Learn about Medicare Part D plans

Does Medicare Cover Prolia?

Does Medicare cover prolia senior woman in wheelchair with nurse

Medicare Part D or Medicare Advantage plan may cover the injectable osteoporosis drug Prolia. When you are in a hospital or skilled nursing facility, Medicare Part A can help pay for Prolia. Furthermore, Medicare Part B may cover a home health nurse visit to inject this drug.

Estimated reading time: 7 minutes

Medicare Coverage for Osteoporosis Drug Prolia

Does Medicare Cover Prolia? injection in arm of senior woman by male nurse

To enroll in a Medicare Advantage plan, you must have both Medicare Part A and Part B. Furthermore, to have Prolia drug coverage, your Medicare Advantage plan must include drug coverage. However, if you have original Medicare, you can get a standalone Part D drug plan by having Medicare Part A or Part B.

Medicare Eligibility for Osteoporosis Drugs

To be eligible for osteoporosis drugs, you must meet the following conditions:

  • Be a woman
  • Have a bone fracture that a doctor certifies is related to postmenopausal osteoporosis

To be eligible for Medicare home health services, you must meet the following conditions:

  • You have Medicare Part B
  • Your doctor certifies you are unable to learn to give yourself the drug by injection
  • A family member or caregiver is unable and unwilling to give you the drug by injection
Does Medicare Cover Prolia? Senior woman with osteoporosis  consults with home health nurse

Furthermore, a doctor must certify you are homebound and do not need more than part-time or intermittent skilled nursing care. If you meet the above conditions, Medicare will cover Prolia injections by a home health nurse.

What is Osteoporosis?

According to the Mayo Clinic, osteoporosis “causes your bones to become weak and brittle.” Osteoporosis is most commonly found in white senior women who are past menopause. CDC.gov data shows 24.5 percent of women 65 years old and over have osteoporosis of the femur, neck, or lumbar spine. Thus, 1 in 5 female seniors has osteoporosis.

Symptoms of Osteoporosis

You may have osteoporosis if you have the following signs and symptoms:

  • Back pain caused by a fractured vertebra
  • Loss of height over time
  • A stooped (bent over) posture
  • A bone that breaks easier than expected
Senior woman in kitchen with back pain
Senior woman in kitchen with lower (lumbar) back pain.

How to prevent osteoporosis?

The Mayo Clinic says, “good nutrition and regular exercise are essential for keeping your bones healthy throughout your life.” Read the article, Senior Fitness Programs, to learn how you can become more active and improve your strength, balance, and more! To maintain healthy bones, women age 50 and over need 1200 milligrams of calcium (Ca). The following foods are good sources of calcium (per 100 grams):

  • Dairy products such as cheddar cheese (707mg)
  • Silk soy milk (450mg per cup)
  • Canned sardines with bones (382mg)

If you consume less than 1200mg per day, please consider taking a calcium supplement. However, consuming too much calcium is associated with kidney stones. Furthermore, too much supplemental calcium may increase your risk of heart disease. Thus, please limit your calcium intake to 2,000mg per day.

Seniors seated lifting weights in Ger-Fit class
Seniors lifting weights in a Geri-Fit class.

In addition to calcium, you also need Vitamin D for healthy bones. So how much vitamin D do seniors need?

Vitamin D and Osteoporosis Prevention

According to the fact sheet at NIH.gov, Vitamin D helps your body absorb calcium. By consuming recommended amounts of calcium and vitamin D, you can help prevent osteoporosis. Adults 19-70 need 15 micrograms (mcg) or 600 International Units (IU). However, seniors over the age of 70 need 20mcg or 800 IU.

Vitamin D Foods

Very few foods contain vitamin D. However, the US fortifies some food with this vitamin. Please check vitamin D on the product Nutrition Facts label. The following foods are excellent vitamin D sources with a Daily Value (DV) of over 20%.

  • Salmon baked (13.7mcg 68% DV)
  • Canned tuna (6.70mcg 34% DV)
  • Canned sardines with bones (4.8mcg 24% DV)
Senior woman making a lox with salmon cream cheese and bagel
Senior woman making a lox with salt-cured salmon, cream cheese, and bagel.

Furthermore, soy milk and whole milk fortified with vitamin D (3mcg 13% DV) are good sources of vitamin D.

