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Medicare Extra Help Programs: Income Limits and Benefits

Medicare Extra Help Programs: Income Limits and Benefits

If you have a lower income, you might wonder how you can afford your Medicare costs. For example, your Medicare Part D prescription drug coverage has a monthly premium, deductible, and copayment for prescriptions.

If you need help paying for those costs, you should consider the Medicare Extra Help program. This guide will help you understand how to use this program and answer common questions that many Medicare beneficiaries have.

What is Medicare Extra Help?

The Extra Help program helps those who struggle to afford their Medicare Part D prescription drug plan. In order to apply, you have to be enrolled in Medicare Part D. You might qualify for either full extra help or partial assistance.

The enrollment you qualify for depends on your monthly income, assets, and other programs you qualify for.

If you qualify for Medicaid, SSI, or a Medicare Savings Program, you automatically receive Extra Help on your Medicare Part D plan. You don’t need to enroll, you simply need to send a copy of the qualifying notice to your drug plan.

Qualifying for Extra Help provides you with a special enrollment opportunity each quarter (except 4th quarter) to change Part D plans to make sure the plan you are in fits your needs.

What Does Medicare Extra Help Pay For?

Medicare Extra Help allows you to get assistance paying for your monthly premium, and deductibles. ,

The extra help you receive includes:

  • Paying your Part D monthly premium and deductible
  • Pay a lower copayment for prescription drugs
  • Removes any Part D late enrollment penalty you might have

The specifics of how much you pay will depend on the level of Extra Help you qualify for.

For example, partial Extra Help allows you to pay no more than 15% of the cost of the drug, and full Extra Help gives you a copayment of $9.20 in 2021 for name-brand drugs, ($9.85 in 2022) and $3.70 in 2021 for generics ($3.95 in 2022).

Of course, if your normal Part D copayment is lower than that, you pay the lower amount.

Medicare Extra Help Income Limits

Many people ask, “What are the income limits with Extra Help with Medicare?” These income limits change from year to year and are based on whether you live alone or as a couple. You also must live in one of the 50 states or the District of Columbia.

What are the income limits for Extra Help with Medicare in 2021?

For 2022, our resource limits must be below $27,950 for a couple, and $14,010 if you are not married or living alone. Your primary residence, vehicles, personal property, life insurance, and burial plots are not included in this total.

Government assistance such as food stamps, housing assistance, and utility help is not counted in the income.

Medicare Extra Help Benefits

The primary benefit of Medicare Extra Help is to make your Medicare Part D plan more affordable. There are a lot of Medicare beneficiaries who struggle to make ends meet due to being on a fixed income or losing a spouse who was a source of income.

With Medicare Extra Help, you can receive partial or full assistance paying for your Medicare Part D monthly premium and deductible, along with adjustments to your copayment for specific drugs. It’s a major benefit, especially for those who need a lot of prescription medication.

Medicare Savings Programs (MSP)

In addition to Extra Help with Medicare Part D, you may qualify for Medicare Savings Programs (MSP) that help you with costs you may have for Medicare Parts A and B. There are four programs, each one with different qualifying criteria when it comes to income and assets.

  1. The Qualified Medicare Beneficiary program provides the most assistance, paying for Part A and B premiums, deductibles, and coinsurance or copayments.
  2. The Specified Low-Income Medicare Beneficiary Program pays for Part B premiums only.
  3. The Qualifying Individual program helps pay for Part B premiums.
  4. The Qualified Disabled and Working Individuals Program helps pay the Part A premium if you lose premium-free Part A because you went back to work and you have a qualifying disability.

You can learn more about these programs in our Medicare Savings Programs guide.

Learn More About Medicare Extra Help Programs

Medicare Extra Help can allow you to save thousands of dollars for costs related to your Medicare Part D plan. This guide addressed many common questions, but you might still need more information. Talking to a licensed insurance agent can help. Contact us today to discuss your Medicare options with a licensed professional.

