap policies also cover services that Original Medicare doesn't cover, like emergency medical care when you travel outside the U.S.

How Original Medicare works

Original Medicare is coverage managed by the federal government. Generally, there's a cost for each service. Here are the general rules for how it works:

Can I get my health care from any doctor, other health care provider, or hospital?

In most cases, yes. You can go to any doctor, health care provider, hospital, or facility that is enrolled in Medicare and accepting new Medicare patients.

Are prescriptions covered in Original Medicare?

With a few exceptions, most prescriptions aren't covered in Original Medicare. You can add drug coverage by joining a Medicare Drug Plan (Part D).

Do I need to choose a primary care doctor?

No, in Original Medicare you don't need to choose a primary care doctor.

Do I have to get a referral to see a specialist?

In most cases, no.

Should I get a supplemental policy?

You may already have employer or union coverage that may pay costs that Original Medicare doesn't. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy.

What else do I need to know about Original Medicare?

• You generally pay a set amount for your health care (deductible) before Medicare pays its share. Then, Medicare pays its share, and you pay your share (coinsurance / copayment) for covered services and supplies. There's no yearly limit for what you pay out-of pocket.
• You usually pay a monthly premium for Part B.
• You generally don't need to file Medicare claims. The law requires providers and suppliers to file your claims for the covered services and supplies you get. Providers include doctors, hospitals, skilled nursing facilities, and home health agencies.

Factors that affect Original Medicare out-of-pocket costs

• Whether you have Part A and/or Part B. Most people have both.
• Whether your doctor, other health care provider, or supplier accepts assignment.
• The type of health care you need and how often you need it.
• Whether you choose to get services or supplies Medicare doesn't cover. If you do, you pay all the costs unless you have other insurance that covers it.
• Whether you have other health insurance that works with Medicare.
• Whether you have Medicaid or get state help paying your Medicare costs.
• Whether you have a Medicare Supplement Insurance (Medigap) policy.
• Whether you and your doctor or other health care provider sign a private contract.

What is Part A (Hospital Insurance)?

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

What is Part B (Medical Insurance)?

Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

When can I join, switch, or drop a plan?

You can join, switch, or drop a Medicare Health Plan or a Medicare Advantage Plan (Part C) with or without drug coverage during these times:

• Initial Enrollment Period. When you first become eligible for Medicare, you can join a plan.
• Open Enrollment Period. From October 15 – December 7 each year, you can join, switch, or drop a plan. Your coverage will begin on January 1 (as long as the plan gets your request by December 7).
• Medicare Advantage Open Enrollment Period. From January 1 – March 31 each year, if you’re enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time. Note: You can only switch plans once during this period.

Learn more below about enrollment periods below.

When you first get Medicare (Initial Enrollment Periods for Part C & Part D)

I'm newly eligible for Medicare because I turned 65.

What can I do?

Sign up for a Medicare Advantage Plan and/or a Medicare drug plan.

When?

During the 7-month period that:

• Starts 3 months before the month you turn 65
• Includes the month you turn 65
• Ends 3 months after the month you turn 65

If you join	Your coverage begins
During one of the 3 months before you turn 65	The first day of the month you turn 65
During the month you turn 65	The first day of the month after you ask to join the plan
During one of the 3 months after you turn 65	The first day of the month after you ask to join the plan

I'm newly eligible for Medicare because I have a disability (under 65).

What can I do?

Sign up for a Medicare Advantage Plan or a Medicare drug plan. Your Medicare coverage begins 24 months after you get Social Security or Railroad Retirement Board (RRB) disability benefits.

When?

During the 7-month period that:

• Starts 3 months before your 25th month of getting Social Security or RRB disability benefits
• Includes your 25th month of getting disability benefits
• Ends 3 months after your 25th month of getting disability benefits

If you join	Your coverage begins
During one of the 3 months before you first get Medicare	The first day of your 25th month of entitlement to disability payments
During your 25th month of getting disability	The first day of the month after you ask to join the plan
During one of the 3 months after your 25th month of getting disability	The first day of the month after you ask to join the plan

I'm already eligible for Medicare because of a disability, and I turned 65.

What can I do?

• Sign up for a Medicare Advantage Plan and/or a Medicare drug plan.
• Switch from your current Medicare Advantage Plan or Medicare drug plan to another plan.
• Drop a Medicare Advantage Plan or a Medicare drug plan completely.

When?

