Medicare Coverage Examples

Georgia will be 65 next month. She has been working part-time since her husband died five years ago, but her income is limited. Georgia has heart disease, so she sees a heart specialist regularly and takes a blood-thinning medicine every day. She cannot afford a Medicare supplement policy.

Georgia's Medicare benefits wish list
 

• Health care at an affordable price
• Access to her trusted doctors
• Discounted prices on her prescription drugs
• The possibility of help with her premiums and cost sharing if she qualifies for low-income assistance
  
  

Georgia's Medicare coverage choices
 

• Original Medicare (Parts A & B)
• Stand-alone Medicare Part D prescription drug plan 
  
  

Georgia's Medicare plan features
 

• Access to the doctors and hospitals she uses now
• Discounted prices on the drugs she takes
  

Georgia's monthly premium costs will be $180.50 total.

Now that we have that number, let's add in Georgia's daily blood-thinning medication. Georgia pays a $10 copay each time she fills a prescription. She fills her blood-thinning prescription once a month. Thus, Georgia's base-line monthly Medicare costs will be $190.50.
 

Georgia's other costs & cost-sharing

Georgia will have other out-of-pocket costs to cover when she receives different health care services and items. She will be responsible for the costs of services and items not covered by Original Medicare (Parts A & B) as well the costs defined by the cost-sharing terms of her Part D plan.
 

Georgia should apply for financial help.

Because Georgia has a limited income, she could explore financial help by seeing if she qualifies for the Extra Help program (to help with her Part D costs) and Medicaid. If she qualifies for either program, her costs could be significantly lower for both Original Medicare and Part D.
 

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David just turned 65 and is about to retire from work. He doesn't plan to keep working past age 65 and does not have any retiree coverage. He plans to get Medicare at age 65, during his Initial Enrollment Period.

David in good shape and generally healthy. He takes a daily prescription drug to keep his high blood pressure in check. David takes good care of himself. He is careful to live within his budget.
 

David's Medicare benefits wish list
 

• Access to a full range of health care services, including preventive care
• Coverage that provides a safety net in case of a serious illness
• Access to specialists if he needs them—he's comfortable with sticking to choices in a plan's network
• Access to prescription drug coverage in case he needs additional medications in the future

David's Medicare coverage choice

A Medicare Advantage plan with built‑in prescription drug coverage
 

David's Medicare plan features
 

• Preventive care
• Fitness program at no additional cost
• Built-in prescription drug coverage
• Network of local doctors and hospitals
• Out-of-pocket maximum of $3,500 in 2021 per year

Now that we have that number, let's add in David's blood pressure medication. With his Medicare Advantage plan, David pays a $15 copay every time he fills a prescription. Thus, we can now say that with David's monthly premiums and his monthly prescription, David's base monthly Medicare costs will be $197.50.
 

David's other costs & cost-sharing

David will have other costs as well as he receives different health care services throughout the plan year. His out-of-pocket costs may include copays, coinsurance and deductibles. His total spending will vary depending on the specific cost-sharing terms of his plan, the health care services he uses, the prescriptions he fills, and whether the services or items were obtained in-network or out-of-network. Because David's plan has an out-of-pocket maximum of $3,500 in 2021 for the year, once his out-of-pocket costs reach that number, his Medicare Advantage plan will be responsible for all the costs for the remainder of the plan year.

Sammy is 65 and decided to enroll in a Medicare Advantage Private-Fee-For-Service (PFFS) plan because he wanted to see any provider as well as see specialists without needing a referral. Sammy also has high blood pressure and takes a daily pill to help keep it regulated. He is generally healthy and doesn't take any other prescriptions, but Sammy does like to be prepared.

Sammy's Medicare benefits wish list
 

• Flexibility to see the providers he wants
• Access to specialists without referrals
• Prescription drug coverage for his blood pressure, and in case he needs anything in the future

Sammy's Medicare coverage choice

A Medicare Advantage Private-Fee-for-Service plan with no network limitation and a low-cost stand-alone Part D plan.
 

