If you face difficulty paying your Medicare premiums, help may be available for you. There are a number of options, and details vary, so read through this information carefully. What is presented here comes directly from the Medicare program.
In some cases, Medicare Savings Programs may pay the following:
- Medicare Part A (Hospital Insurance)
- Medicare Part B (Medical Insurance)
- Deductibles, coinsurance, and copayments if you meet certain conditions (see more on these conditions under “How do I apply for Medicare Savings Programs?” below)
Four Kinds of Programs
There are four types of Medicare Savings Programs, named as follows:
- Qualified Medicare Beneficiary Program (QMB)
- Specified Low-Income Medicare Beneficiary Program (SLMB)
- Qualifying Individual Program (QI)
- Qualifying Disabled and Working Individuals Program (QDWI)
One of the key qualifying factors for any of these programs is your income. The other is resources you have apart from your income. Note that certain resources are countable in determining whether or not you qualify for help; others are not.
Countable resources include:
- Money in a checking or savings account
- Stocks
- Bonds
Countable resources don’t include:
- Your home
- One car
- Burial plot
- Up to $1,500 for burial expenses if you have put that money aside
- Furniture
- Other household and personal items
Now let’s look at the income and resource limits that are set for each of the four programs. These figures are for year 2022. (These limits are slightly higher in Alaska and Hawaii, which we will not address here.)
- Qualified Medicare Beneficiary Program (QMB)
Individual monthly income limit:$1,153
Married couple monthly income limit: $1,546
Individual resource limit: $8,400
Married couple resource limit: $12,600
This program helps pay for: Part A premiums, Part B premiums, and deductibles, coinsurance, and copayments for services and items Medicare covers.
Other things to know about the QMB program:
Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments, except outpatient drugs. Pharmacists may charge you up to a limited amount (no more than $4.00 in 2022) for prescription drugs covered by Medicare Part D.
- If you get a bill for Medicare charges: Tell your provider or the debt collector that you’re in the QMB Program and can’t be charged for Medicare deductibles, coinsurance, and copayments.
- If you already made payments on a bill for services and items Medicare covers: You have the right to a refund.
- If you have a Medicare Advantage Plan: Contact the plan to ask them to stop the charges.
In some cases, you may be billed a small copayment through Medicaid, if one applies.
Make sure your provider knows you’re in the QMB program. Show both your Medicare card and Medicaid card (or QMB card) each time you get care. If you have original Medicare, you can also show a copy of your “Medicare Summary Notice (MSN).” It shows you’re in the QMB program.
If your provider won’t stop billing you, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.
- Specified Low-Income Medicare Beneficiary Program (SLMB)
The SLMB Program is a state program that helps pay only Part B premiums for people who have Part A and limited income and resources. Here are the limits for qualifying for SLMB:
Individual monthly income limit:$1,379
Married couple monthly income limit: $1,851
Individual resource limit: $8,400
Married couple resource limit: $12,600
- Qualifying Individual Program (QI)
The QI Program is a state program that helps pay Part B premiums for people who have Part A and limited income and resources. You must apply every year for QI benefits. QI applications are granted on a first-come, first-served basis, with priority given to people who got QI benefits the previous year. (You can’t get QI benefits if you qualify for Medicaid). Here are the limits for qualifying for QI:
Individual monthly income limit:$1,549
Married couple monthly income limit: $2,080
Individual resource limit: $8,400
Married couple resource limit: $12,600
- Qualifying Disabled and Working Individuals Program (QDWI)
The QDWI program helps pay the Part A premium. You may qualify if all of these apply to you:
- You have a disability.
- You’re working.
- You lost your Social Security disability benefits and premium-free Part A because you returned to work.
Here are the limits for qualifying for QDWI:
Individual monthly income limit:$4,615
Married couple monthly income limit: $6,189
Individual resource limit: $4,000
Married couple resource limit: $6,000
If you qualify for the QMB, SLMB, or QI program, you automatically also qualify to get Extra Help paying for Medicare drug coverage (see more below). These amounts may increase each year. If your income and resources are slightly higher, you should still apply.
How to apply for Medicare Savings Programs
If you answer yes to these 3 questions, call your State Medicaid Program to see if you qualify for a Medicare Savings Program in your state:
- Do you have, or are you eligible for, Part A?
- Is your income for 2022 at, or below, the income limits listed for any of the programs above?
- Do you have limited resources, below the limits above?
It’s important to call or fill out an application if you think you could qualify for savings—even if your income or resources are higher than the amounts listed here.
More information on Medicare Savings Programs for Coloradans is available at https://hcpf.colorado.gov. Choose “Explore Programs,” then “Programs for Adults,” and scroll down to the listings of Medicare Savings Programs. Telephone contacts for the Department of Health Care Policy and Financing of Colorado are 800-221-3943 or 303-866-3513.