During the 7-month period that:

• Starts 3 months before the month you turn 65
• Includes the month you turn 65
• Ends 3 months after the month you turn 65

If you join	Your coverage begins
During one of the 3 months before you turn 65	The first day of the month you turn 65
During the month you turn 65	The first day of the month after you ask to join the plan
During one of the 3 months after you turn 65	The first day of the month after you ask to join the plan

If you sign up for a Medicare Advantage Plan during this time, you can drop that plan any time during the next 12 months and go back to Original Medicare.

I don't have Medicare Part A, and I enrolled in Medicare Part B during the Part B General Enrollment Period (January 1–March 31).

What can I do?

Sign up for a Medicare drug plan.

When?

April 1–June 30

Your coverage will start July 1.

I have Medicare Part A coverage, and I enrolled in Medicare Part B during the Part B General Enrollment Period (January 1–March 31).

What can I do?

Sign up for a Medicare Advantage Plan (with or without drug coverage).

When?

April 1–June 30

Your coverage will start July 1.

During certain times each year (yearly enrollment periods for Part C & Part D)

Each year, you can make changes to your Medicare Advantage or Medicare drug coverage for the following year. There are 2 separate enrollment periods each year:

Open Enrollment Period for Medicare Advantage and Medicare drug coverage.

What can I do?

• Change from Original Medicare to a Medicare Advantage Plan.
• Change from a Medicare Advantage Plan back to Original Medicare.
• Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.
• Switch from a Medicare Advantage Plan that doesn't offer drug coverage to a Medicare Advantage Plan that offers drug coverage.
• Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn't offer drug coverage.
• Join a Medicare drug plan.
• Switch from one Medicare drug plan to another Medicare drug plan.
• Drop your Medicare drug coverage completely.

When?

October 15–December 7

Your coverage will start January 1.

Medicare Advantage Open Enrollment Period.

Enrollment Period

Medicare Advantage Open Enrollment Period

What can I do?

• If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage).
• You can drop your Medicare Advantage Plan and return to Original Medicare. You'll also be able to join a separate Medicare drug plan.

What can't I do?

• Switch from Original Medicare to a Medicare Advantage Plan.
• Join a Medicare drug plan if you're in Original Medicare.
• Switch from one Medicare drug plan to another if you're in Original Medicare

Note
If you enrolled in a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare.

When?

January 1–March 31

Your coverage will start the first day of the month after you ask to join the plan.

How to switch

If you're already in a Medicare Advantage Plan and want to switch, follow these steps:

• To switch to a new Medicare Advantage Plan, simply join the plan you choose during one of the enrollment periods. You'll be disenrolled automatically from your old plan when your new plan's coverage begins.
• To switch to Original Medicare, contact your current plan, or call us at 1-800-MEDICARE.

Unless you have other drug coverage, you should carefully consider Medicare prescription drug coverage (Part D). You may also want to consider a Medicare Supplement Insurance (Medigap) policy. Remember, you may only be able to switch at certain times of the year.

If you have other coverage

Talk to your employer, union, or other benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose employer or union coverage. If you lose coverage for yourself, you may also lose coverage for your spouse and dependents.

In other cases, you may still be able to use your employer or union coverage along with the Medicare Advantage plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back.

Medicare fraud and abuse can happen anywhere, and usually results in higher health care costs and taxes for everyone. Some examples include:

• A provider that bills Medicare for services or supplies they never gave you, like charging you for a visit you never had, or a back brace you never got.
• A provider that charges Medicare twice for a service or item that you only got once.
• A person who steals your Medicare number or card and uses it to submit fraudulent claims in your name.
• A company that offers you a Medicare drug plan that Medicare hasn’t approved.

Remember: Medicare covers the COVID-19 vaccine at no cost to you, so if anyone asks you for your Medicare Number to get the vaccine or a free COVID-19 test, it’s likely a scam.

How to spot & prevent Medicare fraud & abuse

If you think you’ve spotted fraud, you may want to call your provider’s office to ask about it. They may be able to help you understand the charges, or figure out if they made a billing error.

If you suspect that Medicare is being charged for an item or service you didn't get, or your Medicare card or number is stolen, use the contact information below to report suspected fraud or abuse.

When you call, have this information ready:

• Your name and Medicare Number.
• The name of the provider that you’re reporting, along with any identifying information you may have.
• The service or item you’re questioning and when you supposedly got it.
• The amount that Medicare approved and paid.
• The date on your Medicare Summary Notice, health or drug plan's Explanation of Benefits, or claim.

Protecting yourself from identity theft

Identity theft is a serious crime that happens when someone uses your personal information without your consent to commit Medicare fraud or other crimes. Use the following tips to protect yourself from becoming an identity theft victim.

