Medicare coverage examples
Medicare plan combinations
You have multiple options for choosing Medicare coverage. Here are six examples of how plans can work together.
These are not actual people or costs, but they do show how each option can meet real needs.
Original Medicare plus a standalone Part D plan
Original Medicare plus a standalone Part D plan and Medicare Supplement plan
Original Medicare plus Medicare Supplement plan
Medicare Advantage plan that includes Part D prescription drug coverage
Chronic Special Needs plan that includes Part D prescription drug coverage
Medicare coverage examples
Below are some examples of the different kinds of Medicare and Medigap coverage a person may get and what costs could be when used. Note that none of the below examples represent real people, and that the costs below are estimates, intended for learning purposes only.
Coverage and costs for Original Medicare (Part A and Part B) only
Meet Ellen
Ellen is about to turn 65 and retire. She doesn’t take any prescription drugs right now, and is in very good health. Ellen also likes to travel, going to different U.S. National Parks every summer and fall. She is retiring from her position as a director at a global software company with very strong savings and annual pension. Ellen is not concerned about out-of-pocket health care costs and doesn’t anticipate needing more than medical and hospital insurance.
Ellen is choosing Original Medicare, which provides:
- Access to doctors and hospitals throughout the United States
- Basic medical and hospital insurance
Ellen will have a monthly Part B premium of $202.90. She will also be responsible for any cost sharing for covered care, plus all costs for health items and services not covered by Medicare Part A or Part B.
Because Ellen did not add prescription drug coverage, she will be responsible for all her prescription drug costs. If she adds a Part D plan later, she may have to pay Part D late penalties because she will not have had creditable coverage.
Examples are for illustration only. Benefits and costs vary by plan and area.
Coverage and costs for Original Medicare (Part A and/or Part B) plus a standalone Part D plan
Meet Georgia
Georgia will be 65 next month. She has been working part-time since her husband died 5 years ago. Georgia has a family history of heart disease, so she exercises regularly, makes a point of eating healthy foods, and keeps in touch with her primary care physician.
Georgia wants health care at an affordable price, access to her trusted doctors, and predictable out-of-pocket costs on her prescription drugs.
Georgia is choosing Original Medicare plus a standalone Part D plan, so she will have:
- Access to the doctors and hospitals she uses now
- Predictable out-of-pocket costs on the drugs she takes
Her monthly costs will be $202.90 for her Part B premium and $42.98 for her Part D premium, for a total of $245.88.
Georgia will have other out-of-pocket costs to cover when she receives different health care services and items. She will be responsible for any cost sharing for Medicare Part A and Part B covered services, and for the cost sharing defined by her Part D plan. She will also be responsible for the costs of services and items not covered by Medicare Part A and Part B.
Because Georgia has a limited income, she could explore financial help by seeing if she qualifies for the Extra Help program for Part D costs, and for Medicaid. If she qualifies for either program, her costs could be significantly lower.
Examples are for illustration only. Benefits and costs vary by plan and area.
Coverage and costs for Original Medicare (Part A and/or Part B) plus a standalone Part D plan and a Medicare Supplement plan
Meet Juanita
Juanita will be 65 in 3 months and plans to retire at that time. She plans on spending time traveling from her home in Colorado to visit family in California.
Juanita is in good health. She takes two prescriptions — one to keep her bones strong and another to control her cholesterol. She has a comfortable pension but wants to leave a financial legacy for her family so she is careful about what she spends on health care.
She wants access to doctors and hospitals when she’s in California visiting her children, help paying for her prescription drugs, and help paying if her health care costs are high.
Juanita is choosing Original Medicare plus a standalone Part D plan and a Medicare Supplement (Medigap) plan. Together, these plans provide:
- Predictable out-of-pocket costs on the drugs she takes
- Access to doctors and hospitals throughout the United States
- Help with costs not paid by Original Medicare
Her monthly costs will be $202.90 for her Part B premium, $57.48 for her Part D premium, and $167 for her Medigap premium, a total of $427.38.
A Medicare Supplement insurance plan covers most of Juanita’s out-of-pocket costs with Original Medicare, but Medicare Supplement plans do not cover prescription drugs. Her additional out-of-pocket costs may include cost sharing for her Part D plan.
