How Medicare Works
Medicare is a national health insurance program for most people who are age 65 and older, or who meet special criteria. “Original Medicare” has two parts: Part A hospital insurance and Part B medical insurance. Most people do not have to pay a monthly premium for Part A, but will need to pay a monthly premium for Part B. If you are not already receiving Social Security benefits, you won’t be automatically enrolled in Medicare. You’ll need to sign up.
Medicare Part C is a Medicare Advantage Plan. These plans include Medicare Part A and Part B benefits and most include Part D outpatient prescription drug benefits. Medicare Advantage plans often include extras like vision, hearing, dental and fitness benefits.
Medicare Part D outpatient prescription drug coverage is optional and helps pay for prescription drugs. It is available to anyone enrolled in Medicare Part A or Part B. Medicare Part D plans are available and you can enroll through a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage plan that includes Medicare Part D, known as an MAPD.
If you choose not to enroll in Part D when you first become eligible, you will have an opportunity to enroll during the next Annual Election Period (October 15 through December 7 of each year for a January 1 effective date). You may also be required to pay a late enrollment penalty of 1% of the national base beneficiary premium for each full, uncovered month that you were eligible to enroll in a Part D plan but did not do so. This penalty is applied monthly and continues for as long as you have Part D coverage.
There are some situations when the penalty would not be applied, including, but not limited to: (1) if you qualify for Extra Help for Medicare Part D, and (2) if you have maintained creditable drug coverage that is as good as or better than that offered in Medicare Part D plans. Examples of creditable drug coverage include drug coverage through the VA and prescription drug coverage offered by many employer group plans.
Many Medicare Advantage plans come with Part D drug coverage. You can also choose to get your Part D coverage through a separate plan that covers only your prescription drugs.
To be eligible, you must:
- Have Medicare Part A and Part B
- Reside in the service area
No physical exam or other health screening is required. You must enroll within a valid election period.
A set fee you pay for a medical service or prescription (e.g., $100 copay for an emergency visit).
The amount you pay for a medical service or prescription, usually expressed as a percentage (e.g., 20% coinsurance for an office visit).
The amount you must pay for health care services or prescriptions before Original Medicare, your Medicare health plan, or prescription drug plan begins to pay.
The most you have to pay for in-network covered medical services in a plan year.
Plans that contract with Medicare to provide Part A and Part B benefits. Medicare Advantage plans may also include extras like dental, vision, fitness and hearing benefits — like many UCare Medicare Plans. Many also include Medicare Part D.
Plans sold by private insurance companies that help pay some of the costs (“gaps”) Original Medicare doesn’t cover.
These plans do not include Medicare Part D.
The Centers for Medicare & Medicaid Services (CMS) created a Five Star Quality Rating System that rates Medicare Advantage (MA) and Prescription Drug (PDPs or Part D) plans. Ratings are between 1 and 5 (5 being the highest) for health plan quality based on measurements of customer satisfaction and the quality of care the plan delivers.
4.5 Stars for 2023 plans. Every year, Medicare evaluates plans based on a 5-star rating system and ratings could change.
- Review advertising you receive in the mail and see in newspapers
- Ask relatives and friends about their Medicare plans:
- How satisfied are they with their Medicare plan?
- Did the plan answer their questions and pay their bills?
No. You are eligible for Medicare at age 65 regardless of whether or not you’re receiving Social Security income.
You can enroll in any of the following ways:
- Complete and mail a paper enrollment form.
- Enroll online at ucare.org or at medicare.gov.
- Enroll by phone at 612-676-3500.
Medicare created Special Election Periods (SEPs) for specific situations that may allow you to change plans. Some of the most common situations that allow you to qualify for an SEP include:
- Leaving or losing coverage through an employer or union (including COBRA).
- Making a permanent move where new plan options are available.
- Becoming eligible, or losing eligibility, for Medical Assistance.
- You receive Extra Help for Medicare Part D.
Certain time frames and limitations apply to each of the special election periods.
