The PPACA instituted a number of measures to control Medicare fraud and abuse, such as longer oversight periods, provider screenings, stronger standards for certain providers, the creation of databases to share data between federal and state agencies, and stiffer penalties for violators. The law also created mechanisms, such as the Center for Medicare and Medicaid Innovation to fund experiments to identify new payment and delivery models that could conceivably be expanded to reduce the cost of health care while improving quality.[118] 

The intention of both the 1997 and 2003 law was that the differences between fee for service and capitated fee beneficiaries would reach parity over time and that has mostly been achieved, given that it can never literally be achieved without a major reform of Medicare because the Part C capitated fee in one year is based on the fee for service spending the previous year.
Both House Republicans and President Obama proposed increasing the additional premiums paid by the wealthiest people with Medicare, compounding several reforms in the ACA that would increase the number of wealthier individuals paying higher, income-related Part B and Part D premiums. Such proposals are projected to save $20 billion over the course of a decade,[147] and would ultimately result in more than a quarter of Medicare enrollees paying between 35 and 90 percent of their Part B costs by 2035, rather than the typical 25 percent. If the brackets mandated for 2035 were implemented today,[when?] it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. Under the Republican proposals, affected individuals would pay 40 percent of the total Part B and Part D premiums, which would be equivalent of $2,500 today.[148]
Medicare is a national health insurance program in the United States, begun in 1966 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It provides health insurance for Americans aged 65 and older, younger people with some disability status as determined by the Social Security Administration, as well as people with end stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease).
Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks. They can also be paid quarterly via bill sent directly to beneficiaries. This alternative is becoming more common because whereas the eligibility age for Medicare has remained at 65 per the 1965 legislation, the so-called Full Retirement Age for Social Security has been increased to 66 and will go even higher over time. Therefore, many people delay collecting Social Security but join Medicare at 65 and have to pay their Part B premium directly.
While the majority of providers accept Medicare assignments, (97 percent for some specialties),[64] and most physicians still accept at least some new Medicare patients, that number is in decline.[65] While 80% of physicians in the Texas Medical Association accepted new Medicare patients in 2000, only 60% were doing so by 2012.[66] A study published in 2012 concluded that the Centers for Medicare and Medicaid Services (CMS) relies on the recommendations of an American Medical Association advisory panel. The study led by Dr. Miriam J. Laugesen, of Columbia Mailman School of Public Health, and colleagues at UCLA and the University of Illinois, shows that for services provided between 1994 and 2010, CMS agreed with 87.4% of the recommendations of the committee, known as RUC or the Relative Value Update Committee.[67]

To be eligible to enroll in a Medicare Supplement insurance plan, you must be enrolled in both Medicare Part A and Part B. A good time to enroll in a plan is generally during the Medigap Open Enrollment Period, which begins on the first day of the month that you are both age 65 or older and enrolled in Part B, and lasts for six months. During this period, you have a guaranteed-issue right to join any Medicare Supplement insurance plan available where you live. You may not be denied basic benefits based on any pre-existing conditions* during this enrollment period (although a waiting period may apply). If you miss this enrollment period and attempt to enroll in the future, you may be denied basic benefits or charged a higher premium based on your medical history. In some states, you may be able to enroll in a Medigap plan before the age of 65.
Medigap plans may cover costs like Medicare coinsurance and copayments, deductibles, and emergency medical care while traveling outside of the United States. There are 10 standardized plan types in 47 states, each given a lettered designation (Plan G, for example). Plans of the same letter offer the same benefits regardless of where you purchase your plan. Massachusetts, Minnesota, and Wisconsin offer their own standardized Medigap plans.

Of the Medicare beneficiaries who are not dual eligible for both Medicare (around 10% are fully dual eligible) and Medicaid or that do not receive group retirement insurance via a former employer (about 30%) or do not choose a public Part C Medicare health plan (about 35%) or who are not otherwise insured (about 5% -- e.g., still working and receiving employer insurance, on VA, etc.), almost all the remaining elect to purchase a type of private supplemental indemnity insurance policy called a Medigap plan (about 20%), to help fill in the financial holes in Original Medicare (Part A and B) in addition to public Part D. Note that the percentages add up to over 100% because many beneficiaries have more than one type of additional protection on top of Original Medicare.