Medicare Costs for Prolia Injections

Your Medicare costs will depend on who administers your Prolia injection and your Medicare plan. If you have Original Medicare and self-administer Prolia inject, your Part D drug plan covers the cost.

However, if you have Original Medicare and a home health nurse administers your Prolia injections, Part B covers 80% of the drug cost. Consequently, you pay the annual Part B deductible, monthly Part B premium, and 20% of the drug price.

Medicare Advantage Prolia Costs

If you have a Medicare Advantage (MA) plan without drug coverage and self-administer Prolia injections, your drug costs are not covered. Consequently, the list price you would pay maybe $1278. To avoid paying such a high price, we recommend you switch to a Medicare Advantage plan with drug coverage. Otherwise, have a home health nurse administer Prolia. Then your cost is only Medicare Part B deductible, the monthly premium, and your MA plan costs.

However, if you have a Medicare Advantage plan with drug coverage, the costs are similar no matter who administers Prolia injections. For example, you can administer Prolia injections yourself or have a home health nurse do it, and your Medicare costs are about the same. You pay Medicare Part B and your Medicare Advantage plan costs.

Medicare covers the costs of Prolia injections.

Are you at Risk for Osteoporosis?

Some medical conditions put you at greater risk for osteoporosis. For example, estrogen deficiency could put you at higher risk for bone loss. Furthermore, if you are diagnosed with primary hyperparathyroidism, your parathyroid gland(s) enlarge, increasing the blood’s calcium levels. As a result, less calcium enters your bones, causing osteoporosis. (Mayo Clinic)

X-rays can show signs of osteoporosis, osteopenia, or vertebral fractures. Also, taking steroid medications can lead to bone loss and cause osteoporosis. For example, long-term use of Prednisone (Glucocorticoids) may result in bone damage. (Osteoporosis.ca)

If you are at risk for osteoporosis, Medicare pays for the costs of bone mass measurements (bone density tests). Every two years, Medicare covers this cost to evaluate your risk of broken bones.

DEXA bone density test machine female senior
DEXA machine measures bone density in hip and spine to diagnose osteoporosis.

Furthermore, this Medicare-covered test helps your doctor monitor your osteoporosis drug therapy to see if Prolia injections are working. (Medicare.gov)

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4 parts of medicare

Medicare Parts coverage and cost in 2021

What do Medicare Parts cover and cost in 2021?

There are 4 parts of Medicare: Part A, Part B, Part C, and Part D.

  • Part A covers inpatient hospital services.
  • Part B covers outpatient medical services.
  • Part C is Medicare Advantage plan offered by private companies approved by Medicare.
  • Part D provides prescription drug coverage to lower the cost you pay for medications.

Estimated reading time: 9 minutes

Before you receive inpatient hospital benefits, you must first pay Part A deductible of $1484 in 2021. However, you can avoid paying this cost by having a Medicare Supplement plan.

Embed or download 4 Parts of Medicare infographic

What does Medicare Part A cover and cost in 2021?

According to Medicare.gov, Part A covers the following:

  • Inpatient hospital care
  • Skilled Nursing Facility care
  • Long-term Care Hospitals
Medicare Part A - Hospital

Inpatient Hospitals Coverage and Cost in 2021

The first 60 days of inpatient care is covered by Medicare Part A. In other words, you pay $0 coinsurance for each 60 day benefit period. For example, you can be a hospital inpatient multiple times per year and each hospital stay will cost you nothing so long as each stay is 60 days or less. However, hospital stays between 61 days and 90 days will cost you $371 coinsurance per day in 2021.

Skilled Nursing Facility

Skilled Nursing Facility Coverage and Cost in 2021

Medicare Part A also covers 20 days of care in a Skilled Nursing Facility (SNF). Specifically, you pay $0 coinsurance for each 20 day benefit period. Some of the benefits of SNF include physical therapy, meals, and dietary counseling. Therefore, you can get short-term skilled nursing care multiple times per year for no cost so long as each stay is 20 days or less. However, SNF stays between 21 days and 100 days will cost you $185.50 per day in 2021.

Long-term Care Hospital Coverage and Cost in 2021

Medicare Part A covers the first 60 days in a Long-term Care Hospital (LTCH). In particular, the cost of LTCH is $0 for each 60 day benefit period under the following conditions.

  • You are transferred to a LTCH directly from an acute care hospital.
  • You are admitted to a LTCH within 60 days of being discharged from a hospital.

