Medicare in Massachusetts

Medicare Advantage plans are offered by private insurers, whose service areas vary from county to county. Most of Massachusetts has an active Medicare Advantage market, with numerous plans available — 113 in total.⁷ But some counties like Berkshire have lower penetration rates where only 15% of residents are enrolled in a Medicare Advantage plan compared to Worcester county with a 42% penetration rate.²

About 24% of Massachusetts Medicare beneficiaries were enrolled in Medicare Advantage plans as of May 2018.⁸ By May 2023, about 34% of Massachusetts Medicare beneficiaries had Medicare Advantage coverage,¹ mirroring the nationwide increase in Medicare Advantage enrollment (nationwide, almost 49% of Medicare beneficiaries were enrolled in private plans as of May 2023,⁶ nearly all of which were Medicare Advantage plans). But Original Medicare continues to be more popular in Massachusetts than it is nationwide, with about two-thirds of Massachusetts Medicare beneficiaries enrolled in Original Medicare.²

Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries the chance to switch between Medicare Advantage plans and Original Medicare (and add, drop, or switch to a different Medicare Part D prescription drug plan). And people who are already enrolled in a Medicare Advantage plan also have the option to switch to a different Medicare Advantage plan or to change to Original Medicare during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31.

• Learn about Medicare’s annual open enrollment period.
• Learn about how Massachusetts Medicaid can help Medicare beneficiaries with limited financial means (income and assets).
• Questions to ask yourself when you’re deciding between Original Medicare and Medicare Advantage.

Original Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental medical coverage. Nationwide, about 48% of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid.⁹ But for those who don’t, optional private Medigap plans (also known as Medicare Supplement Insurance plans, or MedSupp) will pay some or all of the out-of-pocket costs they would otherwise have to pay if they had only Original Medicare.

According to America’s Health Insurance Plans (AHIP) analysis, there were 346,222 Massachusetts Medicare beneficiaries enrolled in Medigap coverage as of 2021.¹⁰ In some states, Medigap enrollment has been consistently dropping in recent years, because the increase in Medicare Advantage enrollment (which does not need supplemental Medigap coverage) has been outpacing the overall increase in Medicare enrollment. But that’s not the case in Massachusetts, as Original Medicare is still the strongly dominant coverage choice in Massachusetts (Medigap enrollment was down by just over 1,000 people from 2020 to 2021, but was still quite a bit higher than it had been in 2013).

There are eight insurers that offer Medigap plans in Massachusetts.

In all but three states, Medigap plans are standardized under federal rules. But Massachusetts is one of the three states where a waiver allows the state to design different Medigap plans. In other states, there are ten different Medigap plan designs. But in Massachusetts, there’s just the Medicare Core Plan and the Medicare Supplements 1 and 1A.

Massachusetts added Medicare Supplement 1A as of 2020; it’s the same as Supplement 1 except that it does not cover the Medicare Part B deductible, which is $226 in 2023. The addition of Supplement 1A was necessary because federal law (MACRA) does not allow people who become eligible for Medicare in 2020 or later to enroll in a Medicare supplement that covers the Part B deductible. So people who were eligible for Medicare in Massachusetts in 2019 or earlier can choose from among all three supplement options, whereas people who become eligible for Medicare in 2020 or later cannot enroll in Supplement 1 (they can choose the Core Plan or Supplement 1A instead).

(Prior to 2006, Massachusetts also had Medicare Supplement 2, which included coverage for prescription drugs; nationwide, all Medigap plans that included prescription drugs ceased to be available for purchase after the end of 2005 — people began enrolling in Medicare Part D instead — but people who had Supplement 2 in Massachusetts were allowed to keep it if they wanted to).

In addition to having different standardization rules for Medigap coverage, Massachusetts has among the country’s strongest consumer protections for Medigap plans. It’s one of eight states where insurers are required to use community rating, which means that premiums cannot vary based on age. Community rating even extends to disabled Medicare beneficiaries under age 65 in Massachusetts. The state also prohibits pre-existing condition waiting periods on Medigap plans (in most states, Medigap insurers can impose pre-existing condition waiting periods of up to six months if the enrollee didn’t have continuous coverage prior to enrolling).

