Public Part C Medicare Advantage and other Part C health plans are required to offer coverage that meets or exceeds the standards set by Original Medicare but they do not have to cover every benefit in the same way. After approval by the Centers for Medicare and Medicaid Services, if a Part C plan chooses to pay less than Original Medicare for some benefits, such as Skilled Nursing Facility care, the savings may be passed along to consumers by offering even lower co-payments for doctor visits.
In 1977, the Health Care Financing Administration (HCFA) was established as a federal agency responsible for the administration of Medicare and Medicaid. This would be renamed to Centers for Medicare and Medicaid Services (CMS) in 2001. By 1983, the diagnosis-related group (DRG) replaced pay for service reimbursements to hospitals for Medicare patients.
There are several types of Medicare Advantage plans, such as Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO)* plans, Private Fee-For-Service (PFFS) plans, and Special Needs Plans (SNPs). Other Medicare Part Advantage plan options include HMO Point-Of-Service (HMO POS) plans and Medical Savings Account (MSA) plans. Depending on where you live, you might not find every type of plan available to you.
Increased access channels for new applications and additional eligibility verification resources helped increase enrollment following ACA implementation. Increased promotion through health fairs and community events as well partnership with other agencies have contributed to eligible individuals learning about and enrolling in Medi-Cal, as have targeted enrollment efforts such as assisting jail inmates in applying for coverage prior to reentry, use of community based organizations (CBOs) to assist clients in applying online, and placing HSA staff in the community to conduct outreach and enrollment.

The dual-eligible population comprises roughly 20 percent of Medicare's enrollees but accounts for 36 percent of its costs.[142] There is substantial evidence that these individuals receive highly inefficient care because responsibility for their care is split between the Medicare and Medicaid programs[143]—most see a number of different providers without any kind of mechanism to coordinate their care, and they face high rates of potentially preventable hospitalizations.[144] Because Medicaid and Medicare cover different aspects of health care, both have a financial incentive to shunt patients into care the other program pays for.
Popular opinion surveys show that the public views Medicare's problems as serious, but not as urgent as other concerns. In January 2006, the Pew Research Center found 62 percent of the public said addressing Medicare's financial problems should be a high priority for the government, but that still put it behind other priorities.[90] Surveys suggest that there's no public consensus behind any specific strategy to keep the program solvent.[91]
Both House Republicans and President Obama proposed increasing the additional premiums paid by the wealthiest people with Medicare, compounding several reforms in the ACA that would increase the number of wealthier individuals paying higher, income-related Part B and Part D premiums. Such proposals are projected to save $20 billion over the course of a decade,[150] and would ultimately result in more than a quarter of Medicare enrollees paying between 35 and 90 percent of their Part B costs by 2035, rather than the typical 25 percent. If the brackets mandated for 2035 were implemented today,[when?] it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. Under the Republican proposals, affected individuals would pay 40 percent of the total Part B and Part D premiums, which would be equivalent of $2,500 today.[151]
Original Medicare provides no similar OOP spending cap and the exposure of an Original Medicare beneficiary to a financial catastrophe is unlimited (but also rare). Once the OOP maximum is reached for an individual, the plan pays 100% of medical services for the remainder of the calendar year (with no lifetime maximum). This OOP limit does not apply to a Part C plan's Part-D-like self-administered drug coverage (which uses another means of addressing catastrophic costs).
The Chief Actuary of the CMS must provide accounting information and cost-projections to the Medicare Board of Trustees to assist them in assessing the program's financial health. The Board is required by law to issue annual reports on the financial status of the Medicare Trust Funds, and those reports are required to contain a statement of actuarial opinion by the Chief Actuary.[14][15]
Generally, if you already receive Social Security payments, at age 65 you are automatically enrolled in Medicare Part A (Hospital Insurance). In addition, you are generally also automatically enrolled in Medicare Part B (Medical Insurance). If you choose to accept Part B you must pay a monthly premium to keep it. However, you may delay enrollment with no penalty under some circumstances, or with penalty under other circumstances.
Medicare Advantage offers at least the same coverage as Original Medicare, and may offer additional benefits. It may be one way of adding coverage for routine vision, or dental services, dentures, and more. Some Medicare Advantage plans have a $0 premium. However, regardless of how much you pay for a Medicare Advantage plan, you must continue pay your Medicare Part B premium.
As a result, an estimated 320,000 Medicare Cost enrollees in Minnesota need new coverage for 2019. There are 21 counties where Medicare Cost plans will continue to be available, but Medicare Cost enrollees in the remaining counties cannot keep their Cost plans. Instead, they can either enroll in a Medicare Advantage plan (some will be automatically enrollees in a comparable Medicare Advantage plan, although they’ll have an option to pick something else instead), or select a Medigap plan to supplement their Original Medicare (enrollees whose Medicare Cost plans are ending have guaranteed issue rights to a Medigap plan, so they can purchase one even if they have pre-existing medical conditions).
Overall health care costs were projected in 2011 to increase by 5.8 percent annually from 2010 to 2020, in part because of increased utilization of medical services, higher prices for services, and new technologies.[82] Health care costs are rising across the board, but the cost of insurance has risen dramatically for families and employers as well as the federal government. In fact, since 1970 the per-capita cost of private coverage has grown roughly one percentage point faster each year than the per-capita cost of Medicare. Since the late 1990s, Medicare has performed especially well relative to private insurers.[83] Over the next decade, Medicare's per capita spending is projected to grow at a rate of 2.5 percent each year, compared to private insurance's 4.8 percent.[84] Nonetheless, most experts and policymakers agree containing health care costs is essential to the nation's fiscal outlook. Much of the debate over the future of Medicare revolves around whether per capita costs should be reduced by limiting payments to providers or by shifting more costs to Medicare enrollees.
OptumRx is an affiliate of UnitedHealthcare Insurance Company. You are not required to use OptumRx home delivery for a 90-day supply of your maintenance medication. $0 copay may be restricted to particular tiers, preferred medications, or mail order prescriptions during the initial coverage phase and may not apply during the coverage gap or catastrophic stage.

