In our last newsletter, we briefly explained Medicare, in particular Part D and the “Donut Hole”. This article will cover other resources available to you to cover your prescription drugs when Medicare Part D just isn’t enough or if you do not qualify for Medicare for other than financial reasons.

Extra Help – Paying for Medicare Prescription Drug Coverage (Part D)

The Extra Help (also called low-income subsidy) provides additional assistance to pay for prescription drugs up to an estimated $4,000 per year. To qualify for the Extra Help, a person must be (1) on Medicare, (2) have limited income and resources, and (3) reside in one of the fifty states or the District of Columbia. Limited income and resources means the following for the recipient per year:

If you qualify for Extra Help and join a Medicare drug plan, you will get help paying your Medicare drug plan’s monthly premium, any yearly deductible, coinsurance, and copayments; you will not have to pay a coverage gap or late enrollment penalty. You will automatically qualify for Extra Help if you have Medicare and meet one of these conditions, you: (a) have full Medicaid coverage (b) get help from your state Medicaid program paying Part B premiums, or (c) get Supplemental Security Income (SSI) benefits. If you don’t automatically qualify for Extra Help, you can apply online via www.socialsecurity.gov or call 1-800- 772-1213, or visit your state’s Medicaid office.

Medicaid

Medicaid is a state-run program that helps pay medical costs for some people with limited income and resources and meet other eligibility requirements. Medicaid also offers benefits not normally covered by Medicare, like help with personal care and rides to doctor appointments. If you qualify for Medicaid in your state, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage.

Low income is not the sole criteria for getting Medicaid benefits. For the Medicaid application, the eligibility is as follows:

  • Individuals receiving Supplemental Security Income
  • People facing disability, blindness and/or are over 65
  • Pregnant women and children under six with family income at or below 13 percent of the federal poverty level
  • Children between the age 6 and 19 who have family income below federal poverty level
  • Teenagers who are living on their own and are up to the age of 21
  • Adults who take care of children below 18

Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state’s rules, you may also be asked to pay a small part of the cost (copayment) for some medical services. Each state’s program and rules are different. If you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for Medicaid and have a qualified caseworker in your state evaluate your situation. Based on our Patient Registry Database, we have selected the locations where we have the highest number of GISTers in order to provide brief state information on Medicaid.

  • California – Medi-Cal is California’s Medicaid program which provides needed health care services for low-income individuals who are under 21 years of age, seniors, persons’ with disabilities, foster care persons, pregnant women, and lowincome people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS.
  • Illinois – The Department of Healthcare and Family Services (HFS) of Illinois medical benefits may be available for individuals who are age 65 or older, blind or have a permanent disability. To qualify for HFS Medical, persons must live in Illinois and meet income and asset limits. Persons must also be U.S. citizens or qualified immigrants.
  • New Jersey – Medicaid provides health insurance to parents/caretakers and dependent children, pregnant women, and people who are aged, blind or disabled. These programs pay for hospital services, doctor visits, prescriptions, nursing home care and other healthcare needs, depending on what program a person is eligible for. To be eligible for New Jersey Medicaid, a person must be a resident of New Jersey, a U.S. Citizen or qualified alien (most immigrants who arrive after August 22, 1996 are barred from Medicaid for five years, but could be eligible for NJ Family Care and certain programs for pregnant women and meet specific standards for financial income and resources.
  • New York – NY’s Medicaid program is for New Yorkers who can’t afford to pay for medical care and have high medical bills. You qualify for NY’s Medicaid program if you receive Supplemental Security Income (SSI) and/or you meet certain financial requirements.
  • Texas – The Texas’ Health and Human Services Commission Medicaid program is available to those who meet income and resource limits set by the appropriate programs for: persons who are 65 years or older, or a person who has a disability, pregnant women up to two months after birth, women who have been diagnosed with breast or cervical cancer for cancer treatment, children under the age of 19 years old, people who were in foster care on their 18th birthday and are now age 18 through 20 and a family with a parent or relative caring for a child under age 19.

To read more about any state’s Medicaid program and eligibility requirements you can conduct an internet search for the state you live in. You can also visit Kaiser Family Foundation State Health Facts website for individual states health data or to do a comparison to another state or the US. Each state profile provides a link to that state’s Medicaid website under the Government Profile’s Contact Information section at the bottom of the page.

State Pharmaceutical Assistance Programs (SPAPs)

Many states and the U.S. Virgin Islands have State Pharmacy Assistance Programs (SPAPs) that help certain people pay for prescription drugs based on financial need, age or medical condition. Each SPAP makes its own rules about how to provide drug coverage to its members. Some offer help paying drug plan premiums and/or other drug costs. Visit: http://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx

Stay tuned, our next newsletter will provide information on prescription drug assistance provided directly from pharmaceutical companies and other assistance offered by different non-profit organizations.