The Basics
Everybody should have health coverage so that they can visit the doctor or get medications. It used to be that a lot of people, especially people with disabilities, couldn’t afford to get health coverage or couldn’t even qualify to get it. However, that’s changed. Now, there’s a health coverage option for almost everybody, even if you have a disability.
This article introduces your most likely health coverage options:
- Income-based MO HealthNet, a government program which is almost free if you have low income, whether or not you have a disability.
- Disability-based MO HealthNet, which is almost free if you have low income, low resources, and have a disability, are blind, or are a senior (65 or older). Most people who get Supplemental Security Income (SSI) benefits qualify for disability-based MO HealthNet.
- MO HealthNet's Ticket to Work Health Assurance program, which lets you get MO HealthNet coverage if you have a disability, you work, and earn more than MO HealthNet's standard income limit. You may need to pay a monthly premium.
- Medicare, which you get if you have a disability or are a senior (65 and older), if you or a family member has worked long enough while paying Medicare taxes.
- Employer-sponsored coverage, which your employer or a family member’s employer helps you pay for.
- Individual coverage, which you pay for yourself, possibly with the help of government subsidies.
All of these coverage options have:
- Clearly defined services they cover, including most of the physical and mental health needs you may have. For private insurance, all plans must cover Essential Health Benefits. Medicare’s coverage is comparable, while MO HealthNet offers some additional benefits, like personal assistance services, if you need them.
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Payments you must make. Typically, payments for private insurance are highest and the fees for MO HealthNet are lowest. Your payments may include:
- Premiums, a monthly payment you must make whether or not you use any medical services. (MO HealthNet usually has no premium.)
- Copayments, a set amount you have to pay for a medical visit or service. The amount of the copayment depends on the service you get.
- Co-insurance, a set percentage of the cost of a visit or service that you must pay.
- A deductible, a set amount of money that you pay out of your own pocket each year before the insurance company begins to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
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An out-of-pocket maximum, which is an annual cap on how much you have to spend on copayments, co-insurance, and deductibles. That means you never have to spend more than $9,100 if you’re single or $18,200 for a family on these expenses.
- Medicare is an exception: It does not always have an out-of-pocket maximum.
None of these coverage options:
- Have annual or lifetime limits on how much you can get in benefits. No matter how much medical care your insurance has to pay for, they can't stop paying for care you need.
- Can discriminate against you because you have a disability. They cannot deny you coverage, charge you more, or refuse to pay for certain types of treatment because you have a pre-existing condition.
Read the rest of this article to discover which coverage is right for you and how to sign up.
Don’t assume that coverage is too expensive or that you don’t qualify. You may qualify for one of these programs and it may cost less than you think.
You can use DB101's Finding the Right Coverage for You interactive guide to get an idea of which program might work best in your situation.
Note: DB101 keeps track of changes to health coverage and related laws. DB101 articles and tools have recently been updated to include MO HealthNet's expansion of coverage for adults 18-64 years old (Medicaid Expansion). Get more information about applying for this coverage.
Learn more
Income-Based MO HealthNet
Look at income-based MO HealthNet if:
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You are less than 65 years old
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You don’t qualify for SSI or Medicare
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You are a U.S. citizen or eligible immigrant, and
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Your household has low income.
Is It Right for You?
MO HealthNet is government-funded health coverage for people in certain situations. You may qualify if you:
- Have low income, no matter how much you have in resources or whether you have a disability. Income-based MO HealthNet is explained on this page.
- Have low income, low resources, and have a disability, are blind, or are a senior. Learn more about disability-based MO HealthNet.
- Used to get Supplemental Security Income (SSI), but stopped getting SSI because of work. If so, SSI's 1619(b) rule may mean you can get MO HealthNet. Learn more about 1619(b).
- Have a disability and work, even if your income is higher. Learn more about MO HealthNet's Ticket to Work Health Assurance program.
Note: Children under the age of 19, their parents or caretaker relatives, and pregnant women may also qualify for MO HealthNet. Learn more in DB101's article on MO HealthNet Eligibility for Young People.