Do:

• Protect your Medicare Number and your Social Security Number.
• Guard your Medicare card like it’s a credit card.
• Become familiar with how Medicare uses your personal information. If you join a Medicare health or drug plan, the plan will let you know how it will use your personal information.
• Remember that Medicare will never call you to sell you anything or visit you at your home. Medicare, or someone representing Medicare, will only call and ask for personal information in these 2 situations:
  1. A Medicare health or drug plan may call you if you’re already a member of the plan. The agent who helped you join can also call you.
  2. A customer service representative from 1-800-MEDICARE can call you if you’ve called and left a message or a representative said that someone would call you back.
• Contact the Federal Trade Commission if you think you’ve been a victim of identity theft.

Don’t:

• Give your Medicare card, Medicare Number, Social Security card, or Social Security Number to anyone except your doctor or people you know should have it (like insurers acting on your behalf or people who work with Medicare, like your State Health Insurance Assistance Program (SHIP).
• Accept offers of money or gifts for free medical care.
• Allow anyone, except your doctor or other Medicare providers, to review your medical records or recommend services.
• Join a Medicare health or drug plan over the phone unless you called us.

A Medicare Advantage is another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you'll still have Medicare but you'll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.

These "bundled" plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare drug coverage (Part D).

Covered services in Medicare Advantage Plans

With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn't cover, like fitness programs (gym memberships or discounts) and some vision, hearing, and dental services (like routine check ups or cleanings). Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.

Rules for Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs

. They can also have different rules for how you get services, like:

• Whether you need a referral to see a specialist
• If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care

These rules can change each year.

Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors. In most cases, you’ll need to use health care providers who participate in the plan’s network. Some plans won’t cover services from providers outside the plan’s network and service area.

Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for all Part A and Part B services. Once you reach this limit, you’ll pay nothing for services Part A and Part B cover.

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare drug plan with certain types of plans that:

• Can’t offer drug coverage (like Medicare Medical Savings Account plans)
• Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:

• You’re in a Medicare Advantage HMO or PPO.
• You join a separate Medicare drug plan.

Note: If you join an HMO or PPO that doesn't cover drugs, you can't join a separate Medicare drug plan. In this case, either you'll need to use other prescription drug coverage you have (like employer or retiree coverage), or go without drug coverage.

If you decide not to get Medicare drug coverage when you’re first eligible and your other drug coverage isn’t creditable prescription drug coverage, you may have to pay a late enrollment penalty if you join a plan later.

How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans

You can’t buy (and don't need) Medigap while you’re in a Medicare Advantage Plan. You can’t use Medigap to pay for any costs (

copayments, deductibles, and premiums) you have under a Medicare Advantage Plan.

How to switch

If you're already in a Medicare Advantage Plan and want to switch, follow these steps:

• To switch to a new Medicare Advantage Plan, simply join the plan you choose during one of the enrollment periods. You'll be disenrolled automatically from your old plan when your new plan's coverage begins.
• To switch to Original Medicare, contact your current plan, or call us at 1-800-MEDICARE.

Unless you have other drug coverage, you should carefully consider Medicare prescription drug coverage (Part D). You may also want to consider a Medicare Supplement Insurance (Medigap) policy. Remember, you may only be able to switch at certain times of the year.

If you have other coverage

Talk to your employer, union, or other benefits administrator about their rules before you join a Medicare Advantage Plan. In some cases, joining a Medicare Advantage Plan might cause you to lose employer or union coverage. If you lose coverage for yourself, you may also lose coverage for your spouse and dependents.

In other cases, you may still be able to use your employer or union coverage along with the Medicare Advantage plan you join. Remember, if you drop your employer or union coverage, you may not be able to get it back.

You can generally join one of these Medicare Advantage Plans:

• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Private Fee-for-Service (PFFS)
• Medical Savings Account (MSA) Plan

If all of these apply:

• You live in the service area of the plan you want to join. The plan can give you more information about its service area. If you live in another state for part of the year, ask if the plan will cover you there.
• You have Medicare Part A and Part B.
• You're a U.S. citizen or lawfully present in the U.S.

In HMO Plans, you generally must get your care and services from doctors, other health care providers, and hospitals in the plan's network, except:

• Emergency care
• Out-of-area urgent care
• Temporary out-of-area dialysis

HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when the plan requires it.

Are prescription drugs covered in Health Maintenance Organization (HMO) Plans?

In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want

Medicare drug coverage (Part D)

, you must join an HMO Plan that offers prescription drug coverage. If you join an HMO plan without drug coverage, you can’t join a separate Medicare drug plan.

Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans?

In most cases, yes, you need to choose a primary care doctor in HMO Plans.

Do I have to get a referral to see a specialist in Health Maintenance Organization (HMO) Plans?

In most cases you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly screening mammograms, don't require a referral.

