May River Medicare 101
Your complete guide to understanding Medicare — simplified, organized, and powered by May River Medicare’s advanced nationwide technology. Click a topic below to jump directly to that section.
What is Medicare?
Medicare Eligibility
Medicare Part A (Hospital)
Medicare Part B (Medical)
Medicare Part C (Advantage)
Medicare Part D (Prescriptions)
Medigap (Medicare Supplement)
Enrollment Periods
Late Enrollment Penalties
Employer Insurance & Medicare
Drug Tiers & Formularies
Doctor & Hospital Networks
HMO vs PPO
Out-of-Pocket Costs
Extra Help & Savings Programs
Dual Eligible (Medicare + Medicaid)
Disability Medicare
Medicare Referrals
Preventive Care & Screenings
Foreign Travel Coverage
Understanding Medicare Costs
How to Enroll in Medicare
Switching Medicare Plans
Online Enrollment & Mobile App
1. What is Medicare?
Medicare is a federal health insurance program for:
• Adults 65 and older
• Younger individuals with qualifying disabilities
• People with ALS or ESRD
It includes several “parts” that cover hospital, medical, and prescription drug services.
• Adults 65 and older
• Younger individuals with qualifying disabilities
• People with ALS or ESRD
It includes several “parts” that cover hospital, medical, and prescription drug services.
2. Medicare Eligibility
Most people become eligible for Medicare at age 65. You may also qualify earlier due to disability, ALS, ESRD, or certain chronic medical conditions.
Eligibility varies by citizenship, residency, and work history.
Eligibility varies by citizenship, residency, and work history.
3. Medicare Part A — Hospital Insurance
Part A covers inpatient hospital care, skilled nursing, hospice, and some home health care. Most people pay no premium for Part A because they paid Medicare taxes while working.
4. Medicare Part B — Medical Insurance
Part B covers doctor visits, outpatient care, tests, medical equipment, and preventive services. Most people pay a monthly premium for Part B, which may vary by income.
5. Medicare Part C — Medicare Advantage
Medicare Advantage combines Parts A and B, and often Part D, into one plan. Many plans include dental, vision, hearing, OTC allowances, and more.
Your county and ZIP code determine which plans you can choose.
Your county and ZIP code determine which plans you can choose.
6. Medicare Part D — Prescription Drug Coverage
Part D provides prescription drug coverage. Plans vary by formulary, drug tiers, copays, and preferred pharmacies.
Always check your exact medications annually.
Always check your exact medications annually.
7. Medigap (Medicare Supplement)
Medigap helps pay costs not covered by Original Medicare, such as:
• Deductibles
• Copayments
• Coinsurance
Medigap offers nationwide coverage and no networks, making it ideal for travelers or those wanting predictable medical bills.
Enrollment may require underwriting unless you are in a guaranteed issue window.
• Deductibles
• Copayments
• Coinsurance
Medigap offers nationwide coverage and no networks, making it ideal for travelers or those wanting predictable medical bills.
Enrollment may require underwriting unless you are in a guaranteed issue window.
8. Medicare Enrollment Periods
The most important enrollment periods include:
• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Annual Enrollment Period (AEP)
• Medicare Advantage Open Enrollment (OEP)
• Special Enrollment Periods (SEP)
Missing timelines can lead to penalties or delays.
• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Annual Enrollment Period (AEP)
• Medicare Advantage Open Enrollment (OEP)
• Special Enrollment Periods (SEP)
Missing timelines can lead to penalties or delays.
9. Late Enrollment Penalties
Medicare has permanent penalties for delaying certain parts without creditable coverage.
• Part B penalty: +10% for each year you delay
• Part D penalty: +1% for each month you delay
These penalties last a lifetime unless you qualify for an exception.
• Part B penalty: +10% for each year you delay
• Part D penalty: +1% for each month you delay
These penalties last a lifetime unless you qualify for an exception.
10. Employer Insurance & Medicare
If you’re still working at 65, your Medicare enrollment depends on employer size:
• 20+ employees → Employer insurance is primary
• Under 20 employees → Medicare is primary
This determines whether you can delay Part B without penalties.
• 20+ employees → Employer insurance is primary
• Under 20 employees → Medicare is primary
This determines whether you can delay Part B without penalties.
11. Drug Tiers & Formularies (Part D)
Each Part D plan has a formulary — a list of covered medications. Drugs are placed into “tiers” that determine cost:
• Tier 1 — Preferred generics
• Tier 2 — Generics
• Tier 3 — Preferred brand
• Tier 4 — Non-preferred brand
• Tier 5 — Specialty drugs
Your drug costs can change if your medication moves tiers or is removed from the formulary.
• Tier 1 — Preferred generics
• Tier 2 — Generics
• Tier 3 — Preferred brand
• Tier 4 — Non-preferred brand
• Tier 5 — Specialty drugs
Your drug costs can change if your medication moves tiers or is removed from the formulary.
12. Doctor & Hospital Networks
Original Medicare allows you to see any provider nationwide that accepts Medicare. Medicare Advantage plans use networks that may include:
• HMO — must use in-network doctors
• PPO — can use out-of-network (higher cost)
• POS / PFFS — plan-dependent access
Network size and availability vary by ZIP code.
• HMO — must use in-network doctors
• PPO — can use out-of-network (higher cost)
• POS / PFFS — plan-dependent access
Network size and availability vary by ZIP code.
13. HMO vs PPO Plans
Medicare Advantage plans typically come in these types:
• HMO — must use in-network doctors, referrals may be required.
