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Premium and Cost-Sharing Assistance

Several cost assistance programs currently exist within Medicare. Medicare beneficiaries with low incomes and limited resources may qualify for one of three Medicare Savings Programs to assist with premiums and OOP expenses. The Qualified Medicare Beneficiaries (QMB) program is available to beneficiaries with incomes at or below the federal poverty level (FPL). QMB individuals are entitled to receive assistance for all Medicare Part A and Part B cost-sharing charges (including the Part B premium, all deductibles, and all coinsurance), paid by Medicaid. The Specified Low-Income Medicare Beneficiaries (SLMB) program is available to individuals with income greater than 100 percent but less than 120 percent of FPL. Beneficiaries who qualify for the SLMB program have their Medicare Part B premium paid by Medicaid. The Qualifying Individuals (QI) program is for individuals with income between 120 percent and 135 percent of FPL. As shown in Table A-3, Medicaid pays the Medicare Part B premium for these individuals; however, 100 percent of the payment comes from federal government allocations to states. Funds for the QI program come from the Medicare Supplementary Medical Insurance (SMI) Trust Fund.

 

Table A-3: Medicare Savings Programs for Dual-Eligible Beneficiaries, 2019

Program Monthly income limit Asset resources limit Costs paid by Medicaid
Qualified Medicare Beneficiaries <100% of FPL
Single: $1,061
Couple: $1,430
Single: $7,730
Couple: $11,600
All Part A and Part B premiums, deductibles, and coinsurance
Specified Low-Income Medicare Beneficiaries 100% to <120% of FPL
Single: $1,061-$1,269
Couple: $1,430-$1,923
Single: $7,730
Couple: $11,600
Part B premium
Qualifying Individuals 120% to <135% of FPL
Single: $1,269-$1,426
Couple: $1,711-$1,923
Single: $7,730
Couple:11.600

Part B premium

 

Medicare Part D also has cost-sharing and premium assistance programs. Medicare Part D provides low-income subsidies (LIS) to certain beneficiaries with limited incomes and resources to help them pay Part D premiums, cost-sharing amounts, and other OOP expenses. Individuals who receive assistance through an MSP, receive full Medicaid benefits, and/or receive Social Security income cash assistance, are eligible for a full LIS. Eligible enrollees have their monthly premium paid up to a certain benchmark plan amount. Individuals with the full LIS also have no deductible, minimal cost sharing during the initial coverage period and during the coverage gap, and no cost sharing above the catastrophic threshold. Individuals with an income below 150 percent of FPL and limited assets may qualify for a partial low-income subsidy. Individuals may receive premium assistance equal to 25 percent to 75 percent of the cost of full LIS premium assistance, determined by an income based sliding scale (Congressional Research Service 2018).

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