Medicare Eligibility, Coverage &

Prescription Drug Plans


Welcome to Medicare!  Medicare eligibility, coverage, prescription drug plans and costs are discussed in the booklet that the US Department of Health & Human Services sends out via the Centers for Medicare & Medicaid Services (CMS).  It gives you a clear overview of what Medicare is, what you need to consider before deciding to accept it and what you need to do in order to keep (or not keep) Medicare coverage.

In a nutshell, "Medicare is health insurance for people 65 or older, under 65 with certain disabilities, and any age with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)."

MEDICARE.GOV  has a wealth of information about eligibility, coverage, plans, applying online, benefits, finding doctors, costs and more.

Please scroll down to see the different parts of Medicare, as they each involve different aspects of your health care.





Medicare Eligibility Tool  -  find out if you qualify for Medicare after answering some questions.

Tools to Help Get Answers About Medicare:


People with Medicare & Medicaid Center

Links & information about both Medicare & Medicaid, including eligibility, TRICARE, and more.





Medicare is made up of different parts and includes the services below:

Medicare Part A - hospital insurance.  FREE

  • Hospital Stays: semi-private room, meals, in-patient rehabilitation facilities;
  • Skilled Nursing Facility Care: semi-private room, meals, skilled nursing & rehab;
  • Home Health Care Services: part-time skilled nursing care, physical therapy, speech-language pathology, occupational therapy

Medicare Part B - medical insurance, including preventive services.   MONTHLY PREMIUM

 Part B is offered as Original Medicare (run by the Federal government) or as Medicare Advantage Plan (run by a private insurance company, also called Part C).   

  • Medical & Other Services: doctor's services, outpatient medical & surgical services and supplies, diagnostic tests, durable medical equipment, more.
  • Yearly "Wellness" Exam
  • Clinical Lab Services: blood tests, urinalysis, some screenings
  • Home Health Care Services: part-time skilled care, physical & occupational therapy, speech-language pathology
  • Outpatient Hospital Services: Hospital services & supplies
  • Preventive Services: most are free; services include one "Welcome to Medicare" Physical Exam; Bone Mass Measurement; Cardiovascular, Colorectal Cancer, Prostate Cancer or Diabetes Screenings; Glaucoma Tests; Mammograms, Pap Test & Pelvic Exam; Smoking Cessation, and others

Medicare Part C - Medicare Advantage Plan is run by private insurance companies & includes Parts A, B, sometimes D.  MONTHLY PREMIUM

Medicare Part D - prescription drug coverage.  MONTHLY PREMIUM

  • Prescription drug plans offered by private companies that have been approved by and are under contract with Medicare
  • Anyone with Medicare can get a Part D added to his / her Original Medicare


In 2011, the monthly standard premium for Medicare Part B is $115.40, which is determined by your modified adjusted gross income on your IRS tax return 2 years ago being $85,000 or under for individuals, or $170,000 for married filing jointly.

This monthly premium will be deducted from your Social Security payment when Medicare coverage begins.

Once you become eligible for Medicare, you may decline coverage, but you may sign up for it during the General Enrollment Period from January 1 - March 31 each year.  Your coverage would begin July 1 of that year.

A penalty of 10% per 12-month period skipped will be added to your Part B monthly premium if you sign up after you first become eligible.  This penalty may stay as long as you have Part B.





Should you keep Medicare Part B?

If you are entitled to Social Security retirement or disability benefits, you are automatically enrolled in Medicare Parts A & B when you become eligible.  You are eligible for Medicare coverage after receiving Social Security benefits for 24 months, but Social Security enrolls you about 3 months before your coverage begins.  This allows you time to learn about Medicare's plans, to decide whether to keep Medicare Part B, and to choose good plans for Part B and for Part D.

To help you decide, Medicare brings attention to some circumstances, listed below.

  1. Are you, your spouse, or a family member (if you are disabled) still working and getting health insurance benefits?  If so, you may want to keep Part B but enroll later on without a penalty during the Special Enrollment Period [See below].
  2. Do you have TRICARE coverage?  If so, you must have Part B to keep TRICARE coverage.  You may be able to get coverage later during a Special Enrollment Period if you are an active-duty service member, or his/her spouse, or his/her dependent child.
  3. Are you without any other medical insurance or have COBRA?  If so, you may want to keep Part B.


Special Enrollment Period waives the 10% late enrollment penalty if:

  • You are 65, and you or your spouse is working, and covered by an employer or union group health plan based on that employment.
  • You are under 65 and disabled, and you or a family member is working, and you are covered by an employer or union group health plan based on that employment.
  • You sign up for Part B when you are still covered as stated above, or for up to 8 months after that coverage ends, whichever comes first.
  • If you are have COBRA, you are not eligible for the Special Enrollment Period.


Late Penalty for Part B:

  • If you sign up for Part B after you are first eligible, you will pay 10% more for each full 12- month period that you wait to sign up.
  • Your coverage may wait up to 15 months to begin.
  • You only pay an additional 10% if you wait a full 12-month period to sign up.



