Medicare 101

A type of Medicare health plan available in some service areas. If a member receives services outside of the plan's provider network without prior authorization or a referral, their Medicare-covered services will be reimbursed according to the Original Medicare fee schedule. The Cost Plan will cover emergency services or urgent care needs.

With most HMO-based Medicare Advantage plans, enrollees generally receive covered healthcare services from medical providers who are members of the plan's network, except in emergency situations. Additionally, many HMO plans require an enrollee to obtain a referral from their designated primary care physician prior to receiving specialty or hospital-based care. These types of HMO-based Medicare Advantage plans are offered in select areas.

Medicare Savings Account (MSA) plans pair a high-deductible Medicare Advantage insurance plan with a dedicated financial account. Medicare deposits funds into this account to help cover medical costs. Enrollees can access this money to pay for healthcare expenses, though only costs pertaining to Medicare-covered services will accumulate toward satisfying the plan deductible.

Some areas of the United States offer a Medicare Advantage plan where members pay lower costs when utilizing healthcare services from physicians, facilities, and providers within the plan's covered network. While out-of-network care is also available, members would be subject to additional expenses when receiving care outside of the preferred network.

A Private Fee-For-Service plan is a type of Medicare Advantage plan where the plan determines reimbursement levels for healthcare providers and the patient cost-sharing amounts for received medical services. This plan model differs significantly from Original Medicare, and enrollees must carefully adhere to the specific rules of their Private Fee-For-Service plan. Within this plan structure, an individual's out-of-pocket expenses for Medicare-covered benefits may be more or less than under Original Medicare. Close attention to plan benefit designs and network status is important for Private Fee-For-Service enrollees.

State-administered programs that provide financial assistance to individuals with limited means, enabling them to offset some or all Medicare premiums, deductibles, and coinsurance.

A type of Medigap policy that may require the policyholder to utilize in-network hospitals and, if applicable, in-network physicians in order to qualify for full insurance benefits.

A Medicare Advantage plan that provides targeted and specialized healthcare to specific patient populations, such as individuals who are dually eligible for both Medicare and Medicaid benefits, reside in nursing homes, or live with particular chronic medical conditions.

Special projects that aim to test enhancements to Medicare coverage, reimbursement, and quality of care. These are sometimes called demonstrations or research studies.

The Program of All-Inclusive Care for the Elderly (PACE) is a special health plan that provides comprehensive medical and social services covered by both Medicare and Medicaid. In addition to these standard benefits, PACE also offers further medically necessary care and services as determined by an interdisciplinary healthcare team based on the individual's specific needs. By combining medical, prescription drug, social support, and long-term care services, PACE aims to serve enrollees who remain in the community.

A state program that receives federal funding to provide free local health insurance counseling services to Medicare beneficiaries.

A state program that provides financial assistance for prescription drug coverage eligibility based on financial need, age, or medical condition.