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Understanding the Basics of Medicare

Medicare is the nation’s largest health insurance program, but most people don’t know what it covers or costs. We're here to help you understand the basics from Part A to Part D.

Click on the part you want to understand:

 

What is Original Medicare?

Original Medicare is made of two parts: hospital insurance (Part A) and medical insurance (Part B). Please note, Original Medicare is not designed to cover all of your medical expenses, which is why most people choose additional coverage (Medicare Advantage plans, drug coverage, etc.) to help protect themselves from high medical costs. 

*Original Medicare is purchased through the government at ssa.gov. You must have Original Medicare to enroll in a Medicare Advantage plan. 

Part A covers hospital services:

  • Hospital stays
  • A stay in a skilled nursing facility (SNF)
  • Home health and hospice care (if necessary)

Part B covers medical needs:

  • Preventive services (shots, screenings, checkups, etc.)
  • Medically necessary services (doctor visits, lab tests, etc.)
  • Outpatient care and home health care
  • Durable medical equipment, like wheelchairs and walkers

What it costs:

You don't have to pay a monthly premium for Part A if you or your spouse paid into Social Security for at least 10 years. However, you are responsible for paying a deductible for each benefit period. For Part B, you pay a monthly premium based on your income (this is usually taken out of your Social Security check). Learn more at medicare.gov.

Original Medicare can save you money and help you get the care you need, but it doesn't cover everything. You could be left with thousands of dollars to pay from your own pocket. If you want a plan covering prescription drugs, hearing aids, routine vision care, or dental care, learn about a Medicare Advantage plan below.

What are star ratings?

The Medicare Program rates all health and prescription drug plans each year based on a plan's quality and performance. For full details on Medicare plan ratings, see our Star Ratings page.

 

What is Medicare Advantage (Part C)?

Medicare Advantage plans (also known as Medicare Part C), take the place of Original Medicare. Medicare Advantage combines Medicare Part A & Part B coverage into one plan offered by a private insurance company, like BlueShield--meaning you get all your benefits from one source. Think coverage for extra days in the hospital, benefits including dental, vision, and hearing, gym memberships, and other wellness benefits. Most plans also include Part D prescription drug coverage. Check out the comparisons below.

  Original Medicare BlueShield Medicare Advantage
What does it cover?    

Doctor visits

Preventive services

Hospitalizations

Surgeries

Lab test

Urgent care

Nationwide emergency care

Worldwide emergency care

 

Prescription drugs (under Part D)*

 

Optional supplemental dental care**

 

Out-of-pocket maximum

 

Gym membership

 

Health coaching

 

Health and wellness programs

 

Personal member support

 

*Most of our plans include Part D prescription drug coverage. If you are looking for a plan with drug coverage, please check the plan summary of benefits before you enroll. 

**You must continue to pay your Medicare Part B premium and your Medicare Advantage plan premium. 

What it costs:

To enroll in a Medicare Advantage plan, you must be enrolled in Parts A & B and pay your Part B premium. You may also pay a premium for your Medicare Advantage plan, but you'll only pay a percentage of some costs. You may even save money by using providers in the plan's network. 

What are Star Ratings?

The Medicare Program rates all health and prescription drug plans each year based on a plan's quality and performance. For full details on Medicare plan ratings, see our Star Ratings page.

What is Part D?

Medicare Part D helps make prescription medicines more affordable. Part D benefits vary by plan or provider. Each drug plan has a list of drugs it covers (also called a "formulary") as well as different rules and costs. 

View the 2019 Formulary

After you're eligible for Medicare Part A or enrolled in Part B, you're also eligible to enroll in a Part D plan. You can add a stand-alone Part D plan to your Original Medicare benefits, or choose a Medicare Advantage plan that includes Part D coverage.

*Please note, you cannot enroll in a Medicare Advantage plan and a stand-alone Prescription Drug plan. If you want a Medicare Advantage plan with drug coverage, you must choose one that includes Part D.
 

The "donut hole:"

This is the Medicare Part D coverage gap. This is a period when you have limited or no prescription drug coverage. After you and your Medicare drug plan reach your initial coverage limit, you will have to pay a percentage of the costs out-of-pocket for prescription drugs, up to a certain limit (unless you plan has coverage through the gap). Your yearly deductible, coinsurance, or copayments, and what you pay while in the donut hole, all count towards this out-of-pocket limit. However, the limit does not include the drug plan's premium. 
 

Are you eligible for EPIC?

Elderly Pharmaceutical Insurance Coverage (EPIC) is a New York state program that helps pay for Medicare Part D prescriptions and some drugs that are not covered under Part D. EPIC does not replace your Part D coverage, but could help make your drugs more affordable. You could you pay as little as $3 for your prescriptions, and possibly lower your monthly premium.
 

To be eligible for EPIC, you must be 65 years or older, and a New York State resident. If you are single with an income below $75,000 or married with an income below $100,000, you may be eligible for assistance with drug plan costs through EPIC. If you enroll in EPIC, you have one Special Election Period that you can use anytime throughout the year.
 

Learn more about eligibility by viewing our webpage, calling EPIC at 1-800-332-3742 (TTY 1-800-290-9138) Monday – Friday, 8:30 a.m. – 5:00 p.m., or visit the New York State Department of Health.

Medicare Questions?

We're here to help.

1-833-735-4514 (TTY 711)
Oct. 1 - Mar. 31, 8 a.m. - 8 p.m., 7 days a week
Apr. 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday

A division of HealthNow New York Inc., an independent licensee of the Blue Cross Blue Shield Association. BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. This information is not a complete description of benefits. Call 1-800-329-2792 (TTY: 711) for more information. BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY: 711). 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-833-735-4515  (TTY: 711). 

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Content Last Updated October 1, 2018