• What is Medicare?
• Medicare out-of-pocket expenses
• Programs that help pay your out-of-pocket costs
• The three Medicare Savings Programs
  • Qualified Medicare Beneficiary (QMB)
  • Specified Low Income Medicare Beneficiary (SLMB)
  • Additional Low Income Medicare Beneficiary (ALMB)
• How to apply for these programs
• Who to contact for help

What is Medicare?

Medicare is a national health insurance program. You may enroll in Medicare, if you are:

• 65 or older and eligible for Social Security retirement benefits, or
• disabled and eligible for Social Security disability benefits for at least 24 months, or
• eligible for Railroad Retirement or Disability benefits, or
• an individual suffering from end stage renal disease.

For more information on Medicare, call 1-800-Medicare. Information is also available on the Internet at www.medicare.gov.

Medicare has several parts:

• Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services.
• Part B covers a wide range of most frequently used health services, such as doctor visits and diagnostic testing.
• Part D provides assistance in paying for prescriptions

This article tells you about programs that may pay for some common Medicare costs.

Call the Consumer Law Project for Elders for more help, 800-296-1467

Medicare Out-Of-Pocket Expenses

Medicare Part A

1. Premium

Elderly or disabled individuals who do not qualify for Social Security or Railroad Retirement benefits can obtain Medicare Part A coverage by paying a monthly premium.

2. Hospital Deductible and Coinsurance Amounts

Medicare recipients must pay a deductible for every hospital stay. There are additional costs (coinsurance) for hospital stays longer than 60 days.

3. Skilled Nursing Facility Coinsurance

After a hospital stay, Medicare covers the full cost of nursing facility care for the first 20 days. You must pay a portion of the cost of your care (coinsurance) for days 21 to 100.

Medicare Part B

1. Premium

Usually the monthly Part B premium is deducted from your Social Security check.

2. Deductible          

The Part B deductible is the amount you are responsible for paying before Medicare will begin to cover health care expenses.

3. Coinsurance

Medicare Part B pays only a portion of the cost of doctors’ services, outpatient care, ambulance transportation, and some medical supplies and equipment. You must pay a coinsurance (a portion of the cost of your care) of 20% of the cost of these services.

Medicare Part D

Prescription costs:

Medicare Part D helps pay for prescription drugs. Fees may include monthly premiums, deductibles and co-pays.

Programs That Help Pay Your Out-Of-Pocket Costs

Three state-administered programs can provide payment help to elderly or disabled Medicare beneficiaries who have low income.

• The Qualified Medicare Beneficiary (QMB) program,
• The Specified Low Income Medicare Beneficiary (SLMB) program, and
• The Additional Low Income Medicare Beneficiary (ALMB) program

The Qualified Medicare Beneficiary (QMB) Program

The Qualified Medicare Beneficiary (QMB) program fills the gaps in Medicare coverage for low income people by eliminating out-of-pocket expenses for Medicare covered services. If you use providers who accept Medicaid, the following expenses are covered:

• The Medicare Part A monthly premium (unless the person qualifies for free Part A)
• Hospital Deductible and Coinsurance amounts
• Medicare Part A Skilled Nursing Facility Coinsurance
• Medicare Part B Premium
• Medicare Part B Deductible
• Medicare Part B Coinsurance

The Specified Low Income Medicare Beneficiary (SLMB) Program and Additional Low Income Medicare Beneficiary (ALMB) Program

The SLMB and ALMB programs pay the monthly Medicare Part B premium. Usually the monthly Part B premium is deducted from your Social Security check. If you are enrolled in the SLMB or ALMB program, this deduction will stop and your Social Security check will be larger.

Important Note about ALMB: You should apply each year for the ALMB program (as soon after January 1st as possible). ALMB benefits are granted on a first-come, first-served basis each year. Funding for the ALMB program is limited. Once the funding runs out, applications to the program are not accepted.

Who is eligible for these programs?

Medicare beneficiaries are eligible for these programs if all of the following criteria are met:

1. You are a citizen or legal resident of the United States and Connecticut.

2. You are enrolled or eligible to enroll in Medicare Part A.

To be eligible to enroll, you must be a citizen of the U.S., or a permanent legal resident for at least 5 years and be at least 65 years old or disabled.

3. You must have limited income.

Income limits for each program are:

How do I apply for these programs and when do benefits start?

All three programs are administered by the Connecticut Department of Social Services (DSS). To apply, complete a short application form. Call CHOICES at 1-800-994-9422 or visit your local DSS office for an application.

QMB, SLMB and ALMB benefits usually start the month after you apply. In certain cases, SLMB and ALMB benefits are granted up to 3 months before you apply. This means you could get back up to 3 months worth of all or some of the premiums that you paid out before you applied.

If I'm eligible for the QMB program, do I need "Medigap" insurance?

Medicare beneficiaries enrolled in an Original Medicare Program (fee for service) can purchase a Medicare Supplemental Insurance (Medigap) policy to help pay some of the health care costs that Medicare does not cover.

The QMB program offers most of the benefits of Medigap policies if you visit medical providers who accept both Medicare and Medicaid. Before canceling your Medigap insurance, make sure your medical providers accept both Medicare and Medicaid. If your QMB coverage ends, you may
be able to reinstate your former Medigap policy.

Important Note: SLMB and ALMB programs do not offer the benefits of Medigap insurance. If you are enrolled in the Original Medicare Program, you should not cancel your Medigap policy when you enroll in the SLMB or ALMB programs.

If my income changes, can the State seek reimbursement for benefits I received in the past?

No, as long as the payments were made after January 1, 2010.

What should I do if my application is denied or if benefits are cut off?

Legal services may be able to provide free legal assistance. Call Statewide Legal Services at 1-800-453-3320 or 860-344-0380.

Is there help for prescription drug costs?

YES.   If you are enrolled in one of the Medicare Savings programs, you are automatically enrolled in the Part D Low Income Subsidy , also known as "Extra Help." This program cuts Medicare Part D costs dramatically. In 2013, it pays Part D premiums up to $31.35/month, provides coverage during the Deductible and Donut Hole periods, and limits your Part D co-pays to a maximum of $2.50 for generics and $6.30 for brand name drugs.

For More Information, Contact:

Elder Law Services in Connecticut

• 800-296-1467
• www.ctelderlaw.org

This booklet was produced by the Legal Assistance Resource Center of Connecticut in cooperation with Connecticut Legal Services, Greater Hartford Legal Aid, New Haven Legal Assistance Association, and Statewide Legal Services.

The information in this booklet is based on laws in Connecticut as of 3/2013. We hope that the information is helpful. It is not intended as legal advice. For advice on your situation, call Statewide Legal Services or contact a lawyer.