Medicare Coverage Examples

Below are some examples of the different kinds of Medicare and Medigap coverage a person may get and what costs could be when used. Note that none of the below examples represent real people, and that the costs below are estimates, intended for learning purposes only.

Karen is about to turn 65 and is about to retire. She doesn't take any prescription drugs currently and is in very good health. Karen also likes to travel, going to different U.S. National Parks every summer and fall. She is retiring from her position as CEO of a global software company with a very strong savings and annual pension. Karen is not concerned about out-of-pocket health care costs and doesn't anticipate needing more than medical and hospital insurance.

Karen's Medicare benefits wish list

Access to doctors and hospitals throughout the United States
Basic medical insurance

Karen's Medicare coverage choices

Original Medicare (Parts A & B)

Karen's Medicare plan features

Access to doctors and hospitals throughout the United States
Basic medical and hospital insurance

Karen's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly total	$164.90

Karen's monthly premium costs will be $164.90 since she pays nothing for Part A.

Karen's other costs & cost-sharing

Karen's Medicare coverage only works for health care items and services covered by Medicare Part A and Part B. Karen will be responsible for any out-of-pocket costs that are not covered by Medicare Part A or Part B per Original Medicare cost-sharing terms. And because Karen did not get a Part D prescription drug plan or any other additional coverage, she will be 100% responsible for any costs related to health items and services not covered at all by Medicare Part A or Part B.

Georgia will be 65 next month. She has been working part-time since her husband died five years ago, but her income is limited. Georgia has heart disease, so she sees a heart specialist regularly and takes a blood-thinning medicine every day. She cannot afford a Medicare supplement policy.

Georgia's Medicare benefits wish list

Health care at an affordable price
Access to her trusted doctors
Discounted prices on her prescription drugs
The possibility of help with her premiums and cost sharing if she qualifies for low-income assistance

Georgia's Medicare coverage choices

Original Medicare (Parts A & B)
Stand-alone Medicare Part D prescription drug plan

Georgia's Medicare plan features

Access to the doctors and hospitals she uses now
Discounted prices on the drugs she takes

Georgia's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare Part D plan premium	$0
Monthly total	$164.90

Georgia's monthly premium costs will be $164.90 total.

Now that we have that number, let's add in Georgia's daily blood-thinning medication. Georgia pays a $10 copay each time she fills a prescription. She fills her blood-thinning prescription once a month. Thus, Georgia's base-line monthly Medicare costs will be $174.90.

Georgia's other costs & cost-sharing

Georgia will have other out-of-pocket costs to cover when she receives different health care services and items. She will be responsible for the costs of services and items not covered by Original Medicare (Parts A & B) as well the costs defined by the cost-sharing terms of her Part D plan.

Georgia should apply for financial help.

Because Georgia has a limited income, she could explore financial help by seeing if she qualifies for the Extra Help program (to help with her Part D costs) and Medicaid. If she qualifies for either program, her costs could be significantly lower for both Original Medicare and Part D.

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Juanita lives in Colorado and will be 65 in 3 months. She plans to retire then and spend a lot of time traveling to visiting her children and grandchildren in California. Juanita is in good health, although she takes two prescriptions daily—one to keep her bones strong and one to keep her cholesterol down. Juanita has a comfortable pension, but she wants to leave a financial legacy to her family and is therefore looking to be careful about how much she pays for Medicare.

Juanita's Medicare benefits wish list

Access to doctors and hospitals when she's out of state visiting her children
Help with paying for her prescription drugs
Peace of mind of knowing that she will have help paying her health care costs if they are high

Juanita's Medicare coverage choices

Original Medicare (Parts A & B)
Stand-alone Medicare Part D prescription drug plan
Medicare supplement insurance plan (Plan G)

Juanita's Medicare and Medigap coverage features

Access to doctors and hospitals throughout the United States
Discounted prices on the drugs she takes
Help with costs not paid by Original Medicare

Juanita's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare Part D plan premium	$34
Monthly Medicare supplement Plan G premium	$150
Monthly total	$348.90

Juanita's monthly premium costs will be $348.90 total.

Now that we have that number, let's add Juanita's two prescription drugs. Juanita's Part D plan covers a lot of the costs of her prescriptions, but she does have to pay a $10 copay each time she fills a prescription. She refills both prescriptions together once a month. Thus, we can now say that with Juanita's monthly premiums and her monthly prescription copay, Juanita's base monthly Medicare costs will be $358.90.

Juanita needs to consider how to pay for her prescriptions

A Medicare supplement insurance plan covers most of Juanita's out-of-pocket costs with Original Medicare, but Juanita's prescription drug costs are not covered by her Medicare supplement insurance plan. She will have to look at the cost-sharing terms for her Part D plan to determine additional monthly out-of-pocket costs.