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You must enroll in a Part D plan for drug coverage.Routine dental, vision, hearing coverageMay be covered depending on the plan selected.Not covered.Copayments and coinsuranceUsually have copayments and/or coinsurance.Typically pays for copayments and coinsurance.NetworkMedicare Advantage plans have different networks: HMO, PFFS, and PPO. It’s important to understand the rules about going out of network for your healthcare.No network. See almost any doctor or medical facility that accepts Medicare.Medicare Advantage and Medigap plans may provide benefits for the following services (but check your plan details for specific benefits):Hospitalization: Medicare limits the number of days you can spend in the hospital. 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Medicare, as a federal health coverage program, is intended to help provide access to healthcare for those who may not get it through an employer. Often, this means retirement age, which in the United States is age 65. Once you turn 65, you have aged into Medicare eligibility. If you’re approaching your 65th birthday, it’s important to understand what Medicare options are available to you. While you may be automatically enrolled in Medicare, it’s possible that the default options are not the coverage that’s best for your situation. This guide will answer common questions and help you choose the Medicare plan that’s right for you or your family member. Medicare is for the nation's elderly and certain individuals with qualifying disabilities However this article will focus on those aging into Medicare. Are you or someone you care about turning 65? Turns out, you’ll be joined by thousands of birthday buddies. In fact, 10,000 Americans turn 65 every day - a real cause for celebration, whether it’s the milestone of retirement or your journey to the right Medicare coverage. Still, many Americans are confused by Medicare: how to enroll, when their enrollment period is and what plan to even enroll in. But the process doesn’t need to be so complex. In this guide, we’ll help you understand what you should do when you’re aging into Medicare. Remember that while age is one trigger for being eligible for Medicare, it’s not the only one. Aging into Medicare: what you need to know Approaching age 65 may bring a lot of changes into your life. As you look at your Medicare options, you may have some of the questions we address below. At What Age Should I Start Looking Into Medicare?Because Medicare can be a complex subject, it pays to start learning early. There’s nothing wrong with beginning to review Medicare rules in your state, along with the available options, in your early 60’s. By the time you turn 64, it’s a good idea to start looking into specific plans.Your initial enrollment period will start three months before your 65th birthday, include your birthday month, and extend three months afterward. You’ll have unique options in your initial enrollment period that will not happen again, like guaranteed acceptance into a Medigap plan, so it’s important to make the right Medicare plan choices from the very beginning.Is It Mandatory to Go on Medicare at Age 65?Many people who turn 65 will be automatically enrolled in Medicare if they are already receiving social security retirement benefits or other retirement payments. It is not mandatory to enroll in Medicare at age 65, but you might pay a financial penalty if you delay your enrollment.Medicare Part A is premium-free for most people, so there’s no harm in enrolling in that coverage immediately. Medicare Part B, which covers outpatient care, doctor’s visits, and more, does have a monthly premium. 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If you’re a U.S. citizen or permanent legal resident, you qualify for premium-free Part A as long as you have paid payroll taxes for at least 10 years.Call your local Social Security Office to see if you’re eligible for Medicare Part A. You may receive a paper statement from SSA [sample here] as a reference, or you can create an account online at If You Didn’t Work Enough?You may still qualify for Medicare Part A through your spouse if you don’t (or won’t) have 40 quarters of work history. You’re eligible if your spouse qualifies for premium-free Part A, and:You have been married for at least one year and your spouse is eligible for Social Security benefits.You're divorced and your former spouse is eligible for Social Security benefits. 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These plans must cover everything that Original Medicare covers.Medicare Advantage plans work like traditional private health insurance, so you may see certain out-of-pocket costs with Medicare Advantage, including:Monthly premium: Many Part C plans don’t have a monthly premium.Annual deductible: Most plans don’t have a deductible.Copayments or coinsurance for services and procedures.Medicare Advantage plans also offer a number of added benefits, which vary by state and health plan. Some benefits include:Fitness programs like Silver Sneakers or free memberships to local gyms.Vision coverage for exams, lenses, and sometimes frames.Hearing coverage for exams and discounted hearing aids.Dental coverage for basic dental services.Transportation to and from medical appointmentsPrescription drug coverage (some plans)Medicare Advantage plans can also provide emergency coverage outside the United States. With the international coverage, out of pocket maximum protection, and a wide range of extra benefits, you can see why many people choose Medicare Advantage plans.Prescription Drug PlansPrescription Drug plans (PDPs or Medicare Part D) help with the cost of prescription drugs. Each company creates their PDPs differently, but you can expect to pay these costs for coverage:Monthly premium, which varies based on incomeAnnual deductible (although many plans don’t have a deductible)Copayment or coinsurance per filled prescriptionThe copayments and coinsurance costs increase as the total amount your plan pays rises above certain thresholds, also known as coverage stages:Coverage Stage 1 – Deductible Stage: You pay full price until you’ve spent $480 (for 2022).Coverage Stage 2 – Initial Coverage Stage: You pay small copayments or coinsurance for each prescription.Coverage Stage 3 – Coverage Gap Stage: Also known as the Medicare “Donut Hole.” Once your total drug costs (what you’ve paid plus what your plan has paid) exceed $4,020, you hit the coverage gap. You’d then pay 25% of the cost of prescriptions.Coverage Stage 4 – Catastrophic Stage: Once your total drug costs (excluding what your plan has paid) exceed $6,350, you pay no more than 5% for medicationsThese coverage stages reset on January 1 each year. But it’s important to know that there is no out-of-pocket cap on drug costs under Part D.Click the link if you want to more about the phases of Medicare Part D.Medicare Supplement InsuranceMedicare Supplement Insurance, also known as Medigap, is designed to fill the gaps in Original