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Mistake #6: Not Leveraging Assistance Programs

by David Bynon, last updated

The Medicare program allows everyone on Medicare to access quality health care regardless of their race, color, creed, economic status, or health condition.

As discussed in the first article in our Medicare Mistakes Series, Medicare is not free, and the premiums, deductibles, and copayments can add up quickly. For this reason, the government levels the playing field through Medicaid, several Medicare Savings Programs (MSPs), and the Extra Help program.

Key Takeaways

  • Nearly 30% of all Medicare beneficiaries who qualify for government assistance are unaware of MSP, Medicaid, or Extra Help.
  • It is unnecessary to qualify for full Medicaid to access financial aid through MSP and Extra Help.
  • Government assistance is not automatic. If you don’t apply, you won’t receive additional benefits.

Three highly beneficial government programs are designed to assist people with limited incomes. They include Medicaid, Medicare Savings Program (MSP), and Social Security Extra Help. In this MedicareWire article, we’ll cover all three programs, how to qualify, and what to do if you think you qualify.

Medicaid Program

Medicaid is a combined state and federal program that provides health care assistance to families and individuals with income at or below the federal poverty standard. Although is it a joint state/federal program, it is administered at the state level. Plus, each state has its own rules and determines the benefit provided. However, all Medicaid programs must follow the same federal guidelines.1Medicaid.gov, “Eligibility”, Accessed January 15, 2022

For Medicare beneficiaries, Medicaid eligibility is based on federal income guidelines. To qualify, you’ll need your social security number and those of your dependent children. You will also need proof of income. You can apply for Medicaid either online or through your state’s Medicaid agency. Even if you don’t qualify based solely on income, certain disabilities, pregnancy, and the elderly may still qualify for aid.1Medicaid.gov, “Eligibility”, Accessed January 15, 2022

People who are dually enrolled in both Medicare and Medicaid, also known as dual-eligible, fall into several eligibility categories. Dual-eligible beneficiaries are enrolled in Medicare Part A and Part B  and are also enrolled in full-benefit Medicaid and/or the Medicare Savings Programs (MSPs).2Medicare.gov, “Medicaid”, Accessed January 15, 2022

Dual-eligible people must navigate two separate programs:

  • Medicare for the coverage of most preventive, primary, and acute health care services and prescription drugs, and
  • Medicaid for the coverage of long-term care services and supports (LTSS), certain behavioral health services, and Medicare premiums and cost-sharing.

In order to make joining Medicare and Medicaid coverage as seamless as possible, the Centers for Medicare & Medicaid Services (CMS) created the Medicare-Medicaid Coordination Office (MMCO). Its role is to bring together Medicare and Medicaid in order to more effectively integrate benefits and improve the coordination between the federal government and states to enhance access to quality services for individuals who are enrolled in both programs.3CMS.gov, “About the Medicare-Medicaid Coordination Office”, Accessed January 15, 2022

One of the ways that MMCO helps dual-eligible people get their full benefits as easily as possible is through Medicare Advantage Special Needs Plans (SNPs). Now available in about half of all U.S. counties, SNPs cover nearly all costs for their members, and all plans include a prescription drug plan.4Medicare.gov, “Special Needs Plans (SNP)”, Accessed January 15, 2022

Medicare Savings Programs

If you qualify for both Medicare and Medicaid, you also qualify for a Medicare Savings Program that will assist you with shared costs (coinsurance) and/or monthly premiums (when applicable). The level of assistance is broken down into several eligibility categories.5Medicare.gov, “Medicare Savings Programs”, Accessed January 15, 2022

Qualified Medicare Beneficiary (QMB) Program

There are two levels of QMB. QMB “only” means that you qualify for the QMB program but you do not qualify for full Medicaid benefits. Full-benefit Medicaid coverage generally refers to coverage for a range of items and services, beyond coverage for Medicare premiums and cost-sharing. Individuals who are QMB “plus” receive full-benefit Medicaid in addition to Medicare cost-sharing and premium coverage (Part A and B).6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 2022

To qualify for QMB in 2024 your monthly income must be no more than $1,094 if you are an individual or $1,472 if you are married. If your income is slightly above this, the next program to look at is SLMB.6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 2022

Specified Low-Income Medicare Beneficiary (SLMB) Program

The SLMB program is similar to QMB but it only covers the monthly Part B premium. If you have SLMB plus, because you also qualify for Medicaid, your state may also cover your Part A and Part B cost-sharing (coinsurance).6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 2022

To qualify for SLMB in 2024 your monthly income must be no more than $1,308 if you are an individual or $1,762 if you are married. If your income is slightly above this, the next program to look at is QI. Individuals that qualify for this program also qualify for the Extra Help program from Social Security to help pay for their prescription medications.6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 20225Medicare.gov, “Medicare Savings Programs”, Accessed January 15, 2022

Qualifying Individual (QI) Program

Unlike the SLMB program, the QI program only covers the monthly Part B premium6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 2022.