Answer the questions on this page to see if you might qualify for MO HealthNet for people with disabilities, the blind or visually impaired, or seniors age 65 and older. If so, it’s probably your best health coverage option because it doesn’t usually have a premium, the copayments for services are generally lower than copayments required by private plans, and MO HealthNet covers more services than most private plans. Also, if you qualify for MO HealthNet, you cannot get government help paying for an individual plan on Healthcare.gov.
Note: DB101 keeps track of changes to health coverage and related laws. DB101 articles and tools have recently been updated to include MO HealthNet's expansion of coverage for adults 18-64 years old (Medicaid Expansion). Get more information about applying for this coverage.
Do You Meet Income-Based MO HealthNet’s Basic Requirements?
To qualify for income-based MO HealthNet, you must:
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Be under 65 years old
- You can be 65 or older if you are the parent or caretaker of a child.
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Not qualify for Medicare
- You can be on Medicare if you are the parent or caretaker of a child or are pregnant.
- Be a U.S. citizen or meet specific noncitizen requirements
If you are under 65, do not qualify for Medicare, and are either a U.S. citizen or a noncitizen who qualifies, income-based MO HealthNet might cover you.
MO HealthNet’s rules for immigrants:
- Undocumented immigrants do not qualify for full MO HealthNet coverage, but they may qualify for MO HealthNet coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full MO HealthNet coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements.
Is Your Income Low Enough for Income-Based MO HealthNet?
These are the main income rules for income-based MO HealthNet:
- If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.
- If you are 18 or younger and your family’s income is at or under 148% of FPG ($44,400 per year for a family of four), you may qualify for MO HealthNet for Kids Non-SCHIP and won't have to pay a monthly premium.
- If you are 18 or younger and your family’s income is up to 300% of FPG ($90,000 per year for a family of four), you may qualify for MO HealthNet for Kids Non-SCHIP with a monthly premium.
Income-based MO HealthNet, sometimes called "MO HealthNet expansion," is based on your Modified Adjusted Gross Income (MAGI), which includes most earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits, growth of the investments in an ABLE account, and some contributions to retirement accounts. Learn more about what types of income affect income-based MO HealthNet eligibility.
Note: There are no limits to how much money or other resources you can have for income-based MO HealthNet.
| Your family size: | |
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Income limits for your family: | |
| Income-based MO HealthNet, adults (138% FPG) | |
| MO HealthNet for Kids, free (150% FPG) | |
| MO HealthNet for Kids, premium (300% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Notes:
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If your income is low enough and you meet all other requirements, you should sign up for MO HealthNet.
More Ways to Qualify for MO HealthNet if You Have a Disability
There are other ways to qualify for MO HealthNet if you have a disability. You might qualify for disability-based MO HealthNet if:
- You make more money at work than income-based MO HealthNet allows. In that case, you could apply for MO HealthNet's Ticket to Work Health Assurance program.
- You also get Medicare. Usually, MO HealthNet doesn’t cover people getting Medicare, but disability-based MO HealthNet does. It may even help pay your monthly Medicare premiums.
- You are 65 years old or older.
You might qualify for income-based MO HealthNet, even though you have a disability, if:
- Your disability does not meet Social Security’s definition of disability. Disability-based MO HealthNet is only for people who have disabilities meeting this standard.
- You have more resources than are allowed by disability-based MO HealthNet.
- You make enough money that you would have to pay a monthly premium for Ticket to Work Health Assurance.
Learn more about disability-based MO HealthNet and Ticket to Work Health Assurance.
How to Sign Up
To apply for MO HealthNet, you can:
- Apply online at MyDSS.mo.gov; you can also apply at the same time for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance, or other benefits
- Download and print an application (also available in Spanish) and mail it to the address on the form
- Call the Family Support Division Information Center at 1-855-373-4636 to have an application mailed to you, or
- Call or visit your local Family Support Division (FSD) office.
If you need help filling out an application, talk to a benefits specialist.
Staying on MO HealthNet
Usually, once approved for MO HealthNet, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let the Family Support Division (FSD) office know within 10 days of the change. You can do this in person, by phone, or online. When you report your changes, the FSD tells you if you can no longer get MO HealthNet or if you have new health coverage options, like MO HealthNet Spend Down or Ticket to Work Health Assurance.