What else do I need to know about this type of plan?

• If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
• If you get health care outside the plan's

  network

  , you may have to pay the full cost.
• It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.

How PPO Plans Work

A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PPO Plans have network doctors, other health care providers, and hospitals. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You can also use out‑of‑network providers for covered services, usually for a higher cost, if the provider agrees to treat you and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services). You’re always covered for emergency and urgent care.

Can you get your health care from any doctor, other health care provider, or hospital?

In most cases, you can get your health care from any doctor, other

health care provider, or hospital in PPO Plans. Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.

Are prescription drugs covered?

In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a

Medicare drug plan (Part D).

Do you need to choose a primary care doctor?

You don't need to choose a primary care doctor in PPO Plans.

Do you have to get a referral to see a specialist?

In most cases, no. But if you use plan specialists (in-network), your costs for covered services will usually be lower than if you use non-plan specialists (out-of-network).

What else do you need to know about this type of plan?

• Because certain providers are “preferred,” you can save money by using them.
• Check with the plan for more information.

How PFFS Plans Work

A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Can I get my health care from any doctor, other health care provider, or hospital?

In some cases, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans.

If you join a PFFS Plan that has a contracted network of providers, you can also see any of the network providers who have agreed to always treat plan members. If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your plan may not cover your services, or your costs could be higher.

Are prescription drugs covered?

Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn't offer drug coverage, you can join a separate Medicare Drug Plan (Part D) to get coverage.

Do I need to choose a primary care doctor?

You don't need to choose a primary care doctor in PFFS Plans.

Do I have to get a referral to see a specialist?

You don't have to get a referral to see a specialist in PFFS Plans.

What else do I need to know about this type of plan?

• The plan decides how much you pay for services. The plan will tell you about your cost sharing in the “Annual Notice of Change” and “Evidence of Coverage” documents that it sends each year.
• Some PFFS Plans contract with a network of providers who agree to always treat you even if you’ve never seen them before.
• Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
• For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms.
• In an emergency, doctors, hospitals, and other providers must treat you.
• Show your plan membership ID card each time you visit a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment. You can’t use your red, white, and blue Medicare card to get heath care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS Plan. Keep your Medicare card in a safe place in case you return to Original Medicare in the future.
• Check with the plan for more information.

What's a Medicare MSA Plan?

Medicare works with private insurance companies to offer you ways to get your health care coverage. These companies can choose to offer a consumer-directed Medicare Advantage Plan, called a Medicare MSA Plan. These plans are similar to Health Savings Account Plans available outside of Medicare. You can choose your health care services and providers (MSA plans usually don’t have a network of doctors, other health care providers, or hospitals).

Medicare MSA Plans have 2 parts

Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs.

1. High-deductible health plan: The first part is a special type of high-deductible

   Medicare Advantage Plan (Part C). The plan will only begin to cover your costs once you meet a high yearly deductible, which varies by plan.

2. Medical Savings Account (MSA): The second part is a special type of savings account. The Medicare MSA Plan deposits money in a special savings account for you to use to pay health care expenses. The amount of the deposit varies by plan. You can use this money to pay your Medicare-covered costs before you meet the deductible.

How do MSA Plans work?

Read about basic steps for using a Medicare MSA Plan.

What's covered?

Medicare MSA plans cover the Medicare services that all Medicare Advantage Plans must cover. In addition, some Medicare MSA plans may cover some extra benefits like dental, vision, and hearing services. You may pay a premium for this extra coverage.

Contact plans in your area for more information on what extra benefits they cover, if any.

Medicare MSA Plans don't cover Medicare Part D prescription drugs

If you join a Medicare MSA Plan and want Medicare drug coverage, you'll have to join a separate Medicare drug plan. To find available plans in your area, you can:

• Visit the Medicare Plan Finder.
• Call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.
• Look at the back of your "Medicare & You" handbook.

MSA plans don’t charge a premium, but you must continue to pay your Part B premium.

Some types of Medicare health plans that provide health care coverage aren't Medicare Advantage Plans but are still part of Medicare. Some of these plans provide

Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, while most others provide only Part B coverage. Some also provide Medicare drug coverage (Part D).

These plans have some of the same rules as Medicare Advantage Plans. However, each type of plan has special rules and exceptions, so contact any plans you're interested in to get more details.

Medicare Cost Plans

Medicare Cost Plans are a type of Medicare health plan available in certain, limited areas of the country.

