Get Help Paying
Paying for Prescription Drugs
Even with prescription drug coverage through Part D or MA plans, not all beneficiaries can easily afford to make deductible, copayment, and coinsurance payments for their prescription drugs. This is especially true for individuals who fall into the “donut hole” (the coverage gap) where costs can be high even with coverage. Sometimes asking your doctor if you can switch to generics or other less expensive drugs may save you on prescription costs. However, even if you can switch, some still have difficulty affording prescription drugs, especially those with multiple and/or serious medical conditions. There are several additional important resources available to help pay for prescription drugs:
- Medicare Drug Plans – there are drug plans that offer additional coverage during the prescription drug coverage gap. While these plans help reduce expenses during the coverage gap phase, they may carry a higher monthly premium.
- “Extra Help” – See more below.
- Pharmaceutical Assistance Programs – Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare prescription drug coverage (Part D). Find out whether there’s a program that can lower prescription costs for the drugs you take here: www.medicare.gov/pharmaceutical-assistance-program.
- State Pharmaceutical Assistance Programs – Some states offer help paying for prescriptions, drug plan premiums, and/or other drug costs. Find out if your state has a State Pharmaceutical Assistance Program here: www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx.
- Charitable Programs – several national and community-based efforts to help support individuals struggling with drug costs exist across the U.S. For example, you can reach out to:
- The National Patient Advocate Foundation: www.npaf.org/patients-caregivers.
- The National Organization for Rare Disorders: rarediseases.org/for-patients-and-families/help-access-medications/patient-assistance-programs-2/#section-1.
- The National Council on Aging’s “Benefits Check Up” www.benefitscheckup.org.
Getting “Extra Help”
If you have limited income and/or financial resources, Medicare has a program designed to give some additional help! “Extra Help” provides additional resources for paying for prescription drugs to those with a limited income. Drug costs in 2020 for people who qualify will be no more than $3.60 for each generic drug and $8.95 for each brand-name drug.
See who Qualifies:
How do I know if I automatically qualify?
To let you know if you automatically qualify for Extra Help, Medicare will mail you a purple letter that you should keep for your records. You don’t need to apply for Extra Help if you get this letter.
- If you aren’t already in a Medicare drug plan, you must join one to use this Extra Help.
- If you’re not enrolled in a Medicare drug plan, Medicare may enroll you in one so that you’ll be able to use the Extra Help. If Medicare enrolls you in a plan, you’ll get a yellow or green letter letting you know when your coverage begins, and you’ll have a Special Enrollment Period to change plans.
- If you have Medicaid and live in certain institutions (like a nursing home) or get home- and community-based services, you pay nothing for your covered prescription drugs.
I don’t automatically qualify; how do I apply?
If you didn’t automatically qualify for Extra Help, you can apply anytime:
- Visit secure.ssa.gov/i1020/start to apply online.
- Call Social Security at 1-800-772-1213 (TTY users 1-800-325-0778).
- When you apply for Extra Help, you also can start your application process for the Medicare Savings Programs. These state programs provide help with other Medicare costs. Social Security will send information to your state unless you tell them not to on the Extra Help application.
- To get answers to your questions about Extra Help and help choosing a drug plan, call your State Health Insurance Assistance Program (SHIP) by going here: www.shiptacenter.org and using the SHIP Locator to find your local SHIP’s telephone information.
For more information on Extra Help, continue reading here: www.medicare.gov/your-medicare-costs/get-help-paying-costs/find-your-level-of-extra-help-part-d.
Paying for Medicare Health Care Costs
Medicare helps, but it’s not free and it doesn’t cover everything. Health plans like Medigap and Medicare Advantage can help, but won’t cover all the costs included in your healthcare. Here are some additional resources for helping you pay your healthcare costs:
Medicare Savings Programs
There are 4 kinds of Medicare Savings Programs that may offer additional help paying for healthcare costs that Medicare, Medicare Supplements, and Medicare Advantage plans may not cover (programs may vary on a state-to-state basis):
- Qualified Medicare Beneficiary (QMB) Program:
If you’re eligible, the QMB Program helps pay for Part A and/or Part B premiums. In addition, Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments (except outpatient prescription drugs). If you get a bill for these charges, tell your provider or debt collector that you’re in the QMB Program and can’t be charged for items and services Medicare covers, including deductibles, coinsurance, and copayments. If you’ve already made payments on a bill for services and items Medicare covers, you have the right to a refund. Read more here: www.benefits.gov/benefit/6177.
