Other Medicare Health Plans

Health Plans

What's a Medicare health plan?

Generally, a Medicare health plan is offered by a private company that contracts with Medicare to provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) benefits to people who enroll in the plan. Medicare health plans include:

Medicare Cost Plans
Demonstrations/Pilot Programs
Programs of All-inclusive Care for the Elderly (PACE)
Medication Therapy Management (MTM) programs for complex health needs

Some types of Medicare health plans that provide health care coverage aren't Medicare Advantage Plans but are still part of Medicare. Some of these plans provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, while most others provide only Part B coverage. Some also provide Medicare prescription drug coverage (Part D).

These plans have some of the same rules as Medicare Advantage Plans. However, each type of plan has special rules and exceptions, so contact any plans you're interested in to get more details.

Medicare Cost Plans

Medicare Cost Plans are a type of Medicare health plan available in certain areas of the country.

Here are important facts about Medicare Cost Plans:

You can join even if you only have Part B.
If you have Part A and Part B and go to a non-network provider, the services are covered under Original Medicare . You would pay the Part A and Part B coinsurance and deductible .
You can join anytime the plan is accepting new members.
You can leave anytime and return to Original Medicare.
You can either get your Medicare prescription drug coverage from the plan (if offered), or you can join a Medicare Prescription Drug Plan (Part D) .

Another type of Medicare Cost Plan only provides coverage for Part B services. These plans never include Part D. Part A services are covered through Original Medicare. These plans are either sponsored by employer or union group health plans or offered by companies that don't provide Part A services.

Health Savings Account (HSA)

A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in a Health Savings Account (HSA) to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your overall health care costs. HSA funds generally may not be used to pay premiums.

While you can use the funds in an HSA at any time to pay for qualified medical expenses, you may contribute to an HSA only if you have a High Deductible Health Plan (HDHP) — generally a health plan (including a Marketplace plan) that only covers preventive services before the deductible. For plan year 2019, the minimum deductible is $1,350 for an individual and $2,700 for a family. For plan year 2020, the minimum deductible for an HDHP is $1,400 for an individual and $2,800 for a family. When you view plans in the Marketplace, you can see if they’re "HSA-eligible."

For 2019, if you have an HDHP, you can contribute up to $3,500 for self-only coverage and up to $7,000 for family coverage into an HSA. For 2020, if you have an HDHP, you can contribute up to $3,550 for self-only coverage and up to $7,100 for family coverage into an HSA. HSA funds roll over year to year if you don't spend them. An HSA may earn interest or other earnings, which are not taxable.

Some health insurance companies offer HSAs for their HDHPs. Check with your company. You can also open an HSA through some banks and other financial institutions.

PACE

Programs of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility. With PACE, you have a team of health care professionals working with you and your family to make sure you get the coordinated care you need. Usually they care for a small number of people, so they really get to know you. When you enroll in PACE, you may be required to use a PACE-preferred doctor.

How Does PACE Work?

PACE organizations provide care and services in the home, the community, and the PACE center. They have contracts with many specialists and other providers in the community to make sure that you get the care you need. Many people in PACE get most of their care from staff employed by the PACE organization in the PACE center. PACE centers meet state and federal safety requirements.

Who Can Get PACE?

You can have either Medicare or Medicaid, or both, to join PACE. PACE is only available in some states that offer PACE under Medicaid. To qualify for PACE,

you must:

Be 55 or older
Live in the service area of a PACE organization
Need a nursing home-level of care (as certified by your state)
Be able to live safely in the community with help from PACE

Note: You can leave a PACE program at any time.

What Does PACE Cover?

PACE provides all the care and services covered by Medicare and Medicaid if authorized by your health care team. If your health care team decides you need care and services that Medicare and Medicaid doesn't cover, PACE may still cover them.

Here are some of the services PACE covers:

Adult day primary care (including doctor and recreational therapy nursing services)
Dentistry
Emergency services
Home care
Hospital care
Laboratory/x-ray services
Meals
Medical specialty services
Nursing home care
Nutritional counseling
Occupational therapy
Physical therapy
Prescription drugs

Note: If you join a PACE program, you'll get your Part D-covered drugs and all other necessary medication from the PACE program. You don't need to join a separate Medicare Prescription Drug Plan. If you do, you'll be disenrolled from your PACE health and prescription drug benefits.

Preventive care
Social services, including caregiver training, support groups, and respite care
Social work counseling
Transportation to the PACE center for activities or medical appointments, if medically necessary . You may also be able to get transportation to some medical appointments in the community.

How to apply for PACE

To find out if you’re eligible and if there’s a PACE program near you, search for PACE plans in your area, or call your Medicaid office.

What you pay for PACE depends on your financial situation

If you have Medicaid, you won't pay a monthly premium for the long-term care portion of the PACE benefit.

If you don't qualify for Medicaid but you have Medicare, you'll be charged these:

A monthly premium to cover the long-term care portion of the PACE benefit
A premium for Medicare Part D drugs

There's no deductible or co-payment for any drug, service, or care approved by your health care team. If you don't have Medicare or Medicaid, you can pay for PACE privately.

Medicare Costs