• In general, you can join even if you only have Part B.
• If you have Part A and Part B and go to a non-network provider, Original Medicare covers the services. You’ll pay the Part A and Part B Coinsurance and Deductible.
• You can join anytime the Medicare Cost Plan is accepting new members.
• You can leave anytime and return to Original Medicare.
• You can join a separate Medicare drug plan or you can get drug coverage from the Cost Plan (if offered). Even if the Cost Plan offers drug coverage, you can choose to get drug coverage from a separate Medicare drug plan.

You can add or drop Medicare drug coverage only at certain times.

Another type of Medicare Cost Plan only provides coverage for Part B services. These plans never include Part D. Part A services are covered through Original Medicare. These plans are either sponsored by employer or union group health plans or offered by companies that don't provide Part A services.

Demonstrations/pilot programs

Demonstrations and pilot programs, (also called “research studies”) are special projects that test improvements in Medicare coverage, payment, and quality of care. They usually operate only for a limited time for a specific group of people and/or are offered only in specific areas. Check with the demonstration or pilot program for more information about how it works. To find out about current Medicare demonstrations and pilot programs, call us at 1-800-MEDICARE.

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

PACE (Program of All-inclusive Care for the Elderly) is a Medicare/Medicaid program that helps people meet health care needs in community.

Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.

With PACE, you have a team of health care professionals working with you and your family to make sure you get the coordinated care you need. Usually they care for a small number of people, so they really get to know you.

When you enroll in PACE, you may be required to use a PACE-preferred doctor.

How does PACE work?

PACE covers all Medicare- and Medicaid-covered care and services, and other services that the PACE team of health care professionals decides are necessary to improve and maintain your health. This includes drugs, as well as any other medically necessary care, like doctor or health care provider visits, transportation, home care, hospital visits, and even nursing home stays when necessary.

If you have Medicaid, you won’t have to pay a monthly premium for the long‑term care portion of the PACE benefit. If you have Medicare but not Medicaid, you’ll be charged a monthly premium to cover the long‑term care portion of the PACE benefit and a premium for Medicare drug coverage (Part D). However, in PACE, there’s never a deductible or copayment for any drug, service, or care approved by the PACE team of health care professionals.

Who can get PACE?

You can have either Medicare or Medicaid, or both, to join PACE. PACE is only available in some states that offer PACE under Medicaid. To qualify for PACE, you must:

• Be 55 or older
• Live in the service area of a PACE organization
• Need a nursing home-level of care (as certified by your state)
• Be able to live safely in the community with help from PACE

What does PACE cover?

PACE provides all the care and services covered by Medicare and Medicaid if authorized by your health care team. If your health care team decides you need care and services that Medicare and Medicaid doesn't cover, PACE may still cover them.

Here are some of the services PACE covers:

• Adult day primary care (including doctor and recreational therapy nursing services)
• Dentistry
• Emergency services
• Home care
• Hospital care
• Laboratory/x-ray services
• Meals
• Medical specialty services
• Nursing home care
• Nutritional counseling

• Occupational Therapy

• Physical therapy
• Prescription drugs

  Note
  If you join a PACE program, you'll get your Part D-covered drugs and all other necessary medication from the PACE program. You don't need to join a separate Medicare Prescription Drug Plan. If you do, you'll be disenrolled from your PACE health and prescription drug benefits.

• Preventive care
• Social services, including caregiver training, support groups, and

  respite care

• Social work counseling
• Transportation to the PACE center for activities or medical appointments, if medically necessary. You may also be able to get transportation to some medical appointments in the community.

How to apply for PACE

To find out if you’re eligible and if there’s a PACE program near you, search for PACE plans in your area, or call your Medicaid office.

What you pay for PACE depends on your financial situation

If you have Medicaid, you won't pay a monthly premium for the long-term care portion of the PACE benefit.

If you don't qualify for Medicaid but you have Medicare, you'll be charged these:

• A monthly premium to cover the long-term care portion of the PACE benefit
• A premium for Medicare Part D drugs

There's no deductible or copayment for any drug, service, or care approved by your health care team.

If you don't have Medicare or Medicaid, you can pay for PACE privately.

People representing Medicare plans aren't allowed to:

• Ask for your personal information (like your Medicare, Social Security, bank account, or credit card numbers) over the phone unless it’s needed to verify membership, determine enrollment eligibility, or process an enrollment request. Plans don't need your personal information to give a quote.

  Note
  If you applied for Extra Help paying for Medicare prescription drug coverage, someone from the plan may contact you if any information is missing from your application.

