How to get help with Medicare health and drug costs

Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn
Share on pinterest
Pinterest
How to get help with Medicare health and drug costs JPG 173kb

You’re probably familiar with Original Medicare. You may know that when you turn 65 you’ll get certain health care benefits from the government. This article is “How to get help with Medicare health and drug costs“, to understand how you can get help with premiums, copays, coinsurance and deductibles. 

First, you need to figure out why you are having problems paying these fees. I understand that most people will just say “I don’t have the extra money each month” but that is most of the time, not the right answer. 

I have many clients that I have helped over the years who were simply on the wrong plan. Watching tv these days can make you think that you can do it all by yourself, I mean you can google anything these days. 

Why is an Independent Medicare Agent So Important?

No matter where you live in the United States, you most likely have dozen Medicare plans offered in your area. Each plan can help one person or hurt someone else financially. What’s right for your neighbor might be completely wrong for you. 

You first have to understand two terms “Captive” & “Independent”. These are the differences between agents that you meet. 

Captive Agent

A captive agent is an insurance agent who only works for one single insurance company. This means that this agent will try and solve your healthcare financial problem with only the plans that the company offers. If his or her company does not have something, well too bad for you. 

Independent Agent

An Independent Agent is someone who works for themselves and has contracts with many different insurance companies. He or she can shop around until we find what you need exactly. When it comes to Medicare, options are everything. You might need special care or drugs that only certain plans cover. These are the things you have to think about. 

Some plans look awesome on tv but when you go and use them you find out about the small print nobody told you about. Always ask when someone says they sell Medicare Insurance ” Are you an Independent Agent or a Captive Agent?”. Never be afraid to questions someone!!

What premiums, copays, coinsurance, and deductibles do I have?

Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Original Medicare is coverage is managed by the federal government.

Part A

Most people don’t pay a monthly premium for Part A. You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. This is based on Social Security worker’s credits, you get 4 credits for every year that you have worked and paid taxes. You need 40 credits to get premium-free part A, so if you worked for 10+ years you will have earned 40 credits.

If you paid Medicare taxes for less than 30 credits, the standard Part A premium is $499 per month in 2022. If you paid Medicare taxes for 30-39 credits, the premium is $274 per month in 2022.

Part A also has a deductible and coinsurance you have to pay. 

You pay:

  • $1,556 (2022) deductible for each benefit period.
  • Days 1-60: $0 coinsurance for each benefit period.
  • Days 61-90: $389 (2022) coinsurance per day of each benefit period.
  • Days 91 and beyond is $778 (2022) coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
  • Beyond lifetime reserve days you pay 100% of all costs

Part B

The standard Part B monthly premium amount is $170.10 2022 per month (or higher depending on your income).

Part B also has a deductible and coinsurance. In 2022, you have to pay a $233 deductible. After your deductible is met, you typically pay 20% of ALL the Medicare-Approved Bills for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment.

Part D (Prescription Drugs)

If you have original Medicare, you have to purchase your own prescription drug plan (Part D) from an insurance company that’s contracted by Medicare to offer them. You will have several stages of coverage with Part D, if you would like to learn more about Part D, CLICK HERE

When you buy a Part D plan, you will have your monthly premium, you will also have a deductible which you have to cover. Once that is done, you will have to start paying copays and coinsurance for your drugs. This part is different for everyone because everyone takes different drugs. 

Advantage Plan (Part C)

If you decide that you would like to join a Part C plan, you will also have a monthly premium, deductibles, copays, and coinsurance. All these amounts will be different based on the company and plan you choose to join. 

What if I can't pay these fees?

You have many options but you do have to understand that most of the options are income-based. If you bring home 75K per year, don’t expect to be able to qualify for most of these… 

EXTRA HELP

Medicare beneficiaries can qualify for Extra Help paying for their monthly premiums, annual deductibles, and co-payments related to Medicare prescription drug coverage.

Extra Help is worth about $5,100 per year. To qualify for Extra Help, you must be receiving Medicare and have limited resources and income. You must also reside in one of the 50 states or the District of Columbia.

To qualify for extra help with Medicare prescription drug plan costs in 2022, your annual income must be less than $20,385 for an individual ($27,465 for a married couple living together). If you’re eligible for Medicaid or any of the following Medicare Savings Programs, you automatically qualify for Extra Help.

Apply Online

The application for Extra Help does not enroll you in a Medicare Prescription Drug Plan. You do not need to be enrolled in a Medicare Prescription Drug Plan to file for Extra Help. However, the Extra Help assistance does not start until you’re enrolled with an approved Medicare prescription drug provider.

Once You Receive Extra Help….

If you are already receiving Extra Help, we must review your eligibility periodically. We’ll ask you to complete the Review of Your Eligibility for Extra Help (SSA-1026B) to ensure you’re still eligible for Extra Help and receiving all the benefits you deserve.