Learn more
Disability-Based MO HealthNet
Look at disability-based MO HealthNet if you get SSI or if:
- You are a U.S. citizen or eligible immigrant
- You have a disability or are a senior
- You have low resources, and
- You have low income.
Is It Right for You?
MO HealthNet is government-funded health coverage for people in certain situations. You may qualify if you:
- Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based MO HealthNet.
- Have low income, low resources, and have a disability, are blind, or are a senior. Disability-based MO HealthNet is explained on this page.
- Used to get Supplemental Security Income (SSI), but stopped getting SSI because of work. If so, SSI's 1619(b) rule may mean you can get MO HealthNet. Learn more about 1619(b).
- Have a disability and work, even if your income is higher. Learn more about MO HealthNet's Ticket to Work Health Assurance program.
Note: Children under the age of 19, their parents or caretaker relatives, and pregnant women may also qualify for MO HealthNet. Learn more in DB101's article on MO HealthNet Eligibility for Young People.
Answer the questions on this page to see if you might qualify for MO HealthNet for people with disabilities, the blind or visually impaired, or seniors age 65 and older. If so, it’s probably your best health coverage option because it doesn’t usually have a premium, the copayments for services are generally lower than copayments required by private plans, and MO HealthNet covers more services than most private plans. Also, if you qualify for MO HealthNet, you cannot get government help paying for an individual plan on Healthcare.gov.
Note: DB101 keeps track of changes to health coverage and related laws. DB101 articles and tools have recently been updated to include MO HealthNet's expansion of coverage for adults 18-64 years old (Medicaid Expansion). Get more information about applying for this coverage.
MO HealthNet’s rules for immigrants:
- Undocumented immigrants do not qualify for full MO HealthNet coverage, but they may qualify for MO HealthNet coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full MO HealthNet coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements.
Do You Have a Disability That Meets Social Security’s Standards?
To qualify for disability-based MO HealthNet, you must have a disability that meets Social Security’s definition of disability. For adults, Social Security says you have a disability if:
- You have a physical or mental impairment or combination of impairments
- Your impairments limit your ability to work, preventing you from earning Substantial Gainful Activity ($1,470 per month or $2,460 per month if you’re blind), and
- Your condition has lasted or is expected to last for at least 12 months.
If you currently get Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), you already meet Social Security’s disability standards. If not, a Medical Review Team looks at your medical records and other documents to see if your disaiblity qualifies for MO HealthNet.
Note: You can also qualify for MO HealthNet if you are 65 years old or older.The other eligibility rules described for disability-based MO HealthNet apply.
Note: Learn about Social Security’s definition of disability for children under 18 in DB101’s Benefits for Young People article.
If you already have a disability determination from Social Security or think that your disability meets Social Security’s standards, or if you are 65 or older, disability-based MO HealthNet might cover you.
Do You Have Very Low Resources?
Resources are money and property you own. For disability-based MO HealthNet, you and your spouse (or your parents if you are under 18) must have very low resources:
- If you are single, the most you can have is $5,726 in available resources.
- For couples, the limit is $11,452.
Some resources don’t count towards disability-based MO HealthNet’s resource limit, like the home you live in, one car, and any money you have in an ABLE account.
If your resources are below the limit, disability-based MO HealthNet might cover you.
Do You Have Very Low Income?
To get disability-based MO HealthNet, your countable income has to be low:
- If you have a disability or are a senior, it must be 85% of the Federal Poverty Guidelines (FPG) or less ($1,033 per month you are single, $1,397 or less for couples).
- If you are blind, it must be 100% of FPG or less ($1,215 per month if you're single, $1,644 for couples).
Not all of your income is counted. The way your income is counted for disability-based MO HealthNet is very similar to SSI’s countable income calculation:
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Most of your unearned income is counted.
- Important: SSI and Supplemental Nutrition Assistance Program (SNAP) benefits are not counted for disability-based MO HealthNet eligibility.
- Less than half of your earned income is counted.
This means that if you have a disability determination, you might be able to get a job and make $2,000 per month or more without losing your disability-based MO HealthNet, because more than half of your earned income wouldn’t be counted.
