There are four “corners” to your Medicare benefits, and they are Part A, Part B, Part C and Part D.
- Medicare “Part A” and “Part B” are often called “Original Medicare.”
- Medicare Advantage plans are often called Medicare “Part C” or “MA Plans.”
- Medicare Prescription Drug Coverage is often called “Part D.”
Medicare Part A (also called Original Medicare) is hospital coverage
Part A is managed by Medicare and provides Medicare benefits and coverage for:
- Inpatient hospital care
- Inpatient stays in most skilled nursing facilities
- Hospice and home health services
You usually don’t pay a monthly premium for Medicare Part A coverage if you or your spouse paid Medicare taxes while working. This is sometimes called “premium-free Part A.”
You can get premium-free Part A at 65 if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You’re eligible to get Social Security or Railroad benefits but haven’t filed for them yet.
- You or your spouse had Medicare-covered government employment.
If you’re under 65, you can get premium-free Part A if:
- You got Social Security or Railroad Retirement Board disability benefits for 24 months.
- You have End-Stage Renal Disease (ESRD) and meet certain requirements.
Medicare Part B (also called Original Medicare) is medical coverage
Part B is also managed by Medicare and provides Medicare benefits and coverage for:
- Doctor and clinical lab services
- Outpatient and preventive care
- Screenings, surgical fees and supplies
- Physical and occupational therapy
Combined, Medicare Part A and Part B are sometimes also called “Original Medicare.”
Medicare Part C (also called Medicare Advantage) combines both A and B
Medicare Part C is a different way of getting Medicare Part A and Part B coverage. Medicare Advantage Plans (called MA Plans) combine Part A (hospital insurance) and Part B (medical insurance) together in one plan. They can also be combined with Part D prescription drug coverage called Medicare Advantage Prescription Drug (MA-PD) Plans. Generally, these plans are offered as:
- Medicare Advantage Preferred Provider Organizations (PPO plans)
- Medicare Advantage Health Maintenance Organizations (HMO plans)
- Medicare Advantage Private Fee-for-Service (PFFS plans)
Medicare Advantage plans are Medicare health plans offered by private companies that contract with Medicare to provide you with all your Part A and Part B benefits. MA plans provide the coverage for these benefits instead of the benefits being offered under Original Medicare. MA plans have specific rules regarding eligibility and enrollment as well as certain rules for how you get services, such as requiring you to select a Primary Care Physician or going to a contracted provider in the network for many services.
Medicare Advantage plans as available for a specific service area, meaning the location of eligible members. Not all Medicare Advantage plans are available in all counties within a state or even in multiple states. Many MA plans are only available within certain counties.
Many MA plans include prescription drug coverage, commonly called Part D
Medicare Part D is Prescription Drug Coverage
A Medicare Part D Prescription Drug Plan (PDP) can be a stand-alone plan (not joined with other insurance), or it may be combined with a Medicare Advantage Plan called a Medicare Advantage Prescription Drug (MA-PD) Plan.
Medicare Special Needs Plans (SNP)
Certain Medicare Advantage plans are designed as Special Needs Plans or SNP. These are plans that are limited to members with specific medical conditions or diseases, eligibility to reside in long term care facilities, or currently enrolled in both Medicare and Medicaid (commonly called Dual Eligible).
A Special Needs Plan is classified as one of the following three types:
Chronic Condition or C-SNP limit their members to individuals with one or more of the specified severe or chronic conditions.
Institutional or I-SNP offer their coverage to individuals who live in various residential facilities like nursing homes or require nursing care while living at home.
Dual Eligible or D-SNP provide coverage to individuals who have both Medicare and Medicaid.
If you meet the characteristics of the SNP, you can join the plan if it is available in your area. Many of the plans allow enrollment without having to wait for any annual enrollment period or the beginning of a plan year. If events change and you no longer meet the criteria of the SNP, you must disenroll and select a different Medicare option.
Like all Medicare Advantage plans, all medically-necessary and preventative care services that Original Medicare (Part A and Part B) would cover, must be covered by the SNP. Additionally, every SNP must cover prescription drugs just as Part D. However, many MA Special Needs Plans offer enhanced benefits tailored to the needs of their populations. Benefits such as dental coverage or extra days in the hospital may be offered.
For more information about Medicare Special Needs Plans, click here for Your Guide to Medicare Special Needs Plans, a document provided by the United States Department of Health and Human Services Centers for Medicare & Medicaid Services. (Please note that by clicking on this link, you will leave Kalos Health’s website).
Kalos Health Gold Plus is a Health Maintenance Organization (HMO) Special Needs Plan (SNP) with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Kalos Health Gold Plus depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. You must continue to pay your Medicare Part B premium (unless your part B premium is paid for you by Medicaid or another third party).
Last Updated 04-11-2018