Sammy's Medicare coverage features
 

• Preventive care
• Fitness program at no additional cost
• Prescription drug coverage
• National access to doctors and hospitals
• Out-of-pocket maximum of $3,000 in 2021 per year
  

Now that we have that number, let's add in Sammy's blood pressure medication. With his stand-alone Part D plan, Sammy pays a $5 copay every time he fills a prescription. Thus, we can now say that with Sammy's monthly premiums and his monthly prescription, his base monthly Medicare costs will be $188.50.
 

Sammy's other costs & cost-sharing

Sammy will have other costs as well as he receives different health care services throughout the plan year or if he needs to purchase additional prescription drugs. His out-of-pocket costs may include copays, coinsurance and deductibles. His total spending will vary depending on the specific cost-sharing terms of his plan, the health care services he uses and the prescriptions he fills. And, because Sammy's plan has an out-of-pocket maximum of $3,000 in 2021 for the year, once his out-of-pocket costs reach that number, his Medicare Advantage plan will be responsible for all the costs for covered services for the remainder of the plan year. Sammy's Part D plan doesn't have an out-of-pocket maximum, and what he pays will also depend on the Part D coverage stage he is in.

Alexa just turned 65 and is retiring from her job as a banker. She lives in Hawaii and doesn’t really enjoy traveling out of the state. Alexa is very healthy. She doesn’t have any major health conditions Alexa is also a veteran and has VA benefits. She gets all her medications filled through her VA benefits.

Alexa's Medicare benefits wish list
 

• Access to a full range of health care services, including preventive care
• Access to specialists if she needs them—she's comfortable with sticking to choices in a plan's network
• Fitness, dental and vision benefits
• Wellness program and healthy habit rewards

Alexa's Medicare coverage choice

A Medicare Advantage plan with rewards for healthy habits.
 

Alexa's Medicare plan features
 

• Preventive care
• Fitness program at no additional cost
• Wellness rewards
• Network of local doctors and hospitals
• Out-of-pocket maximum of $3,200 in 2021 per year
  
  

And this number will be her monthly Medicare base cost as she gets her prescription drugs through her VA benefits.

Alexa's other costs & cost-sharing

Alexa will have other costs as well as she receives different health care services throughout the plan year. Her out-of-pocket costs may include copays, coinsurance and deductibles. Her total spending will vary depending on the specific cost-sharing terms of her plan, the health care services she uses, and whether the services or items were obtained in-network or out-of-network. Because Alexa's plan has an out-of-pocket maximum of $3,200 in 2021 for the year, once her out-of-pocket costs reach that number, her Medicare Advantage plan will be responsible for all the costs for the remainder of the plan year.

See Medicare Advantage plans available in your area  

Leroy is about to turn 65. He has had serious health problems for years. He suffers from diabetes and high blood pressure, and his doctor has told him he needs to lose a considerable amount of weight. Leroy takes insulin and blood pressure medication every day. He has had trouble in the past with interactions of the drugs he is taking.

Leroy's Medicare benefits wish list
 

• Expert help with managing his health problems
• Help with improving his diet, exercise and weight management
• Discounted prices on prescription drugs

Leroy's Medicare coverage choice
 

Medicare Advantage Special Needs Plan (SNP) for people with diabetes, with built-in prescription drug coverage

Leroy's Medicare plan features
 

• Access to a care manager who will create a plan for coordinating his care
• Help with finding out if he qualifies for financial assistance with Medicare costs
• Discounted prices on the drugs he takes
• Help with adopting a healthier lifestyle 

Leroy's other costs & cost-sharing
 

Leroy pays out-of-pocket for services and items he receives during the year. How much he pays is determined by the cost-sharing terms as determined by his plan. His total spending will also depend on the specific health care services he uses and the medications he takes.
 

Leroy should see if he can also qualify for Medicaid. Because Leroy has been dealing with serious health problems for years, it's likely that his health care costs are high. Leroy should see if he qualifies for Medicaid in his state to see if he may get additional health care coverage and financial help that way.

View Special Needs Plans available in your area