A Medicare Part D Prescription Drug Plan (PDP) can help pay your prescription drug costs. Designed to work alongside Original Medicare coverage, Medicare Prescription Drug Plans are available from private insurance companies approved by Medicare and doing business in Minnesota. You can also enroll in a Medicare Prescription Drug Plan if you enroll in a Medicare Advantage plan that does not include Part D prescription drug coverage in its benefits.

Tufts Health Plan Senior Care Options is available to individuals who are at least 65 years old and have Medicare and MassHealth Standard (Medicaid) or just MassHealth Standard (Medicaid). This plan provides members who qualify with medical and prescription benefits along with a Primary Care Team, whose key goal is to improve the coordination of care you receive. 

Retirement of the Baby Boom generation — which by 2030 is projected to increase enrollment to more than 80 million as the number of workers per enrollee declines from 3.7 to 2.4 — and rising overall health care costs in the nation pose substantial financial challenges to the program. Medicare spending is projected to increase from $523 billion in 2010 to just over $1 trillion by 2022.[20] Baby-boomers' health is also an important factor: 20% have five or more chronic conditions, which will add to the future cost of health care. In response to these financial challenges, Congress made substantial cuts to future payouts to providers as part of PPACA in 2010 and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and policymakers have offered many additional competing proposals to reduce Medicare costs further.
Sicker people and people with higher medical expenditures are more likely to switch from Medicare Advantage plans to Original Medicare. This statistic is primarily driven by people on Medicaid in custodial care at nursing home; such people no longer have need of any Medicare supplement, either a public Part C plan or a private Medigap or group retirement plan.[15] The Part C risk adjusted payments to Medicare Advantage plans are designed to limit this churn between types of Medicare (managed vs. FFS), but it is unclear how effective that policy is.[16]
The Minnesota Board on Aging (MBA) may be helpful for seniors seeking a wide range of information. The office provides education in a broad range of areas, including health-care coverage and Medicare plans. The office was first established in 1956. Since that time, seniors have been able to turn to the Minnesota Board of Aging for a variety of programs, including:
We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
Tufts Health Plan Senior Care Options is available to individuals who are at least 65 years old and have Medicare and MassHealth Standard (Medicaid) or just MassHealth Standard (Medicaid). This plan provides members who qualify with medical and prescription benefits along with a Primary Care Team, whose key goal is to improve the coordination of care you receive. 
We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
For doctors and medical procedures (Part B) at the hospital and at home: You would pay 20% of all costs after meeting your $147 deductible. Unlike many other health insurance policies, there is no cap or maximum out-of-pocket amount on what you could owe. The American Heart Association says that the average cost of heart surgery is $62,509 – in that case, your Part B copay would be over $12,000. 
This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Special Needs Plans (SNPs) are designed for people with special health care or financial needs. All Special Needs Plans include drug coverage. They may also include coordination of care, transportation to and from medical appointments, credits to buy everyday health items, and routine vision and dental coverage. There are four main types of Special Needs Plans:
Renew or change your current plan. During the open enrollment period, you can renew your existing plan. You won’t have to do anything if you want to keep what you have. But if your current plan is changing — for instance, your PCP is leaving the network, or your drugs aren’t in the list of covered medications — then you may want to switch to a plan that best suits your current needs. If you need to change policies, the open enrollment period is the best time.
Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks. They can also be paid quarterly via bill sent directly to beneficiaries. This alternative is becoming more common because whereas the eligibility age for Medicare has remained at 65 per the 1965 legislation, the so-called Full Retirement Age for Social Security has been increased to 66 and will go even higher over time. Therefore, many people delay collecting Social Security and have to pay their Part B premium directly.
