Medicare beneficiaries have choices for receiving health care services. The Original Medicare Plan is the traditional fee-for-service Medicare plan that is available nationwide. A beneficiary can see any doctor or provider who accepts Medicare and is accepting new Medicare patients. Or a beneficiary can choose a Medicare Advantage Plan (Part C). These plans combine Medicare Part A and Part B and, in some cases, Part D prescription drug coverage. In limited instances, other Medicare health plans may be available. To find out which plans are available in an area, visit medicare.gov, or call 1-800-MEDICARE
A beneficiary must have both Medicare Part A and Part B to join a Medicare Advantage Plan, and the individual must live in the plan's service area. Under a Medicare Advantage Plan, a beneficiary may pay lower copayments and receive extra benefits.
Original Medicare Plan (Part A and Part B)
Under the Original Medicare Plan, patients visit the hospital, doctor, or health care provider of their choice who accepts Medicare patients. Medicare pays a set percentage of the expenses, and patients are responsible for certain deductible and coinsurance payments.
Persons enrolled in the Original Medicare Plan who want prescription drug coverage must join a Medicare Prescription Drug Plan (Part D) as described here, unless they already have drug coverage from a current or former employer or union that is at least as good as the standard Medicare prescription drug coverage.
When a patient receives hospital insurance benefits, he or she is billed by the hospital only for the deductible amount, any coinsurance amount, and any noncovered services. The remainder of the bill from the hospital, as well as bills for services in skilled nursing facilities or home health visits, is sent to Medicare to pay its share.
Claims for medical insurance benefits filed on behalf of railroad retirement beneficiaries in the Original Medicare Plan are generally handled by Palmetto GBA on a nationwide basis. Palmetto GBA is a private company that contracts with the RRB and Medicare to pay Part B claims for railroad retirement beneficiaries, and can be reached at:
Railroad Medicare Part B Office
P.O. Box 10066
Augusta, GA 30999-0001
Many private insurance companies sell insurance, called Medigap for short, that helps pay for services not covered by the Original Medicare Plan. Policies may cover deductibles, coinsurance, copayments, health care outside the United States, and more. Generally, individuals need Medicare Part A and Part B to enroll, and a monthly premium is charged.
When someone first enrolls in Medicare Part B at age 65 or older, he or she has a 6-month Medigap open enrollment period. During this period, an insurance company cannot deny coverage, place conditions on a policy, or charge more for a policy because of past or present health problems.
Visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for detailed information about Medigap policies.
Medicare Advantage Plans (Part C)
Medicare Advantage Plans combine Medicare Part A and Part B coverage, and are available in most areas of the country. A beneficiary must have both Medicare Part A and Part B to join a Medicare Advantage Plan, and the individual must live in the plan's service area. Medicare Advantage Plan choices include regional preferred provider organizations (PPOs), health maintenance organizations (HMOs), private fee-for-service plans, and others. A PPO is a plan under which a beneficiary uses doctors, hospitals, and providers belonging to a network; beneficiaries can use doctors, hospitals, and providers outside the network for an additional cost. Under Medicare Advantage, a beneficiary may pay lower copayments and/or Part B premiums, and receive extra benefits. Most plans include prescription drug coverage (Part D). Advantage Plans are managed by private insurance companies approved by Medicare.
The monthly Part C premium can be deducted from railroad retirement or social security benefits paid by the RRB, if the beneficiary contacts his or her Part C plan and requests that the RRB withhold Part C premiums.
For those in a Medicare Advantage Plan, information on out-of-pocket costs is available by visiting medicare.gov
or by calling 1-800-MEDICARE (1-800-633-4227).