Medicare has limits to when and how often you can change your Medicare health plan. These specific “election periods” determine when you can enroll in, or disenroll from, a Medicare Advantage Plan. These periods include:
- Initial Coverage Election Period – when you first become eligible for Medicare.
- Annual Election Period – every year between October 15 and December 7.
- Special Election Periods – for specific situations that occur throughout the year that may allow you to change plans.
During the Open Enrollment Period (OEP) that runs from January 1 through March 31, Medicare Advantage members can make a one-time change and switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and go back to Original Medicare only.
You can first enroll in Medicare through Social Security about three months before your 65th birthday month by going online at ssa.gov, by phone at 1-800-772-1213, or in person at a Social Security office.
Once UCare receives your application, your enrollment information is sent to Medicare. Upon approval, a letter is mailed to you confirming your UCare coverage. You can expect to receive your ID card approximately a week after you get your confirmation letter.
UCare will try to reach you by phone to complete your enrollment. If unable to reach you by phone, we will mail a letter to you asking for the missing information.
If you are already receiving Social Security benefits, you’ll be enrolled in Medicare automatically. Your Medicare card will arrive about three months before the month you turn 65.
You can reach our Customer Service team by calling the number on the back of your ID card. You can also find our phone lines here: ucare.org/en-us/about-us/customer-services/
Special Coverage Requests
UCare may require your doctor to send us information about why a service or prescription is medically necessary to determine if it will be covered. This process is called prior authorization. Members are not responsible for getting prior authorization; it is your doctor’s responsibility.
- For prescription authorizations, your doctor's office should contact Express Scripts.
- For other services requiring prior authorization, your doctor's office can contact UCare’s Provider Assistance Center.
When you enroll in a UCare Medicare plan, chances are you can keep your doctor, since 96% of all Minnesota providers are in our network. We also have plans where you get all your care within one care system, like Essentia Health or M Health Fairview and North Memorial Health, for example.
You may see any specialist in the network without a referral.
UCare Medicare Plans include some out-of-network benefits and also cover emergency care worldwide.
You can see any specialist as long as they accept Medicare.
When you receive care from a dentist outside your plan network, you will need to submit your bills and pay the difference between the dental fees you were charged and the amount your plan allows.
You can search our network a few different ways:
- Use the Search Network tool to get the most up-to-date information. You can search for a doctor, pharmacy, dentist, or chiropractor.
- Get help from our Customer Service team to find providers in your plan network.
- Check your provider directory. Call Customer Service and we'll mail you a directory.
UCare Medicare Plans are Medicare Advantage plans (also called Medicare Part C) that contract with the federal government to administer Medicare Part A and Part B. They cover everything that Original Medicare covers, but provide additional benefits like Part D prescription drug coverage. Because you get all your health coverage in one plan, you won’t have to deal with Medicare deductibles and coinsurances. You’ll be responsible only for cost-sharing (copays, coinsurance) with our plans. With a Medicare supplement (also called “Medigap”) plan, the bills you receive from your providers are first sent to Medicare, then to your plan. Medicare supplement plans cannot include Part D prescription drug coverage.
All UCare Medicare Plans include dental benefits. Some plans give you the option to add more dental coverage.
No. If you are satisfied with your current UCare Medicare Plan, you do not have do anything during the Medicare Annual Election period. Your coverage will continue. If you choose to change plans, you can do so October 15 – December 7 for coverage beginning January 1.
Yes. Unlike many other Medicare plans, you do not need to be an inpatient for 3 days before you can use your skilled nursing facility benefit. The 3-day inpatient hospital stay requirement is waived.
We offer meetings throughout Minnesota and Northwest Wisconsin both online and in the community. Visit this page to find a meeting.
You can use One Pass fitness benefits at local gyms and when you travel. The network includes more than 23,000 gyms and fitness locations nationwide.
No, you do not have to inform UCare that you are traveling. You also have emergency coverage worldwide.
UCare Medicare Plans do cover you when you're out of the state, including emergency and urgent care. Other services are also covered when you see a provider that accepts Medicare. With UCare Anywhere℠, you can travel in the U.S. and get care from any provider that accepts Medicare, and you have emergency coverage worldwide. Plus, you're covered with many out-of-state providers that participate in the MultiPlan Network. See your Evidence of Coverage for details.
