Understanding Your Medicare Coverage
When it’s time to consider your coverage options, nothing is more important than a firm grasp of the Medicare coverage basics. Review this information and you will be well on your way to finding the right solution for your budget and needs.
When am I eligible for Original Medicare?
Medicare Eligibility and Enrollment
Initial Enrollment Period:
If you're already getting benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month.
If you're under 65 and disabled, you will automatically get Part A and Part B after you get disability benefits from Social Security for 24 months or certain disability benefits from the RRB for 24 months.
General Enrollment Period:
If you didn't sign up for Part A and/or Part B (for which you must pay premiums) during your Initial Enrollment Period and you are not eligible for a Special Enrollment Period, you can sign up January 1- March 31 each year. Your coverage will begin July 1 of that year. You may have to pay a higher Part A and/or Part B premium for late enrollment.
Special Enrollment Period:
Once your Initial Enrollment Period ends, you may have the chance to sign up for Medicare during a Special Enrollment Period. If you did not sign up for Part A and/or Part B when you were first eligible because you are covered under a group health plan based on current employment (your own, a spouse's, or if you're disabled, a family member's), you can sign up for Part A and/or Part B:
- Anytime you're still covered by the group health plan
- During the 8-month period that begins the month after the employment ends or the coverage ends, whichever happens first.
Usually, you don't pay a late enrollment penalty if you sign up during a Special Enrollment Period.
This Special Enrollment Period doesn't apply to people with End-Stage Renal Disease (ESRD). You may also qualify for a Special Enrollment Period if you're a volunteer serving in a foreign country.
What are my Benefits with Original Medicare?
Medicare Coverage and Parts - The A, B, C & D of Medicare
Medicare comes in four parts. Parts A and B are typically referred to as Original Medicare. Part C plans are Managed Care plans that provide services to Medicare eligibles in particular service areas. Part D is the prescription drug coverage that you purchase from a Part D carrier, not Medicare.
- Medicare Part A helps pay for such services as hospital stays, skilled nursing home stays, home health care, ,and hospice. You qualify for Part A if you or your spouse worked 40 quarters (10 years) and paid Social Security and the Medicare tax. Enrollment is automatic unless you notify Medicare that you have other qualifying employer-based coverage. The Part A deductible is$1,260.00 for each Part A covered hospital admission in 2015. This deductible covers the first 60 days of hospital charges. If you are still in the hospital after 60 days the benefit changes to a per day charge: Days 61-90 you pay $315.00 / day and for days 61-90 you are responsible for $315.00 / day. For days 91 and beyond you would need to use your Lifetime Reserve days. You will pay $630.00 for each “Lifetime Reserve day”, (up to 60 days over your lifetime). Beyond these 60 additional Lifetime Reserve days, you would be responsible for all Part A costs.. If you had two hospital stays with several months in between, you would pay the Part A deductible each time. There is no Out Of Pocket maximum with Original Medicare.
- Medicare Part B helps pay for outpatient care like physician services (in or out of the hospital), laboratory tests, outpatient hospital services, diagnostics tests like x-rays or MRI’s and Durable Medical Equipment. Part B is optional, but most Medicare beneficiaries receive both Parts A and B. Medicare doesn’t cover everything, such as health care outside of the U.S., and prescription drugs. You do need to enroll in Part B through the Social Security Administration. There is a monthly premium cost for Part B and typically this premium is deducted from your Social Security retirement or Social Security Disability check each month. Part B has an annual deductible and once that has been met, Medicare will cover 80% of the Medicare approved amount for Part B services. You are responsible for the other 20%. So if you had two outpatient surgeries, you would pay 20% of all those charges. There is no Out Of Pocket Maximum with Original Medicare.
- Medicare Part C (also called Medicare Advantage (MA) Plans) are plans offered by a private company that contracts with Medicare to provide Beneficiaries with all Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. If a Beneficiary is enrolled in a Medicare Advantage Plan, Medicare provides the Medicare Advantage Plan with a monthly payment to provide and coordinate their care. The Beneficiary’s services are covered through the Medicare Advantage Plan, not through Original Medicare. Medicare Advantage Plans usually require Beneficiaries to use only in-network providers and may require referrals.