Matt is about to turn 65 and lives in Texas. He is an Army veteran with Veterans Administration (VA) benefits. Matt enjoys traveling each year to see his four grandchildren in Arizona and Wyoming. He is retired with good savings but wants to make sure he leaves each of his grandchildren something behind. Matt is in good health and takes only one prescription daily—for lowering his cholesterol. Matt gets this prescription, and any others he needs, through the VA.

Matt's Medicare benefits wish list

Access to doctors and hospitals when he's out of state
Peace of mind knowing that he will have help paying for health care costs if they are high

Matt's Medicare coverage choices

Original Medicare (Parts A & B)
Medicare supplement insurance plan (Plan L)

Matt's Medicare and Medigap plan features

Access to doctors and hospitals throughout the United States
Help with costs not paid by Original Medicare
A yearly out-of-pocket limit of $3,470 for the year

Matt's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare supplement Plan L premium	$130
Monthly total	$294.90

Matt's monthly premium costs will be $294.90 total.

Matt's other costs & cost-sharing

Matt's Medicare supplement insurance plan will help with the costs of his Original Medicare (Parts A & B) services, but he will still have some out-of-pocket costs to cover. His costs will vary based on the service he receives. His Medicare supplement plan will pay 100% of covered services for the rest of the calendar year once the out-of-pocket limit is met. Matt will also be responsible for the costs of services and items not covered by Original Medicare (Parts A & B) or his Medicare supplement insurance plan.

Matt's VA costs are not included as part of this example and will be separate from his Medicare costs.

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David just turned 65 and is about to retire from work. He doesn't plan to keep working past age 65 and does not have any retiree coverage. He plans to get Medicare at age 65, during his Initial Enrollment Period.

David in good shape and generally healthy. He takes a daily prescription drug to keep his high blood pressure in check. David takes good care of himself. He is careful to live within his budget.

David's Medicare benefits wish list

Access to a full range of health care services, including preventive care
Coverage that provides a safety net in case of a serious illness
Access to specialists if he needs them—he's comfortable with sticking to choices in a plan's network
Access to prescription drug coverage in case he needs additional medications in the future

David's Medicare coverage choice

A Medicare Advantage plan with built‑in prescription drug coverage

David's Medicare plan features

Preventive care
Fitness program at no additional cost
Built-in prescription drug coverage
Network of local doctors and hospitals
Out-of-pocket maximum of $3,500 for the year

David's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare Advantage plan premium	$0
Monthly total	$164.90

David's monthly premium costs will be $164.90 total.

Now that we have that number, let's add in David's blood pressure medication. With his Medicare Advantage plan, David pays a $15 copay every time he fills a prescription. Thus, we can now say that with David's monthly premiums and his monthly prescription, David's base monthly Medicare costs will be $179.90.

David's other costs & cost-sharing

David will have other costs as well as he receives different health care services throughout the plan year. His out-of-pocket costs may include copays, coinsurance and deductibles. His total spending will vary depending on the specific cost-sharing terms of his plan, the health care services he uses, the prescriptions he fills, and whether the services or items were obtained in-network or out-of-network. Because David's plan has an out-of-pocket maximum of $3,500 for the year, once his out-of-pocket costs reach that number, his Medicare Advantage plan will be responsible for all the costs for the remainder of the plan year.

Sammy is 65 and decided to enroll in a Medicare Advantage Private-Fee-For-Service (PFFS) plan because he wanted to see any provider as well as see specialists without needing a referral. Sammy also has high blood pressure and takes a daily pill to help keep it regulated. He is generally healthy and doesn't take any other prescriptions, but Sammy does like to be prepared.

Sammy's Medicare benefits wish list

Flexibility to see the providers he wants
Access to specialists without referrals
Prescription drug coverage for his blood pressure, and in case he needs anything in the future

Sammy's Medicare coverage choice

A Medicare Advantage Private-Fee-for-Service plan with no network limitation and a low-cost stand-alone Part D plan.

Sammy's Medicare coverage features

Preventive care
Fitness program at no additional cost
Prescription drug coverage
National access to doctors and hospitals
Out-of-pocket maximum of $3,500 for the year

Sammy's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare Advantage PFFS plan premium	$20
Monthly Part D plan premium	$15
Monthly total	$199.90

Sammy's monthly premium costs will be $199.90 total.

Now that we have that number, let's add in Sammy's blood pressure medication. With his stand-alone Part D plan, Sammy pays a $5 copay every time he fills a prescription. Thus, we can now say that with Sammy's monthly premiums and his monthly prescription, his base monthly Medicare costs will be $204.90.

