What is Original Medicare? 

Medicare is a federal health insurance program for people 65 years old or older, certain disabled people younger than 65, and people with End-Stage Renal Disease.

How does Medicare work?

Medicare has four parts:

Medicare Part A is hospital insurance that helps pay for inpatient hospital stays, rehabilitative nursing facilities, home health care, and hospice. You likely will not have to pay a premium for Part A, because you prepaid the premium through payroll taxes while you were working. You are generally automatically enrolled in Medicare hospital insurance (Part A) without a premium when you apply for Social Security benefits – usually upon reaching 65 years of age, or after receiving disability payments for two years and if you have 10 years of creditable employment.

Medicare Part B is medical insurance that helps pay for doctors' services and outpatient care. You will pay a monthly premium for Part B. If you do not sign up for Part B when you become eligible at age 65, or when you have been disabled for two years and you decide you need to join in the future, you may have to pay a penalty for each year you were eligible but do not enroll. You are responsible for paying the Part B premium that is usually deducted from your Social Security benefits. Medicare pays for many healthcare services and supplies, but not all of your healthcare costs. For example, you pay a deductible for each hospital stay and may pay coinsurance anytime you use the services of a physician or surgeon. Also, drug coverage is limited. Because Medicare rarely pays the full cost of covered services, you may want to consider a Medicare Advantage or Medicare Supplement plan.

Medicare Part C is the Medicare Advantage program. With this option, you can choose to have your Medicare Parts A and B provided by a private insurance company like CarePlus. A Medicare Advantage plan provides Part A and Part B coverage – and generally, additional benefits, which may include Part D coverage.

Medicare Part D is prescription drug coverage. If you do not enroll in Part D when you become eligible, you may have to pay a penalty when you enroll.

What is Medicare Advantage?

Medicare Advantage is a type of health plan that lets you get your Original Medicare benefits from a private insurance company. The Balanced Budget Act of 1997 and the Medicare Modernization Act of 2003 created Medicare Advantage. Some examples of Medicare Advantage plans are:

  • Health Maintenance Organization (HMO) plans
  • Preferred Provider Organization (PPO) plans
  • Private Fee-for-Service (PFFS) plans

Medicare Advantage plans often provide additional benefits not found in Original Medicare, including reduced cost-sharing, prescription drug coverage, and wellness or fitness programs. If you select a Medicare Advantage plan, you use it instead of your Original Medicare coverage. However, you can return to Original Medicare in the future if you wish.

What is a Medicare Advantage HMO?

An HMO maintains a network of accredited doctors, hospitals, and other providers that you must use to receive benefits. You generally must get your care and services from providers in the plan's network, except for emergency care, out-of-area urgent care, and out-of-area dialysis. In some plans, you may be able to go out-of-network for certain services. However, it usually costs less if you get your care from a network provider. An HMO that offers any coverage out-of-network is called an HMO with a point-of-service (POS) option.

What is the Medicare Part D drug benefit?

Anyone entitled to Medicare Part A or enrolled in Medicare Part B, regardless of income, is eligible to enroll in Medicare Part D, which is a prescription drug benefit plan. This benefit was designed to help Medicare consumers get the prescription drugs they need at an affordable cost. Most CarePlus Medicare Advantage plans include Part D prescription drug coverage in addition to hospital and medical coverage.

What is a Prescription Drug Plan (PDP)?

A PDP is a private, stand-alone plan that only offers coverage for prescription medications (Part D coverage). You can use this plan with Original Medicare or with a Medigap plan. CarePlus does not offer a stand-alone prescription drug plan. Prescription drug coverage is included in most of our Medicare Advantage plans. All Medicare Advantage plans also include Part A hospital coverage and Part B medical coverage.

You cannot enroll in more than one PDP at the same time, or in a PDP and a Medicare Advantage plan that includes prescription drug coverage (MAPD). Exceptions include Medicare Advantage Private-Fee-For-Service (PFFS) plans that do not offer the Part D benefit, a Medicare Savings Account (MSA), or exceptions provided under CMS waiver authority.

If you are considering a PDP, please keep the following in mind:

  • Optional plan. A PDP is an option – not a requirement. However, if you don't join a Medicare Advantage plan with prescription drug coverage or a PDP when you first become eligible to join and do not already have drug coverage that’s as least as good as Medicare’s, you will have to pay a higher premium if you join later.