If the above conditions do not apply, then you must pay Part A $1484 deductible in 2021 before Medicare will pay anything. Furthermore, LTCH stays from 61 days to 90 days will cost you $371 coinsurance per day in 2021.

Medicare Part A - Long-Term Hospital Care

What does Medicare Part B cover and Cost in 2021?

Medicare Part B covers the following services:

  • Medical outpatient services for stays at any hospital or medical facility for less than 24 hours. For example, a stay that occurs overnight but for less than 24 hours is outpatient service.
  • Preventive services to prevent illness such as seasonal flu-shot and annual wellness visits.
first aid kit

Medicare Outpatient Coverage and Cost in 2021

Original Medicare covers 80% of medically necessary services and supplies. These Part B medical services include:

Before Medicare pays for these medical services and supplies, you must first pay Part B deductible of $203 in 2021. Furthermore, you are responsible to pay the 20% that Medicare does not cover. However, Medicare Supplement Plan C and Plan F pay Part B deductible and your 20% coinsurance.

Medicare Preventive Coverage and Cost

Medicare preventive services cover screening tests that help detect health conditions at early stages when treatment is most effective. In the tables below, we list 31 preventive tests covered by Medicare Part B. 

Medicare Part B preventive screening table 1
Click to view larger table size
Medicare Part B preventive screening table 2
Click to view larger table size

In the above tables, 71% of these screening tests are free after you pay the $203 Part B deductible. Furthermore, 19% of tests require payment of Part B deductible and 20% coinsurance. Finally, 10% of tests you pay absolutely nothing: neither Part B deductible nor 20% coinsurance. If you qualify, you many pay nothing for the following preventive screening tests:

  • Nutrition Therapy Service – you pay nothing if you have diabetes or kidney disease.
  • “Welcome to Medicare” preventive visit – you pay nothing as long as the doctor does not perform additional tests or services.
  • Yearly Wellness Visit – available every 12 months as long as the doctor does not perform additional tests or services.

To receive Part B coverage you need to pay a monthly premium. In 2021, the standard premium for Part B is $148.50.

What does Medicare Part C cover and cost in 2021?

Part C Medicare Advantage network
MA plans have a network of doctors, hospitals, and other medical services.

Medicare Part C is an alternative to Original Medicare and covers Part A (Hospital Insurance) and Part B (Medical Insurance). Part C is also known as Medicare Advantage (MA) Plan.

Medicare Advantage (MA) Coverage

MA plans often include Medicare Part D prescription drug coverage. Moreover, many MA plans include extra benefits not covered by Original Medicare. For example, MA plans may include dental, vision, and hearing. Some MA plans even include gym memberships such as Silver Sneakers! MA plans are offered through a network of healthcare providers HMO or PPO.

Medicare Advantage (MA) Costs

To enroll in Medicare Advantage Plan (Part C) you must first be enrolled in Part A and Part B. Most Medicare beneficiaries pay no premium for Part A. However, you will have to pay Part B monthly premiums. In 2021, the standard premium for Part B is $148.50. Furthermore, you will need to pay a monthly Part C premium. According to The Kaiser Family Foundation, the average Medicare Advantage Plan premium is $36 in 2020.

When you add standard Part B and average MA premiums, the total monthly cost is $180.66 in 2020. Conversely, Original Medicare Part B and Part D premiums may only cost on average $177.34 in 2020. However, you may be thrilled to get a gym membership for only a few extra dollars per month!

You can choose a lower premium MA plan. As a result, you may be excited to pay less every month. However, some MA plans will have higher deductibles, copays, and larger out-of-pocket limits. Consequently, the cost to use your health insurance may be much higher. You may be able to avoid these excessive costs by choosing an MA premium of $40 or more.

What does Medicare Part D cover and cost in 2021?

 Part D drug plan
Part D drug plans save you money

Part D saves you money on prescription drugs. Specifically, it reduces your cost for brand-name and generic drugs. For example, rather than paying the full retail price for medications, you only pay small copayments with Part D. To join a Part D drug plan, you must be enrolled in certain parts of Medicare.

How to Join a Drug Plan

You must have either Part A or Part B to join a stand-alone Part D drug plan with Original Medicare. However, you must have both Part A and Part B to join a Medicare Advantage plan.