Sammy's other costs & cost-sharing

Sammy will have other costs as well as he receives different health care services throughout the plan year or if he needs to purchase additional prescription drugs. His out-of-pocket costs may include copays, coinsurance and deductibles. His total spending will vary depending on the specific cost-sharing terms of his plan, the health care services he uses and the prescriptions he fills. And, because Sammy's plan has an out-of-pocket maximum of $3,500 for the year, once his out-of-pocket costs reach that number, his Medicare Advantage plan will be responsible for all the costs for covered services for the remainder of the plan year. Sammy's Part D plan doesn't have an out-of-pocket maximum, and what he pays will also depend on the Part D coverage stage he is in.

Alexa just turned 65 and is retiring from her job as a banker. She lives in Hawaii and doesn’t really enjoy traveling out of the state. Alexa is very healthy. She doesn’t have any major health conditions Alexa is also a veteran and has VA benefits. She gets all her medications filled through her VA benefits.

Alexa's Medicare benefits wish list

Access to a full range of health care services, including preventive care
Access to specialists if she needs them—she's comfortable with sticking to choices in a plan's network
Fitness, dental and vision benefits
Wellness program and healthy habit rewards

Alexa's Medicare coverage choice

A Medicare Advantage plan with rewards for healthy habits.

Alexa's Medicare plan features

Preventive care
Fitness program at no additional cost
Wellness rewards
Network of local doctors and hospitals
Out-of-pocket maximum of $3,500 for the year

Alexa's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare Advantage plan premium	$0
Monthly total	$164.90

Alexa's monthly premium costs will be $164.90 total.

And this number will be her monthly Medicare base cost as she gets her prescription drugs through her VA benefits.

Alexa's other costs & cost-sharing

Alexa will have other costs as well as she receives different health care services throughout the plan year. Her out-of-pocket costs may include copays, coinsurance and deductibles. Her total spending will vary depending on the specific cost-sharing terms of her plan, the health care services she uses, and whether the services or items were obtained in-network or out-of-network. Because Alexa's plan has an out-of-pocket maximum of $3,500 for the year, once her out-of-pocket costs reach that number, her Medicare Advantage plan will be responsible for all the costs for the remainder of the plan year.

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Leroy is about to turn 65. He has had serious health problems for years. He suffers from diabetes and high blood pressure, and his doctor has told him he needs to lose a considerable amount of weight. Leroy takes insulin and blood pressure medication every day. He has had trouble in the past with interactions of the drugs he is taking.

Leroy's Medicare benefits wish list

Expert help with managing his health problems
Help with improving his diet, exercise and weight management
Discounted prices on prescription drugs

Leroy's Medicare coverage choice

Medicare Advantage Special Needs Plan (SNP) for people with diabetes, with built-in prescription drug coverage

Leroy's Medicare plan features

Access to a care manager who will create a plan for coordinating his care
Help with finding out if he qualifies for financial assistance with Medicare costs
Discounted prices on the drugs he takes
Help with adopting a healthier lifestyle

Leroy's Premium Costs

Item	Amount
Monthly Part B premium (2023)	$164.90
Monthly Medicare Advantage Special Needs Plan premium	$24
Monthly total	$188.90

Leroy's other costs & cost-sharing

Leroy pays out-of-pocket for services and items he receives during the year. How much he pays is determined by the cost-sharing terms as determined by his plan. His total spending will also depend on the specific health care services he uses and the medications he takes.

Leroy should see if he can also qualify for Medicaid. Because Leroy has been dealing with serious health problems for years, it's likely that his health care costs are high. Leroy should see if he qualifies for Medicaid in his state to see if he may get additional health care coverage and financial help that way.

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Medicare Coverage Examples

Georgia will be 65 next month. She has been working part-time since her husband died five years ago, but her income is limited. Georgia has heart disease, so she sees a heart specialist regularly and takes a blood-thinning medicine every day. She cannot afford a Medicare supplement policy.

David just turned 65 and is about to retire from work. He doesn't plan to keep working past age 65 and does not have any retiree coverage. He plans to get Medicare at age 65, during his Initial Enrollment Period.

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Medicare Coverage Examples

Original Medicare Only

Original Medicare + Part D Plan

Georgia will be 65 next month. She has been working part-time since her husband died five years ago, but her income is limited. Georgia has heart disease, so she sees a heart specialist regularly and takes a blood-thinning medicine every day. She cannot afford a Medicare supplement policy.

Original Medicare + Part D + Medicare Supplement Insurance

Original Medicare + Medicare Supplement Insurance

Medicare Advantage (with included prescription drug coverage)

David just turned 65 and is about to retire from work. He doesn't plan to keep working past age 65 and does not have any retiree coverage. He plans to get Medicare at age 65, during his Initial Enrollment Period.

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