• Come to your home uninvited to sell or endorse anything.
• Call you unless you’re already a member of the plan. If you’re a member, the agent who helped you join can call you.
• Require you to speak to a sales agent to get information about the plan.
• Offer you cash (or gifts worth more than $15) to join their plan or give you free meals during a sales pitch for a Medicare health or drug plan.
• Ask you for payment over the phone or online. The plan must send you a bill.
• Tell you that they're Medicare supplement insurance (Medigap) policies.
• Sell you a non-health related product, like an annuity or life insurance policy, during a sales pitch for a Medicare health or drug plan.
• Make an appointment to tell you about their plan unless you agree. During the appointment, they can only try to sell you the products you agreed to hear about.
• Talk to you about their plan in areas where you get health care like an exam room, hospital patient room, or at a pharmacy counter.
• Market their plans or enroll you during an educational event like a health fair or conference.

Independent agents and brokers selling plans must be licensed by the state, and the plan must tell the state which agents are selling their plans.

Rules for meeting with an agent

If you're going to meet with an agent, the agent must follow all the rules for Medicare plans and some specific rules for meeting with you.

During the meeting, Medicare plans and people who work with Medicarecan:

• Give you plan materials.
• Tell you about the plan options and how to get more plan information.
• Give you an enrollment form.
• Collect your completed enrollment form.
• Leave business cards for you to give to friends and family.

During the meeting, Medicare plans and people who work with Medicare can't:

• Charge you a fee to process your enrollment into a plan.
• Steer you into a particular plan.
• Communicate incorrect information about their plan type or use inappropriate statements like their plan is "the best" or "highest ranked."
• Tell you about other plan options you haven't agreed to discuss, unless you specifically ask about them (to discuss these options, you need to complete a separate appointment form).
• Pressure you to join their plan by saying things like "you have to join this plan or you won't have coverage next year."
• Ask you to give names and phone numbers or addresses so they can sell to your friends or family.
• Ask you to sign the enrollment form before you’re ready to join.

After the meeting:

• The plan will contact you to make sure you want to join and that you understand how the plan works.
• The agent who helped you join the plan can call you to talk about other plan options.

Extra rules for agents selling Medicare Private-Fee-For-Service (PFFS) Plans

Agents selling Medicare PFFS Plans must:

• Give you written information with a complete description of how the plan works.
• Make clear that there's no guarantee that your doctor or hospital will agree to accept the plan's terms and conditions or provide you with treatment if you join the plan.
• Send you a letter if they can't reach you by phone with instructions on how to disenroll if you change your mind.
• Have people available to answer any questions from you, your doctor, or other providers about the plan.

Kidney failure treatment—hemodialysis, peritoneal dialysis, and kidney transplantation—is expensive. Many people with kidney failure need help paying for their care.

For many people with kidney failure, the Federal Government—through Medicare—helps pay for much of the cost of their treatment. The U.S. Congress passed the Social Security Amendments of 1972 that guarantee Medicare coverage for most people with kidney failure—even those under age 65.

You can also find financial help for kidney failure treatment from other sources, such as joint federal-state programs, private health insurance, private organizations, and medication assistance programs.

The amount you pay for premiums, copays, coinsurance, deductibles, prescriptions, and other costs is based on the services and medicines you need and the health care coverage you have. You can live for years with kidney failure, so it’s important that you get help to pay for your treatment.

Learn key terms about kidney failure costs, insurance, and financial aid.

Federal Government health insurance

What is Medicare?

Medicare is a federal health insurance program that pays health care costs for eligible people who are

• age 65 or older
• under age 65 with certain disabilities and those who have received Social Security Disability Insurance (SSDI) for 2 years
• of any age with end-stage renal disease (ESRD)—permanent kidney failure treated with a kidney transplant or blood-filtering treatments called dialysis

How can I get Medicare for kidney failure?

Visit Medicare.gov and search on “I have end-stage renal disease” to find information about whether you qualify for Medicare and how to sign up.

What health plans does Medicare offer?

Medicare has two main ways to get coverage—Original Medicare, which includes Part A and Part B, or a Medicare Advantage Plan, also called Part C. You can also choose to have prescription drug coverage through Medicare Part D.

Most people with kidney failure are not allowed to join a Medicare Advantage plan. However, beginning in 2021, the 21st Century Cures Act will allow people with ESRD to choose a Medicare Advantage plan instead of Original Medicare. Medicare Advantage plans may limit where you get care, but they cap out-of-pocket costs. With Original Medicare, there is no cap on out-of-pocket costs, but you can get care anywhere that Medicare is accepted.

You can find out more about the Medicare health plans by visiting Medicare.gov and searching on “ESRD,” then clicking on “Signing up for Medicare if you have ESRD.”

Other Medicare health plans are available that have special rules or are for specific groups of people. Medicare offers more information about these alternate plans online.

Learn more about Medicare benefits, rules, and coverage details at Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048).

