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Does My Zip Code Affect My Medicare Coverage?

By John McGuire
You might be surprised to know that your zip code can affect your Medicare coverage. Here’s how the availability of certain Medicare programs can change based on where you live.

The Centers for Medicare & Medicaid Services reports that, with Original Medicare (Parts A and B), you can use any doctor or hospital that takes Medicare, anywhere in the U.S. Medicare plans like Medigap and Medicare Advantage are a different story, though. The pricing, rules, and availability of these plans vary by state, and even sometimes by zip code. Here, we cover what you need to know about Medicare coverage based on where you live, using the official U.S. government website for Medicare as a guide.

Is Medicare Different In Each State?

Before we begin our discussion of Medicare coverage by state, let’s consider basic eligibility for Medicare. The Centers for Medicare & Medicaid Services reports that the following factors make you eligible for Medicare: 

  • Age. If you are 65 or older, you qualify.
  • Disability. If you get disability income from Social Security or the Railroad Retirement Board (RRB), you'll gain eligibility for Medicare once you've recieved your Social Security or RRB disbursements for 24 months. There are also special qualifying criteria for those with Lou Gehrig's disease (ALS) and end-stage renal disease (ESRD) which  can eliminate waiting periods. 

Assuming now that you are eligible, let’s address the question—is Medicare different in each state? Since Original Medicare is a completely federal program, it’s equally available to residents in all U.S. states. 

However, certain programs within Medicare vary from state to state in terms of rules, availability, and pricing. Two such Medicare plans are Medigap and Medicare Advantage. The coverage and features of these Medicare plans will vary depending on where you live.  

Medigap

Medigap, sometimes called Medicare Supplement, is available to Original Medicare beneficiaries. It works like an insurance policy to cover the “gap” between what Original Medicare pays and what you owe in out-of-pocket expenses (like copayments, coinsurance, and deductibles). 

Medigap plans must follow Medicare rules, but because they are run by private insurance companies, their availability and pricing will vary from state to state. You can compare the plans available in your region using the official U.S. government website for Medicare.

In addition, your State Health Insurance Assistance Program or State Insurance Department are good resources for more information about local Medigap availability and pricing.

Medicare Advantage

Medicare Advantage takes the place of Original Medicare and is a form of managed care. It relies on the use of pooled resources as well as networks of caregivers to provide you with low out-of-pocket expenses. Medicare Advantage Plans come in several forms, including:

  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Special Needs Plans (SNPs)

Like Medigap, Medicare Advantage Plans are offered by private insurers who must follow Medicare's rules. Medicare Advantage Plans must offer the same coverage as Original Medicare, with the exception of hospice care. 

Because Medicare Advantage networks of care are dependent upon the private insurer supplying each individual plan, the availability of Medicare Advantage Plans will vary according to region. This is where your zip code matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for specific Medicare Advantage plans require you to live in that plan’s service area.

Get started now. 

Interested in learning more about Medicare, Medigap, and Medicare Advantage plans? WebMD Connect to Care Advisors may be able to help.