- Specified Low-Income Medicare Beneficiary (SLMB) Program:
Helps pay Part B premiums only. Read more here: www.benefits.gov/benefit/6178.
- Qualifying Individual (QI) Program:
Helps pay Part B premiums only. Funding for QI benefits is limited, and the applications are granted on a first come, first-served basis. You can’t get QI benefits if you qualify for Medicaid. Read more here: www.benefits.gov/benefit/6176.
- Qualified Disabled and Working Individuals (QDWI) Program:
Helps pay Part A premiums only. You may qualify for this program if you have a disability and are working. Read more here: www.benefits.gov/benefit/6180.
If you qualify for a QMB, SLMB, or QI Program, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage.
Do I qualify?
Usually, to qualify for a Medicare Savings Program, you must have income and resources below a certain limit.
To see more about each MSP qualification standard, go here: www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs.
States have different limits and ways of counting your income and resources, so check with your state Medicaid office to see if you qualify. Call or visit your State Medical Assistance Office and ask for information about Medicare Savings Programs. To find the phone number for your state, visit www.medicare.gov/contacts/#resources/msps. You can also call 1-800-MEDICARE (1-800-633-4227, TTY users call 1-877-486-2048).
Medicaid is a joint federal and state program that helps pay health care costs if you have limited income and resources and meet other requirements. Some people qualify for both Medicare and Medicaid. (Learn more about dual eligibility here: [INSERT Medicaid vs. Medicare subsection hyperlink]) What does Medicaid help cover?
- If you have Medicare and full Medicaid coverage, most of your health care costs are covered. You can get your Medicare coverage through Original Medicare or a Medicare Advantage Plan.
- If you have Medicare and/or full Medicaid coverage, Medicare covers your Part D prescription drugs. Medicaid may still cover some drugs that Medicare doesn’t cover.
- People with Medicaid may get coverage for services that Medicare doesn’t cover or only partially covers, like nursing home care, personal care, transportation to medical services, home- and community-based services, and dental, vision, and hearing services.
Programs of All-inclusive Care for the Elderly (PACE)
PACE is a Medicare and Medicaid program offered in many states that allows people who need a nursing home-level of care to remain in the community.
To qualify for PACE, you must meet these conditions:
- You’re 55 or older.
- You live in the service area of a PACE organization.
- You’re certified by your state as needing a nursing home-level of care.
- At the time you join, you’re able to live safely in the community with the help of PACE services.
PACE covers all Medicare and Medicaid covered care and services, as well as other services that the PACE team of health care professionals decides are necessary to improve and maintain your health. This includes:
- Prescription drugs
- Medically necessary care (doctor or health care provider visits)
- Home care
- Hospital visits
- 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 Part D drugs. 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. Read more here: www.medicare.gov/your-medicare-costs/get-help-paying-costs/pace, and visit www.medicare.gov/find-a-plan/questions/pace-home.aspx to see if there’s a PACE organization that serves your community.
Supplemental Security Income (SSI) benefits
SSI is a cash benefit paid by Social Security to people with limited income and resources who are blind, 65 or older, or have a disability. SSI benefits aren’t the same as Social Security retirement benefits. You may be able to get both SSI benefits and Social Security benefits at the same time if your Social Security benefit is less than the SSI benefit amount, due to a limited work history, a history of low-wage work, or both. If you’re eligible for SSI, you automatically qualify for Extra Help, and are usually eligible for Medicaid. You can visit ssabest.benefits.gov, and use the “Benefit Eligibility Screening Tool” to find out if you’re eligible for SSI or other benefits. Call Social Security at 1-800-772-1213 (TTY users call 1-800-325-0778). or contact your local Social Security office for more information. You can read more about SSI here: www.ssa.gov/benefits/ssi.