Part D Costs for Original Medicare and MA Plans

To enroll in Part D with Original Medicare you need to have either Part A or Part B. However, most people have both Part A and Part B coverage. Since private health insurance companies such as Aetna and Mutual of Omaha provide drug coverage, the price you pay will vary.

Part D drug costs in 2021 

All Part D drug plans have a monthly Part D premium. This amount will depend on the income reported on your 2019 tax return. Some Part D plans have an annual deductible which can not be more than $445 in 2021. However, other drug plans may have little or no deductible. 

After the out-of-pocket deductible, you pay either a copay or coinsurance for each prescription drug. For example, you pay less for drugs in tier 1 and more for drug in tier 2. Discover the differences in Medicare Part D tier costs. Furthermore, after you and your drug plan spend a certain amount, you enter a coverage gap called the donut hole.

Donut Hole Costs in 2021

In 2021, you enter the donut hole after your plan spends $4,130. Then you pay no more than 25% coinsurance for the plan’s covered brand-name and generic prescription drugs. After total out-of-pocket drug costs are $6,550 in 2021, you exit the donut hole. Learn more about the 4 stages of drug coverage and costs in 2021.

Want More Help with Medicare Parts?

You can speak with a licensed agent at 1-855-368-4717 and get more help with the 4 parts of Medicare: A, B, C, and D. Our team is very experienced at explaining Medicare parts and how they work. 

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Woman wearing pink to celebrate Breast Cancer Awareness

Does Medicare cover cancer treatment?

Does Medicare cover cancer treatment senor woman chemotherapy
Medicare covers chemotherapy cancer treatment

Medicare does cover medically necessary cancer treatment supplies, services, and prescription drugs. Seniors are at greater risk of developing cancer. According to Cancer.net, “60% of people who have cancer are 65 or older.”

Estimated reading time: 3 minutes

Medicare provides cancer treatment coverage for the following:

Medicare Part A 

Woman wearing pink to celebrate Breast Cancer Awareness
Woman celebrate Breast Cancer Awareness

Medicare Part A hospital insurance covers inpatient hospital stays, including cancer treatments. For example, breast cancer may involve surgically-implanted breast prostheses after a mastectomy. If your surgery takes place in an inpatient setting, Medicare Part A covers 80% of the cost. Consequently, you pay the remaining 20% unless you have a Medicare Supplement Plan.

Senior Healthcare Direct recommends Medigap Plan G, which covers 100% of your Part A costs.

Medicare Part B

Medicare Part B medical insurance covers many cancer-related services and treatments provided on an outpatient basis. Furthermore, Part B includes preventive services. For example, you can get lung cancer and prostate cancer screenings. 

Medicare Part B cancer treatment coverage includes chemotherapy drugs administered through your vein in an outpatient clinic or doctor’s office. Part B also covers the following:

  • Some oral chemotherapy treatments
  • Radiation treatments in an outpatient clinic
  • Diagnostic tests such as X-rays and CT scans
  • Durable Medicare Equipment (DME) like wheelchairs and walkers

Furthermore, Part B covers outpatient surgeries. For example, cancer surgery to remove a tumor. It also covers mental health services to help you cope with these difficult times.

Medicare Lung Cancer Screening - senior man gets LDCT
Senior man has a low-dose CT lung cancer screening.

Patients with head, neck, or esophageal cancers, can get enteral nutrition equipment (feeding pump) as DME. If you have oral intake issues, your doctor can prescribe a feeding pump for use in your home to help you avoid malnutrition and recover for cancer treatment. Medicare covers 80% of feeding pump costs “under the prosthetic device benefit.”

Medicare Part D

Senior gets good news about her cancer treatment
Senior gets good news about her cancer treatment.

Medicare Part D covers chemotherapy and other cancer-related drug treatments. Original Medicare does not cover prescription drugs. To get drug coverage, you must enroll in either a Medicare Advantage Plan with drug coverage or a Part D plan. When you enroll in a drug plan, make sure your plan covers your list of drugs (formulary) and check the drug tiers.

You can learn more about Part D tier costs to minimize your out-of-pocket drug costs. Furthermore, Senior Healthcare Direct can help you choose a drug plan that saves you the most money per year. Please fill out our Part D Drug Finder form.

