What Medicare Copay Programs are Available to Seniors?

Medicare Benefits Solutions

Nov 28, 2022

Copayments are one of the ways we share costs with insurance companies. If you visit the doctor often, have a chronic condition that requires frequent outpatient care, or take prescription medications, you may be aware of how copays can add up. Overall copay amounts depend on your health and what plan you’re enrolled in.

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Can You Use Copay Assistance with Medicare?

There are different programs available that may be able to help provide you with financial support for Medicare co-payments and other expenses. If you meet certain income criteria, you may be eligible for assistance on the local or state level. Medicare savings programs, Medicare give-back programs, Extra Help, and Patient Assistance Programs are just a few options to research.

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Get Help Paying for Copays and Prescriptions

Original Medicare helps pay the costs of many covered medical expenses, but you are expected to share the expenses. Cost-sharing comes in the form of premiums, deductibles, copayments and coinsurance. For instance, you’ll pay 20% of your services for care covered by Part B, including doctor office visits. Out-of-pocket costs can add up quickly and there is no out-of-pocket maximum spending limit. This means that if you unexpectedly have to visit the doctor frequently due to a new diagnosis, the total amount of your coinsurance costs may seem overwhelming.

Alternatively, if you’re enrolled in a Medicare Advantage plan, you will likely have a cap on your annual out-of-pocket costs. With that being said, if you live on a limited income, you may still struggle with paying copays when you visit a plan provider.

If you’re enrolled in a stand-alone Prescription Drug Plan or a Medicare Advantage plan that includes drug coverage, you’ll be responsible for copays for your medications. If your copay expenses are higher than you’re comfortable with, there are a variety of programs that may be able to lower your costs if you qualify.

TIP: Learn more about how to lower your generic drug copays and brand-name drug copays with Medicare.

Copay Assistance for Medicare Patients

Assistance may be available through state or local programs. Millions of Americans qualify for both Medicare and Medicaid. To be dual-eligible for both programs, you’ll have to meet the criteria for both. Unlike Medicare, which is a federal program based on age or disability, Medicaid is a federal and state health insurance program for individuals with low income. Medicaid requirements and restrictions may vary from state to state.

If you qualify for full Medicaid benefits, your state may pay your copays and you’ll be eligible for Extra Help, a federal program that helps lower your drug costs. If you are dual-eligible, you may have the option to enroll in a Medicare Advantage Dual-eligible Special Needs Plan (D-SNP) if one is available in your area.

Even if your income levels aren’t low enough to qualify for Medicaid, there are other copay assistance programs that may be able to assist you.

TIP: Discover the top 7 reasons why most people change their Medicare Advantage plans.

Medicare Savings Programs

Medicare assistance programs are established for beneficiaries with limited income and financial resources who need help paying for healthcare services and medications. There are four types of Medicare programs available across the U.S., except in Puerto Rico and the U.S. Virgin Islands. Though program names may vary by state, the Medicare Savings Programs include:

  • Qualified Medicare Beneficiary (QMB) program: Helps pay Part A and/or Part B deductibles, copayments, or coinsurance
  • Specified Low-income Medicare Beneficiary (SLMB) program: Helps pay Part B premiums only
  • Qualifying Individual (QI) program: Helps pay for Part B premiums only
  • Qualified Disabled and Working Individuals (QDWI) program: Helps pay Part A premiums only

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Extra Help Program

Extra Help is a program that can help cover Medicare Prescription drug plan costs, deductibles, premiums and more. The income and resource limit amounts change annually for Extra Help.

Assets taken into account include bank accounts, retirement funds, stocks and bonds. You will be enrolled automatically if you get full Medicaid coverage, help from a Medicare Savings Program, or Supplemental Security Income (SSI) from Social Security.

PACE Program for the Elderly

PACE, which stands for Program of All-Inclusive Care for the Elderly, is a joint Medicare and Medicaid program that offers the support of a professional healthcare team. You don’t have to be enrolled in Medicaid, but you must be 55 or older and reside in a state that offers PACE under Medicaid.

The PACE team assesses the care and medications you need so that you can continue living in your community and not have to move to a nursing home or comparable setting. If you don’t have Medicaid, you are responsible for premiums. However, you don’t have to pay deductibles or copays for medically necessary medications, services or care that the PACE team has signed off on.

State Health Insurance Assistance Programs

The Administration for Community Living (ACL) manages the State Health Insurance Assistance Program (SHIP). Counselors provide individualized counseling, including Medicare low-income assistance, to help beneficiaries make informed decisions.

The agency is named differently in each state. When you receive your Medicare handbook each year, look on the back cover to find the name and phone number of the local office in your state.

Medicare Advantage Giveback Program

Another way to save money is to join a Medicare Advantage plan (Part C) that offers a Give Back benefit. The Part B premium is required in addition to the Medicare Advantage premium if your plan has one. With the Give Back program, the insurance company gives back all or a portion of your Part B premium.

A limited number of Medicare Advantage plans participate in the giveback program. If you find a plan in your region that offers this benefit, be sure to compare the plan’s premium against the Part B premium reduction to be sure you are getting a good value. Some Medicare Advantage plans charge no premium. What’s most important is selecting a Medicare plan with the comprehensive coverage you need.

Non-profit Organizations May Offer Assistance

Organizations such as the Patient Advocate Foundation Co-Pay Relief (CPR) and the HealthWell Foundation provide funding for specific diseases. Grants can be used for deductibles, copays and coinsurance for pharmaceutical treatments and prescription medications.

Try the Medicare Plan Finder

TIP: If you’re thinking of switching plans to offset your copays and other out-of-pocket expenses, an online plan finder can help you get started.

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