What if I can’t afford my Medicare Coverage?

Medicare may cover many health-care services, but it isn’t FREE. Medicare coverage typically requires out-of-pocket costs – your pocket that is – like monthly premiums, annual deductibles, coinsurance, and copayments. If you can’t afford these expenses, you may be able to get help with some Medicare coverage costs.

Medicare Coverage: Out-of-pocket costs

Your costs under Medicare depend on the type of Medicare coverage you have. For example, Original Medicare (Part A and Part B) each come with annual deductibles, coinsurance and/or copayments. If you’ve worked for at least ten years while paying Medicare taxes, you generally don’t have to pay a monthly premium for Part A (hospital insurance). Part B generally comes with a premium, although if you have a low income, you might qualify for assistance as described below.

Types of Medicare Coverage assistance

If you have trouble affording Medicare coverage, there are a few kinds of assistance you might want to take a look at. You might qualify for one or more of these:

  • Medicaid
  • Medicare Savings Program
  • Medicare Part D Extra Help

These types of assistance are discussed below.

Medicaid and Medicare Coverage assistance

You might be able to get assistance from your state to help pay for medical care- even if you have Medicare coverage. Depending upon your income, you may be eligible for Medicaid. Generally, each state determines Medicaid eligibility for its residents, while the federal government determines eligibility for Medicare coverage.

Some low-income Medicare beneficiaries are dual eligible – qualifying for both Medicare and Medicaid. If you have Medicaid and Medicare coverage, after Medicare pays its portion of covered services, Medicaid might pay its portion of Medicare covered services. Medicaid might also covers such services as personal care and custodial nursing home care that Medicare doesn’t typically cover.

Medicare Savings Programs and Medicare Coverage assistance

If you aren’t eligible for full Medicaid to work alongside your Medicare coverage, you might qualify for an income-based Medicare Savings Program.

There are four types of Medicare Savings Programs to provide assistance with the cost of Medicare coverage if you meet eligibility requirements.

  1. Qualified Medicare Beneficiary (QMB): The QMB program may help pay Medicare costs such as Part A deductibles, Medicare Part B premiums and deductibles, and coinsurance, copayments and deductibles for Medicare coverage (Part A and Part B).
  2. Specified Low-income Medicare Beneficiary (SLMB): This program may help pay your Medicare Part B Premium.
  3. Qualifying Individual (QI-1) Program: Under this program, applications may be granted on a first-come, first-served basis, with priority given to people who go QI benefits the prior year. Even if you’re enrolled in the QI-1 program, you must re-apply each year. Medicaid beneficiaries are not eligible. It may help pay your Medicare Part B Premium.
  4. Qualified Disabled and Working Individuals (QDWI) Program: This program may help pay your Medicare Part A premium (if you don’t otherwise qualify for premium-free Part A).
QMB-Qualified Medicare BeneficiarySLMB-Specified Low-Income Medicare BeneficiaryQI – Qualified Individual Program
Individual Monthly Income$1,153$1,379$1,549
Married Monthly Income$1,546$1,851$2,080
Individual Resource Limit$8,400$8,400$8,400
Married Couple Resource Limit$12,600$12,600$12,600
Program Helps Pay For:Part A Premiums, Part B Premiums, Deductibles, Coinsurance and CopaymentsPart B Premiums OnlyPart B Premiums Only

To qualify for one of these programs, you must be eligible for Medicare Part A (even if you are not enrolled), and your income and resources must be at or below certain levels. The income and resource requirements vary from state to state. You can contact your state Medicaid agency to learn more about whether a Medicare Savings Program could help pay some of the cost of your Medicare coverage. If you qualify for a QMB, SLMB, or QI program, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage.

The Extra Help Program and Medicare coverage for Part D Prescription Drugs.

The Extra Help program is a federal program for people with Medicare who meet income and resource limits for prescription drugs (Part D). If you receive Medicaid or Supplemental Security Income (SSI) or if your state pays your Medicare premiums, you might automatically qualify for full Extra Help. Many people who qualify for Extra Help will pay:

  • No Medicare premiums
  • No Medicare deductibles
  • No more than $9.85 in 2022 for each brand name drug their plan covers.

The amount of Extra Help you get typically depends on your income and resources. If you qualify for Extra Help, you can enroll in a Medicare Part D Prescription Drug Plan at any time. (You generally will not have to pay a penalty, even if you enroll late.)

Dual Eligible Medicare Advantage Plans

A dual special needs plan is a type of Medicare Advantage plan. It’s for people who have both Medicaid and Medicare. A dual special needs plan works together with your Medicaid health plan. You’ll keep all your Medicaid benefits. Most dual plans also give you more benefits and features than you get with Original Medicare. Dual special needs plans are for people who could use some extra help, maybe because of income, disabilities, age and/ or health conditions.

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