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Medicare Part D Tier Costs

Your Medicare prescription drug plan categorizes your medications into tiers that have varying costs. Each drug plan can divide its tiers in different ways. Thus, each drug tier costs a different amount. For example, a Medicare drug plan may have the following coverage and costs:

  • 1st tier preferred generic drugs with the lowest copays
  • 2nd tier non-preferred generic drugs with higher copays
  • 3rd tier preferred brand name drugs
  • 4th tier non-preferred brand name drugs
  • 5th tier specialty drugs

Estimated reading time: 3 minutes

You can determine whether your prescriptions are generic or brand name by looking at your plan’s drug formulary.

Medicare Part D Tier Costs bar graph shows rising drug cost
Bar graph shows rising drug cost for each drug tier

Drug Formulary Costs

According to GoodRx, your medication formulary “is a list of generic and brand name prescription drugs covered by your health plan.” When you use the drugs in your formulary, you will pay less for prescriptions. Furthermore, Medicare.gov says, “if you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance.” (unless you qualify for a formulary exception).

In most cases, tier 1 and 2 generic drugs will cost less than tier 3 and Specialty tiers. The price you pay for both generic and brand name prescriptions will change depending on your coverage stage. You can learn more about the four stages of drug coverage and costs in 2021.

Senior at pharmacy with pharmacist wearing face mask
Senior at pharmacy with pharmacist during COVID-19.

Medicare Part D Costs for Tier 1 and 2

In the MedicareBob video, Robert Bache says, “most drug plans cover tier-1 medications for $1 or $2, and tier-2 drugs for $3 to $5.” Furthermore, the price you pay for tier-1 and tier-2 prescriptions does not apply towards the Part D deductible. Depending on your Part D drug plan, it can divide tiers in different ways.  

Medicare Part D Costs for Tiers 3, 4, and 5

Part D drug plans have their own formularies. Depending on your plan, you may pay the full prescription cost in tiers 3, 4, and 5. Some drug plans have a deductible and some don’t. However, no Medicare drug plan may have a deductible larger than $445 in 2021.

Once you have spent $4,130 in 2021, you enter the Donut Hole. Then you pay 25% on all drugs tiers until you spend $6,550. After paying $6,550, you are out of the Donut Hole. Finally, you have reached Catastrophic Coverage and you only pay a small coinsurance or copayment amount for covered drugs until the end of the year.

Senior Healthcare Direct can help you choose a drug plan that saves you the most money per year.

Medicare Part D costs prescription bottle with hunder dollar bill

Choosing a Cost-Effective Drug Plan

Senior couple sitting inside on couch

When you provide a list of your prescriptions, Senior Healthcare Direct can shop all available drug plans to find you the most cost-effective. Find out which drug plan will save you the most amount of money based on your prescriptions. Fill out the Part D Drug Finder form.

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Do Any Medigap Plans Cover Drugs?

Medigap plans do not cover maintenance medications, aka drugs that treat chronic health conditions. All lettered Medigap Plans: A, B, C, D, F, G, K, L, M, and N do not cover prescription drugs. However, your Medigap Plan will cover drugs while an inpatient in a hospital under Part A. Furthermore, your Medigap may pay for drugs administered in your doctor’s office under Part B.

For example, Medicare Part B may cover Humira injections when administered by a licensed medical provider. Discover how MedicareBob’s advice results in a Medigap client getting their Humira injections covered by Part B.

Do Any Medigap Plans Cover Drugs

What are maintenance medications?

Maintenance medications are the everyday drugs you take to treat chronic health conditions. For example, Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory lung disease that obstructs airflow to your lungs. Most people with COPD use bronchodilator inhalers. This medication makes breathing easier by relaxing your airways. For people with Medigap Plans, you will need a separate Part D plan to cover maintenance medications.

A Brief History of Medicare Part D

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 adds a new Part D drug benefit program effective January 1, 2006. The act adds prescription drug coverage to Medicare Advantage plans. Furthermore, this public law allows beneficiaries with Part A or Part B to join Medicare Part D stand-alone Prescription Drug Plan (PDP). Thus, Medigap Plans sold after January 1, 2006, are not allowed to include prescription drug coverage. 

Brief History of Medicare Part D

Medicare Part D Plan

You can enroll or change your Medicare Part D, Advantage, or Medigap Plan during the Annual Election Period (AEP). Changes made during AEP go into effect January 1 of the following year. Furthermore, you can sign up for a Part D plan during your initial Medicare enrollment period. Moreover, you can avoid a late enrollment penalty by enrolling when you are first eligible.

