Do You Qualify for Assistance with Medicare Costs?
Key Takeaways
- Medicare and Medicaid have several income-based programs to assist in paying for your health care costs. These can include premiumsA premium is a fee you pay to your insurance company for health plan coverage. This is usually a monthly cost. , deductiblesA deductible is an amount you pay out of pocket before your insurance company covers its portion of your medical bills. For example: If your deductible is $1,000, your insurance company will not cover any costs until you pay the first $1,000 yourself. , copaymentsA copayment is the fixed amount you pay directly to your provider for medical services or prescription drugs covered in your plan. For example: If your plan includes a copayment of $20 for office visits, you’ll pay $20 to your doctor whenever you have an appointment. and coinsuranceCoinsurance is the percentage of your medical costs that you pay after you meet your deductible. Your insurance company pays the remaining amount. For example: If you have a $1,000 medical bill and your coinsurance is 20%, you’ll pay $200. Your insurance company will cover the final $800. .
- If you’re dual eligible, Medicare is the primary payer for your care. Medicaid typically pays the rest. Income-based Medicare Savings Programs can help cover additional costs associated with Original MedicareOriginal Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). .
- Extra Help, or Low Income Subsidy (LIS), helps pay for your Medicare Part DMedicare Part D is prescription drug coverage for people enrolled in Medicare. Part D is optional and is offered by private insurance companies. and keeps at-the-counter costs low.
Medicare is funded by the Federal Government through your tax dollars. Still, some people may need help paying for coverage. Out-of-pocket medical costs often eat up a considerable chunk of seniors’ budgets on things like monthly premiums and prescription drugs. Some rely on younger loved ones for assistance, while others simply don’t know where to turn.
Fortunately, there are several programs available for people who need help paying for insurance. Here’s an overview of potential options:
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65 or Older With Low Income? You May Be Dual Eligible
If you’re 65 or older and have a limited income, you may qualify for both Medicare and full Medicaid coverage. When you are eligible for both programs, it’s called dual eligibility. Medicare will be the primary payer for your health care costs before Medicaid picks up some, or all, of the rest. Services covered can include:
- Prescription drugs
- Hospitalizations
- Physician services
- Skilled nursing facility care
- Home health visits
- Hospice care
Who’s Considered Dual Eligible?
Just like real estate, this is all about location, location, location. Medicaid is overseen by your state, and each has different eligibility rules. If your state has expanded Medicaid, your income and resource levels may be enough to qualify. For up-to-date dual-eligibility standards, contact your state’s Medicaid office.
Medicare Savings Programs Help With Part A and B Costs
Medicare Savings Programs (MSP) may help pay for Medicare Part A and B premiums, deductibles, coinsurance, and copayments if you have limited income and resources. Being enrolled in an MSP may automatically qualify you for a low income subsidy. This will help you pay for Medicare Prescription Drug Plan (Part D) premiums and copays.
Who’s eligible for an MSP?
Generally, there are four different Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB) Program
- Specified Low-Income Medicare Beneficiary (SLMB) Program
- Qualifying Individual (QI) Program
- Qualified Disabled and Working Individuals (QDWI) Program
Each MSP can help enrollees based on their level of income and resources. Medicare Savings Programs (MSP) are federally funded and administered by the states. While the Federal Government has its eligibility standards, each state can establish its income levels and requirements.
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Need Help With Prescription Costs? Look for Extra Help.
Extra Help is a Medicare program that helps enrollees pay for their Part D costs. Also called the Low Income Subsidy (LIS), Extra Help may pay some or all of your Part D premium and deductible. Recipients also enjoy significantly reduced copays and coinsurance at the counter.
Who’s Eligible for the Part D LIS?
Your income and resources determine your Part D LIS eligibility. As of 2024, you could qualify if:
- You’re single, make up to $22,590 per year, and have no more than $17,220 in resources.
- You’re married, make up to $30,660 per year, and have no more than $34,360 in resources together.
If you’re fully dual eligible or have an MSP to help pay for your Part B costs, you may be automatically qualified for Extra Help.
How Do Medicare and Medicaid Define Personal Resources?
To determine your resources, Medicare looks at your:
- Bank accounts
- Stocks
- Bonds
These are used, along with your income, to figure out if you qualify for cost assistance programs like MSPs or Extra Help. While the states may apply different eligibility standards when Medicaid is involved, certain assets won’t be counted against you when determining your eligibility, including wedding rings, your primary house, one car, and more.
Can I Get Help From A State Pharmaceutical Assistance Program for Prescription Drugs?
The answer here is — maybe. Some states offer a robust State Pharmaceutical Assistance Program (SPAP) to help pay your Part D costs. Many states, however, only allow certain drugs or don’t fund an SPAP at all. Medicare keeps a listing of the SPAPS offered in each state.
Need Help With Costs AND Care? PACE Yourself
Short for Programs of All-Inclusive Care for the Elderly, PACE is a program that pairs you with a team of healthcare providers when you need nursing home-level care but aren’t ready to move into one. PACE enrollees typically don’t pay copayments or deductibles for care and services approved by their PACE care team.
Who’s Eligible for PACE?
To be eligible for PACE, you need to:
- Be 55 or older
- Be certified by your state as needing nursing home-level care
- Live within a PACE service area
- Be able to live safely in your community with the help of a PACE team
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FAQ
Can you enroll in Medicare Advantage if you’re dual eligible?
I’m already enrolled in Medicare — how do I know if I’m dual eligible?
You can also call one of our licensed Medicare agents. GoHealth offers plans for Dual Eligible beneficiaries. We may be able to help you find out if you are dual eligible and if you qualify for a Dual Eligibility Special Needs Plan (DSNP).
What is Expanded Medicaid?
Sources
- Medicare’s Role in Reducing Senior Poverty. CMS.gov.
- Who is eligible for Medicaid? HHS.gov.
- Contact Your State With Questions. Medicaid.gov.
- Find out if your state has a State Pharmaceutical Assistance Program. Medicare.gov.
- PACE. Medicare.gov.
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