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*Pre-existing conditions are generally health conditions that existed before the start of a policy. They may limit coverage, be excluded from coverage, or even prevent you from being approved for a policy; however, the exact definition and relevant limitations or exclusions of coverage will vary with each plan, so check a specific plan’s official plan documents to understand how that plan handles pre-existing conditions
Some "hospital services" are provided as inpatient services, which would be reimbursed under Part A; or as outpatient services, which would be reimbursed, not under Part A, but under Part B instead. The "Two-Midnight Rule" decides which is which. In August 2013, the Centers for Medicare and Medicaid Services announced a final rule concerning eligibility for hospital inpatient services effective October 1, 2013. Under the new rule, if a physician admits a Medicare beneficiary as an inpatient with an expectation that the patient will require hospital care that "crosses two midnights," Medicare Part A payment is "generally appropriate." However, if it is anticipated that the patient will require hospital care for less than two midnights, Medicare Part A payment is generally not appropriate; payment such as is approved will be paid under Part B.[29] The time a patient spends in the hospital before an inpatient admission is formally ordered is considered outpatient time. But, hospitals and physicians can take into consideration the pre-inpatient admission time when determining if a patient's care will reasonably be expected to cross two midnights to be covered under Part A.[30] In addition to deciding which trust fund is used to pay for these various outpatient vs. inpatient charges, the number of days for which a person is formally considered an admitted patient affects eligibility for Part A skilled nursing services.
Less expensive plans have fewer benefits and higher out-of-pocket costs. More expensive plans include extra benefits, like some Medicare deductibles, additional hospital benefits, at-home recovery, and more. You have to decide what sort of plan makes the most sense for you. If you drop your Medigap policy, there is no guarantee you will be able to get it back.
Basic Plan helps cover Medicare's Parts A and B coinsurance, hospice care coinsurance, skilled nursing facility coinsurance, Home Health Care Services, Medical Supplies, and foreign travel emergency care. Extended Basic Plan provides the same benefits listed for the Basic Plan, plus benefits for Medicare's Part A hospital deductible, Medicare's Part B deductible, non-Medicare eligible expenses, and preventive medical care when not paid by Medicare.
There have been a number of criticisms of the premium support model. Some have raised concern about risk selection, where insurers find ways to avoid covering people expected to have high health care costs.[123] Premium support proposals, such as the 2011 plan proposed by Senator Ron Wyden and Rep. Paul Ryan (R–Wis.), have aimed to avoid risk selection by including protection language mandating that plans participating in such coverage must provide insurance to all beneficiaries and are not able to avoid covering higher risk beneficiaries.[124] Some critics are concerned that the Medicare population, which has particularly high rates of cognitive impairment and dementia, would have a hard time choosing between competing health plans.[125] Robert Moffit, a senior fellow of The Heritage Foundation responded to this concern, stating that while there may be research indicating that individuals have difficulty making the correct choice of health care plan, there is no evidence to show that government officials can make better choices.[121] Henry Aaron, one of the original proponents of premium supports, has recently argued that the idea should not be implemented, given that Medicare Advantage plans have not successfully contained costs more effectively than traditional Medicare and because the political climate is hostile to the kinds of regulations that would be needed to make the idea workable.[120]
Even if your prescriptions are covered, there may be hurdles to accessing them, so check the plan's rules. Starting in 2019, Medicare Advantage plans are allowed to require "step therapy," which means, in certain cases, you’ll need to try a less expensive drug before you'll be covered for a more expensive one. Or you may be steered toward a preferred pharmacy instead of your local drugstore.

If you are a Minnesota beneficiary and considering enrollment in a Medicare Advantage plan, it is important to compare and evaluate the Medicare plan options available to you. While similar Medicare Advantage plans may be offered throughout the state, the cost for premiums may vary depending on your county of residence. You should also take note that some Medicare Advantage plans in Minnesota may offer monthly premiums as low as $0. If your service area offers a Medicare Advantage plan with a $0 premium, keep in mind that the plan may still include other costs besides the premium, such as copayments, coinsurance, and deductibles. In addition, you must still pay your Medicare Part B premium.
We often run into individuals who have been on Plan F for several years. Because the coverage is so good, they find themselves fearful to change carriers. The good news is that benefits for Plan F with one Medigap company will be exactly the same as benefits with a Plan F from a different company. This means you should be comparing the Medicare Plan F cost between insurance companies annually and looking for the cheapest Medigap Plan F in your area.