If you live alone, try this tool to see if your countable income is below disability-based MO HealthNet’s income limit.
| Your Monthly Earned Income | $ |
| Your Monthly Unearned Income (not including SSI) | $ |
| Your Monthly Impairment Related Work Expenses (IRWEs) | $ |
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| Your Monthly Countable Income | |
| Your Annual Countable Income | |
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| Your Countable Income as a Percent of FPG |
If you live with a spouse, some of their income may be counted and your combined countable income will be compared to the limit for a couple.
If your income is low enough and you meet all other requirements, you should sign up for MO HealthNet.
If your income is over the standard MO HealthNet limits, you may have two options:
- MO HealthNet Spend Down: A spend down is like a monthly deductible: you pay the first part of your monthly medical costs and MO HealthNet only pays for your health care expenses after you've paid the spend down. Your monthly spend-down amount depends on your countable income. If you prefer, you can pay your spend-down amount directly to MO HealthNet each month (like a premium). Learn more about the Spend Down program, including answers to Frequently Asked Questions.
- MO HealthNet's Ticket to Work Health Assurance program: If you work, you may qualify for MO HealthNet through the Ticket to Work Health Assurance program, which has a higher income limit than disability-based MO HealthNet. You might have to pay a monthly premium, depending on your countable income, but the premium will probably be less than what you would pay under the Spend Down program. Learn more about Ticket to Work Health Assurance.
Note: If you work, the Family Support Division will figure out if you qualify for Ticket to Work Health Assurance and MO HealthNet Spend Down, and let you choose the option that is best for you.
More Ways to Qualify for MO HealthNet if You Have a Disability
There are other ways to qualify for MO HealthNet if you have a disability. You might qualify for income-based MO HealthNet if:
- Your disability does not meet Social Security’s definition of disability. Disability-based MO HealthNet is only for people who have disabilities meeting this standard.
- You have more resources than are allowed by disability-based MO HealthNet.
- You make enough money that you would have to pay a monthly premium for Ticket to Work Health Assurance.
You might qualify for disability-based MO HealthNet instead of income-based MO HealthNet if:
- You make more money at work than income-based MO HealthNet allows. In that case, you could apply for MO HealthNet's Ticket to Work Health Assurance program.
- You also get Medicare. Income-based MO HealthNet doesn’t cover people getting Medicare, but disability-based MO HealthNet does. It may even help pay your monthly Medicare premiums.
- You are 65 years old or older.
Learn more about income-based MO HealthNet and Ticket to Work Health Assurance.
How to Sign Up
To apply for MO HealthNet, you can:
- Apply online at MyDSS.mo.gov; you can also apply at the same time for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance, or other benefits
- Download and print an application (also available in Spanish) and mail it to the address on the form
- Call the Family Support Division Information Center at 1-855-373-4636 to have an application mailed to you, or
- Call or visit your local Family Support Division (FSD) office.
If you need help filling out an application, talk to a benefits specialist.
Staying on MO HealthNet
Usually, once approved for MO HealthNet, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let the Family Support Division (FSD) office know within 10 days of the change. You can do this in person, by phone, or online. When you report your changes, the FSD tells you if you can no longer get MO HealthNet or if you have new health coverage options, like MO HealthNet Spend Down or Ticket to Work Health Assurance.
Learn more
MO HealthNet's Ticket to Work Health Assurance
Look at Ticket to Work Health Assurance if:
- You are 16-64 years old
- You have a disability
- You work
- You have limited resources, and
- You are a citizen or eligible immigrant.
Is It Right for You?
MO HealthNet is government-funded health coverage for people in certain situations. You may qualify if you:
- Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based MO HealthNet.
- Have low income, low resources, and have a disability, are blind, or are a senior. Learn more about disability-based MO HealthNet.
- Used to get Supplemental Security Income (SSI), but stopped getting SSI because of work. If so, SSI's 1619(b) rule may mean you can get MO HealthNet. Learn more about 1619(b).
- Have a disability and work, even if your income is higher. MO HealthNet's Ticket to Work Health Assurance program is explained on this page.