  • To help you decide on your plan, ask your current doctor if he / she accepts Original Medicare or Medical Advantage Plans.  We found that our doctor only accepts Original Medicare.
  • Medical Advantage Plans [MAP's] charge a FEE above Medicare's Part B premium of $115.40 in 2011.
  • MAP's often include prescription drug plans, while Original Medicare does not.
  • Know what types of medical care and medicines you will need so that you sign up for health benefits that address your specific needs.






Choosing Medicare Part D - Prescription Drug Plan

You can get prescription drug coverage by signing up for:

  1. Medicare Prescription Drug Plan;   OR
  2. Medicare Advantage Plan that covers medicines

There is a late enrollment penalty for joining a Medicare Drug Plan later as well.  This penalty changes every year and will remain in place while you are enrolled.

Drug plan #1 has its own monthly premium.  Both #1 and #2 have additional costs for medicines in the form of copays, coinsurance, deductibles and varying coverage for generic and for branded prescription drugs.



  • Visit   MEDICARE.GOV/find-a-plan to find plans available in your area
  • Call   1-800-MEDICARE   (1-800-633-4227)
  • TTY   1-877-486-2048



  • Make a list of all the drugs and health services you will need so that you can estimate their cost under each health & drug plan.  Visit MEDICARE PLAN FINDER when you are ready to look for a drug plan. When choosing a drug plan, call a representative from the drug plan that you are interested in: he or she can take a list of your meds & see if they are covered by the plan, if they have any quantity limits, or if your doctor needs to justify or approve using that particular drug.  Or you can enter the meds yourself at the MEDICARE PLAN FINDER.  You can then compare them to see which one suits your budget best.
  • After speding $2840 in 2011 in copays and coinsurance on your Medicare drug plan, you reach a Coverage Gap, also known as the "DONUT HOLE."  Once there, you are responsible for all of your prescription drug expenses until you reach an annual spending limit of $4550.  This second limit is called CATASTROPHIC COVERAGE.  Once there, you only pay a small copay or coinsurance for prescription drugs.  However, different plans cover different amounts, ranging from $0 for generics to 50% of branded meds and above.
  • Not all prescription drugs are covered by plans and limits on quantities per month exist for some drugs.  Drug plan carriers can make exceptions, though, when you follow their instructions on how to request an approval for meds above their limits.  This entails filling out a form and getting your doctor to justify a higher dosage.
  • High Risk Pools are Federal health insurance plans that may cover you without excluding your pre-existing condition if you have had no insurance coverage for the past 6 months.  Please visit PRE-EXISTING CONDITION INSURANCE PLAN to find out more & how to apply.
  • Please visit HEALTH INSURANCE HIGH RISK POOLS & specify your state to find out what plans are offered in your area to persons who cannot be insured due to pre-existing conditions & have been denied private insurance coverage.
  • Several plans are available to help pay for prescription drugs, both through the government and through private carriers.  Please see what the government offers by scrolling down to:


  • Please visit Assistance: meds & copays in the Information section of this website to find out about several other ways that a qualified applicant can get help getting or paying for meds or health care.
  • Medicare Under 65: Information on Medicare for people who are under 65 years old with disabilities, ESRD or ALS provided by eHealth.







134  — Section 2: Your Medicare Choices
What You Pay [in a Medicare drug plan]

Below and continued on the next page are descriptions
of the payments you make throughout the year in a
Medicare drug plan. Your actual drug plan costs will
vary depending on the prescriptions you use, the plan
you choose, whether you go to a pharmacy in your
plan’s network, whether your drugs are on your plan’s
formulary (drug list), and whether you get Extra Help
paying your Part D costs.

•    Monthly premium
Most drug plans charge a monthly fee that varies by
plan. You pay this in addition to the Part B premium. If
you belong to a Medicare Advantage Plan (like an HMO
or PPO) or a Medicare Cost Plan that includes Medicare
prescription drug coverage, the monthly premium you
pay to your plan may include an amount for prescription
drug coverage.

Note: Contact your drug plan (not Social Security) if you
want your premium deducted from your monthly Social
Security payment. Your first deduction will usually take
3 months to start, and 3 months of premiums will likely
be deducted at once. After that, only one premium will
be deducted each month. You may also see a delay in
premiums being withheld if you switch plans.


135  — Section 2: Your Medicare Choices
What You Pay (continued)

NEW — Starting January 1, 2011, your Part D monthly
premium could be higher based on your income. This
includes Part D coverage you get from a Medicare
Prescription Drug Plan, or a Medicare Advantage Plan or
Medicare Cost Plan that includes Medicare prescription
drug coverage. If your modified adjusted gross income
as reported on your IRS tax return from 2 years ago (the
most recent tax return information provided to Social
Security by the IRS) is above a certain amount, you will
pay a higher monthly premium. See page 251 for more

•    Yearly deductible
The amount you must pay before your drug plan begins
to pay its share of your covered drugs. Some drug plans
don’t have a deductible.

•    Copayments or coinsurance  [up to $2840]
Amounts you pay at the pharmacy for your covered
prescriptions after the deductible (if the plan has one).
You pay your share, and your drug plan pays its share
for covered drugs.


