What is Medicare?

Medicare is the largest health insurance program in the United States. It is run by the Centers for Medicare and Medicaid (CMS), a government agency.

You can join Medicare if you’re 65 or older and:

  • You are either a citizen or a permanent resident of the United States, and
  • You or your spouse worked at least 10 years in the Medicare-covered employment
  • You are under 65 with certain disabilities and
  • People of all ages with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.

What is Medicare

Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). It is a “fee-for-service” health plan. This means you pay for each service you receive. To better understand Original Medicare, let’s take a look at what each part covers.

Medicare Part A

Hospital Insurance
Medicare Part A covers care you receive when you stay in a hospital (this is called “inpatient” care). It also covers care you get at skilled nursing facilities, home health care and hospice care.
Most people get Part A from the Federal government when they turn 65 if they:
  • Have worked for a combined 10 years, or
  • Worked 40 quarters (three-month periods) paying into Medicare. They do not need to be quarters that come one after the other.
Most people do not pay any monthly fee, or a “premium,” for Part A.
You do pay part of the costs for services you get under Part A. You pay a deductible plus your share of the Medicare-approved cost for services (“coinsurance”).

Medicare Part B

Medical Insurance
  • Medicare Part B helps you pay for medical services. These are services like doctor visits, tests, outpatient hospital services and other like services. Part B is voluntary, which means you can choose to join it. If you choose Part B, you pay a monthly fee, or “premium,” of $134 per month. (This fee might be higher, based on your income.)
  • If you do not sign up for Part B when you are first able to join Medicare, you will pay a higher monthly fee if you choose to join later.

How much do I pay for care I receive under Part B?
  • You must first pay a deductible, or a yearly fee for services, before your plan pays for any costs under Part B.
  • After you pay your deductible, Medicare pays up to 80 percent of Medicare-approved charges for most covered services.
  • You pay the remaining costs — typically 20 percent of the total.
  • Medicare Part B covers many preventive health care services at no cost to you, like annual exams, screenings and certain vaccines.
  • Sometimes you may pay more than 20 percent. This can happen if your doctor does not accept “assignment” — the Medicare-approved rate for services. If a doctor does not accept assignment, you must pay your doctor what Medicare does not cover.
  • Medicare Part A and Part B do not cover everything. There are many services that you will need to pay for in full.
  • To learn more about what Medicare covers and does not cover, please call Medicare at 800-633-4227, or see the “Medicare & You” handbook at medicare.gov.

Original Medicare coverage is good, but it can be hard to manage multiple plans, ID cards, bills and networks. With a Medicare Advantage plan from a private company like EmblemHealth, you can get what you need from a single plan. So there’s less hassle.

Having a Medicare Advantage means that you will still get all the benefits of Medicare Parts A and B, you don’t lose them! Plus you’ll get extra benefits — often for no more than what you already pay each month for Part B.

For example:

  • Dental care
  • Eye exams related to prescribing glasses
  • Fitness programs
  • Hearing aids and exams for fittings
  • Prescription drug coverage

Who can join an EmblemHealth Medicare Advantage plan?
You can join a plan if you:
  • Are eligible for Medicare Part A and are enrolled in Medicare Part B (continue to pay your part B premium). and
  • Live in EmblemHealth’s service area.

    2019 EmblemHealth HMO Medicare Service Area Map
  • View EmblemHealth’s 2019 Service Area map which includes the following counties in New York: Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk , Sullivan, Westchester and Ulster.

What kinds of Medicare Advantage plans are there?
  • Health Maintenance Organization (HMO) plans give you all the benefits of Original Medicare plus extra benefits. With an HMO plan:
    • You choose a doctor who will provide your everyday care called a primary care doctor (PCP).
    • Your PCP will arrange for any referrals that you need to see specialists.
    • You are usually only covered for care and services you get from your HMO network of doctors.
    • In an emergency, you can go to any doctor or hospital.
  • Health Maintenance Organization Point of Service (HMO-POS) plans give you all the benefits of Original Medicare plus extra benefits. They are just like HMO plans, but with added flexibility. With an HMO-POS plan:
    • You can get covered services from doctors and other health care professionals in your plan’s network.
    • You can also get care outside of the network. When you get care outside of the network, the services you can get outside of the network may vary by plan.
    • You often pay less when you use your plan’s provider network.
    • Some HMO-POS plans ask you to choose a PCP. This is the doctor who will provide your everyday care. This doctor can be in or out of your plan’s network.
    • In an emergency, you can go to any doctor or hospital. But you may pay more if the doctor or hospital is not in the network.
  • Preferred Provider Organization (PPO) plans, Like HMOs, PPOs give you all the benefits of Original Medicare plus extra benefits. In most cases, PPOs will:
    • Have a network of doctors, other health care professionals and facilities.
    • Let you also get covered services outside the network, often at a higher cost.
  • Special Needs Plan (SNP) is a type of Medicare Advantage plan that is only available to people who:
    • Are eligible for both Medicare and Medicaid,
    • Live in certain institutions (like a nursing home) or who require nursing care at home, or
    • Have specific chronic or disabling conditions (like diabetes or chronic heart failure).
    It can be an HMO or a PPO plan. You can join an SNP plan at any time if you qualify for one.
    What is Medicare Part D and how do I enroll?
    Medicare Part D is a prescription drug coverage plan for people who have either Medicare Part A or Part B. To sign up, all you need to do is join a plan that offers Part D.

