HICAP is here to help.

Medicare can be expensive, and many beneficiaries need assistance paying for prescription drug related costs, or help with paying their Medicare premiums, co-payments, and co-insurance.

Federal, state and other programs can help you with your Medicare related costs. “Extra Help” is a prescription drug assistance program that can help you save money on plan premiums, deductibles and co-payments. “Medicare Savings Programs” can help pay for your Medicare Part A and B premium and some or all of your Medicare deductibles and co-payments.

The Health Insurance Counseling & Advocacy Program (HICAP) provides free, unbiased Medicare counseling to Medicare beneficiaries and their families and can help you apply for these programs.

Who is eligible?

You must be eligible for Medicare in order to be eligible for any MSP. And, you must meet the income and assets limitations displayed on the MSP Chart below.
If you qualify for QMB, SLMB or QI, you automatically qualify for Extra Help (Low Income Subsidy – LIS), which helps pay for Medicare prescription drug related costs such as plan premiums, deductibles and co-payments.
Qualified Disabled Working Individual (QDWI) Program is available to you if you are disabled, under age 65, and lost your premium-free Part A when you returned to work.
Eligibility is generally re-determined each year.

MSP Summary Chart

Program Name Benefits Monthly Income Single/Married Asset Limits Single/Married
Qualified Medicare Beneficiary (QMB)
  • Pays Part A & B premium
  • Pays Medicare deductibles, copayments, coinsurance
  • Does not provide 3 month retroactive Part B premium reimbursement
  • You can have both Medi-Cal and QMB
$1,061 / $1,430 $7,730 / $11,600
Specified Low-Income Medicare Beneficiary (SLMB)
  • Pays Part B premium
  • Provides 3 month retroactive Part B premium reimbursement
  • You can have both Medi-Cal and SLMB
$1,269 / $1,711 $7,730 / $11,600
Qualifiying Individual (QI)
  • Pays Part B premium
  • Provides 3 month retroactive Part B premium reimbursement
  • You cannot have both Medi-Cal and QI
$1,426 / $1,923 $7,730 / $11,600
Qualified Working Disabled Individual (QDWI)
  • Pays Part A premium
  • You cannot have both Medi-Cal and QDWI
$4,249 / $5,722 $4,000 / $6,000

MSP Benefits and Protections

  • No Part B late enrollment penalty (waived for individuals that qualify for QMB, SLMB, and QI)

  • No estate recovery (states cannot ask for repayment for costs covered under the MSP from estates of deceased MSP recipients)

  • Beneficiaries eligible for MSPs automatically get Extra Help to cover prescription drug related costs

  • QMB recipients cannot be “balanced billed” (billed for co-payments/co-insurance)

  • Claims should automatically transfer from Medicare to Medi-Cal for processing

Who qualifies?

Some people automatically qualify for Extra Help, and others must apply for the program.
You automatically qualify –
  • If you are enrolled in both Medicare and full Medi-Cal

  • If you are receiving Supplemental Security Income (SSI)

  • If you qualify for a Medicare Savings Program (MSP)

What if My Plan Denies Coverage?

Our Health Insurance Counseling & Advocacy Program (HICAP) counselors can help you understand the reason for the denial and can assist you with filing an appeal.
Your plan may deny coverage if:
  • Prior Authorization – required before your plan covers the drug

  • Step Therapy – your plan requires you to try a different drug first

  • Quantity Limits – your plan only covers a certain quantity of a drug over a certain period; e.g. 30 tablets per month

  • Off-Formulary – medication is not on the plan’s formulary

  • Off-Label – drug prescribed for reason other than approved by U.S. Food and Drug Administration (FDA)

  • Excluded – drug excluded from Medicare Coverage

Contact HICAP for Application Assistance

 (800) 434-0222 or (714) 560-0424
OR
Contact your closest Senior Center to schedule an appointment with a local HICAP Counselor

HICAP does not sell, endorse, or recommend insurance products.

This project was supported, in whole or in part by grant number(s) 1801CAMISH, 1801CAMIAA, 1801CAMIDR, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

This project is funded in part through a grant from the California Department of Aging, as allocated by the Orange County Board of Supervisors and administered by the Office on Aging.