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Medicare in Rhode Island


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Overview of Medicare in Rhode Island

If you’re a Rhode Island resident who’s wondering how Medicare works, you’ve come to the right place.

As a Medicare beneficiary, you can choose from a variety of Medicare coverage options in Rhode Island. The common options are described below.

To start, there’s Original Medicare, Part A and Part B, which is the federally administered health-care program. In Rhode Island, as in the rest of the country, you’re eligible for Medicare if you’re 65 or older and either an American citizen or a legal resident who has lived in the United States at least five continuous years. You may also be eligible for Medicare before age 65 if any of the following situations apply to you.

  • You have a disability and have been receiving Social Security Disability Insurance (SSDI) for more than 24 months.
  • You have been diagnosed with permanent kidney failure, also called End Stage Renal Disease or ESRD, and you have received a kidney transplant or are receiving dialysis treatment.
  • You have been diagnosed with Amyotrophic Lateral Sclerosis (ALS), commonly known as Lou Gehrig’s disease.

Original Medicare is made up of two parts Part A and Part B.

  • Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Medicare Part B covers doctors’ services, outpatient care, medical supplies, lab services, and some preventive services and screenings.

Typically people can get Medicare Part A without a premium if they’ve worked at least 10 years (40 quarters) and paid Medicare taxes. If you have not paid Medicare taxes for at least 10 years, you may owe a premium for your Part A coverage. Most Medicare beneficiaries pay a premium for Part B coverage, along with any deductibles, copayments, and coinsurance costs that may come with Medicare Part A and Part B coverage.

Please note that Original Medicare does not pay for some services that beneficiaries may need. For example, if you only have Original Medicare you may be responsible for paying:

  • Prescription drugs (except for those you get in an inpatient hospital or skilled nursing facility and certain medications you receive during outpatient care)
  • Nursing home care
  • Routine dental care
  • Dentures
  • Routine vision care
  • Eyeglasses or contacts (with some exceptions, such as after eye surgery)
  • Health services received outside of the country

As mentioned, Original Medicare coverage of prescription drugs is limited. However, Rhode Island beneficiaries have the option of enrolling in a stand-alone Medicare Part D Prescription Drug Plan (PDP) to help pay for prescription drug costs. These plans are available through Medicare-approved private insurance companies. Medicare Part D Prescription Drug Plans work alongside your Original Medicare coverage.

Another option you may have if you’re enrolled in Original Medicare is Medigap (Medicare Supplement) insurance, which is also offered by private insurance companies. Medicare Supplement insurance plans can help you pay for certain out-of-pocket costs for services covered under Original Medicare.

As an alternative to Original Medicare, you may be eligible to enroll in a Medicare Advantage plan in Rhode Island. Also known as Medicare Part C, Medicare Advantage provides a different way of receiving Medicare Part A and Part B benefits. Medicare Advantage plans are offered by private insurance companies that contract with the Centers for Medicare & Medicaid Services (CMS). They are required to provide at least the same level of coverage as Original Medicare (with the exception of the hospice benefit, which continues to be paid by Medicare Part A).

One advantage of Medicare Part C is that it provides an opportunity to get coverage beyond Original Medicare. Many Medicare Advantage plans include additional benefits, such as routine dental and vision care, hearing, wellness programs, and prescription drug coverage. Medicare Advantage plans that include prescription drug coverage are known as Medicare Advantage Prescription Drug (MA-PD) plans. These plans give you the convenience of having your Medicare medical and prescription drug benefits through one plan instead of having to enroll in a separate plan for your Medicare Part D coverage.

Another notable feature of Medicare Advantage plans is that they are required to limit your out-of-pocket spending for services covered under Medicare Part A and Part B. Once your out-of-pocket costs reach this limit (including the deductible), your Medicare Advantage plan pays 100% of covered health-care costs for the remainder of the year. In contrast, Original Medicare doesn’t have a maximum spending cap, so there’s no limit to your potential out-of-pocket costs if you have an illness or injury that requires costly treatment.

If you’re interested in enrolling in a Medicare Advantage plan, you must:

  • Have Medicare Part A and Medicare Part B
  • Not have end-stage renal disease (unless you meet certain exceptions)
  • Live in the Medicare Advantage plan’s service area

If you’re enrolled in Medicare Advantage, you must continue to pay your Medicare Part B premium and may also pay an additional premium directly to your Medicare Advantage plan.

You can compare Medicare plan options where you live by using the eHealth plan finder tool on this page. Type your zip code into the tool to get started. You can even provide your current list of prescription drugs to find Medicare plan options that cover those medications.

Medicare resources in Rhode Island

Rhode Island Division of Elderly Affairs – Managed by the Rhode Island Department of Human Services, this agency provides a number of programs and services for the senior population in the state. It also provides information about Medicare plan options in Rhode Island through a variety programs, such as:

  • Senior Health Insurance Program (SHIP) – This program offers free counseling and information about Medicare plans to beneficiaries in Rhode Island. The SHIP offices are staffed by highly trained volunteers who have no ties to the insurance industry. Offices are located at many of the senior centers throughout the state.
  • Pharmaceutical Assistance to the Elderly – This program is available to Rhode Island Medicare beneficiaries who are enrolled in Medicare Part D prescription drug plan coverage. The program provides financial assistance to qualified residents of the state who need help paying for their prescription medications, particularly during the Medicare Part D coverage gap. Eligibility is based on income level.
  • Senior Medicare Patrol – The Division of Elderly Affairs receives grant funding from the U.S. Department of Health and Human Services for the Senior Medicare Patrol (SMP) program. This program educates seniors about Medicare fraud, waste, and abuse so they can do their part to prevent fraud and errors on Medicare claims.

Rhode Island Department of Human Services – In addition to overseeing the Division of Elderly Affairs, the Department of Human Services is also the location for the Rhode Island Medical Assistance program, also known as Medicaid. This program offers financial assistance to Medicare beneficiaries in Rhode Island that cannot afford to pay their premiums or deductibles on their healthcare coverage. Eligible beneficiaries can qualify for this program based on their income level. You can download the application for the Medical Assistance program from the Executive Office of Health and Human Services website or obtained by visiting one of the local offices of the Department of Human Services.

The Point – This website offers information for Medicare beneficiaries in Rhode Island who qualify for benefits by age or disability. A state guide on purchasing additional insurance coverage is available here, as well as links to both state and federal offices that work with Medicare beneficiaries. Information about the state’s SMP program and SHIP program is also available through this website, which is a part of the state’s government offices and services.

Medicare statistical trends in Rhode Island

In 2018, almost 214,000 Rhode Island residents were enrolled in Medicare, according to CMS. Approximately 163,000 people had Medicare prescription drug coverage in Rhode Island.

You may be wondering about the availability and cost of some of these coverage options. Here are some interesting facts from a CMS report regarding Medicare coverage in Rhode Island during 2018:

  • At least one of the 17 Medicare Advantage plans operating in the state is available to every Medicare beneficiary in Rhode Island.
  • Rhode Island also has 22 Medicare Prescription Drug Plans available statewide.
  • 85% of people residing in Rhode Island with Medicare Part D prescription coverage have access to a plan with a lower premium than they paid in 2017.
  • The lowest monthly premium for a stand-alone Medicare Part D Prescription Drug Plan is $12.60 (subsidies and late enrollment penalties excluded).
  • 29% of people with Medicare prescription Drug Plans receive Extra Help (also called the low-income subsidy, or LIS) to reduce the cost of enrolling in Medicare prescription drug coverage.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

The product and service descriptions, if any, provided on these eHealth Insurance Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.
Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

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