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Medicare Plans in Massachusetts – Coverage and Benefits

If you are soon approaching the age of 65, you will be eligible to enroll yourself into parts A and B of the Federal Medicare Program. This program, offered by the federal government, provides Massachusetts citizens various forms of health care coverage. Part A of Traditional Medicare primarily covers hospital visits and associated treatment. Part B, on the other hand, will help cover costs from your primary care physician, outpatient procedures, and similar treatments. Unfortunately, however, there are some health care services, both in and out of the hospital, which are not covered at all by Traditional Medicare. We will discuss these coverage gaps on this page.

Medicare Parts A and B aren’t free, but they are offered at a much lower cost than traditional health insurance policies for those 65 and older. The initial costs and fees come in the form of a monthly premium for Part B (which you can learn more about here). For most seniors, Part A is free if you have a significant work history. And a “significant” work history is defined as ten years (40 quarters) of employment or more.

Medicare Part A (Hospital Coverage)

  • Inpatient care in hospitals
  • Skilled nursing facility care
  • Hospice care
  • Home health care
Medicare Part B (Medical Insurance)

  • Services from doctors and health providers
  • Outpatient care
  • Home health care
  • Durable medical equipment
  • Some preventive services
Medicare Part C (Medicare Advantage)

  • Includes all benefits and services covered under Part A and Part B
  • Usually includes Medicare prescription drug coverage (Part D) as part of the plan
  • Run by Medicare-approved private insurance companies
  • May include extra benefits and services for an extra cost
Medicare Part D (Drug Coverage)

  • Helps cover the cost of prescription drugs
  • Run by Medicare-approved private insurance companies
  • May help lower your prescription drug costs and help protect against higher costs in the future

Common Medicare Plans in Massachusetts

There are more than one million seniors (1,104,483) with a Traditional Medicare policy living in the state of Massachusetts. Of those, one-fifth of the population (220,897) has their benefits covered by a Medicare Advantage policy instead of Traditional Medicare. An additional 210,571 citizens (19% of all Massachusetts seniors) have a Medigap supplement insurance policy covering the gaps in their Traditional Medicare benefits. The remaining 61% of seniors either rely on some sort of employer sponsored benefits, or are hoping that Parts A and B of Medicare will cover all of their medical needs.

Whether you supplement your Medicare through a Medigap policy, an Advantage Program, or through some other means, you have to be enrolled in Medicare first. Click that link for more information on the process, as well as important enrollment dates.

Why Isn’t Traditional Medicare Enough? Why Purchase Additional Coverage?

Well, the answer to this question is dependent upon your specific circumstances. If you are still closer to 65, in relatively good health, and don’t require frequent medical treatment for any chronic conditions, you might not be vulnerable to the gaps in Traditional Medicare coverage. However, the older you get, and the more demanding your medical care becomes, the more likely you will be to incur any of the following out-of-pocket expenses:

Medicare Part A Costs Medicare Part B Costs
  • $1,184 (as of 2014) Part A Annual Deductible for access to Basic Hospital Services
  • $296/day for an Inpatient hospital Stay between 61-90 days long
  • $147 Annual Deductible (as of 2014) for basic Part B Medical Coverage
  • 80/20 Coinsurance costs for all Medicare coverage; Medicare pays 80%, you pay 20% Out-of-Pocket

To protect yourself and your finances, supplementing your Traditional Medicare with additional coverage is a cost-effective solution. You could go with either a Medicare Advantage policy, or a Medigap insurance supplement plan. We’ll cover each option in detail below.

Eliminating Coverage Gaps with Medigap Supplemental Insurance

There are ten Medigap plans in total: A, B, C, D, F, G, K, L, M, and N. There used to be more, but recent legislation has eliminated plans E, H, I, and J to eliminate redundancies in the system. Each plan is designed to cover common, problematic gaps in Traditional Medicare coverage. Additionally, each plan is exactly the same from state to state. For example, Plan F in Texas comes with the exact same benefits that it does in Massachusetts. The only thing that varies is cost, of course, as well as the companies available to underwrite the policy.

This useful chart details what each Medigap plan covers:

[chart category=”supplement” name=”planTypes” state=”MA” zipcode=”02124″]

Medicare Part C: Medicare Advantage

Medicare Advantage goes by many names, including Medicare Part C or “Medicare Replacement”. The last moniker is probably the most accurate, because a Medicare Advantage policy effectively replaces your government-provided Traditional Medicare benefits with an identical (the bare minimum amount of coverage required by law has to equal that of Traditional Medicare) or a better policy from a private insurer.  For some, the flexibility of being able to add additional coverage options, such as prescription drugs or dental, is appealing. For others, the elevated price tag which comes with such extras might be out of their budget range.