MA plans feature a network of doctors and hospitals that enrollees must use to get the maximum payment, whereas supplements tend to provide access to a broader set of health care providers, said Shawnee Christenson, an insurance agent with Crosstown Insurance in New Hope. While that might sound good to beneficiaries, supplements can come with significantly higher premiums, Christenson said.

Several measures serve as indicators of the long-term financial status of Medicare. These include total Medicare spending as a share of gross domestic product (GDP), the solvency of the Medicare HI trust fund, Medicare per-capita spending growth relative to inflation and per-capita GDP growth; general fund revenue as a share of total Medicare spending; and actuarial estimates of unfunded liability over the 75-year timeframe and the infinite horizon (netting expected premium/tax revenue against expected costs). The major issue in all these indicators is comparing any future projections against current law vs. what the actuaries expect to happen. For example, current law specifies that Part A payments to hospitals and skilled nursing facilities will be cut substantially after 2028 and that doctors will get no raises after 2025. The actuaries expect that the law will change to keep these events from happening.

Some have questioned the ability of the federal government to achieve greater savings than the largest PDPs, since some of the larger plans have coverage pools comparable to Medicare's, though the evidence from the VHA is promising. Some also worry that controlling the prices of prescription drugs would reduce incentives for manufacturers to invest in R&D, though the same could be said of anything that would reduce costs.[136]


Many experts have suggested that establishing mechanisms to coordinate care for the dual-eligibles could yield substantial savings in the Medicare program, mostly by reducing hospitalizations. Such programs would connect patients with primary care, create an individualized health plan, assist enrollees in receiving social and human services as well as medical care, reconcile medications prescribed by different doctors to ensure they do not undermine one another, and oversee behavior to improve health.[145] The general ethos of these proposals is to "treat the patient, not the condition,"[139] and maintain health while avoiding costly treatments.
There can be many benefits to Medicare Advantage, also known as Medicare Part C. Perhaps you prefer the convenience of having all of your health and drug benefits under a single plan, instead of enrolling in a stand-alone Medicare Prescription Drug Plan for your Medicare Part D coverage. Or you may be looking for extra benefits that Original Medicare doesn’t cover, such as routine vision and dental coverage.
Currently, people with Medicare can get prescription drug coverage through a Medicare Advantage plan or through the standalone private prescription drug plans (PDPs) established under Medicare Part D. Each plan established its own coverage policies and independently negotiates the prices it pays to drug manufacturers. But because each plan has a much smaller coverage pool than the entire Medicare program, many argue that this system of paying for prescription drugs undermines the government's bargaining power and artificially raises the cost of drug coverage.
As of 2015, individuals who qualified for Medicare by virtue of their age alone made up 86 percent of Minnesota Medicare recipients. The balance — 14 percent — were on Medicare as the result of a disability. Kentucky had the highest percent of Medicare recipients listed as disabled (25 percent), followed by Alabama, Mississippi, West Virginia and Arkansas. Hawaii had the smallest percentage at 10 percent, followed by New Jersey, and North and South Dakota at 13 percent each.
Additionally, the PPACA created the Independent Payment Advisory Board ("IPAB"), which is empowered to submit legislative proposals to reduce the cost of Medicare if the program's per-capita spending grows faster than per-capita GDP plus one percent.[87] While the IPAB would be barred from rationing care, raising revenue, changing benefits or eligibility, increasing cost sharing, or cutting payments to hospitals, its creation has been one of the more controversial aspects of health reform.[113] In 2016, the Medicare Trustees projected that the IPAB will have to convene in 2017 and make cuts effective in 2019.