Medicare Savings Program

 If you’re also on a fixed income, you could qualify for financial assistance with the high cost of health care. A Medicare Savings Program (MSP) can help pay deductibles, coinsurance, and other expenses that Medicare usually doesn’t cover.

Below, we explain who is eligible for these programs and how to get the assistance you need to pay for your Medicare. There are 4 kinds of MSPs. Each type of MSP is tailored to different needs and circumstances.

  • Qualified Medicare Beneficiary (QMB) Programs pay most out-of-pocket costs for Medicare, protecting beneficiaries from cost-sharing. These programs offer full coverage of Part B premiums. Your Part A premium will also receive coverage if you haven’t worked 40 quarters. Deductibles, copays, and coinsurance receive coverage contingent on the state in which the beneficiary resides. Those who qualify for the QMB program are also automatically eligible for the Extra Help program for prescription drugs.
  • Specified Low-Income Medicare Beneficiary (SLMB) Programs pay your Part B premium. Like QMBs, those who qualify as SLMB are automatically eligible for Extra Help.
  • Qualifying Individual (QI) Programs are also known as Additional Low-Income Medicare Beneficiary (ALMB) programs. Like the SLMB programs, they offer Part B premium payment. Yet, you can qualify with a higher income. Those who qualify are also automatically eligible for Extra Help.
  • Qualified Disabled and Working Individuals (QDWI) helps pay for Part A premium if you have a disability, you’re working or you lost your Social Security disability benefits and premium-free Part A because you returned to work.

Medicaid

Medicaid is a joint federal and state program that:

  • Helps with medical costs for some people with limited income and resources
  • Offers benefits not normally covered by Medicare, like nursing home care and personal care services

Each state has different rules about eligibility and applying for Medicaid. Call your State Medical Assistance (Medicaid) office for more information and to see if you qualify. You can also call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s Medicaid office. 

Even if you have too much income to qualify, some states let you “spend down” to become eligible for Medicaid. The “spend down” process lets you subtract your medical expenses from your income to become eligible for Medicaid. In this case, you’re eligible for Medicaid because you’re considered “medically needy.”

To be eligible as “medically needy,” your measurable resources must also be under the resource amount allowed in your state.

Dual Eligibility


If you have Medicare and full Medicaid coverage, most of your health care costs are likely covered. You can get your Medicare coverage through Original Medicare or a  Medicare Advantage Plan (Part C). If you have Medicare and full Medicaid, you’ll get your Part D prescription drugs through Medicare. And, you’ll automatically qualify for Extra Help paying for your Medicare Drug Coverage (Part D). Medicaid may still cover some drugs and other care that Medicare doesn’t cover.

PACE

The program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility. 

With PACE, you have a team of health care professionals working with you and your family to make sure you get the coordinated care you need. Usually, they care for a small number of people, so they really get to know you.

When you enroll in PACE, you may be required to use a PACE-preferred doctor.

PACE covers all Medicare and Medicaid covered care and services, and other services that the PACE team of health care professionals decides are necessary to improve and maintain your health. This includes drugs, as well as any other medically necessary care, like doctor or health care provider visits, transportation, home care, hospital visits, and even nursing home stays when necessary.

If you have Medicaid, you won’t have to pay a monthly premium for the long‑term care portion of the PACE benefit. If you have Medicare but not Medicaid, you’ll be charged a monthly premium to cover the long‑term care portion of the PACE benefit and a premium for Medicare drug coverage (Part D). However, in PACE, there’s never a deductible or copayment for any drug, service, or care approved by the PACE team of health care professionals.

You can have either Medicare or Medicaid, or both, to join PACE. PACE is only available in some states that offer PACE under Medicaid. To qualify for PACE, you must:

  • Be 55 or older
  • Live in the service area of a PACE organization
  • Need a nursing home-level of care (as certified by your state)
  • Be able to live safely in the community with help from PACE

To find out if you’re eligible and if there’s a PACE program near you, search for PACE plans in your area, or call your Medicaid office.

If you have questions about anything relating to this article or any general questions about Medicare, don’t hesitate to call me directly on my cell phone. My name is Daniel and my number is 727-777-3661. You can also visit us online at www.LocalMedicareServices.com to schedule an appointment.

Share This Article...

Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn
Share on pinterest
Pinterest
Daniel Vujinovic

Daniel Vujinovic

Daniel Vujinovic has been a licensed Insurance Agent since 2012. He started working in the corporate insurance world at first to get his feet wet. After about a year in corporate, he decided that he can help more people as an independent agent who can offer more companies and products. As he started growing his book of business, Daniel and his wife Shannon decided to open LocalMedicareServices.com and continue growing a local presence in his community.

Keep Reading Articles...