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Who Can Help Me With Health Care Costs?

 

When you are struggling just to get by, it can feel like you are all alone. You’ve probably heard about other people getting help through some kind of program, but you don’t have any idea how they found the program or what the program even does. Without some kind of assistance, you aren’t sure how you will keep going. Your medical bills are getting out of hand and your prescriptions are ridiculously expensive.

You don’t want a handout, you just want HELP.

The good news is that there are a lot of programs that help people just like you. Finding the programs can be a little overwhelming but this article should get you started.

 

Medicare

Medicare is guaranteed health insurance for those who might not otherwise qualify for, or have the means to afford, health insurance.

Medicare is made up of 4 parts and they are named alphabetically: Parts A, B, C, and D.

When you apply for Medicare, you are given the option of choosing Original Medicare (Part A and Part B) or choosing a Medicare Advantage Plan (Part C). If you choose Original Medicare, you also have the option of adding Part D to your services.

Part A Covers:

  • inpatient hospital care
  • long-term hospital care
  • eligible home health services like intermittent skilled nursing care, physical therapy, speech-language pathology services
  • continued occupational services, skilled nursing facility care, hospice, and home health services
  • They will only cover nursing home care if you actually need health-related care and not just custodial care.

 

Part B Covers:

 

  • clinical health studies
  • ambulance services
  • durable medical supplies (like canes, commode chairs, hospital beds, infusion pumps, ostomy supplies, wheelchairs, etc)
  • mental health services (including inpatient, outpatient, and partial hospitalization)
  • getting a second opinion before surgery
  • outpatient prescription drugs (limited to the sort of medication that is usually administered by a doctor like I.V. drugs)
  • services to prevent illness (like flu shots)
  • services to detect illness at an early stage when it’s more likely to respond to treatment.

 

What Part A and Part B Do NOT Cover:

 

  • Hearing aids and exams to get them fitted
  • Long-term, custodial care (basically medical and non-medical care for people who can’t perform basic activities like bathing, eating, etc)
  • Routine dental care and dentures
  • Routine eye care
  • Routine foot care
  • Acupuncture
  • Cosmetic surgery

 

To find out if Medicare Part B covers your test, item, or service, look at: https://www.medicare.gov/coverage/your-medicare-coverage.html

 

Part C

 

Part C is also called “Medicare Advantage Plans” and they are health insurance plans offered by private companies. They should provide you with all the same benefits as Part A and Part B.

 

These plans include HMOs, PPOs, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.

 

Medicare pays the Advantage Plans a fixed amount each month to offer services.

 

Advantage Plans must comply with certain Medicare rules, but they can still set their own rules for how you get health services. For example, Advantage Plans can decide whether or not you can see providers outside of your plan or whether you need a referral to see a specialist.

 

Additionally, because each Advantage Plan is through a private insurance company, they can set their own out-of-pocket costs.

 

It’s also possible that the rules will change every year.

 

Most of the Advantage Plans (PPOs or HMOs) do include prescription coverage. There are some that do not, like some Private Fee-for-Services plans.

 

If you were to join a Medicare Advantage HMO or PPO and then attempt to join a Part D prescription plan, you will be disenrolled from the Advantage Plan and re-enrolled into Original Medicare.




Part D

 

Medicare Part D is prescription coverage under the umbrella of Medicare but provided through private insurance companies.

 

Each Medicare Prescription Drug plan has its own formulary with different medications as well as different prices for medications.

 

The drugs are usually organized into tiers, depending on their cost. It’s extremely important to find the Part D Drug Plan with a formulary that offers all or most of your medications so that you won’t have to pay a lot.

 

Most Medicare drug plans do have a coverage gap commonly called the “donut hole.”

 

The donut hole begins when the medication costs covered by your drug plan have reached a certain amount ($3,750 in 2018 – it can change every year). After that, you will have to cover the cost of your medication with no help from your drug plan.

 

Happily, you will only have to pay up to 40% of drug plan’s cost for the covered brand-name medications. So, if the drug plan would have paid $100 for a medication, you would only have to pay $40 in the donut hole.

 

Once you have paid over $5,000 in out-of-pocket fees, catastrophic coverage kicks in. At that point, you will only pay a small copay or coinsurance for the rest of the year.

 

Medicare Savings Program

If you need help paying for your Medicare premiums and you have income from working, you might qualify for a Medicare Savings Program.

The Medicare website encourages you to apply for the Medicare Savings Program even if your income is a bit higher than the limits they have listed on their website.

There are four different types of Medicare Savings Plans: Qualified Medicare Beneficiary (QMB) Program, Specified Low-Income Medicare Beneficiary (SLMB) Program, Qualifying Individual (QI) Program, and Qualified Disabled and Working Individuals (QDWI) Program. They each have their own rules for how much money your household can make and still qualify.