  • Monthly premium. All CarePlus Medicare Advantage Prescription Drug plans offer medical and prescription drug coverage together for one monthly premium. PDPs, on the other hand, have a monthly premium just for prescription drug coverage. In addition to the plan premium, you must continue to pay your Medicare Part B premium, unless the state Medicaid program pays your Part B premium for you.

How does a PDP plan work with a Medicare Advantage plan? If you are enrolled in a CarePlus Medicare Advantage Prescription Drug plan, it includes prescription drug coverage, in which case, you do not need to choose a PDP. If you were to enroll in a stand-alone PDP while enrolled in a Medicare Advantage plan with prescription drug coverage, you would be automatically disenrolled from your Medicare Advantage coverage. You cannot be enrolled in two Medicare plans with prescription drug coverage at the same time.

What is the difference between a preferred cost-share mail order pharmacy and a standard cost-share mail order pharmacy?

Preferred cost-share mail order pharmacies may provide prescriptions at a lower cost-share (e.g., copayments) than standard cost-share mail order pharmacies.

Standard cost-share mail order pharmacies may provide prescriptions at a higher cost-share (e.g., copayments) than preferred cost-share mail order pharmacies. You can find the cost-share information of a pharmacy in our Provider Directories.

What questions should I consider when choosing a Medicare health plan?

Before you select a plan, carefully consider the following questions:

  • Do you have a doctor you like?
  • Are you choosing a new doctor?
  • Do you want the ability to go to any doctor and any hospital?
  • What are your current or previous health conditions?
  • Do you need prescription drug coverage?
  • What prescription drugs are you currently taking?
  • Does the plan's formulary (drug list) include the prescription drugs you take?
  • Do you have Medicare and Medicaid?

When can I enroll in a Medicare Advantage (MA) plan?

If you recently became eligible for Medicare, through age or disability, you generally have the option to apply for coverage in a Medicare Advantage plan close to the date when your Medicare Part A and Part B coverage starts.

Your Medicare Advantage plan cannot start before both your Part A and Part B coverage begins. However, you generally have a period of 7 months to apply for Medicare Advantage plan coverage.

This means you can apply for a Medicare Advantage plan 3 months before, the month of, or 3 months after your Medicare Part A and Part B coverage starts. You must be enrolled in Medicare Part A and in Medicare Part B. This period is known as the Initial Coverage Election Period (ICEP).

Already enrolled in Medicare?

If you did not recently become eligible for Medicare, your enrollment options are different and may be limited to certain times during the year.

Annual Enrollment Period (AEP): October 15 - December 7

During this time, you may change or enroll in a Medicare Advantage (MA), Medicare Advantage Prescription Drug (MAPD), or Prescription Drug Plan (PDP), or return to Original Medicare. Changes made during this period will take effect on Jan. 1 of the following year.

Open Enrollment Period (OEP): January 1 - March 31

If you enrolled in a Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD) plan, you may be able to switch plans or return to Original Medicare during this time. You can change plans only one time during this enrollment period.

Special Enrollment Period (SEP)

In certain situations, outside of the ICEP or AEP, Medicare beneficiaries may be able to join, switch, or leave a Medicare Advantage plan or a prescription drug plan during a Special Enrollment Period (SEP).

Some examples of special enrollment situations are:

  • Your current plan is not renewing its contract with the Centers for Medicare & Medicaid Services (CMS).
  • You recently moved to the plan coverage area.
  • You have Medicare and Medicaid.
  • You qualify for Extra Help. 
  • You are disenrolling from an Employer’s or Union’s health coverage.
  • You want to enroll in a plan that received a 5-star rating from Medicare for that plan year.
  • You enter, reside in, or leave a long-term care facility.
  • You involuntarily lost creditable prescription drug coverage.
  • You were impacted by a state-declared emergency such as a hurricane.
  • Other conditions for a special enrollment period may exist, as determined by Medicare.

Where can I get more information about Medicare Advantage and prescription drug plans, financial assistance, and my Social Security benefits?

For more information about Medicare Advantage or prescription drug plans you can call the Centers for Medicare & Medicaid Services (CMS), or go online:

For more information about Medical Assistance through the state, you can contact Florida Medicaid or call your State Health Insurance Assistance Program (SHINE). 

For more information about Social Security or Railroad Retirement earnings, call or go online: 

Get started today!

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Last Updated:

09/24/2024