Medicare addresses the issue of medical insurance for the senior population, and some individuals under the age of 65 due to disability. Many Medicare recipients face difficulty paying their healthcare costs and need support. If you need help paying for the cost of Medicare, there are several programs to explore and apply for with different qualification criteria.

Assistance with medical coverage
Medicaid is a program jointly held by federal and state governments designed for low-income individuals. Medicaid not only supports people with limited means but also offers benefits not typically covered by Medicare. Some additional benefits that may be offered by Medicaid include care in a nursing home and assistance in personal care. Rules and eligibility vary by state.

Medicaid applicants include families with children as well as individuals who are elderly, disabled or pregnant, and children who are in foster care. Low-income individuals with specific diseases may qualify as well. Breast cancer, tuberculosis and HIV/AIDS are examples of afflictions that may be considered criteria for determining qualification. California’s equivalent of Medicaid is Medi-Cal.

Only available in certain states is PACE, which stands for Programs of All-Inclusive Care for the Elderly. The objective is coordination of care in your home, community or a PACE service center versus a nursing home. Applications would go through Medicaid.

Special situations
For those who are employed and earn an income that is insufficient to pay all Medicare costs but too high to qualify for Medicaid, there are alternatives. Seniors and people with disabilities who need help may look to a Medicare Premium Payment Program, which is synonymous with Medicare buy-in. The Medicare Savings Program is an overarching name for the following four programs:

  • Qualified Medicare Beneficiary (QMB)
  • Specified Low-income Medicare Beneficiary (SLMB)
  • Qualifying Individual (QI)
  • Qualified Disabled and Working Individuals (QDWI)

Medicare operates under the Centers for Medicare & Medicaid Services (CMS). The Social Security Administration (SSS) makes the determination on eligibility for Medicare benefits. Medicare buy-in programs were developed to lower out-of-pocket expenses of recipients with modest income and assets. To assess income eligibility, the buy-in model uses the same resource limits but with different thresholds.

Dual benefits
People who have Medicare benefits plus Medicaid are said to have dual benefits. Medicare is the first to issue payment for services covered by both health insurance plans. Medicaid is considered the payer only as a last resort. The existence of Medicare buy-in as well as the Medicare Part D state contribution payment plan helps to make this work.

Solutions and challenges
While Medicare buy-in offers a solution to healthcare access, coverage continuity, better health in the community and potentially lower healthcare spending in the long-term, there are challenges, mostly in terms of financing. However, access to affordable and quality medical care is critical for optimum health and cost efficiency.

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