What's in this chart
Type: The chart below shows four types of health plans with drug coverage — HMO, PPO, HMO-POS, PFFS. They are explained on the next page.
Premium: The monthly charge for the plan. This is in addition to whatever monthly Part B payment you make to Medicare.
Part B rebate: Some plans pay part of your monthly Part B premium, which for most people will be $104.90.
Doctor copay: This is your cost every time you see a doctor. The first dollar figure is for primary care physicians, the second for specialists. Costs are listed for physicians inside the network (Net:) and outside the network (Out:).
Hospital copay: This is your cost for inpatient hospital care, for each admission. Costs are listed for hospitals inside the network (Net:) and outside the network (Out:).
Estimated total cost: Medicare's estimate of annual out-of-pocket costs under this plan, including Part B premium and drugs. It is based on an average person in good health, but could vary greatly depending on the drugs you take and what services you actually need. The best way to assess the projected cost of different plans is with Medicare's Plan Finder at medicare.gov.
Out-of-pocket cap: Your maximum payment for the year inside the network (Net:) and outside the network (Out:). The lower the cap the better.
Network size: The total number of providers in a network, including doctors, hospitals and other services. Some networks cover a specific region, others the entire state. Before signing up with any plan, check its provider network to see if its hospitals and doctors are acceptable to you.
Generics in the gap: Whether a plan pays for generic drugs in the coverage gap, or "donut hole,'' which begins when total drug costs hit $2,850 and ends when your out-of-pocket costs reach $4,550.
Rating: Medicare rates plans from 1 to 5 stars, based on customer satisfaction and certain health measures. The top rating is five. Plans that have received a low rating three years in a row earn a "warning" symbol.
What's not in this chart
Special Needs Plans: See explanation below.
Copayments for other services: Plans usually charge copayments for drugs, skilled nursing homes, ambulances, emergency rooms and many other services. Check individual plans for these details.
Goodies: Some plans offer some dental, hearing and vision coverage, exercise classes, transportation to the doctor and other extra benefits. Check plans for details.
Health plans without drugs: A few plans are cheaper because they do not offer drug coverage, but choosing those plans can result in stiff penalties in subsequent years unless you receive comparable drug coverage elsewhere
Health plans: how they differ
Medicare allows several types of private health plans, which cover all your care. Here is how they differ:
HMO (Health Maintenance Organization): Generally require you to use providers within a network, unless an emergency forces you to seek treatment elsewhere. A personal physician usually coordinates your care and must approve visits to specialists.
PPO (Preferred Provider Organization): Also encourages you to use providers within a network, with low copayments, but also allows you to use providers outside the network at a higher cost. Usually allows you to see specialists within the network without prior approval of a personal physician. "Regional'' PPOs generally have larger networks, such as the entire state. Some bigger companies allow you to use their PPOs in other states, useful to snowbirds. Verify before signing up.
HMO-POS (HMO-Point of Service): A hybrid between an HMO and PPO. Usually requires you to stay within a network and seek approval of a personal physician before seeing network specialists. But also may cover some care outside the network, with a referral. Some POS plans approve very little coverage outside the network, so check plans for details.
PFFS (Private Fee for Service): Has network, but also allows members to get care outside the network if the provider will accept the plan's payment, which many do not. Make sure your providers will accept payment before incurring bills.
Special Needs Plans: People with certain chronic conditions like diabetes and COPD can sometimes qualify for a Special Needs Plan, which may include extra services for managing their disease. Make sure you qualify before purchasing. People living in nursing homes may also qualify for special plans, as can people on Medicaid.
• Special Needs Plans are not listed in this chart. See medicare.gov for information.