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Publication #FCS2344

Important Things to Know about Medicare: Chapter Eight--What if I need help paying my health care and prescription drug costs?1

Amanda Terminello and Martie Gillen2

Important Things to Know about Medicare is a series of 10 publications that will cover the most common Medicare concerns. The series will provide general information about Medicare, including the four major plans, supplemental policies, interactions with different types of insurance, and assistance programs. This section describes programs that can assist you if you need help paying health care or prescription drug costs.

There are five main programs that can assist you with your Medicare health care and prescription drug costs if you qualify.

  • 1. For Medicare prescription drug costs, you may qualify for Extra Help.

    • In 2012, the yearly income and resource limits to qualify for this program were (1) if you are single and have an income less than $16,755 and resources less than $13.070 (2) if you are married and living with a spouse (no dependents) and have an income less than $22,695 and resources less than $26,120. Keep in mind that these limits may not be the same in 2013.

    • If you are still working or live with other dependents, you may qualify even if you don’t mean the income requirements.

    • For these purposes, “resources” include stocks, bonds, mutual funds, Individual Retirement Accounts, and money in a bank account. Assets associated with your home, car, household items, burial plot, burial expenses (up to $1,500 per person), or life insurance policies do not contribute to these eligibility criteria.

    • You automatically qualify for Extra Help if you have Medicare and have full Medicaid coverage, get assistance from your state Medicaid program paying your Medicare Part B premiums, or you receive supplemental security income (SSI) benefits (CMS 2013).

    • In order to get the benefits of this program, you must be enrolled in a Medicare Prescription Drug Plan (Part D). If you do not join one on your own when you automatically qualify for Extra Help, Medicare may enroll you in a prescription drug plan. If you do not want to be enrolled in a Medicare Prescription Drug Plan for any reason, contact Medicare to discuss it with them.

    • Keep in mind that if you have Medicaid and live in an institution (like a nursing home) or receive certain home- and community-based services, you may be able to receive covered prescription drugs at no cost to you.

    • Some of the benefits of the Extra Help program include help paying Medicare monthly premiums, yearly deductible, coinsurance, and copayments, as well as being able to avoid the coverage gap or donut hole, and have the late enrollment penalty waived. You will also be able to switch to a different Medicare Prescription Drug Plan at any time if you wish.

    • To apply for Extra Help benefits, contact social security, your state Medicaid office, or Medicare at any time (CMS 2013). You can reach the United States Social Security Administration at www.ssa.gov or by calling 1-800-772-1213. You can reach the Florida Medicaid office at 1-866-76ACCESS or 1-866-762-2237.

The other four types of Medicare Savings Programs can help with other health care costs. Usually in order to qualify for a Medicare Savings Program, you must be enrolled in Medicare Part A. Also, if you are single, you must have a monthly income less than $1,277 and resources less than $6,940, or if you are married and living together your monthly income must be less than $1,723 and your resources less than $10,401. Keep in mind that these rates may change per year and may vary by state. For these purposes, “resources” include stocks, bonds, mutual funds, Individual Retirement Accounts, and money in a bank account. Assets associated with your home, car, household items, burial plot, burial expenses (up to $1,500 per person), or life insurance policies do not contribute to these eligibility criteria. If you believe you may be eligible but don’t necessarily meet these criteria, contact your state Medicaid office for more information (CMS 2013).

  • 2. Qualified Medicare Beneficiary (QMB) Program is one program that helps pay for Medicare Part A and Part B monthly premiums, yearly deductibles, coinsurance, and copayments.

  • 3. Specified Low-Income Medicare Beneficiary (SLMB) Program can help pay your Medicare Part B monthly premiums.

  • 4. Qualifying Individual (QI) Program can help pay Medicare Part B monthly premiums as well. However, for this program, you must re-apply every year for benefits, and the applications are approved on a first-come, first-served basis.

  • 5. Qualified Disabled and Working Individuals (QDWI) Program can help pay Medicare Part A monthly premiums only if you have a disability and are working (CMS 2013).

Medicaid is another program that helps cover medical costs for people who have limited income and resources and meet other criteria. Only the state Medicaid office will be able to determine if you are eligible for Medicaid. If you are eligible for both Medicare and Medicaid, you qualify as a dual eligible. If you have full Medicaid coverage and Medicare, Medicaid may cover services and prescription drugs that Medicare doesn’t cover or doesn’t cover in full. Medicare and Medicaid are currently in the process of creating demonstration Medicare-Medicaid plans that will combine Medicare and Medicaid benefits, including prescription drug coverage. These plans are still in the process of being finalized and are not yet available (CMS 2013).

Programs of All-inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that allows people who need a nursing home-level of care to remain in their community. In order to qualify for this program, you must be 55 years of age or older, live in the service area of a PACE organization, be certified by the state as needed a nursing home-level of care, and be able to live safely in the community with the assistance of PACE services at the time you join. The benefits of this program may include coverage for prescription drugs, doctor’s visits, transportation, home care, and hospital visits. You may also be eligible for long-term care benefits, for a monthly premium (unless you have Medicaid). There is no deductible or copayment for prescription drugs and services approved by PACE health care professionals. For more information, visit www.pace4you.org or call your state Medicaid office (CMS 2013).

If you still need further assistance, make sure to contact your State Health Insurance Assistance Program (SHIP), which may be able to identify other state programs, such as State Pharmacy Assistance Programs, that can help with additional health care and prescription drug costs. The SHIP for Florida is Serving Health Insurance Needs of Elders (SHINE) and can be contacted at 1-800-963-5337 (CMS 2013).

Reference

Centers for Medicare and Medicaid Services. 2013. Medicare and You: The Official U.S. Government Medicare Handbook (CMS Product No. 10050-28). Washington, DC: Government Printing Office.

Footnotes

1.

This document is FCS2344, one of a series of the Department of Family, Youth, and Community Sciences, UF/IFAS Extension. Original publication date September 2013. Visit the EDIS website at http://edis.ifas.ufl.edu.

2.

Amanda Terminello, graduate student, College of Public Health; and Martie Gillen, assistant professor and specialist in family and consumer economics for older adults, Department of Family, Youth, and Community Sciences; UF/IFAS Extension Gainesville, FL 32611.


The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations. For more information on obtaining other UF/IFAS Extension publications, contact your county's UF/IFAS Extension office.

U.S. Department of Agriculture, UF/IFAS Extension Service, University of Florida, IFAS, Florida A & M University Cooperative Extension Program, and Boards of County Commissioners Cooperating. Nick T. Place, dean for UF/IFAS Extension.