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Because of how Part D works and depending on income, a patient could pay between 35 percent and 85 percent of the cost of some of their prescription drugs if they need enough medication to push them into the notorious doughnut hole, when Part D's full prescription-drug coverage runs out after a person has spent $3,750, until their medication costs exceed $5,000 per year. (In 2019, coverage will end at $3,750 and begin again at $5,000.) During the coverage gap, the patient would be responsible for 25 percent of covered, brand-name prescription drugs.
Medicare supplement plans are related to Medicare. Like Medicare’s “Parts”, each plan letter offers different benefits and has a different premium amount. They are designed to fill the “coverage gaps” in Original Medicare benefits (hence the name Medigap). These products will cover healthcare expenses otherwise left out of Original Medicare coverage, like coinsurance and deductibles. However, Medigap plans do not include dental, vision, or any other supplemental health insurance benefits.
The standardized Medigap plans each cover certain Medicare out-of-pocket costs to at least some degree. Every Medigap plan covers up to one year of Medicare Part A coinsurance and hospital costs after Medicare benefits are used up. But, for example, Medigap Plan G plans don’t cover your Medicare Part B deductible, while Medigap Plan C plans do. So, if you’d like to enroll in a Medicare Supplement insurance plan, you might want to compare the Medigap policies carefully.
The average cost of monthly premiums for insurance in Minnesota is $477, which may be too expensive for some of the residents in the state. However, the US federal government offers more affordable Minnesota Medicare insurance coverage for beneficiaries over the age of 65, and some workers with disabilities may qualify as well. The Minnesota state government also offers various assistance programs for Medicare beneficiaries.
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*Pre-existing conditions are generally health conditions that existed before the start of a policy. They may limit coverage, be excluded from coverage, or even prevent you from being approved for a policy; however, the exact definition and relevant limitations or exclusions of coverage will vary with each plan, so check a specific plan’s official plan documents to understand how that plan handles pre-existing conditions.
If you are a Minnesota beneficiary and considering enrollment in a Medicare Advantage plan, it is important to compare and evaluate the Medicare plan options available to you. While similar Medicare Advantage plans may be offered throughout the state, the cost for premiums may vary depending on your county of residence. You should also take note that some Medicare Advantage plans in Minnesota may offer monthly premiums as low as $0. If your service area offers a Medicare Advantage plan with a $0 premium, keep in mind that the plan may still include other costs besides the premium, such as copayments, coinsurance, and deductibles. In addition, you must still pay your Medicare Part B premium.
The standardized Medigap plans each cover certain Medicare out-of-pocket costs to at least some degree. Every Medigap plan covers up to one year of Medicare Part A coinsurance and hospital costs after Medicare benefits are used up. But, for example, Medigap Plan G plans don’t cover your Medicare Part B deductible, while Medigap Plan C plans do. So, if you’d like to enroll in a Medicare Supplement insurance plan, you might want to compare the Medigap policies carefully.
Established in 1929, BCBS provides Medicare Supplement insurance and personalized, affordable health plans to more than 106 million Americans, equal to nearly one out of every three health insurance consumers across the country. Blue Cross Blue Shield is the umbrella company for 36 different U.S.-based independent health insurance companies like Anthem, CareFirst and Regence, among others.

Enrollment in public Part C health plans, including Medicare Advantage plans, grew from about 1% of total Medicare enrollment in 1997 when the law was passed (the 1% representing people on pre-law demonstration programs) to about 36% in 2018. Of course the absolute number of beneficiaries on Part C has increased even more dramatically on a percentage basis because of the large increase of people on Original Medicare since 1997. Almost all Medicare beneficiaries have access to at least two public Medicare Part C plans; most have access to three or more.


Payment for physician services under Medicare has evolved since the program was created in 1965. Initially, Medicare compensated physicians based on the physician's charges, and allowed physicians to bill Medicare beneficiaries the amount in excess of Medicare's reimbursement. In 1975, annual increases in physician fees were limited by the Medicare Economic Index (MEI). The MEI was designed to measure changes in costs of physician's time and operating expenses, adjusted for changes in physician productivity. From 1984 to 1991, the yearly change in fees was determined by legislation. This was done because physician fees were rising faster than projected.
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