Understanding Medicare Costs
| Medicare | Coverage Type | 2025 Costs |
|---|---|---|
| Part A | Hospital Insurance |
- $0 premium for most people with 40+ work credits - $278–$505 monthly premium for those with fewer credits - $1,632 deductible per benefit period - Daily coinsurance for extended stays |
| Part B | Medical Insurance |
- $174.70 standard monthly premium - $240 annual deductible - 20% coinsurance for most services |
| Part C | Medicare Advantage |
- Varies by plan and location - Includes Parts A & B coverage plus additional benefits |
| Part D | Prescription Drug Coverage |
- Varies by plan - Monthly premiums average $31–$50 - Annual deductibles up to $545 - Coverage gap ("donut hole") costs |
These costs can represent a significant financial burden, particularly for those living on fixed incomes. Fortunately, several assistance programs exist to help ease this burden.
Medicare Savings Programs
Medicare Savings Programs (MSPs) are state-run programs that help pay Medicare premiums, deductibles, coinsurance, and copayments for people with limited income and resources.
| Program | Eligibility (2025) | Benefits |
|---|---|---|
| Qualified Medicare Beneficiary (QMB) |
Individual: $1,235/month Couple: $1,663/month Resources: $9,090 (ind) / $13,630 (couple) |
• Pays Part A & B premiums • Pays deductibles, coinsurance, copays • Automatic qualification for Extra Help |
| Specified Low-Income Medicare Beneficiary (SLMB) |
Individual: $1,478/month Couple: $1,992/month Resources: $9,090 (ind) / $13,630 (couple) |
• Pays Part B premiums only • Automatic qualification for Extra Help |
| Qualifying Individual (QI) |
Individual: $1,660/month Couple: $2,239/month Resources: $9,090 (ind) / $13,630 (couple) |
• Pays Part B premiums only • Limited funding (first-come basis) • Automatic qualification for Extra Help |
| Qualified Disabled & Working Individual (QDWI) |
Individual: $2,470/month Couple: $3,326/month Resources: $4,000 (ind) / $6,000 (couple) |
• Pays Part A premiums only • For working disabled under 65 |
Types of Medicare Savings Programs
Medicare Savings Programs (MSPs) are state-run programs that help pay Medicare premiums, deductibles, coinsurance, and copayments for people with limited income and resources.
Extra Help Program for Prescription Drugs
Extra Help Benefits
| Benefit Type | Full Extra Help | Partial Extra Help |
|---|---|---|
| Monthly Premium | Full premium subsidy up to benchmark amount | Sliding scale premium subsidy |
| Annual Deductible | $0 | Reduced deductible ($104) |
| Copayments |
$1.45–$4.15 for generics $4.30–$10.35 for brand-name |
15% coinsurance or plan copay |
| Coverage Gap | No coverage gap | No coverage gap |
| Catastrophic Coverage | $0 copays | Minimal copays |
Extra Help Eligibility (2025)
Full Extra Help:
- Income below 135% of Federal Poverty Level (FPL)
- Individual: up to $20,535 annual income
- Couple: up to $27,705 annual income
- Resources: up to $10,090 (individual) or $15,110 (couple)
Partial Extra Help:
- Income below 150% of FPL
- Individual: up to $22,815 annual income
- Couple: up to $30,780 annual income
- Resources: up to $16,660 (individual) or $33,240 (couple)
State Pharmaceutical Assistance Programs
State Pharmaceutical Assistance Programs (SPAPs) provide additional prescription drug coverage to residents beyond what Medicare Part D offers. These programs vary widely by state.
SPAP Availability by Region
| Region | States with Comprehensive SPAPs |
|---|---|
| Northeast |
Connecticut, Delaware, Maine, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, Rhode Island, Vermont |
| Midwest | Illinois, Indiana, Missouri, Wisconsin |
| South | North Carolina, Virginia |
| West | Colorado, Montana, Nevada, Washington |
Medicaid and Medicare Dual Eligibility
Individuals eligible for both Medicare and Medicaid (“dual eligibles”) receive comprehensive coverage with minimal out-of-pocket costs.
Dual Eligibility Categories
| Category | Description | Coverage |
|---|---|---|
| Full Dual Eligibles | Meet requirements for full Medicaid coverage |
• All Medicare premiums, deductibles, coinsurance • Long-term care services • Prescription drugs • Additional services not covered by Medicare |
| Partial Dual Eligibles | Qualify for Medicare and Medicare Savings Programs but not full Medicaid |
• Varies by MSP category • May only cover Medicare premiums and cost-sharing |
Patient Assistance Programs
Pharmaceutical manufacturers offer Patient Assistance Programs (PAPs) to provide free or low cost medications to people who cannot afford them and have limited or no prescription drug coverage.
Accessing PAPs
- Partnership for Prescription Assistance (PPA) - Connects eligible individuals to multiple PAPs through one application
- NeedyMeds - Directory of PAPs and resources
- RxAssist - Database of pharmaceutical company programs
- Direct manufacturer programs - Each pharmaceutical company manages its own PAP
Common PAP Eligibility Requirements
- U.S. residency
- Proof of income (typically below 200-300% FPL)
- Limited or no prescription coverage
- Proof of prescription from healthcare provider
Additional Resources and Support
| Resource | Description | Contact Information |
|---|---|---|
| State Health Insurance Assistance Program (SHIP) | Free Medicare counseling and assistance | 1-877-839-2675 or www.shiphelp.org |
| Benefits CheckUp | Online screening tool for benefit programs | www.benefitscheckup.org |
| Area Agencies on Aging | Local resources and support services | 1-800-677-1116 or www.eldercare.acl.gov |
| Aging and Disability Resource Centers | Information and referral services | Contact through eldercare.acl.gov |
| Foundation for Health Coverage | Information about health coverage | www.coverageforall.org |
Beyond the major programs discussed, several other resources can help Medicare beneficiaries access affordable care:
How to Apply for Assistance
Application Process for Medicare Assistance Programs
Medicare Savings Programs:
- Apply through your state Medicaid office
- Required documentation: proof of income, resources, Medicare card, identification
- Application processing typically takes 30-90 days
Extra Help Program:
- Apply online at ssa.gov/benefits/medicare/prescriptionhelp
- Apply by phone: 1-800-772-1213
- Apply in person at local Social Security office
- Required documentation: proof of income, resources, Medicare information
State Pharmaceutical Assistance Programs
- Application procedures vary by state
- Contact your state's SPAP directly or through your SHIP counselor
Patient Assistance Programs
- Apply directly through pharmaceutical manufacturers
- Applications typically require healthcare provider involvement
- May need to reapply every 6-12 months
Tips for Successful Applications
Application Process for Medicare Assistance Programs
- Apply even if you're slightly above income limits (some states have higher thresholds)
- Don't overlook asset exclusions that might make you eligible
- Seek assistance from SHIP counselors to navigate the application process
- Keep copies of all submitted documentation
- Follow up regularly on pending applications
- Reapply or appeal if initially denied
Conclusion
Medicare assistance programs provide vital support to millions of beneficiaries who would otherwise struggle to afford healthcare. By understanding and utilizing these programs, individuals can significantly reduce their out-of-pocket costs while ensuring access to necessary medical care and prescription medications.
Remember that eligibility requirements, benefits, and application procedures may change annually. For the most current information, consult with a SHIP counselor in your area or contact Medicare directly at 1-800-MEDICARE (1-800-633-4227).