UCare Medicare Plans include coverage for dental, chiropractic, hearing and vision services. For more specific details on how these services are covered, please refer to your Evidence of Coverage (EOC) for cost sharing or contact Customer Services for detailed information.
Medicare Part D medications do not have a cap. However, once you reach Catastrophic Coverage, your prescription drug costs are reduced for the remainder of the year.
No, the Medicare Part D benefit is a separate benefit that has its own coverage limits. Therefore, it does not apply to your out-of-pocket maximum.
Medicare Part B drugs that are administered by a health care professional in the form of a shot or infusion, such as chemotherapy, do count toward your medical out-of-pocket maximum.
To find out if a medication is included in our list of covered drugs, go to https://home.ucare.org/en-us/search-network/formulary/ . For a printed list of covered drugs, call 1-877-523-1518 and we'll mail one to you.
Check the pharmacy list at https://search.ucare.org/providersearch/search?entity_type=pharmacy&distance=60
Medicare Part D is a voluntary outpatient prescription drug program available to anyone who is enrolled in Medicare Part A or Part B. It helps Medicare beneficiaries pay for their prescription drugs. There are four phases of coverage:
- Deductible - You pay your share of the cost for your drugs and UCare pays its share. Your cost is based on the prescription deductible and may include coinsurance or different copay amounts for “tiers” of drugs. You stay in this stage until your payments for the year, plus UCare’s payments, reach the initial coverage stage limit set by Medicare for the year.
- Initial Coverage Phase - You pay a part of the cost for your drugs until you reach a limit set by Medicare for the year. Your cost will differ for brand-name vs. generic drugs and may include coinsurance or different copay amounts for “tiers” of drugs.
- Coverage gap - Once you have reached the limit described in stage 2 set by Medicare, you enter the Catastrophic Coverage Stage.
- Catastrophic coverage - UCare will pay most of the cost of your covered drugs for the rest of the calendar year. You pay the greater of a low copay or coinsurance (set by Medicare) for drugs for the remainder of the year.
Not all plans have the same deductible or copays for drug tiers. See your Summary of Benefits for specifics and for the Medicare coverage limits set each year.
UCare Medicare members have several options for lowering prescription costs:
- Drug tier changes: If your medication falls in a tier 4 or a tier 2, it may be eligible to be reviewed for a tiering exception. If approved, the cost of your drug would be lowered to the tier below, in turn lowering your copay. To start the tiering exception process, your provider can either contact Express Scripts (ESI) at 877-558-7521 or send an exception form to UCare.
- Financial assistance: You may also apply and qualify for Low Income Cost Sharing (LICS). To find out if you qualify, contact Medicare at 1-800-633-4227 or visit the Medicare website for information.
- Patient assistance programs: Certain drugs have patient assistance programs that can help pay for a particular medication. To find out if your drug qualifies, contact UCare's Customer Service.
- Generic prescriptions: If you are taking a brand name drug, contact your doctor to see if there is a generic alternative for the medication. Keep in mind not all brand name medications have generic substitutes.
You can pay your premium in one of the following ways:
- Using Automatic Payment/Electronic Funds Transfer (EFT) from a checking or savings account.
- By mail. You will receive your monthly billing statement around the 20th of each month for the next coverage month.
- Social Security or Railroad Retirement Board withdrawal.
- Online at member.ucare.org
Medicare Part A usually has no premium because it was paid for by payroll tax deductions during your (or your spouse’s) working years. Medicare Part B does have a premium. Premiums for the following year are usually announced in late October or early November.
It is a Medicare requirement that we send annual updates and required information to each member enrolled in an individual plan such as UCare Medicare. This ensures you and your spouse stay informed of any updates or changes with your health care coverage.
To help keep our members’ information as secure as possible, we require each individual member to register for the secure member site separately. This ensures your private health information and claims are only accessible by you, and helps minimize the risk of error when entering your information.