Massachusetts also has an annual Medigap open enrollment period (see 211 CMR 17.10 (5)). The open enrollment window runs from February 1 to March 31 each year, and gives people a guaranteed-issue opportunity to enroll in Medigap for the first time, if they missed their initial six-month enrollment window, or to switch from one plan to another. This is an unusual provision; people in most states who miss their initial six-month enrollment period or wish to pick a different plan later on do not have another guaranteed-issue opportunity to enroll, unless they qualify for one of the federal government’s very limited guaranteed-issue rights for Medigap.

Under federal Medicare rules, people who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, or if they have ALS or end-stage renal disease. But federal rules do not guarantee access to Medigap plans for people who are under 65. Massachusetts is among the majority of the states that have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans. Massachusetts requires Medigap insurers to offer coverage to disabled Medicare beneficiaries under age 65, and does not allow insurers to charge those enrollees higher premiums; the state’s Medigap community rating rules extend to disabled beneficiaries as well (this is unusual; while the majority of the states do require Medigap insurers to offer at least some plans to disabled beneficiaries, most states allow them to charge these enrollees higher premiums).

But while most of those states simply require Medigap insurers to offer at least some plans to any Medicare beneficiary under the age of 65, Massachusetts law notes that Medigap insurers are not required to offer coverage to people who are eligible for Medicare due to having end-stage renal disease.

Medicare beneficiaries who are disabled and under the age of 65 have the option to enroll in a Medicare Advantage plan instead of Original Medicare,¹¹ and this now includes people with kidney failure (people with kidney failure were barred from enrolling in most Medicare Advantage plans prior to 2021, but federal rules changed that as of 2021). Medicare Advantage plan monthly premiums are not higher for those under 65. But as noted above, Medicare Advantage plans have more limited provider networks than Original Medicare, and total out-of-pocket costs can be as high as $8,300 for in-network care in 2023, plus the out-of-pocket cost of prescription drugs.¹²

Original Medicare does not provide coverage for outpatient prescription drugs. About 48% of Original Medicare beneficiaries nationwide have supplemental coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription drug coverage.⁹

But Medicare beneficiaries who do not have prescription drug coverage through Medicaid or an employer-sponsored plan … Medicare prescription drug plans can be enrolled as a stand-alone Medicare Part D prescription drug plan, or with a Medicare Advantage plan that includes Medicare prescription drug coverage. Medicare Part D was created under the Medicare Modernization Act of 2003, which was signed into law by President George W. Bush.

There are 24 stand-alone Medicare Part D prescription drug plans for sale in Massachusetts for 2023, with premiums starting at $6.80.⁴

696,612 beneficiaries of Medicare in Massachusetts had stand-alone Medicare Part D prescription drug coverage as of May 2023. Another 447,117 had Medicare Part D prescription drug coverage as part of their Medicare Advantage plans.¹ Enrollment in Part D coverage is optional, but people who forego it without having creditable drug coverage from another source will end up paying a late enrollment penalty if they decide to sign up for Part D later in life.

Medicare Part D enrollment is available on an annual basis, during the Medicare Annual Election Period (October 15 to December 7). Medicare beneficiaries also have an opportunity to enroll in a Medicare Part D prescription drug coverage when they’re first eligible for Medicare, or after another creditable prescription drug plan ends.

Many Medicare beneficiaries receive financial assistance through Medicaid with the cost of Medicare premiums, prescription drug expenses, and services Medicare doesn’t cover – such as long-term care.

Our guide to financial assistance for Medicare enrollees in Massachusetts includes overviews of these benefits, including long-term care coverage, Medicare Savings Programs, and eligibility guidelines for assistance.

If you have questions about Medicare eligibility in Massachusetts or Medicare enrollment in Massachusetts, the SHINE Program (Serving the Health Insurance Needs of Everyone) can help.

Massachusetts also maintains a web page devoted to Massachusetts Medicare laws.

The Medicare Rights Center is a nationwide service that can provide a variety of information and assistance with questions related to Medicare eligibility, enrollment, and benefits.