    Medicare Part D is a voluntary program. This means you don’t have to buy it when you join Medicare. Many people buy it, and some people choose not to. But if you decide to buy a Part D plan after you first sign up for Medicare, you may pay more for it each month. This is called a “late enrollment penalty.”

    What drugs are covered under Medicare Part D?
    All Medicare Part D plans have a list of covered drugs. This is called a “formulary.” Plan drug lists will include both generic and brand name drugs, and will list them in levels, or “tiers,” based on cost. The lower the level or tier, the lower your cost for the drug will be.

    How much will a Medicare Part D plan cost?
    To join, you simply pay a monthly amount, or “premium,” to the plan you choose. Some Medicare Advantage plans include the Part D cost in their monthly plan premium, like EmblemHealth. Depending on your plan, you may also pay deductible and coinsurance costs. If you need help paying for your drugs, you may qualify for “Extra Help.”.

    Companies that offer Medicare Part D may cover different drugs or charge different amounts for them. So choose a plan that offers you the best solution for your own needs.
    There are many programs that can help you pay for Medicare:
    Medicare Savings Programs
    If you have limited income and resources, you may be able to get help from your state to pay your Medicare costs. Some of the programs may help to pay your Medicare Part B premium, or some of your costs to get services, like deductibles, coinsurance or copays.


    Medicaid is a health plan for low-income and disabled people. Each state runs its own program. The federal government and each state government share the costs of this program. Some people have both Medicare and Medicaid. They are called “dual eligibles.” As a dual eligible, most of your health care expenses will be covered.
    What is “Extra Help”?
    Extra Help is a Medicare program to help people with limited income and resources pay Part D drug plan costs. It can help pay monthly premium fees, deductibles, and coinsurance.

    You can get Extra Help if:
    • You have full Medicaid coverage.
    • You get help from your state Medicaid program to pay your Part B premiums in a Medicare Savings Program.
    • You get Supplemental Security Income (SSI) benefits.

    If you get Extra Help, what you pay for your plan and what you pay at the pharmacy will be lower. It may even lower your premium and deductible costs to $0. You will also have no coverage gap, pay no late enrollment penalties, and you can switch plans at any time.


    If you have any questions about any of these programs or to see if you can get Extra Help, an EmblemHealth Medicare specialist can help you.
    How can My Advocate help you save money?
    My Advocate helps seniors and disabled individuals apply for Medicare Savings Programs, Extra Help and other community assistance programs.

    Helpful Medicare Resources

    2019 EmblemHealth Medicare Made Simple Guide — An EmblemHealth guide to help you make the right Medicare decisions.

    Document Download (PDF)
    2019 EmblemHealth Medicare Made Simple Guide

    2019 CMS Medicare & You Brochure — Helpful information for people eligible for Medicare and their caregivers.

    Document Download (PDF)
    2019 CMS Medicare & You Brochure

    Official U.S. Government website for people with Medicare — General information and helpful tools.

    Medicare Rights Center —A national not-for-profit consumer service organization dedicated to making sure that older adults and people with disabilities get affordable health care.

    Administration for Community Living — The Administration for Community Living educates people and their caregivers about the benefits and services available to help them.

    Social Security Administration800-772-1213 (TTY: 800-325-0778), Monday through Friday, 7 am to 7 pm.

    Elderly Pharmaceutical Insurance Coverage EPIC Help Line— This program helps income-eligible people 65+ to supplement their out-of-pocket Medicare Part D drug plan costs.

    800-332-3742, Monday through Friday, 8 am to 5 pm.
    (TTY: 800-421-1220).

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