Medicare

What Medicare Options Are Right for You?

When you work, some of the money you earn automatically comes out of your paycheck and helps fund Medicare, a national public health insurance program.

If you or your spouse worked enough time while paying Medicare taxes, you will qualify for Medicare:

• When you turn 65
• When you’ve been getting Social Security Disability Insurance (SSDI) benefits for two years, or
• If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).

If you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record, you will also qualify for Medicare.

If you qualify for Medicare, you can choose to get your coverage through either of these options:

• Original Medicare, including Part A, which helps pay for medical care you get while you’re in a hospital; Part B, which helps pay for medical care you get outside of a hospital, like when you go to the doctor’s office; and Part D, which helps pay for prescription drugs. You also have the option of getting a private Medicare supplement policy, which covers some expenses that Parts A and B do not cover.
  • You automatically get Medicare Parts A and B if you’ve been getting SSDI or CDB for two years. Otherwise, you may need to sign up, depending on your situation.
• A Medicare Advantage plan, which combines Parts A, B, and D into a single plan run by a private company. There are many different Medicare Advantage plans to choose from.
  • If you want a Medicare Advantage plan, you need to sign up during your initial Medicare enrollment or during the annual open enrollment period between October 15 and December 7 each year.

Most people don’t have to pay a premium for Part A, but they do have to pay monthly premiums for Parts B and D, or for Medicare Advantage plans. For this reason, nobody is required to get them.

Answer the questions on this page to see if it makes sense for you to get Original Medicare or a Medicare Advantage plan, and also whether you might qualify for programs that can help you pay your monthly premiums, copayments, co-insurance, and deductibles.

Do You Qualify to Get Medicare and Other Coverage at the Same Time?

If you qualify to get Medicare at the same time as you get employer-sponsored coverage, Medicaid, or Medicaid Buy-In for Workers with Disabilities (MBIWD), having those other benefits may impact your Medicare decisions:

• If you also qualify for Medicaid or Medicaid Buy-In for Workers with Disabilities, they may help pay for some medical expenses that Parts B and D would not pay for.
• If you also qualify for employer-sponsored coverage, you may wish to decline Part B and Part D coverage, so that you don’t have to pay their premiums. However, your private coverage must meet certain standards, or else you may have to pay monthly penalties if you choose to sign up for Parts B and D later.
  • Important: Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future. Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact the Ohio Senior Health Insurance Information Program (OSHIIP).

You may have other options as well, such as retirement benefits, Veterans (VA) benefits, or military (TRICARE) benefits. Learn more about how Medicare interacts with other types of coverage.

Can You Get Help Paying for Medicare Parts A and B?

While Medicare offers good coverage, it is not as low-cost as Medicaid. Depending on the care you need, you may have to pay large copayments, co-insurance, or deductibles. And, for Part B, you may have to pay a monthly premium (usually $174.70 per month or a bit less).

However, if you have low income and low resources, you may qualify for a Medicare Premium Assistance Program (MPAP). There are four Medicare Premium Assistance Programs:

• The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,255 per month or less if you live alone). QMB helps pay for your Part B premium, copayments, and deductibles.
• The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,506 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
• The Qualified Individual-1 (QI-1) program helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,695 per month or less if you live alone). QI-1 helps pay for the Part B premium, but does not help with anything else.
• The Qualified Disabled Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,550 per month), but have countable income that’s 200% of FPG or less ($2,510 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it will pay for the Part A premium that would otherwise apply.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,255
	$20
	$65
	$943
Your Monthly Countable Income
Your Annual Countable Income
	$15,060
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

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The resource limit for QMB, SLMB, and QI-1 is $9,430 if you live alone and $14,130 if you live with someone else. For QDWI, it’s $4,000 if you live alone and $6,000 if you live with another person.

You can apply for any of these:

• Online, or
• By filling out the application form and turning it in at your local County Department of Job and Family Services (CDJFS) office.

If you need help with your application, call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or 1-800-292-3572 (TTY).

Can You Get Help Paying for Medicare Part D?

Part D helps you pay for your medications, but there are some expenses for you, such as the monthly premium, a deductible, copayments, and co-insurance.

If you cannot afford these costs, you may qualify for the Low Income Subsidy (LIS), which is also called “Extra Help.” With it, you don't have to pay a Part D premium or deductible, and there may be lower copayments.

The Low Income Subsidy is for people who also get Medicaid coverage or who are in a Medicare Premium Assistance Program. You may also qualify if your countable income is less than $20,331 per year and your resources are less than $15,720 if you are single (the limits are higher for larger households). Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply even if you don’t think you qualify.

Apply for the Low Income Subsidy at your local Social Security office.

Note: Before 2024, there used to be a "Partial LIS" that didn't help as much. Now, everybody who qualifies for the LIS gets the full subsidy.

Do You Want a Medicare Supplement Plan That Covers Costs that Original Medicare Doesn't?

If you get Original Medicare with Parts A, B, and D, you can choose to get a private Medicare supplement (sometimes called a Medigap plan) to cover some of the expenses that Medicare Parts A, B, and D won’t cover. For example, a Medicare supplement could cover things like your co-insurance payments for Part B.

You will have to pay a monthly premium for a Medicare supplement, in addition to your premiums for Part B and D. The amount you have to pay depends on the plan.

Learn more about Medicare supplements or find one in your area.

Do You Want a Medicare Advantage Plan That Combines Parts A, B, and D?

With Medicare Advantage (sometimes called “Part C”), you can get all of your Medicare benefits combined into a single plan run by a private company. As long as a company follows Medicare’s rules, it can have more flexibility in the benefits it offers, how it organizes payments, and how much the plan costs. Also, Medicare Advantage plans have an out-of-pocket maximum, unlike Original Medicare.

The amount you pay depends on your plan, but most plans make you pay as much as the Part B premium would cost plus an additional amount for extra benefits and prescription drug coverage. A Medicare Premium Assistance Program and the Low Income Subsidy may help you pay for your Medicare Advantage plan.

Use the Medicare Plan Finder to see which Medicare Advantage plans might be best for your needs.