To qualify for SLMB in 2024 your monthly income must be no more than $1,469 if you are an individual or $1,980 if you are married. If your income is slightly above this, the next program to look at is QI. People who qualify for this program also qualify for the Social Security Extra Help program to help pay their Medicare Part D costs for prescriptions.6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 20225Medicare.gov, “Medicare Savings Programs”, Accessed January 15, 2022

Qualified Disabled and Working Individuals (QDWI) Program

The QDWI program helps working individuals pay their Part A premium. You may qualify if any of these situations apply:6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 2022

  1. You’re a working disabled person under 65
  2. You lost your Social Security disability benefits and premium-free Part A because you returned to work
  3. You do not receive health care benefits from your state
  4. You meet the income and resource limits required by your state

To qualify for QDWI in 2024 your monthly income must be no more than $1,308 if you are an individual or $1,762 if you are married6CMS.gov, “DUALLY ELIGIBLE BENEFICIARIES UNDER MEDICARE AND MEDICAID”, Accessed January 15, 2022.

Social Security Extra Help Program

Extra Help, also known as the Medicare Part D Low-Income Subsidy (LIS), helps Medicare beneficiaries afford their prescription medications. According to the Social Security Administration, Extra Help saves its beneficiaries an average of $5,000 per year.7SSA.gov, “Extra Help with Medicare Prescription Drug Plan Costs”, Accessed January 15, 2022

To receive Extra Help, you must be enrolled in Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia. You are automatically eligible for Extra Help if you meet one of three criteria:8Medicare.gov, “Find your level of Extra Help (Part D)”, Accessed January 15, 2022

  1. You are dually eligible for both Medicare and Medicaid
  2. You have both Medicare and Supplemental Security Income (SSI)
  3. You are currently enrolled in one of the Medicare Savings Programs (above)

If you do not qualify based on one of the criteria above, you may still qualify based on your income. If your income, or joint income if married, is less than 150% of the Federal Poverty Level (FPL) you can qualify.9SSA.gov, “Understanding the Extra Help with Your Medicare Prescription Drug Plan”, Accessed January 15, 2022

To qualify for Extra Help, your resources must be limited to $16,660 for an individual or $33,240 for a married couple. By resources, Social Security means things of value that you own, including:9SSA.gov, “Understanding the Extra Help with Your Medicare Prescription Drug Plan”, Accessed January 15, 2022

  • Real estate (not including your primary residence).
  • Bank accounts including checking, savings and
    certificates of deposit.
  • Stocks, Bonds, and Mutual funds.

Applying for Extra Help is quick and easy. Simply complete Social Security’s Application for Extra Help with Medicare
Prescription Drug Plan Costs (Form SSA-1020). You can use one of the following methods:7SSA.gov, “Extra Help with Medicare Prescription Drug Plan Costs”, Accessed January 15, 2022

  1. Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
  2. Apply online at www.ssa.gov/extrahelp.
  3. Apply at your local Social Security office.

Social Security will review your application and mail you a letter of acceptance or denial. If you are denied and disagree with the decision, complete an Appeal of Determination.

Social Security will contact you periodically to review your status by sending you a form called Social Security Administration Review of Your Eligibility for Extra Help (SSA-1026). Reviews are done every year in August. If you are not selected for a review, there will be no change in the amount of Extra Help you receive in the new year. You’ll have 30 days to complete and return the SSA-1026 form.

Annual income and resource requirements change annually, so you will typically be assessed for eligibility yearly. Don’t ignore it. Complete the form and send it back.

Summary

If your income and assets are limited, take the time to apply for the assistance programs available to you. There’s no need to go without medical care or your prescriptions if you are unable to afford them. Don’t be one of the nearly 30% of Medicare beneficiaries who qualify for Medicaid, Medicare Savings Programs, or Extra Help, but don’t apply. These programs are available to those who need them.

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