Additionally, the PPACA created the Independent Payment Advisory Board ("IPAB"), which is empowered to submit legislative proposals to reduce the cost of Medicare if the program's per-capita spending grows faster than per-capita GDP plus one percent.[87] While the IPAB would be barred from rationing care, raising revenue, changing benefits or eligibility, increasing cost sharing, or cutting payments to hospitals, its creation has been one of the more controversial aspects of health reform.[113] In 2016, the Medicare Trustees projected that the IPAB will have to convene in 2017 and make cuts effective in 2019.
As of 2015, individuals who qualified for Medicare by virtue of their age alone made up 86 percent of Minnesota Medicare recipients. The balance — 14 percent — were on Medicare as the result of a disability. Kentucky had the highest percent of Medicare recipients listed as disabled (25 percent), followed by Alabama, Mississippi, West Virginia and Arkansas. Hawaii had the smallest percentage at 10 percent, followed by New Jersey, and North and South Dakota at 13 percent each.
Both House Republicans and President Obama proposed increasing the additional premiums paid by the wealthiest people with Medicare, compounding several reforms in the ACA that would increase the number of wealthier individuals paying higher, income-related Part B and Part D premiums. Such proposals are projected to save $20 billion over the course of a decade,[150] and would ultimately result in more than a quarter of Medicare enrollees paying between 35 and 90 percent of their Part B costs by 2035, rather than the typical 25 percent. If the brackets mandated for 2035 were implemented today,[when?] it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. Under the Republican proposals, affected individuals would pay 40 percent of the total Part B and Part D premiums, which would be equivalent of $2,500 today.[151]
If you’re enrolled in Original Medicare during your Medicare Initial Enrollment Period (IEP), automatically or otherwise, your Initial Coverage Election Period and your Initial Enrollment Period happen at the same time. The Initial Enrollment Period starts three months before the month you turn 65, includes your birth month, and ends three months after that (seven months total). If you didn’t sign up for Original Medicare during the Initial Enrollment Period (if you still have health insurance through an employer or union, for example), your Initial Coverage Election Period is the 3-month period before your Medicare Part B start date. For example, if you enrolled in Medicare Part B during the General Enrollment Period (January 1–March 31), your Part B start date would be July 1, so your Initial Coverage Election Period would be April 1 to June 30.
Part A Late Enrollment Penalty If you are not eligible for premium-free Part A, and you don't buy a premium-based Part A when you're first eligible, your monthly premium may go up 10%. You must pay the higher premium for twice the number of years you could have had Part A, but didn't sign-up. For example, if you were eligible for Part A for 2 years but didn't sign-up, you must pay the higher premium for 4 years. Usually, you don't have to pay a penalty if you meet certain conditions that allow you to sign up for Part A during a Special Enrollment Period.

Many look to the Veterans Health Administration as a model of lower cost prescription drug coverage. Since the VHA provides healthcare directly, it maintains its own formulary and negotiates prices with manufacturers. Studies show that the VHA pays dramatically less for drugs than the PDP plans Medicare Part D subsidizes.[135][136] One analysis found that adopting a formulary similar to the VHA's would save Medicare $14 billion a year (over 10 years the savings would be around $140 billion).[137]