Medicare. Medigap supplements Original Medicare by paying some or all of the expenses that you’d normally have to pay out of pocket.Medigap policies are issued in 10 standardized plans: A, B, C, D, F, G, K, L, M, and N. Each of these plans cover a slightly different portion of the Original Medicare gaps.Plan G is a popular Medigap option that covers every gap except for the Part B deductible. If you have Plan G, you can expect to pay for the first $198 in Part B expenses (like doctor’s visits). Plan G will then cover every penny of any Medicare-approved service or procedure.Several Medicare supplements provide some international coverage, including plans C, D, F, G, M, and N.Medigap plans also give you maximum flexibility, so you can see any doctor or use any facility that accepts Medicare patients, anywhere in the United States. You’re not bound to a network, or reliant upon referrals.Medicare Supplement Insurance plans don’t cover prescription drugs, so you’ll need to enroll in a stand alone Prescription Drug plan to get drug coverage.Considerations Before Choosing A PlanMake sure any Medicare plan you consider:Covers the doctors you want to seeCovers the medications you needHas a premium you can affordYou can also narrow your choices down further by asking yourself:Do I intend to split my time between two or more States?Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re fine with HMO-type medical groups and plan to live in one place, then Medicare Advantage could be right for you.As you approach age 65, it’s important to start your research sooner rather than later. Make sure you know what plans your doctors will accept, and which plans cover your medications.Comparing Medicare plan features and costs doesn’t have to be complicated though. You can get Medicare quotes through our site. Or you can call 800-620-4519 to reach one of our licensed Medicare agents who can guide you through your Medicare plan options.
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A CDC study conducted over the span between 2017 and 2020 reports that 42.5% of Americans are obese. Because long-term weight loss is so challenging and often puts people on a cycle of losing and gaining weight repeatedly, many obese Americans research weight loss surgery as an alternative. If you’re currently on Medicare and are struggling with your weight, you might wonder, “Does Medicare cover weight loss surgery?” You may also wonder if you can get coverage for skin removal after a significant weight loss due to surgery. This guide will help you understand what coverage you can receive through Medicare and Medicare Advantage. We’ll answer the most common questions about this topic, but feel free to contact us if you’d like to talk about your specific situation. Let’s get started! Does Medicare Pay for Weight Loss Surgery? Original Medicare may cover certain bariatric surgeries if you meet specific criteria. Generally, this is to ensure that the surgery is medically necessary rather than simply cosmetic. In order to qualify for coverage, you’ll need to have: A BMI of 35 or higherA health condition related to your obesity, such as sleep apnea, diabetes, etc.A letter from your doctor recommending the surgery as medically necessaryBlood and psychological testingMedical records showing you’ve been obese for at least five yearsRecords that you’ve tried at least one weight loss program that was medically supervisedIf the surgery will be an inpatient process and coverage is approved under Medicare, it will generally be covered under Medicare Part A, which will change your costs compared to an outpatient procedure covered under Medicare Part B. Be sure you talk to your doctor to fully understand what kind of procedure is being recommended..Medicare Advantage plans are required to offer at least as much coverage as Original Medicare, but they might have different requirements and costs for covering the surgery. You may also get additional benefits. You’ll want to talk to your Advantage provider to get a clear understanding of what’s covered.Does Medicare Pay for Weight Loss Revision Surgery?Some patients continue to gain weight after bariatric surgery. The first step if this happens is to work with your doctor to explore lifestyle factors, mental health needs, and other behaviors that might be a primary cause of this weight gain.If those are ruled out, your doctor might recommend a revision surgery to ensure that the surgery was successful or to fix problems that have been found. If you’ve already qualified for the original bariatric surgery, you’ll likely have coverage for the revision as long as it’s proven to be medically necessary.That means that you may have to pass additional psychological assessments and physical testing to show that there’s no other cause for the failure to lose weight. Does Medicare Cover Skin Removal After Weight Loss Surgery?Medicare coverage focuses on medically-necessary care. However, excess skin after significant weight loss can often cause medical problems, so you may be able to get coverage for skin removal after successful weight loss. To qualify for skin removal surgery, you’ll need to meet the following conditions:You’ve maintained a stable weight for at least six monthsThe excess skin is causing a skin condition that threatens your healthThe excess skin impacts your daily movementYou’ve dropped at least 5 BMI points as a result of your weight lossIf you have excess skin to do significant weight loss and it’s making your life difficult, talk to your doctor about how to get coverage for skin removal surgery. Is Weight Loss Management Covered by Medicare?If you’re in a position where you want to focus on weight loss but aren’t interested in (or don’t qualify for) bariatric surgery, there’s good news. Medicare offers coverage for a variety of other weight management strategies.If you have a BMI of 30 or more, your Part B coverage may help pay for behavioral counseling and obesity screening to help you lose weight through diet and exercise. Medicare offers coverage if your primary care doctor or another qualified practitioner offers the counseling in a primary care setting like the doctor’s office. Your personalized plan will be coordinated with your other medical care. If you work with a doctor that accepts assignments from Medicare, your costs will fall under Part B coverage rules.   If you have Medicare Advantage, there may be different out-of-pocket costs, so be sure to check with your insurer.Contact Us to Learn More About Medicare and Weight Loss SurgeryStruggling with your weight can be frustrating and is often a lifelong struggle. Weight loss surgery can help some people radically change their eating habits so that they can finally lose the weight that’s threatening their health.If you have questions about how Medicare covers weight loss surgery, or you’re interested in comparing Medicare plans to get the best coverage for your needs, we’re here to help. Contact us today for more information!
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