When does Medicare coverage start for people with ESRD?

If kidney failure is the only reason you are signing up for Medicare, your Medicare start date will depend on the type of kidney failure treatment you receive. Find out more about when your Medicare coverage may start.

When does Medicare coverage end for people with ESRD?

If kidney failure is the only reason you have Medicare, your coverage end date will depend on whether you had a kidney transplant or dialysis treatment. Learn more about when your Medicare coverage will end.

Medicare coverage will not end if you are eligible because of age or disability.

How does Medicare coordinate with other coverage?

Learn more about which insurance pays first if you have Medicare and other health coverage.

Where can I get more information about Medicare’s kidney failure treatment coverage?

You can find more information about Medicare’s kidney failure treatment coverage from the following resources

• Medicare Coverage of Kidney Dialysis & Kidney Transplant Services (PDF, 1.47 MB)
• Getting Started: Medicare’s Coverage of Dialysis & Kidney Transplant Benefits (PDF, 3.92 MB)
• Getting Started: Medicare for Children with End-Stage Renal Disease (PDF, 3.55 MB)

Joint federal-state programs

You may also be able to get help paying for your kidney failure treatment from one or more programs that are run jointly by the Federal Government and state governments, including Medicaid and the Children’s Health Insurance Program (CHIP).

What is Medicaid?

Medicaid provides free or low-cost health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Each state runs its own Medicaid program based on rules set by the Federal Government. Medicaid may pay for services that Medicare does not.

Find out whether you qualify for Medicaid in your state and learn how to apply at

• Healthcare.gov, 1-800-318-2596 (TTY: 1-855-889-4325)
• National Association of Medicaid Directors state agency locator

Learn more at Medicaid.gov or call 1-877-267-2323 (TTY: 866-226-1819).

What is the Children’s Health Insurance Program (CHIP)?

CHIP offers free or low-cost Medicaid to children whose parents earn too much for Medicaid but not enough to pay for a private health plan. CHIP is run by the states, based on federal rules. In some states, CHIP may cover pregnant women and parents. Find out if your family members qualify for CHIP through Healthcare.gov or your state’s Medicaid or CHIP agency.

Learn more about CHIP at InsureKidsNow.gov, or call 1-877-543-7669.

Other federal programs

What other federal programs can help?

The Social Security Administration can provide financial help through two programs—Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).

• SSDI pays a monthly amount to people who can’t work and have paid enough Social Security taxes. If you have an illness or injury that Social Security believes will keep you out of work for at least a year, SSDI payments may be an option. There is a 5-month waiting period before SSDI payments begin.
• SSI pays a monthly amount to disabled children and adults who earn little and don’t have many financial assets. A person who gets SSI may be able to get food stamps and Medicaid, too.

Read more about both SSDI and SSI and learn how to apply at SSA.gov or by calling 1-800-772-1213 (TTY: 1-800-325-0778).

Other state programs

What other state programs can help?

Medicare Savings Programs are programs in which your state may pay your Medicare premiums, deductibles, and/or coinsurance if you have a low income and few assets. How Medicaid works in U.S. territories varies. Learn more about how your state Medicaid works online.

State Health Insurance Assistance Programs (SHIPs) give local advice about health insurance to people who have Medicare or who are eligible for Medicare. SHIP counselors can help you choose the best plan for your needs. Find a SHIP counselor at shiptacenter.org or call 1-877-839-2675.

State kidney programs provide financial help and other services to people with kidney disease. Talk with your dialysis or transplant clinic social worker or financial counselor to find out if your state has a kidney program.

State Pharmaceutical Assistance Programs (SPAPs) help pay for prescription medicines in certain states. Learn what’s available in your state with the SPAP online locator.

Private health insurance

What types of private health insurance can help?

Some people with kidney failure use private health insurance to help pay for their health care

• Group health insurance. People buy this kind of health insurance through their employer, union, or a family member’s employer or union.
  
  Group health plans pay for the first 30 months from the time you become eligible for Medicare for kidney failure. After that, a group plan can work with Medicare to help pay for costs that aren’t paid for by Medicare, such as copays, coinsurance, and deductibles. If you have or are eligible for group health insurance, you can contact the benefits administrator at the company or union that provides your insurance to find out what the plan covers and how it works with Medicare.
• Individual health insurance. People buy this coverage for themselves and their families.
  • The Health Insurance Marketplace offers health insurance plans to people who are legally present in the United States and who don’t have any other health insurance options. You can find, compare, and buy individual insurance plans in most states—or connect to your state’s insurance marketplace—at HealthCare.gov.
    