In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage.
Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply). There are only certain times of the year that Beneficiaries can join a Medicare Advantage Plan or switch to a different Medicare Advantage Plan or Prescription Drug Plan (PDP).
Rocky Mountain Medicare offers a Medicare Cost plan. Medicare Cost Plans are plans operated by a HMO or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed contract under section 1876(h) of the Act.
Cost Plan Beneficiaries have both their Original Medicare coverage, as well as coverage through the Medicare Cost Plan. Cost Plans cover all Medicare Part A and Part B benefits, as well as supplemental benefits not covered by Original Medicare such as routine physicals, hearing and vision exams. Beneficiaries pay a premium to the Cost Plan.
Cost Plan Beneficiaries can use in-network or out-of-network providers.
Cost Plans may also offer Prescription Drug plans that cover Part D outpatient drugs. Beneficiaries can purchase either medical only coverage or a bundled plan that has both medical and Part D outpatient drug coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End-Stage Renal Disease (unless certain exceptions apply). There are only certain times of the year that enrollees can join a Prescription Drug Plan or switch to a different Medicare Advantage Plan or Prescription Drug Plan. Beneficiaries can join a Medicare Cost Plan at any time during the year. Feel free to call us with any detailed questions that you may have.
- In-network: Services are paid by Original Medicare and the Cost Plan pays the Original Medicare coinsurance (usually 20%) and the Original Medicare deductible on behalf of the Beneficiary. The Beneficiary pays the cost–sharing established by the Cost Plan.
- Out-of-network: Services are paid by Original Medicare and the Beneficiary pays the Original Medicare coinsurance (usually 20%) and the Original Medicare deductible.
- Medicare Part D is offered through private insurance companies like RMHP. It helps pay for prescription drugs you receive at the pharmacy. You choose the drug plan and pay a monthly premium. There is an Extra Help program that helps reduce the costs of this coverage for people with lower incomes, it is known as the Low Income Subsidy (LIS). You can call Social Security to see if you may qualify (or go to our Extra Help page (have link here)). Like other insurance, if you decide not to enroll in a Medicare Part D drug plan when you are first eligible, you may pay a penalty if you choose to join at a later time. All Part D plans have an Initial Coverage limit, a coverage gap and a Catastrophic benefit.
Initial coverage limit (Level 1) – For the first $ 2,960 of drug cost, depending on the carrier, you will have a potential deductible, coinsurance or copays for your medications. The actual amount you pay depends on if the drug is covered by the plan’s formulary drug list. The drugs on the formulary are ranked by tiers- usually the lower the tier, the smaller the cost to you.
Coverage Gap (Level2) - after $2,960 of total drug costs, you will have a coinsurance (percentage) amount to pay instead of the previous copays. This coinsurance arrangement remains in place until you have spent a total of $4,700 out of your pocket. This amount includes the real spending that you have and also the additional brand name discount that you are given.
Catastrophic coverage (Level 3) - After spending the $4,700 in the Level 2 coverage gap, for the rest of the calendar year you will have a fixed copay for most of your medications. Generics would be $2.65 each and brand names would cost $6.60 each.
Learn more about Medicare Coverage Basics and Medicare Cost plans from RMHP:
Medicare Part C (also known as Medicare Advantage or Cost Plans)
Medicare Part D
Get cost and enrollment information on RMHP Medicare.
Medical and Prescription plans available in your area.
Enroll in an RMHP Medicare Cost plan now
This information is available for free in other languages. Please call our Customer Service number at 888-282-1420 (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct. 1–Feb.14, and 8am - 8pm, M-F, Feb.15–Sept.30. Esta información está disponible gratuitamente en otros idiomas. Por favor llame a la línea de Atención a Clientes, al 888-282-1420 (TTY marque 711). Horario de 8am - 8pm, 7 días a la semana, del 1 de octubre al 14 de febrero; y de 8am - 8pm, de lunes a viernes, del 15 de febrero al 30 de septiembre.
This page was last updated: 10/1/2015. Please call to confirm you have the most up to date information about our Medicare Cost plans. Medicare Disclaimers
RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. H0602_MS_MC400WEB_RMHP1 Approved