Medicare is a health insurance program through the federal government for people over 65. You may also qualify if you’re under 65 and meet certain qualifications. If you live in New Jersey, you have several options for Medicare plans, including:
- Original Medicare.This is offered through the federal government and includes Medicare Part A (hospital insurance) and Part B (outpatient services).
- Medicare Advantage (Part C). These plans are offered through private insurers, and cover Part A and Part B benefits, and sometimes Part D.
- Prescription drug plans (Part D). These plans are available through private insurers and cover the cost of prescription drugs. You can purchase Part D with original Medicare or Medicare Advantage plans.
- Medicare supplement (Medigap). Medigap is offered through private insurers to cover some out-of-pocket costs for Medicare services.
Both original Medicare and Medicare Advantage plans must cover certain services.
Part A (hospital inpatient)
- care during hospital stays in certain critical access hospitals and skilled nursing facilities
- home health care
Most people don’t pay a premium for Part A coverage, but you will pay a $1,408 deductible each time you’re admitted into a hospital.
Part B (outpatient services)
- doctor’s visits
- preventive care, screenings, imaging, and lab tests
- medical equipment, such as walkers, wheelchairs, and oxygen
Part B has a monthly premium of $144.60. Deductibles and premiums are determined by the Centers for Medicare & Medicaid Services (CMS) and change each year. Part B premiums are higher for individuals with high income.
Part D (prescription drug coverage)
Prescription drug coverage is not included in original Medicare and must be purchased separately through private insurers. If you have a Medicare Advantage plan and it does not include Part D (prescription drug coverage), you can also purchase it separately.
Medicare Advantage plans
You may prefer to get coverage through private insurers that bundle Part A, Part B, and sometimes Part D into a single Medicare Advantage plan. These private insurers contract with CMS and their plans must cover the same things that are covered under original Medicare.
Even with a Medicare Advantage plan, you still pay the Part B premium.
Some Medicare Advantage plans cover things like dental and vision care, non-emergency medical transportation, home meal delivery, and more. These plans may have additional premiums for the extra coverage.
One advantage of choosing a Medicare Advantage plan is the annual out-of-pocket spending limits. Once you reach the limit, the plan pays 100 percent of covered expenses for the rest of the year. Original Medicare does not have an out-of-pocket limit.
There are three types of Medicare Advantage plans in New Jersey:
- HMOs are plans that require you to select a primary care physician who coordinates your care and refers you to specialists as needed. You must choose a physician in the network and follow plan rules for referrals to get treatments covered.
- PPOs are plans with a network of physicians and facilities where you can receive care. If you go outside of the network your care may not be covered or it may cost more. You do not need a primary care doctor’s referral to see a specialist.
- PFFS, or private fee-for-service plans, negotiate directly with doctors and hospitals on payment for services. Some have networks of providers and facilities, while others allow you to go to any doctor or hospital that will accept the plan. However, not all providers and hospitals will, so be sure to check before you get care.
Special Needs Plans (SNPs) are also available for New Jersey residents who:
- are dual-eligible for Medicaid and Medicare
- have one or more chronic or disabling conditions
- need long-term care in a facility or home
Medicare New Jersey plans are available from the following carriers:
- Aetna Life Insurance Company
- Clover Insurance Company
- Sierra Health and Life Insurance Company
- Oxford Health Plans (NJ)
- Horizon Insurance Company
- Amerigroup New Jersey
- WellCare Health Plans of New Jersey
- Humana Insurance Company
- Anthem Insurance Companies
- LIFE St. Francis
- QCC Insurance Company
- Inspira Health Network LIFE
- LIFE at Lourdes
- Care Improvement Plus South Central Insurance Co.
- Acute Care Health System
- Lutheran Senior Healthcare
Not all carriers offer plans in every New Jersey county, so choices for Medicare Advantage plans will vary based on where you live.
You’re eligible for Medicare in New Jersey if you’re:
- 65 years old
- a U.S. citizen or legal resident for 5 or more years
You may also be eligible if you are under 65 and:
- have end stage renal disease (ESRD)
- receive kidney dialysis or had a kidney transplant
- have ALS (Lou Gherig’s disease)
- received Social Security (SSDI) or Railroad Retirement Board (RRB) disability payments for 24 months
You will not pay a premium for Part A if:
- You or a spouse worked and paid Medicare taxes for at least 10 years
- You receive retirement benefits from SSDI or the RRB (or are eligible but have not yet filed for them)
- You or a spouse had Medicare-covered government employment
You can determine your eligibility with the Medicare.gov eligibility tool.
Enrollment periods are designated times when you can sign up for or change plans.
Initial enrollment period (IEP)
The IEP is when you can first sign up Medicare. The IEP is a 7-month period. It starts 3 months before your 65th birthday and ends 3 months after you turn 65.
General enrollment period
The general enrollment period is from January 1 through March 31. You can sign up for Medicare Part A or B during this time if you missed the IEP and you are not eligible for a special enrollment period.
The annual enrollment is from October 15 through December 7. During this time, you can sign up for Medicare Advantage, switch plans, or leave a plan.
Medicare Advantage open enrollment
Medicare Advantage open enrollment is from January 1 through March 31. During this period, you can switch Medicare Advantage plans or switch from a Medicare Advantage plan to original Medicare.
You must enroll in original Medicare before you can get a Medicare Advantage plan.
Special enrollment period (SEP)
Outside normal enrollment periods, you may be able to change plans or sign up for a plan if you have a life event. Some life events that qualify could be losing coverage through an employer after retiring or leaving a job, or moving out of your plan’s network.
All plans must cover the same benefits and services as original Medicare, but costs and other benefits under Medicare Advantage plans vary.
Before selecting a plan, carefully consider:
- What services are covered
- CMS star ratings that measure plans’ health and drug services, and beneficiary satisfaction
- Whether hospitals and doctors you prefer are in the plan’s network
Several resources are available to answer your questions or help with New Jersey Medicare plans.
- Medicare Information & Referral Service / SHIP (1-800-792-8820): free, unbiased Medicare counseling for New Jersey seniors.
- Aging & Disability Resource Connection (1-877-222-3737): helps New Jersey residents who are older, people who have physical disabilities, and caregivers find healthcare resources.
- Area Agency on Aging (AAA): offices in all 21 New Jersey counties to help seniors and adults with disabilities connect to local resources for comprehensive, coordinated services. Find locations and phone numbers online or call 1-877-222-3737 to connect to your local AAA.
- NJ Save: online application for low-income seniors and people with disabilities who cannot afford Medicare premiums and prescription costs.
- Medicare (1-800-633-4227): contact Medicare directly with questions.