• PPO — can see out-of-network providers at a higher cost.
• PFFS — provider can accept or decline plan terms.
• SNP — designed for specific medical or financial needs.
The right choice depends on your doctors, travel habits, and medications.
• HMO — must use in-network doctors, referrals may be required.
• PPO — can see out-of-network providers at a higher cost.
• PFFS — provider can accept or decline plan terms.
• SNP — designed for specific medical or financial needs.
The right choice depends on your doctors, travel habits, and medications.
14. Out-of-Pocket Costs
Out-of-pocket costs vary depending on your coverage type.
Original Medicare has:
• Deductibles
• Copayments
• 20% coinsurance with no cap
Medicare Advantage plans include an out-of-pocket maximum, protecting you financially each year.
Original Medicare has:
• Deductibles
• Copayments
• 20% coinsurance with no cap
Medicare Advantage plans include an out-of-pocket maximum, protecting you financially each year.
15. Extra Help & Savings Programs (LIS)
Extra Help (LIS) reduces prescription drug costs for individuals who qualify based on income and resources.
Benefits may include:
• Low or $0 Part D premiums
• Reduced drug costs
• No Part D late penalty
• Lower deductibles
Many people qualify without realizing it.
Benefits may include:
• Low or $0 Part D premiums
• Reduced drug costs
• No Part D late penalty
• Lower deductibles
Many people qualify without realizing it.
16. Dual Eligible: Medicare + Medicaid
Individuals who qualify for both Medicare and Medicaid may receive enhanced benefits, including:
• $0 premium plans
• Comprehensive drug coverage
• Dental, vision, hearing
• Transportation
• OTC allowances
• Care coordination
Plan availability depends on your county.
• $0 premium plans
• Comprehensive drug coverage
• Dental, vision, hearing
• Transportation
• OTC allowances
• Care coordination
Plan availability depends on your county.
17. Disability Medicare (Under 65)
Individuals under 65 may qualify for Medicare after receiving SSDI for 24 months, or immediately if diagnosed with ALS.
Coverage may include:
• Part A & B
• Advantage Plans
• Prescription drugs
State rules may affect Medigap availability.
Coverage may include:
• Part A & B
• Advantage Plans
• Prescription drugs
State rules may affect Medigap availability.
18. Medicare Referrals & Prior Authorizations
Some Medicare Advantage plans require referrals to see specialists. Prior authorization may also be required for services such as:
• MRIs
• Hospital stays
• Procedures
• Specialty drugs
Original Medicare does not require referrals for specialists.
• MRIs
• Hospital stays
• Procedures
• Specialty drugs
Original Medicare does not require referrals for specialists.
19. Preventive Care & Screenings
Medicare includes numerous preventive services at no additional cost, including:
• Annual Wellness Visit
• Flu and pneumonia vaccines
• Mammograms
• Colonoscopies
• Diabetes screenings
• Heart disease screenings
Staying up to date helps catch issues early and reduce long-term medical costs.
• Annual Wellness Visit
• Flu and pneumonia vaccines
• Mammograms
• Colonoscopies
• Diabetes screenings
• Heart disease screenings
Staying up to date helps catch issues early and reduce long-term medical costs.
20. Foreign Travel Coverage
Original Medicare generally does not cover medical care outside the United States.
Medigap plans like Plan G or Plan N may include limited foreign travel benefits.
Some Medicare Advantage plans also include emergency worldwide coverage.
Medigap plans like Plan G or Plan N may include limited foreign travel benefits.
Some Medicare Advantage plans also include emergency worldwide coverage.
21. Understanding Medicare Costs
Medicare costs include:
• Part A premium (if applicable)
• Part B premium
• Part D premium
• Copays
• Deductibles
• Coinsurance
Your exact costs depend on your county and ZIP code, income, and chosen plan.
• Part A premium (if applicable)
• Part B premium
• Part D premium
• Copays
• Deductibles
• Coinsurance
Your exact costs depend on your county and ZIP code, income, and chosen plan.
22. How to Enroll in Medicare
You can enroll in Medicare:
• Online at SSA.gov
• By phone with Social Security
• In person at a Social Security office
After enrollment, you can compare and choose plans that fit your doctors, medications, and budget.
• Online at SSA.gov
• By phone with Social Security
• In person at a Social Security office
After enrollment, you can compare and choose plans that fit your doctors, medications, and budget.
23. Switching Medicare Plans
You can switch Medicare plans during certain periods:
• Annual Enrollment: Oct 15 – Dec 7
• Medicare Advantage OEP: Jan 1 – Mar 31
• Special Enrollment Periods (life events)
You may switch plans due to moving, losing coverage, or qualifying conditions.
• Annual Enrollment: Oct 15 – Dec 7
• Medicare Advantage OEP: Jan 1 – Mar 31
• Special Enrollment Periods (life events)
You may switch plans due to moving, losing coverage, or qualifying conditions.
24. Online Enrollment & Mobile App
May River Medicare offers powerful technology to make Medicare easier.
• Compare plans in your county and ZIP code
• Get instant quotes nationwide
• Check drug prices and formularies
• Review doctor networks
• Submit your preliminary application online
• Schedule appointments with licensed advisors
Our mobile app gives you Medicare tools wherever you are.
• Compare plans in your county and ZIP code
• Get instant quotes nationwide
• Check drug prices and formularies
• Review doctor networks
• Submit your preliminary application online
• Schedule appointments with licensed advisors
Our mobile app gives you Medicare tools wherever you are.