Examples are for illustration only. Benefits and costs vary by plan and area.
Coverage and costs for Original Medicare (Part A and Part B) plus a Medicare Supplement Insurance (Medigap) plan
Meet Matt
Matt is about to turn 65 and lives in Texas. He is an Army veteran with Veterans Administration (VA) benefits. Matt enjoys traveling each year to see his four grandchildren in Arizona and Wyoming. He is retired with good savings but wants to make sure he leaves something behind for each of his grandchildren. Matt is in good health and takes only one prescription daily, for lowering his cholesterol. Matt gets this prescription and any others he needs through the VA.
He wants access to doctors and hospitals nationwide, and peace of mind knowing that he will have help paying for health care costs if they are high.
Matt is choosing Original Medicare plus a Medicare Supplement (Medigap) plan, which includes:
- Access to doctors and hospitals throughout the United States
- Help with costs not paid by Original Medicare
- A yearly out-of-pocket limit of $4,000 before 75% of the benefit is paid at 100%
His monthly costs will be $202.90 for his Part B premium and $113 for his Medigap premium, a total of $315.90.
Matt’s Medicare Supplement insurance plan will help with the costs of his Original Medicare covered services. His out-of-pocket costs will vary based on the services he receives, and may be lower once he reaches the annual out-of-pocket limit for his Medicare Supplement insurance plan. Matt will also be responsible for the costs of services and items not covered by either plan. His VA costs will be separate from his Medicare costs.
Examples are for illustration only. Benefits and costs vary by plan and area.
Coverage and costs for a Medicare Advantage (Part C) plan with included Part D prescription drug coverage (MAPD)
Meet David
David just turned 65 and is retiring. He doesn’t have retiree coverage and is in his Medicare Initial Enrollment Period (IEP). David takes good care of himself and is generally healthy. He takes a daily prescription drug for his high blood pressure. He is careful to live within his budget.
David wants coverage for preventive care and other health care services, access to specialists, prescription drug coverage in case he needs additional medications, and a safety net in case of a serious illness.
David is choosing a Medicare Advantage plan with Part D prescription drug coverage that includes preventive care, access to a network of local doctors and hospitals, and a fitness program. This plan has an out-of-pocket maximum of $4,900 per year.
His monthly costs will be $202.90 for his Part B premium. He is eligible for a Medicare Advantage plan with a $0 premium, so his total monthly premium will be $202.90.
David may have out-of-pocket costs like copays, coinsurance and deductibles. His total spending will vary depending on the health care services he uses, the prescriptions he fills, the cost-sharing terms of his plan, and whether his providers are in-network or out-of-network. Once David’s out-of-pocket costs for Medicare covered services reach $4,900, his Medicare Advantage plan will be responsible for the rest. He will still be responsible for costs not covered by Medicare or the plan.
Examples are for illustration only. Benefits and costs vary by plan and area.
Coverage and costs for a Chronic Special Needs plan (C-SNP) for people with diabetes, with included prescription drug coverage
Meet Leroy
Leroy is about to turn 65. He has had serious health problems for years. He suffers from diabetes and high blood pressure, and his primary care provider 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 with the drugs he is taking.
Leroy wants prescription drug coverage, expert help to manage his health problems, and help to improve his diet, exercise and weight management.
Leroy is choosing a Chronic Special Needs plan (C-SNP) that includes help with adopting a healthier lifestyle, access to a care manager who can create a plan for coordinating his care, and predictable out-of-pocket costs on the drugs he takes.
A Chronic Special Needs plan is a Medicare Advantage plan for people living with specific chronic or disabling long-term health conditions.
His monthly costs will be $202.90 for his Part B premium, $3.15 for his C-SNP premium and $25 for his insulin prescription copay, a total of $231.05 per month.
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 of his plan. His total spending will also depend on the health care services he uses and the medications he takes.
Leroy has been dealing with serious health problems for a long time, and his health care costs are high for his income. He may want to see if he qualifies for additional health care coverage and financial help from Medicaid in his state.
Examples are for illustration only. Benefits and costs vary by plan and area.
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