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Medical and Dental Care

Cut down on medical costs by obtaining low cost or no cost insurance that not only pays for some of your medical bills, but also reduces the size of your bills—medical providers charge insurers far lower rates than they charge an uninsured consumer.

Medicare. If you are 65 or older, make sure you are getting available Medicare benefits. A Medicare prescription drug program for seniors, Medicare Part D, is voluntary and lets you shop for a prescription drug plan from a number of private insurance companies. Selecting a plan that is favorable for you could save you a lot of money on drug costs. For those below 150% of the poverty line, Medicare Part D provides subsidies for premiums and co-payment for drugs. A number of programs also supplement Part D coverage.

Those with incomes below $17,500 a year if single or $23,500 if a couple and with few assets may be able to get help paying for Medicare premiums or cost-sharing from “Medicare Savings” programs. Seniors or people with disabilities on Medicare may also qualify for Medicaid (see below).

For more information, visit www.medicare.gov. For low-income programs, visit www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs.

State Health Insurance Assistance Programs (SHIP) are available to provide counseling on Medicare choices. https://www.shiptacenter.org/. Other excellent resources include: Justice in Aging (202-289-6976; www.justiceinaging.org) and the Center for Medicare Advocacy (860-456-7790; www.medicareadvocacy.org).

Subsidized Exchange or Marketplace Coverage. Many people are eligible to purchase health insurance in a marketplace called an “Exchange” or “Marketplace.” Families with incomes up to 400% of the federal poverty level (in 2020, $68,960 for a family of two or $104,800 for a family of four, and higher in Hawaii and Alaska) receive tax credits to make this coverage more affordable. People in families with incomes up to 250% of the poverty line who are enrolled in certain Marketplace silver level plans also receive subsidies to help them pay for out-of-pocket health care costs, such as deductibles and co-insurance.

For information on plan choices in each state, how insurance coverage works, and how to apply, visit www.healthcare.gov. There is one open enrollment period each year, but anyone losing their job, aging out of coverage under their parent’s policy, or losing coverage because of other life events can enroll at any time during the year.

Medicaid. Apply for both subsidized Marketplace coverage and Medicaid coverage at the same time by going to www.healthcare.gov or calling 800-318-2596. You can also apply for Medicaid at your local public assistance office. If initially denied enrollment, you have appeal rights.

Eligibility for Medicaid varies by state. Most states have opted into a federal program that standardizes most eligibility standards. Generally, in these states, people automatically qualify if their income is 138% of the poverty line or below—in 2021, $17,608 if single or $36,156 for a family of four. There is no longer a requirement in these states that an individual’s personal assets be under a certain amount to be eligible.

Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming have not joined the federal program that standardizes eligibility. (Missouri and Oklahoma are scheduled to join on July 1, 2021, and Wyoming is considering joining.) In the states not opting into the federal program, eligibility standards are far stricter, often requiring a lower income, few personal assets, and even a particular personal status, such as being pregnant or being a child.

Income limits for children are higher than for adults in all states. Thus low-income and working families may be able to get Medicaid for their children, even if they don’t qualify. Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provides coverage for a broad array of diagnostic, preventive, and treatment services for beneficiaries under age 21.

The website www.healthcare.gov provides information about Medicaid by state and links to state programs.

Children’s Health Insurance Program (CHIP) and Other State Programs. CHIP provides health insurance to children in families with incomes that are above the Medicaid limit, often to 200% of the poverty line or higher. Each state program has its own rules. Check with your state health department to find out more information. Apply for CHIP at www.insurekidsnow.gov, www.healthcare.gov, or by calling 877-543-7669. In most states, you can apply for CHIP at the same time and location that you apply for Medicaid. If you have insurance coverage through your job but qualify as low income, your children may still be eligible for CHIP coverage.

Health Insurance for Young Adults. Health plans that offer coverage to the insured person’s children must generally make coverage available until the children turn 26 years old. Children can join or remain on their parent’s plan even if they are married, not living with their parents, or are financially independent.

Keeping Your Health Insurance After Losing Your Job. If you have recently left work at a private employer with more than 20 employees and were covered by your employer’s health insurance, you may be able to keep that insurance, although you must pay the premium. This program is called COBRA. When your old employer contacts you about COBRA, you have 60 days to decide whether to pay the premium to keep the coverage. State-based insurance navigators can help you compare COBRA and Marketplace options to make an informed choice.

Other Medical Care Options. Some states have plans to assist with major medical expenses. When medical bills exceed a certain percentage of an applicant’s household income, the balance of the bill above that percentage is reimbursed. Local service clubs also sometimes have programs designed to meet particular needs. The best known is the Lions Club, which helps to purchase eyeglasses for children.

Medical Prescriptions. When receiving a prescription, ask whether a less expensive generic drug can be substituted. Many states have programs to assist seniors in paying for prescription drugs. Medicaid covers some prescriptions for most beneficiaries and, as discussed above in the Medicare section, a Medicare prescription drug program, Medicare Part D, provides subsidies if you qualify as low income.

Doctors may have free samples of medication available. Most drug companies run programs which provide reduced cost or free medication for those in need. Search online for patient assistance programs based on the name of the specific drug or the drug’s manufacturer. Hospitals run by the Department of Veterans Affairs generally provide medicine to veterans for a small fee.

Low-Cost Dental Care. Some dental care may be covered by your health insurance policy, and some state Medicaid programs include dental coverage for adults. All must provide children’s dental checkups. Community college dental hygiene programs and university dental schools may provide free or low-cost services as part of their teaching program. Some hospitals have low-cost oral surgery clinics.

Avoiding Out-of-Network Medical Providers. If you have insurance, make sure that, for non-emergency care, your medical provider is within your insurance network, and thus covered by your insurance. Confirming in-network status is complicated because individual doctors, surgeons, or other medical service providers (such as radiologists, anesthesiologists, or pathologists) may be out-of-network even if a hospital is listed as in-network. A few states have protections for out-of-network charges in certain situations, such as emergency room care or for health maintenance organization (HMO) patients. For health insurance plans purchased in 2022 or after, federal law also provides some protections against surprise medical bills—this includes instances where the hospital was in-network but some of the doctors were not. Try to negotiate surprise or unexpected bills—especially for large bills—before agreeing to pay.

Financial Assistance/Charity Care. Nonprofit hospitals have a duty to provide charity care or financial assistance to low-income patients because of their tax-exempt status. The Affordable Care Act requires all nonprofit hospitals to have a written financial assistance policy that explains who is eligible and how to apply for financial assistance.