Keep in mind that when switching to a Medicare Replacement policy, it is highly likely that you may also have to switch doctors as well. Part of the reason that Medicare Advantage policies are competitively priced is due to their restricted networks. They choose the lowest-cost doctors and practices so that they can pay out low-cost claims. Then, hopefully, they pass those savings on to you. But for many senior citizens, the cost of keeping their doctor might be worth paying a little extra in premiums.

There are two different types of provider networks which Medicare Advantage plans utilize in order to deliver you the best possible care. They are called Health Maintenance Organizations (HMOs for short) and Preferred Provider Organizations (or PPOs). Take a look at the HMO and PPO plans below:

[chart category=”advantage” name=”topHMOPlans” zipcode=”02124″ state=”MA”]

[chart category=”advantage” name=”topPPOPlans” zipcode=”02124″ state=”MA”]

Comparing Medigap and Medicare Advantage

As stated earlier, no one policy is superior to the other. It all depends on your personal circumstances. In some states, the Medigap supplements offered might be more affordable and more flexible than a Medicare Advantage policy. In other areas, it may be the opposite case. But to understand which one is right for your specific situation, you might want to reflect upon the table below. It outlines some of the more significant differences between the two forms of coverage:

Questions Medicare Advantage Medicare Supplement
How are the plans funded? Medicare will pay your insurance company a fixed amount based on average healthcare costs for your region. You may also be required to pay a premium based on your location and insurance company. Your monthly premium takes care of the majority of your expenses.
Do I continue paying for Part B? Yes Yes
What does it cost me? Some plans offer a zero-dollar premium (because the government subsidy covers the full cost). Other plans may cost up to 0-0 monthly. While each plan does require a monthly premium, many of them are affordably priced.
What does the plan cover? Depending on your plan, it will cover at least the same benefits offered by Medicare parts A & B. Possibly other benefits; but the more benefits you sign up for, the higher your out-of-pocket expenses may be. All eligible expenses are split between Medicare, and your Medicare Supplement plan. If you have a comprehensive plan, such as Plan F, 100% of eligible expenses not covered by Medicare will be covered by your supplement insurance.
Can I budget my health care expenses? It’s challenging; the more often you require medical care, the more often you may be required to pay out-of-pocket. Budgeting is much easier with a Medicare supplement. You have fewer out-of-pocket expenses, and one simple monthly premium.
Can my plan be cancelled? Yes. Unfortunately, your health insurance company has the legal right to review their Medicare Advantage services annually and decide whether or not they wish to continue providing coverage. No – not unless you fail to pay your monthly premium, or your insurance company goes bankrupt. Only under such extenuating circumstances could your plan be cancelled.
Are pre-approvals or pre-certifications required? Unfortunately, yes. These Plans usually require pre-certification or other qualification for some specific types of care. No pre-approvals are required. If you qualify for Medicare, you will qualify for a Medicare supplement plan.
Can I use any doctor or hospital? Usually, you choose from a network of pre-approved providers. These networks can fluctuate over time. Yes. You are free to choose any doctor and/or hospital in the U.S. which accepts Medicare.
Can drug, vision, or dental coverage be included in the policy? Yes. No. These forms of coverage must be purchased separately.
Who is this plan type generally best suited for? If you are relatively young, healthy, live in an urban area, and have a limited income, a Medicare Advantage plan could work for you. If you live in a rural area without easy access to provider networks, if you like to budget your finances, or if you want comprehensive coverage, you might prefer a Medicare supplement plan.

Helpful Medicare Resources for Massachusetts Residents

As informative as this article aims to be, we can only give you enough information to help you get started. Below, we’ve included a directory of experts who have experience in the Medicare field. If you get in touch with anyone at the offices below, they can help you with any specific Medicare insurance questions you may have:

[chart category=”general” name=”usefulContacts”]

Important Medicare-Related Healthcare Terms

  • HMO: Health Maintenance Organization, this refers to a network of doctors and hospitals with a plans’ network.
  • PPO: Preferred Provider Organization, this refers to a network of doctors and hospitals with a plans’ network.
  • Co-Pay: Amount of money charged per visit to doctor, specialist, etc.
  • Co-Insurance: A percentage required by the policyholder to pay out-of-pocket. For example, 80/20 coinsurance means the insurance company will cover 80% of the charges, and the policyholder pays the remaining 20% of the charges.
  • Deductible: This is the amount of money required out-of-pocket by the policyholder before the insurance will kick-in and pay for any remaining charges. For example, a policy with a $1,000 deductible means that you must pay full healthcare costs out-of-pocket up to $1,000 before the plan will start coverage.

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