    You cannot enroll in a Health Insurance Marketplace plan if you already have Medicare. Some people choose to keep their Marketplace plan instead of enrolling in Medicare. You may pay more for Medicare later if you don’t enroll in Medicare when you first become eligible.
  • Insurance companies, agents, brokers, and online insurance stores are other ways to find and buy individual health insurance plans. Learn how to find a trustworthy insurance company at USA.gov or by calling 1-844-USA-GOV1 (1-844-872-4681).
• Medigap, also called Medicare Supplemental Insurance. People buy this extra health insurance from a private company. Medigap plans help cover some costs that are not covered by Original Medicare, such as copays, coinsurance, and deductibles. If you’re 65, federal law protects your right to buy a Medigap plan. If you’re under 65 and are on dialysis, you may or may not be able to buy a Medigap policy from a licensed insurance company in your home state. Learn more online about Medigap rules, benefits, deadlines, and premiums.

Help for special populations

What help is available for special populations?

There are programs that help people who are members of specific populations

• U.S. veterans can get help with health costs from the U.S. Department of Veterans Affairs.
• Active-duty service members, military retirees, and their families may be able to get health care coverage through TRICARE.
• American Indians and Alaska Natives may be able to get help from the Indian Health Service.
• People with disabilities can find help from the U.S. Department of Labor, which offers resources such as information on benefits, civil rights, and employment.
• Job seekers with disabilities, including those with kidney failure, may find help with job training and support from the Social Security Administration’s Ticket to Work Program.
• People in need of a kidney transplant can get information on organ transplant from the United Network for Organ Sharing (UNOS) (PDF, 1.01 MB) , a government-sponsored organization that manages the nation’s organ transplant system.
• Potential organ donors who want to donate an organ—but cannot afford to—can apply for help to pay travel and living costs from the National Living Donor Assistance Program.

Help from private organizations

What private organizations can help?

Private organizations such as charities and foundations can help people with kidney disease and kidney failure. The National Kidney Foundation provides patient education, advocacy, and, in some cases, limited financial help, scholarships, or both (call 1-800-622-9010).

Help paying for medicines

Talk with your health care team if you have trouble paying for your medicines, including asking about cheaper options. Your team may suggest other ways to cut your costs, such as using mail-order pharmacies or contacting local aid programs.

Drug discount programs may help you find the medicines you need for free or at a lower cost. Try these resources

• BenefitsCheckUp. Seniors with limited incomes can search for help with medicines, health care, rent, and other needs through this service of the National Council on Aging.
• Blink Health. Blink Health has negotiated prices for 15,000 medicines that may cost less than you’d pay with your insurance online or at your local pharmacy.
• GoodRx. GoodRx compares prices and provides coupons for FDA-approved drugs at over 70,000 pharmacies. Your medicines may cost less with the coupon than with your insurance.
• Medicine Assistance Tool. Some drug manufacturers have programs that provide free or low-cost drugs to people who meet their guidelines.
• NeedyMeds. This organization lists programs that help pay for medicines and supplies. You can search by medicine or manufacturer name.
• RxAssist. An online resource that lists drug company assistance programs, state programs, discount drug cards, copay help, and more.
• Rx Outreach. A nonprofit, mail-order pharmacy that provides affordable medicine to people in need through its website or by phone at 1-888-RXO-1234 (1-888-796-1234).
• State Pharmaceutical Assistance Program. Some states have programs that limit drug costs for people with limited income or who are elderly.

Key Terms

Some terms listed here have many meanings; only those meanings that relate to the financial and medical aspects of kidney failure and its treatment are included.

coinsurance: an amount a person may still need to pay after a deductible for health care. The amount is most often a percentage, such as 20 percent.

coordination period: if a person has more than one health plan, a coordination period is used to figure out which plan pays first and for how long. For example, if a person has an employer group plan and Medicare, the employer group plan is the first payer for the first 30 months the person is eligible for Medicare.

copay (or copayment): an amount a person may have to pay for health care. A copay is often a set fee. A person might pay $10 or $20 for a health care provider visit or prescription.

deductible: an amount a person must pay for health care or prescriptions before the health plan(s) will pay.

network: a group of health care providers that gives members a discount. Some plans pay for health care and prescriptions only if received from a network provider.

out of network: health care providers who are not in a plan’s network. In some health plans, health care and prescriptions cost more if received from these providers.

premium: an amount a person must pay periodically—monthly or quarterly—for Medicare, another health plan, or drug plan coverage.

social worker: a person who is trained to help people solve problems in their daily lives, especially people with disabilities or low incomes. A social worker may help with financial, employment, and emotional issues. Dialysis clinics and transplant centers must have a social worker with a Master of Social Work degree to help their patients.