Medicare in Massachusetts

Medicare is a health care program for adults aged 65 and older, younger people with disabilities and citizens diagnosed with end-stage renal disease. Around 63 million Americans currently receive Medicare, with the figure projected to rise to 93 million by 2060. As of 2022, 1,370,926 residents of Massachusetts (about 19.5% of the population) are enrolled in one or more Medicare plans, costing the state $18.5 billion (as of 2020).

Original Medicare is federally managed and divided into parts, with Part A covering hospital stays, hospice care, nursing home care and some home health care expenses and Part B covering outpatient services, medical supplies and preventative care. Part A recipients in Massachusetts pay $0 in premiums if they or their spouses have paid into the Medicare system for at least 10 years. As of 2022, those receiving Part B pay a premium of $170.10 per month, which starts to rise incrementally with earnings once the individual’s annual income reaches $88,000 (or $176,000 for a married couple). 

Medicare Advantage (or Part C), is administered by Centers for Medicare & Medicaid Services (CMS)-approved private insurance companies. In 2022, Part C premiums in Massachusetts typically cost $50.48 per month, which covers all the services provided by Parts A and B, with the exception of hospice care, which Part A covers. Most Part C plans include Part D, which pays for additional services, such as prescription drugs. Finally, there are Medicare supplement plans, commonly known as Medigap, a private insurance that helps Original Medicare beneficiaries pay their share of costs. 

This guide provides detailed information about Medicare in Massachusetts, including how the variety of options allows for personalized coverage. It also lists organizations that can provide local information and give advice on how Medicare plans can pay for long-term health care services.

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 is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay 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)

Seniors unsatisfied with the coverage provided by Parts A and B may want to consider Part C. Medicare Advantage is administered by CMS-approved private insurance companies and covers all parts of Original Medicare (except hospice care, which is covered by Part A). It has more flexibility, which allows coverage for additional services, such as prescription drugs and hearing, vision and dental care. Enrollees can also set a limit on out-of-pocket expenses to protect them from costs they couldn’t cover if their treatments become too expensive.

There are 113 Medicare Advantage plans in Massachusetts as of 2022, but they may not all be available in every area. Every resident can get coverage from $0, but the average monthly premium is $50.48 due to enrollees taking out additional coverage. Deductibles, copayments and coinsurance will likely be included in a plan, so residents should consider this when preparing their budgets.

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 2022. 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 2022 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.