Medicare Advantage Plan

You can enroll or change your Medicare Advantage Plan with or without drug coverage during the Annual Election Period. Changes become effective January 1 of the following year. Furthermore, you can switch Advantage plans or disenroll from Medicare Advantage (MA) and join a Part D drug plan. Discover when you can make these MA changes during the Medicare Advantage Open Enrollment Period.

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Happy Seniors

Medicare Part D Premium 2021

Medicare Part D Premium 2021 for senior women

In a CMS press released dated July 29, 2020, the average Medicare Part D premium for seniors will be approximately $30.50 in 2021. This low Part D premium is the same price from 2013. For example, Robert Bache quotes a 2013 monthly premium of $29.10 for Medicare Part D in Salt Lake County, Utah.

Medicare Part D Premium will be lower in 2021. According to ‘2020 Medicare Costs‘, Medicare Prescription drug plans (Part D) national base premium is $32.74. You will save an average of $2.24 per month on prescription drug costs in 2021. Moreover, the Trump Administration is lowering the price of life-saving insulin.

Medicare Copay Cap on Insulin

On March 26, 2020, CNN reports President Trump announced a plan to reduce the price of insulin for people on Medicare. Trump said seniors on Medicare would be able to get prescription plans that cap copay costs for insulin. Furthermore, seniors can access various insulin types at no more than a copay of $35 for a month’s supply. Trump said:

Today, I’m proud to announce that we have reached a breakthrough agreement to dramatically slash the out-of-pocket cost of insulin.

President Trump Medicare Copay Cap on Insulin

Part D Senior Savings Model

Part D Senior Savings Model
Insulin in 2021 will only cost $35 per month or less!

Earlier in 2020, CMS launched the Part D Senior Savings Model. It allows you to choose a plan that provides access to a broad set of insulins at a maximum of $35 copay for a month’s supply. You can select these Part D plans during the 2020 open enrollment period. Starting October 15 through December 7, you can purchase a plan and save an average of $446 per year (66%) of your insulin out-of-pocket costs. 

Furthermore, there are over 1,600 standalone Medicare Part D and Medicare Advantage Plans you can choose. These Medicare plans are available nationwide. Senior Healthcare Direct can help you shop and compare Medicare plans. To get the best price, call 1-855-368-4717 or get your quote.

Extra Help Medicare Part D

What is Extra Help for Medicare Part D?

Extra Help Medicare Part D

Extra Help for Medicare Part D is a program to help people with limited income and resources pay Medicare prescription drug costs. For example, Extra Help can help pay your Medicare Part D premiums, deductibles, and copayment costs. To join a Medicare Part D drug plan, you must have Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance). However, you must have both Part A and Part B to join a Medicare Advantage plan. Now that you know Extra Help pays for your prescription drug costs, how do you qualify?

Do I Qualify for Extra Help?

According to SSA.gov, to qualify for Part D Extra Help, you must be receiving Medicare and have limited resources and income. Furthermore, you must reside in one of the 50 States or the District of Columbia. As MedicareBob shows in his video, Extra Help is not available in Puerto Rico, U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa. In this video, Robert Bache showed income requirements to qualify for Extra Help in 2019.

Do You Automatically Qualify For Extra Help?

You automatically qualify for Extra Help under the following three conditions: 

  • You have Medicare and Supplemental Security Income (SSI)
  • Have Medicare and Medicaid
  • You’re in a Medicare Savings Program

If you meet any of the above conditions, Medicare will send you a PURPLE notice. We advise you to keep this “Deemed Status Notice.” You do not need to apply for Extra Help. Then provide your Medicare Part D plan this document. It proves you qualify for Extra Help.

Furthermore, you can provide Medicare Part D with the following documents as proof that you qualify for Extra Help:

  • A yellow or green automatic enrollment notice from Medicare
  • Extra Help “Notice of Award” from Social Security
  • An orange notice from Medicare that says your copayment amount will change next year
  • Your award letter from Social Security that you have SSI

Extra Help Income and Resource Qualifications

As of March 2020, SSA.org published Understanding the Extra Help With Your Medicare Prescription Drug PlanIt states your resources and income must be limited to $14,610 for an individual or $29,160 for a married couple living together. Resources include things of value that you own, which may include the following:

  • Real estate (other than your primary residence)
  • Bank accounts
  • Stocks
  • Bonds
  • Mutual Funds
  • IRAs
  • Cash

On the other hand, resources that do not count include the following:

