Medicare in Massachusetts

Medicare is a federal health insurance program that provides affordable access to care services for those aged 65 and over, along with those who are living with a disability or end-stage renal disease. Medicare is divided into several categories or parts. Part A covers the cost of hospital stays, nursing home care, hospice care and other similar long-term care arrangements. Part B covers durable medical equipment, outpatient care and preventative care. These parts are offered together as “Original Medicare”. In addition to Parts A and B, seniors can opt for Part D coverage for prescription medications.

There’s also the option to take out coverage with a private provider, in the form of Medicare Advantage, which is known as Medicare Part C. Out of 1,420,625 who are eligible, there are currently 1,389,292 individuals enrolled in some form of Medicare. There were 432,907 enrolled in Medicare Advantage as of July 2023. This is an increase of 9.54% compared to 2022. Medicare Advantage adoption in Massachusetts is quite low compared to the wider United States, Only 30% of those eligible for such coverage have chosen it, compared to 48% nationwide. However, enrollment increased from 393,852 in 2022 to 432,907 as of July 2023, so awareness and interest is growing.

Medicare spending in the state was just over $11 billion in 2021, a small fraction of the $395 billion spent on Part A and Part B payments nationwide. Eligible individuals have a choice of 113 different Medicare Advantage Plans, and the average cost of a Medicare Advantage Plan fell by 13.1% between 2022 and 2023. This reduction in fees, combined with the wide variety of plans available, may help drive adoption of the program over the coming years.

In this guide, we’ll explore the cost of Medicare in Massachusetts and how it’s changed over time. We’ll also look at the cost of other care types, and provide some resources to help seniors who are planning their long-term care arrangements.

Options for Medicare Coverage in Massachusetts

Original Medicare can cover an array of costs, but it doesn’t allow for all potential medical care expenses, which is why private companies offer forms of coverage to fill the gaps in the federal program. The benefit for Massachusetts residents is that it’s now possible to choose from different plans, which can be tailored to meet their needs and minimize their out-of-pocket expenses.

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and offers Part A and Part B coverage to eligible individuals anywhere in the United States. In general, Medicare will not cover health care received while abroad.

Under Original Medicare, seniors pay for services as they receive them. They must also pay an annual deductible, which is $1,600 for Part A and $226 for Part B in 2022. Medicare will then cover 80% of the cost of covered care services, while the beneficiary pays the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage provides most of the same benefits of Original Medicare (with the exception of hospice care), but is overseen by private insurance companies. It may offer additional coverage options such as transportation to medical appointments or coverage for vision and dental care. The five Medicare Advantage Plans typically have more network and location limitations than Original Medicare, but more flexibility for customization.

There are 113 Medicare Advantage Plans in Massachusetts as of 2023, and everyone who is eligible for Medicare has access to at least one Medicare Advantage Plan. Many of the available plans have zero monthly premiums.

Who Should Consider Medicare Advantage?

Medicare Advantage can be useful for those who:

• Need coverage not provided by Original Medicare
• Will accept managed care
• Want limits on their out-of-pocket expenses
• Are generally healthy, so may benefit from lower premiums

The Top 10 Medicare Advantage Plans in Massachusetts

There are many well-regarded Medicare Advantage plans available to the people of Massachusetts. Using the grand total of enrollees as a guide, the following table lists the 10 most popular in the commonwealth. It also details the types of plans and likely costs as of 2023. Residents seeking more information should visit Medicare Advantage Plans in Massachusetts. 

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later. Most Medicare Advantage Plans include prescription drug coverage, and therefore most seniors enrolled in these plans do not need separate enrollment in Part D.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2023 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Massachusetts

Reviewing the wealth of Medicare plans available in Massachusetts can be time-consuming and demanding, but residents don’t need to do it on their own because there are agencies that help for free. Trained staff can explain in plain English the various plans available locally and advise on the pros and cons of each relative to the resident’s long-term care needs and their budgets. Depending on the resource, it may also be able to support those who need legal assistance because their Medicare enrollment requests have been denied.