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How to lower prescription drug costs
To lower your prescription drug costs, you can:
- Ask about generic drugs—your doctor can tell you if you can take a generic drug instead of a brand-name drug or a cheaper brand-name drug
- Look into using mail-order pharmacies
- Compare Medicare drug plans to find a plan with lower drug costs
- Apply for Extra Help, a program to help pay drug costs for people with limited income and resources (more details below)
- Look into whether the manufacturer of your drug offers help paying for it
Getting Extra Help
If you meet certain income and resource limits, you may qualify for Extra Help. This program helps pay for your Medicare drug coverage, such as plan premiums, deductibles, and costs when you fill your prescriptions, called copays or coinsurance.
How much would you pay if you qualify for Extra Help?
Plan premiums & deductibles: Depending on your income level, you may pay less or pay nothing for your plan premium and yearly deductible (an amount you have to pay before your plan starts to pay.)
Copays & coinsurance: In 2022, drug costs are no more than:
- $3.95 for each generic drug
- $9.85 for each brand-name covered drug
How to qualify for Extra Help
In 2022, you may qualify if you have up to $20,385 in yearly income ($27,465 for a married couple) and up to $15,510 in resources ($30,950 for a married couple).
Resources that count to see if you qualify (same as for Medicare Savings Programs):
- Money in a checking or savings account
- Stocks
- Bonds
Resources that don’t count to see if you qualify:
- Your home
- One car
- Burial plot
- Up to $1,500 for burial expenses if you have put that money aside
- Furniture
- Other household and personal items
How to get Extra Help
Some people automatically qualify for Extra Help. You’ll get the Extra Help program if you have Medicare and get any of the following:
- Full Medicaid coverage
- Help from your state Medicaid program paying your Part B premiums (from a Medicare Savings Program)
- Supplemental Security Income (SSI) benefits
If you don’t automatically qualify, you can apply for Extra Help at any time.
How to apply to get Extra Help
To get extra help with Medicare Prescription Drug plan costs, you must complete and submit an application. Medicare will review your application and send you a letter to let you know if you qualify for extra help. If you need help completing the application, call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
By completing this form, you will also start your application process for a Medicare Savings Program (as described above). Medicare will send information to your state who will contact you to help you apply for a Medicare Savings Program unless you say not to when you complete this application.
If you need more information about Medicare Savings Programs, Medicare Prescription Drug plans or how to enroll in a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov.
You also can request information about how to contact your State Health Insurance Counseling and Assistance Program (SHIP), which offers help with Medicare questions.
Colorado’s SHIP can be found at
https://doi.colorado.gov/insurance-products/health-insurance/senior-health-care-medicare. The description there says SHIP “helps Medicare enrollees navigate the Medicare system and provides free, unbiased and individualized information. Housed within the Division of Insurance, Colorado SHIP has 17 local locations at partner agencies around the state.” A sister program called the Senior Medicare Patrol (or SMP) “helps Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse.”
After submitting your application, you’ll get a letter from Medicare if you qualify. If you don’t qualify for Extra Help, you can reapply for it at any time if your income and resources change.
Important: The application for Extra Help does not enroll you in a Medicare prescription drug plan. You will have to enroll directly with an approved Medicare prescription drug provider for coverage. If you need information about Medicare Prescription Drug plans or how to enroll in a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov.
Who should complete this application?
You should complete the application for Extra Help if:
- You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
- You live in one of the 50 States or the District of Columbia; and
- Your combined savings, investments, and real estate are not worth more than $30,950, if you are married and living with your spouse, or $15,510 if you are not currently married or not living with your spouse. (Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.) If you have more than those amounts, you may not qualify for the Extra Help. However, you can still enroll in an approved Medicare prescription drug plan for coverage.
EXCEPTION: Even if you meet these conditions, DO NOT complete this application if you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid because you automatically will get the Extra Help.
Things to know after you qualify for Extra Help
How long will you get Extra Help?
Once you qualify for the Extra Help program, you’ll have it as long as you meet the year’s income and resource limits. Even if you automatically qualify this year, you may not qualify for Extra Help next year. Changes in your income or resources may cause you to no longer to qualify.
How will you know if you no longer qualify?
- If you got Extra Help, but no longer automatically qualify for next year: You’ll get a letter by the end of September. If you get this notice, you may still qualify for help with prescription costs, but you need to apply to find out.
- If your copays change next year: You’ll get a notice in the mail in early October with the new amounts.
- If you don’t get a notice from Medicare: You’ll get the same level of Extra Help that you got for this year.
What do I do if I think my drug costs are wrong?
If you’re not sure if you’re paying the right amount, call your drug plan. Your plan may ask you to give information to help them check the level of Extra Help you should get.
Can I get money back if I’ve been paying too much?
If you paid for prescriptions since you qualified for Extra Help and you aren’t enrolled in Medicare drug coverage, you may be able to get some money back. Keep receipts with your prescription drug prices, and call your plan. Or, you can contact Medicare’s Limited Income Newly Eligible Transition (NET) Program at 1-800-783-1307 for more information (TTY: 711).