SLMB and QI only cover Part B premiums. QDWI only covers Part A premiums. QMB covers both Part A premiums and Part B premiums as well as deductibles, coinsurance, and copayments.

If you qualify for a QMB, SLMB, or QI program, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage.

You can apply for Medicare Savings Programs by calling your nearest Medicaid office.

Who Qualifies for Medicare?

You will be automatically enrolled with Medicare if:

  • You will be getting benefits from Social Security or from the Railroad Retirement Board for at least 4 months before you turn 65 years of age.

 

  • You are under 65 years old and you’ve been getting disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board for 24 months.

 

  • You have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease). The first month your disability benefits begin, you will be enrolled in Part A and Part B.

 

You qualify for Medicare but will have to sign up if:

  • People who are 65 years old or older, have been legal residents of the U.S. for at least 5 years, and they or their spouse (or qualifying ex-spouse) have paid Medicare taxes for at least 10 years (You can still enroll if you haven’t paid into the system for 10 years but you will have to pay premiums for Medicare Part A)
  • People who need a kidney transplant or who endure continuing kidney dialysis for End-Stage Renal Disease (ESRD)

 

If you qualify for Medicare the year you turn 65, you will have a 7-month Initial Enrollment Period that includes the 3 months before your birth month, your birth month, and the 3 months after your birth month.

If you wait until the month you turn 65, or the 3 months after your birth month, your Part B coverage might be delayed and cause a lapse in coverage.

If you miss this initial enrollment time, you will have to wait until the General Enrollment Period (from January 1st to March 31st) to apply. In that case, your Part B coverage won’t kick in until July 1st.

If you are 65 or older and you (or your spouse) has not paid the qualifying Medicare payroll taxes, you can still enroll in Medicare, but you will have to pay a monthly premium for Part A.

Extra Help

You will be automatically enrolled with Medicare if:

  • You will be getting benefits from Social Security or from the Railroad Retirement Board for at least 4 months before you turn 65 years of age.
  • You are under 65 years old and you’ve been getting disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board for 24 months.
  • You have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease). The first month your disability benefits begin, you will be enrolled in Part A and Part B.

You qualify for Medicare but will have to sign up if:

  • People who are 65 years old or older, have been legal residents of the U.S. for at least 5 years, and they or their spouse (or qualifying ex-spouse) have paid Medicare taxes for at least 10 years (You can still enroll if you haven’t paid into the system for 10 years but you will have to pay premiums for Medicare Part A)
  • People who need a kidney transplant or who endure continuing kidney dialysis for End-Stage Renal Disease (ESRD)

 

If you qualify for Medicare the year you turn 65, you will have a 7-month Initial Enrollment Period that includes the 3 months before your birth month, your birth month, and the 3 months after your birth month.

If you wait until the month you turn 65, or the 3 months after your birth month, your Part B coverage might be delayed and cause a lapse in coverage.

If you miss this initial enrollment time, you will have to wait until the General Enrollment Period (from January 1st to March 31st) to apply. In that case, your Part B coverage won’t kick in until July 1st.

If you are 65 or older and you (or your spouse) has not paid the qualifying Medicare payroll taxes, you can still enroll in Medicare but you will have to pay a monthly premium for Part A.

 

Medicaid

It is the responsibility of each state to offer Medicaid to those who are eligible. Although the federal government partially funds the program and sets basic requirements, Medicaid is administered by each state. That means each state can decide to cover optional benefits like prescription drugs, case management, and physical or occupational therapy. All states must provide mandatory benefits such as inpatient and outpatient hospital services, doctor services, access to laboratories and x-ray services, and home health services. Some of the benefits are not covered by Medicare so Medicaid can be a great help, especially for things like nursing home care, personal care services, and prescription drugs.

 

Some people who are eligible for Medicare would also qualify for Medicaid. These people are called “dual eligibles.” If you were to have both Medicare and full Medicaid, you would likely have most of your health care costs covered. Medicare will pay first and whatever they don’t cover is passed on to Medicaid. For more information about Medicaid benefits in your state, go to this website: https://www.medicaid.gov/medicaid/by-state/by-state.html

 

CHIP

CHIP is short for the Children’s Health Insurance Program. If your family makes too much to qualify for Medicaid, CHIP can provide low-cost health coverage for your kids. CHIP will also cover pregnant women in some states.

Like Medicaid, each state will have different rules for qualification and benefits, so you will need to check the Health Insurance Marketplace to see if your kids are covered in your state. The good news is that you can apply at any time; there is no special enrollment period.