In 2006, the SGR mechanism was scheduled to decrease physician payments by 4.4%. (This number results from a 7% decrease in physician payments times a 2.8% inflation adjustment increase.) Congress overrode this decrease in the Deficit Reduction Act (P.L. 109-362), and held physician payments in 2006 at their 2005 levels. Similarly, another congressional act held 2007 payments at their 2006 levels, and HR 6331 held 2008 physician payments to their 2007 levels, and provided for a 1.1% increase in physician payments in 2009. Without further continuing congressional intervention, the SGR is expected to decrease physician payments from 25% to 35% over the next several years.
These coverage gaps mean that a particularly bad health year could leave you with tens of thousands of dollars in hospital bills. That's why most people purchase  Medicare supplement insurance – also called Medigap – or enroll in Part C, a Medicare Advantage Health Plan. Both options are offered by private insurance companies. They do, however, have to follow Medicare guidelines in what they are allowed to sell.
Promoting collaboration across sectors—health, education, social services, and others—to improve prevention, early intervention, and treatment services for children, and supporting a comprehensive approach to health care that goes beyond treating illness to addressing community factors that impact health, such as access to healthy food or safe housing; this could help reduce health inequities at the population level and lower costs related to preventable conditions (8, 9)
Remember, you still have Medicare if you enroll in an MA Plan. This means that you likely pay a monthly premium for Part B (and a Part A premium, if you have one). If you are enrolled in an MA Plan, you should receive the same benefits offered by Original Medicare. Keep in mind that your MA Plan may apply different rules, costs, and restrictions, which can affect how and when you receive care. They may also offer certain benefits that Medicare does not cover, such as dental and vision care.

Special Needs Plans (SNP): Special Needs Plans are for beneficiaries with certain unique situations and meet certain eligibility criteria. These plans may limit membership to people who have certain chronic conditions, live in an institution (such as a nursing home), or are dual eligibles (receive both Medicare and Medicaid benefits). You must meet the eligibility requirements of the Special Needs Plan to enroll; for example, to enroll in a Dual-Eligible Special Needs Plan in your service area, you must have both Medicare and Medicaid coverage.
Beneficiaries are primarily defaulted because they do not receive the enrollment packet, they do not understand the information because it was sent in English and they speak another language, or they submitted an incomplete enrollment form. Some are defaulted due to administrative and processing errors. Beneficiaries that are defaulted are not prevented from later choosing a health plan of their choice.

Of the Medicare beneficiaries who are not dual eligible for both Medicare (around 20%) and Medicaid or that do not receive supplemental insurance via a former employer (40%) or a public Part C Medicare Advantage health plan (about 30%), almost all elect to purchase a type of private supplemental insurance coverage, called a Medigap plan (20%), to help fill in the financial holes in Original Medicare (Part A and B). Note that the percentages add up to over 100% because many beneficiaries have more than one type of supplement. These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs. Medicare regulations prohibit a Medicare beneficiary from being sold both a public Part C Medicare Advantage health plan and a private Medigap Policy. As with public Part C health plans, private Medigap policies are only available to beneficiaries who are already signed up for benefits from Original Medicare Part A and Part B. These policies are regulated by state insurance departments rather than the federal government though CMS outlines what the various Medigap plans must cover at a minimum. Therefore, the types and prices of Medigap policies vary widely from state to state and the degree of underwriting, open enrollment and guaranteed issue also varies widely from state to state.


HAP Senior Plus (HMO)/(HMO-POS)/(PPO) and HAP Primary Choice Medicare (HMO) are health plans with Medicare contracts. HAP Empowered Duals (HMO SNP) is a Medicare health plan with a Medicare contract and a contract with the Michigan Medicaid Program. Enrollment in the plans depends on contract renewals. HAP Senior Plus (PPO) is a product of Alliance Health and Life Insurance company, a wholly owned subsidiary of HAP.

No part of Medicare pays for all of a beneficiary's covered medical costs and many costs and services are not covered at all. The program contains premiums, deductibles and coinsurance, which the covered individual must pay out-of-pocket. A study published by the Kaiser Family Foundation in 2008 found the Fee-for-Service Medicare benefit package was less generous than either the typical large employer preferred provider organization plan or the Federal Employees Health Benefits Program Standard Option.[46] Some people may qualify to have other governmental programs (such as Medicaid) pay premiums and some or all of the costs associated with Medicare.
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