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What if I cannot afford Medicare?

Medicare was developed to expand medical care and health insurance affordability for citizens who are disabled or 65 and older. Original Medicare (Medicare Parts A and B) provides many benefits, but you may have to pay out-of-pocket costs to use those benefits. Medicare coverage comes with monthly premiums, deductibles, co-payments, co-insurance, and other out-of-pocket costs.

There are several programs available to reduce the overall cost of health care services and prescription drugs. Some Medicare cost assistance programs and other forms of financial support include:

  • Medicaid
  • Medicare Savings Programs
  • Programs of All-inclusive Care for the Elderly
  • Pharmaceutical Assistance Program
  • Supplemental Security Income
  • Extra Help for Medicare Part D
  • Assistance Programs for U.S. Territories

Medicaid

Medicaid is a federal and state program that helps reduce the costs associated with health care that are usually not covered by Original Medicare, such as nursing home care and personal care services. It is for those with limited income and resources.

Each state defines the eligibility requirements for its Medicaid program. If you qualify for Medicare cost assistance in your state, you automatically qualify for the Extra Help program, which helps pay for prescription drug coverage under Medicare Part D.

Please contact your individual state’s Medicaid program for more information.

Medicare Savings Programs

Medicare Savings Programs help cover Medicare premiums and out-of-pocket costs. Each program covers different Medicare-related costs and has its own qualifying income limits. According to Medicare.gov, there are four types of Medicare Savings Programs:

  1. Qualified Medicare Beneficiary (QMB) Program
    The QMB program helps pay for Medicare Part A and Part B premiums and may pay for deductibles, co-insurance, and co-payments. In 2016, the monthly income limit is $1,010 for individuals and $1,355 for married couples.
  2. Specified Low-Income Medicare Beneficiary (SLMB) Program
     The SLMB program reduces the cost of Medicare Part B premiums. In 2016, the monthly income limit is $1,208 for individuals and $1,622 for married couples.
  3. Qualifying Individual (QI) Program
     The QI program helps pay for Medicare Part B premiums. In 2016 the monthly income limit is $1,357 for individuals and $1,823 for married couples. You must apply every year for QI program benefits. Applications are granted on a first-come, first-served basis. You cannot access QI benefits if you qualify for Medicaid.
  4. Qualified Disabled and Working Individuals (QDWI) Program
    The QDWI program reduces the cost of Medicare Part A premiums. In 2015, the monthly income limit is $1,962 for individuals and $2,655 for married couples. You may qualify for this program if any of the following statements apply:
    • You are a working disabled person under 65
    • You lost your premium-free Medicare Part A when you returned to work
    • You are not receiving state medical assistance
    • You meet your state income and resource limitations

Please note: You may qualify for one of the Medicare Savings Programs even if your monthly income is higher than the stated income limits. Other “countable resources” may impact your program eligibility. These resources include money in a checking or savings account, stocks, and bonds.

If you qualify for QMB, SLMB, or the QI programs, you are automatically qualified for the Extra Help program which helps pay for Medicare Part D prescription drug coverage.

Program of All-inclusive Care for the Elderly

The Program of All-inclusive Care for the Elderly (PACE) is a Medicare and Medicaid state option that provides community-based health care for seniors. You can have Medicaid, Medicare, or both in order to join PACE. You can also pay for PACE privately if you do not have Medicaid or Medicare. You must meet the following requirements to qualify for PACE:

  • Age 55 or older
  • Live in the service area of a PACE organization
  • Need nursing home level care (certified by your state)
  • Able to live safely in the community if you get PACE services

PACE organizations offer Medicare Part D prescription drug coverage. The program also covers health care services including adult day care, dentistry, transportation, nursing home care, and hospital care. Medicare.gov provides a complete list of the PACE health care services.

Pharmaceutical Assistance Program

Some pharmaceutical companies provide financial assistance programs to lower the cost of prescription drugs. Each prescription drug company has its own eligibility criteria, such as income level, age, and citizenship status.

For a complete search listing of each medication and its program limitations, please visit the Medicare.gov pharmaceutical assistance program page.

Supplemental Security Income

The Supplemental Security Income (SSI) program assists disabled adults and children with limited income and resources. The program also helps people 65 and older without disabilities who meet the financial requirements. The federal assistance program provides cash so that recipients can afford basic needs including food, clothing, and shelter.

For more information about the SSI cost assistance program, please visit the official Social Security website.

Extra Help for Medicare Part D

The Extra Help Medicare cost assistance program reduces prescription drug costs on Medicare Part D plans. It may lower the cost of Part D premiums, deductibles, and co-payments. Proof is required to apply for Extra Help. You can mail your Medicare Part D plan provider one of the following documents, which are separated into colored forms (purple, yellow, green, or orange):

  • A purple Medicare notice that states you qualify for Extra Help
  • A yellow or green automatic enrollment notice from Medicare
  • An Extra Help “Notice of Award” from Social Security
  • An orange Medicare notice that says your co-payment amount will change next year
  • A Supplemental Security Income (SSI) award letter as proof you have SSI

There are other documents that can act as proof of evidence that you receive Medicaid. The “Best Available Evidence” items can be any one of the following:

  • A bill from an institution (such as a nursing home) or a copy of a state document showing Medicaid paid for your stay for a month or more
  • A print-out from the state Medicaid system showing that you lived in the institution for a month or more and Medicaid paid for it
  • A state document that proves you receive Medicaid and are getting home and community-based services
  • A copy of your Medicaid card
  • A copy of a state document that shows you have Medicaid
  • A print-out from a state electronic enrollment file or from your state’s Medicaid systems that shows you have Medicaid
  • Any other state document which shows you have Medicaid

After the proof is submitted and accepted by your Part D plan, you should not pay more than the LIS drug coverage cost limit. In 2017, drug costs for qualified individuals should not exceed $3.30 for each generic medication and $8.25 for a brand-name medication.

Medicare Cost Assistance Programs for U.S. Territories

Medicare financial assistance is available to those with limited incomes and resources living in the U.S. territories of Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Territory programs may vary.

Contact your state Medicaid office for more information about Medicare cost assistance programs in your area.

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