While coverage will differ from state to state, all CHIP plans will cover check-ups, immunizations, prescriptions, dental and vision care, labs, doctor visits, X-rays, inpatient and outpatient hospital visits, and emergency services.

As with many insurance plans, “well child” medical and dental check-ups are free. Other premiums and copayments will depend on your state’s version of CHIP.

To get more information or to sign up for CHIP, you can call 1-800-318-2596 (TTY: 1-855-889-4325) or you can go to: https://www.healthcare.gov/screener/

ADAP

The AIDS Drug Assistance Program is better known as ADAP. This program provides medications and services to low-income people living with HIV or AIDS. About 1/3 of Americans with HIV will receive care from ADAP.

The specific medications that are covered differ from state to state as well as the qualifications. Most states determine financial eligibility by multiplying the Federal Poverty Level. Some ADAPs will go as high as 5 times the Federal Poverty Level.

If you have HIV or AIDS and you need assistance getting care and medications, go to the ADAP Directory at: http://adap.directory/ and find your state.

Patient Assistance Programs/Foundations

Patient Assistance Programs/Foundations are sometimes called PAPs or PAFs. They are charitable programs run by pharmaceutical programs that provide free (or nearly free) prescription medication to those who are eligible for their programs.

There are almost 300 PAPs in America! That means there is probably a PAP for your prescription medication. Each patient assistance program is unique and decides eligibility by different standards, but they are all designed to help people with low income who have no insurance coverage or not enough insurance coverage.

To find out if your prescriptions are on a patient assistance program, Google the name of your medication with the words “patient assistance program” and you should be able to find the correct website.

If you need help enrolling, you can try an advocacy program such as Prescription Lifeline. For a small monthly fee, they will help you get into patient assistance programs and maintain your enrollment. Check out their site here: www.prescriptionlifeline.org

 

Veterans Benefits

If you have served in the armed forces or you are a survivor or dependent of someone who has, you might qualify for assistance through the Veterans Health Administration. The benefits included are traditional hospital-based services as well as medical specialty services (like dermatology, neurology, etc.) and surgical services.

There are 1,243 health care facilities included in their network, so there is likely a location near you. To apply for health care assistance from the Veterans Health Administration, you can call 1-877-222-8387, Monday-Friday between 8am and 8pm, EST. You can also apply online at: https://www.vets.gov/health-care/apply/

Coupons and Discounts

Many drug manufacturers offer discounts and coupons for their medications. You often hear about them at the end of medication commercials. Listen carefully, they usually mention a website for you to visit.

If you haven’t seen an ad, the Internet is another great place to find discounts and coupons. Often, you only need to Google your medication name with the words “discount” or “coupon” to find them.

You can also ask your doctor if they have any coupons in their office. Sometimes drug company representatives will leave samples and coupons with doctors.

Free or Low-Cost Clinics

All over the country, there are free or low-cost clinics. Some of the low-cost clinics are at places like CVS or other pharmacies and others are free-standing. There are even mobile clinics that operate out of remodeled buses or RVs. The mobile clinics usually specialize in one particular thing like immunizations, dentistry, or vision.

To find out what is in your area, you can look at this website: www.nafcclinics.org/find-clinic

You can also Use Google to search terms like “free clinic in my area” or “non profit medical clinic” or something similar to that.

Copay Charities

Are you aware that there are programs that will help you with expensive copays? There are some programs specifically for people with Medicare and others for those who don’t have Medicare.

Like many of the solutions for healthcare assistance, the Internet is a big help in identifying programs. Google the phrase “copay charity” or “help with copay” to find the program that’s right for you.

PACE

If you (or a loved one) are age 55 or older, you need nursing home-type care, and it’s safe for you to live in the community with help, you might qualify for PACE. PACE stands for Programs of All-Inclusive Care for the Elderly and it’s only available in state that offer the program under Medicaid. (You can see if it’s available in your state here: https://www.medicare.gov/find-a-plan/questions/pace-home.aspx)

PACE covers a lot of services including: home care, hospital care, adult day care, labs, meals, physical therapy, prescription drugs, emergency services, and more.

Paying for PACE depends on your insurance. If you have Medicaid, the long-term care benefits will be covered by Medicaid. If you have Medicare, you will have to pay a premium for long-term care benefits and Medicare Part D drugs. If you don’t have either Medicare or Medicaid, you can pay for PACE on your own.

For more information, and to see if you qualify for assistance with PACE, go to: https://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html

 

These are just a few of the programs available to people who need help paying for their medical and prescription costs. Your situation is not hopeless, there is something out there for you. Often, you just need the time and patience to look.




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