136  — Section 2: Your Medicare Choices
What You Pay (continued)

•    Coverage gap  [when you have paid $2840]
Most Medicare drug plans have a coverage gap (also
called the “donut hole”). This means that after you and
your drug plan have spent a certain amount of money for
covered drugs, you have to pay all costs out-of-pocket
for your prescriptions up to a yearly limit. Not everyone
will reach the coverage gap. Your yearly deductible, your
coinsurance or copayments, and what you pay in the
coverage gap all count toward this out-of-pocket limit.
The limit doesn’t include the drug plan premium you pay
or what you pay for drugs that aren’t covered.
There are plans that offer some coverage during the gap,
like for generic drugs. However, plans with gap coverage
may charge a higher monthly premium. Check with the
drug plan first to see if your drugs would be covered
during the gap. For more information, visit to view the fact sheet “Bridging
the Coverage Gap.” You can also call1 800 633 - 4227
to see if a copy can be mailed to you. TTY users should
call 1 877 486 - 2048.

NEW — If you reach the coverage gap in 2010, (and you
aren’t already getting Extra Help), you will get a one-time
$250 rebate check to help you with your drug costs. For
more information, visit to view the
publication, “Closing the Prescription Drug Coverage


137  — Section 2: Your Medicare Choices
What You Pay (continued)

If you reach the coverage gap in 2011, you will get a
50% discount on covered brand-name prescription
drugs at the time you buy them. There will be additional
savings for you in the coverage gap each year through
2020 when you will have full coverage in the gap. Talk to
your doctor or other health care provider to make sure
that you’re taking the lowest cost drug available that
works for you.

•    Catastrophic coverage  [when you have paid $4550]

Once you reach your plan’s out-of-pocket limit, you
automatically get “catastrophic coverage.” Catastrophic
coverage assures that once you have spent up to your
plan’s out-of-pocket limit for covered drugs, you only
pay a small coinsurance amount or copayment for the
drug for the rest of the year.

Note: If you get Extra Help paying your drug costs, you
won’t have a coverage gap and will pay only a small or
no copayment once you reach catastrophic coverage.
See pages 158 – 163.


138  — Section 2: Your Medicare Choices
What You Pay (continued)

The example below shows costs for covered drugs in
2011 for a plan that has a coverage gap.
Ms. Smith joins the ABC Prescription Drug Plan. Her
coverage begins on January 1, 2011. She doesn’t
get Extra Help and uses her Medicare drug plan
membership card when she buys prescriptions.
Monthly Premium—Ms. Smith pays a monthly
premium throughout the year.

1.  Yearly Deductible
Ms. Smith pays the first $310 of her drug costs before
her plan starts to pay its share.

2.  Copayment or Coinsurance  (What you pay at the
Ms. Smith pays a copayment, and her plan pays its
share for each covered drug until their combined
amount (plus the deductible) reaches $2,840.

3.  Coverage Gap
Once Ms. Smith and her plan have spent $2,840 for
covered drugs, she is in the coverage gap. In 2011,
she gets a 50% discount on covered brand-name
prescription drugs that counts as out-of-pocket
spending, and helps her get out of the coverage gap.


139  — Section 2: Your Medicare Choices
What You Pay (continued)

4.  Catastrophic Coverage

Once Ms. Smith has spent $4,550 out-of-pocket for the
year, her coverage gap ends. Now she only pays a small
copayment for each drug until the end of the year.
Important: Call the plans you’re interested in to get
more details. You can visit, or call 1 800 633 - 4227
to compare the cost of plans in your area. TTY users
should call 1 877 486 - 2048. For help comparing plan
costs, contact your State Health Insurance Assistance Program (SHIP).

See pages 227 – 236 for the telephone



Section 3 includes information about the following:
•    Extra Help Paying for Medicare Prescription Drug Coverage (Part D) ___ Pages 158 – 165
•    Medicare Savings Programs ___ Pages 166 – 167
•    Medicaid ___ Pages 168 – 169
•    State Pharmacy Assistance Programs (SPAPs) ___ Page 169
•    Programs of All-inclusive Care for the Elderly (PACE) ___ Page 170
•    Supplemental Security Income (SSI) Benefits ___ Page 170
•    Programs for People Who Live in the U.S. Territories ___ Page 171
•    Children’s Health Insurance Program ___ Page 171

In addition, you can get Medigap policies, which are supplemental insurance policies provided by private companies that pay for some of your out-of-pocket expenses (like coinsurance and deductibles) under Original Medicare.  They too have a premium and you must have Medicare Parts A & B.

This section only highlights a small but important part of the 268-page document!







CARE IMPROVEMENT PLUS - provides specialized benefits and services for Medicare beneficiaries with conditions such as diabetes and/or heart failure.  Our plans for 2011 will continue to include additional offerings for those with full Medicaid or Low Income Subsidy (LIS).  We also have a plan for those with Medicare only.

We all have the choice to sink or to swim.  Choose to swim!

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