  • Your primary residence
  • Personal possessions such as jewelry or home furnishings
  • Your vehicle
  • Property you need for self-support, such as rental property or land you use to grow produce for home consumption
  • Non-business property essential to your self-support
  • Life insurance polices
  • Burial expenses

Benefits of Extra Help

The amount of Extra Help you receive depends on your income and resources. You can receive either a full-subsidy or a partial subsidy. Anyone who meets State Medicaid financial eligibility qualifies for Full Low-Income (LIS) Subsidy and pays no premiums, no deductible, no copay, and no coinsurance. Furthermore, anyone who qualifies for Full LIS will pay no more than $8.95 copay for brand-name and $3.60 copay for generic drugs.

In addition to lower out-of-pocket expenses, Medicare beneficiaries with Extra Help have three Special Enrollment Periods. You can join or switch Medicare Part D drug plans every three months from January through September. Furthermore, you can join or switch during the Annual Enrollment Period (Oct 15 – Dec 7). Moreover, you do not pay any Part D late enrollment penalty.

How to Apply for Extra Help Medicare Part D?

Senior Using Smartphone

You can apply for Extra Help online. To complete the application, you will need to provide SSA.gov information about your income and resources. Documents that can help you include the following:

  • Social Security card
  • Bank account statements
  • Individual Retirement Acounts, stocks, bonds, mutual funds
  • Tax returns
  • Payroll slips
  • Your most recent Social Security benefits award letters or statements for Railroad Retirement benefits, Veterans Benefits, pensions and annuities

Apply for Extra Help at Social Security Administration website.

Medicare Part D

Medicare Part D 2021 Costs

Medicare Part D 2021 Costs

Medicare Part D 2021 Costs

The cost of Medicare Part D will increase in 2021. Medicare Part D is insurance coverage that lowers your out-of-pocket costs for prescription drugs. There are four stages of Medicare Part D, and each stage has new drug costs.

4 Stages of Drug Coverage and Costs in 2021

Below are the four stages of Part D drug coverage and costs in 2021.

Stage 1 – Part D Deductible

Before your Part D drug plan pays anything, the deductible (if any) needs to be paid. Stage one may have a Part D deductible, which increased $10 from $435 in 2020 to $445 in 2021. If your plan has no deductible or you pay this initial Part D deductible, you enter stage two.

Stage 2 – Part D Initial Coverage

Stage two is Initial Coverage. In this stage, Medicare helps pay for your prescription drugs. Your copays and coinsurance vary and are a percentage of an approved amount. However, in Original Medicare, the coinsurance is usually 20% of Medicare’s assignment.

For most plans, when you spend $4,130 in total drug costs in 2021, you enter the donut hole. However, if you do not spend $4,130 on prescription drugs in 2021, you will not enter the donut hole.

Stage 3 – Part D Coverage Gap

Stage three is Donut Hole, also called Coverage Gap. You pay 25% coinsurance for generic and brand-name (non-discounted cost) prescription drugs in stage three. The 2021 coinsurance costs inside the coverage gap are the same as in 2020. However, the total amount you spend inside the donut hole increases $200 from $6,350 in 2020 to $6,550 in 2021. Once you pay $6,550 in out-of-pocket drug costs, you enter stage four.

Stage 4 – Part D Catastrophic Coverage

Stage four is Catastrophic Coverage. While inside stage four, you pay the greater of 5% prescription drug cost or $9.20 brand-name / $3.70 generic. For example, if your brand-name drug costs $100, you would pay $9.20. On the other hand, if your brand-name drug costs $300, you would pay 5% or $15. However, if a generic drug only costs $50, you would pay $3.70.

Medicare Part D 2021 Deductible

In the MedicareBob video below, Robert Bache provides more details about “Tier Deductibles.” Watch this video and discover which drug tiers allow you to avoid paying the $445 Part D deductible in 2021. Furthermore, Robert announces when you can purchase the new 2021 drug plans.

Learn more about Medicare Part D drug tiers.

Get Help with your 2021 Drug Plan

As Robert says in the video, we can help you with your 2021 Drug Plan. Update: the Medicare Part D Finder form has gone away. However, the licensed agents at Senior Healthcare Direct can assist you in finding the right Part D plan. Our agents can provide you a side-by-side comparison of Medicare Part D drug plans so that you can choose the most cost-effective plan for 2021.

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