Many Medicare Advantage plans have yearly limits on the amount you pay for covered Part A and B services. They may also cover prescription drugs, and some include a Medicare Part D drug plan. Go here to learn more about these plans and their benefits.
Some Medicare Advantage plans have special supplemental benefits like transportation, meal service or home utility assistance. These benefits are typically available to people with qualifying chronic health conditions.
Medicare Part A
For those who are 65 or older, Medicare Parts A and B offer the most basic coverage. These parts cover hospital services, home health care and hospice care. EmblemHealth offers plans that include these benefits and also prescription drug coverage.
Part A usually begins the month an individual turns 65, or earlier if they file an application with the Social Security Administration. To keep this coverage, people must pay a monthly premium and meet a deductible.
Individuals who miss their Initial Enrollment Period (IEP) due to certain life events may be able to enroll in Part B and Premium Part A without paying a penalty. This includes individuals who lose their group health plan coverage, have a change in employment or move. The SEP is only available for a limited time. Individuals must demonstrate that circumstances beyond their control caused them to miss the SEP.
Medicare Part B
Medicare Part B covers medical services, like doctor visits and telehealth services, as well as laboratory tests and X-rays. Part B also covers certain vaccinations, such as flu shots and hepatitis B shots. It pays 80% of an approved charge, and the patient pays the remaining 20% coinsurance. Many Original Medicare enrollees purchase supplemental insurance (also called Medigap) to help cover these out-of-pocket costs.
Individuals who missed their seven-month initial enrollment period can still enroll in premium Part B during a Special Enrollment Period. However, they may be required to pay a late-enrollment penalty. This penalty is 10% of the standard premium for each year they could have had Part B coverage but didn’t. This percentage “stacks,” so two years equals 20%, and so on.
Typically, individuals who were advised to delay their Medicare Part B enrollment will have the chance to request equitable relief to waive this fee. However, this is not available for everyone.
Medicare Part D
Medicare Part D helps pay for your prescription drugs at participating pharmacies. You typically pay a monthly premium, and possibly an annual deductible and copays. If you have limited income and resources, you may be eligible for Extra Help with your costs.
Medicare prescription drug plans offer low copays, extensive coverage and national pharmacy networks. They can include or exclude certain medications, and can also use utilization management tools such as prior authorization, quantity limits, step therapy, and mail order.
Medicare Part D spending is largely driven by the price of drugs, but other factors can influence it as well, such as discounts (rebates) from manufacturers and preferred pricing arrangements with pharmacies, and management of use via prior authorization, step therapy, mail order and utilization review. In 2025, the Congressional Budget Office estimates that the average Part D plan will receive rebate payments that offset about 17% of their total costs.
Medicare Advantage
Traditional Medicare provides health and prescription drug coverage for beneficiaries 65 or older. It also has a monthly premium, deductible and cost sharing for some services. Some people choose to enroll in a Medicare Advantage plan.
These plans combine Medicare Part A and B with prescription drug coverage and may offer extra benefits like vision, hearing, or dental care. They usually have a network of providers and require enrollees to obtain prior authorization before seeing specialists or getting certain medical treatments.
Medicare Advantage plans are rated from one to five stars each year based on up to 38 unique quality and performance measures. A plan that receives a five-star rating has the best overall performance. A rebate is given to plans that do not earn a five-star rating, and the bid amount is “risk adjusted” to take into account enrollees’ health status. These changes are reflected during the open enrollment period, which runs from Oct. 15 to Dec. 7. People can make a Medicare Advantage change during this time or during a Special Enrollment Period.