Answer the questions on this page to see if you might qualify for Ticket to Work Health Assurance. If so, it’s a good option to consider because it lets you earn a lot more money and pay a monthly premium, low copayments, and no deductible to get MO HealthNet’s comprehensive coverage. You can also download a Ticket to Work Health Assurance brochure.
Do You Meet Ticket to Work Health Assurance’s Basic Requirements?
To qualify for Ticket to Work Health Assurance, you must:
- Be 16 – 64 years old
- Have a disability or a medically improved condition that meets Social Security's standards
- Be working
- Have gross and net income at or below the Ticket to Work Health Assurance limits
- Have available resources at or below the MO HealthNet limits
- Live in Missouri, and
- Be a U.S. citizen or meet specific noncitizen requirements.
If you live in Missouri, are 16 – 64 years old, working, have a disability, are either a U.S. citizen or a non-citizen who qualifies, and your income and resources aren't more than the limits, Ticket to Work Health Assurance might be an option for you.
MO HealthNet’s rules for immigrants:
- Undocumented immigrants do not qualify for full MO HealthNet coverage, but they may qualify for MO HealthNet coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full MO HealthNet coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements.
Do You Have a Disability That Meets Social Security’s Standards?
To qualify for Ticket to Work Health Assurance, you must either have a disability that meets Social Security’s definition of a disability or have a medically improved condition.
For adults, Social Security says you have a disability if:
- You have a physical or mental impairment or combination of impairments, and
- Your condition has lasted or is expected to last for at least 12 months.
If you work and no longer qualify for MO HealthNet solely due to medical improvement (your condition getting better), you can also get Ticket to Work Health Assurance coverage.
Note: For Ticket to Work Health Assurance, Social Security’s disability rules related to having earned income above the Substantial Gainful Activity (SGA) level do not apply.
If you currently get Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), your disability qualifies. If not, a Medical Review Team looks at your medical records and other documents to see if your disability qualifies for Ticket to Work Health Assurance.
If you already have a disability determination from Social Security, think that your disability meets Social Security’s standards, or have a medically improved condition, Ticket to Work Health Assurance might be an option for you.
Do You Have Low Resources?
Resources are money and property you own. For Ticket to Work Health Assurance, you must have less than $5,726 in available resources for an individual, or $11,452 for an eligible couple.
Some resources don’t count towards Ticket to Work Health Assurance’s resource limit, like the home you live in, one car, and money you have in an ABLE account.
If your resources are below the limit, Ticket to Work Health Assurance might be an option for you.
Is Your Income Below Ticket to Work Health Assurance’s Income Limit?
To get Ticket to Work Health Assurance coverage, there are two income limits:
- Gross income, including both your unearned income and earned income, must be at or below 300% of the Federal Poverty Guidelines (FPG). That's $3,645 per month or less for an individual, $4,930 or less for a couple.
- Net income, which doesn't include your earnings and has some other deductions, must be below 85% of FPG ($1,033 per month if you are single, $1,397 or less for couples).
If your gross income is more than 100% of FPG ($1,215 per month if you are single; $1,644 per month for couples), you have to pay a monthly premium for Ticket to Work Health Assurance. The cost of your premium depends on your income, but the most you might have to pay is $156 per month for an individual and $211 for a couple.
Get more information about the Ticket to Work Health Assurance income limits.
If your income is low enough and you meet all other requirements, you should sign up for Ticket to Work Health Assurance. If you can also get employer-sponsored coverage, MO HealthNet may pay the premium for it.
How to Sign Up
To apply for Ticket to Work Health Assurance, you can:
- Apply online at MyDSS.mo.gov; you can also apply at the same time for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance, or other benefits
- Download and print an application (also available in Spanish) and mail it to the address on the form
- Call the Family Support Division Information Center at 1-855-373-4636 to have an application mailed to you, or
- Call or visit your local Family Support Division (FSD) office.
If you need help filling out an application, talk to a benefits specialist.
Staying on Ticket to Work Health Assurance
Usually, once approved for Ticket to Work Health Assurance, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your Family Support Division (FSD) office know within 10 days of the change. You can do this in person, by phone, or online. When you report your changes, FSD will tell you if your Ticket to Work Health Assurance premium changes, or your coverage will end or change to another MO HealthNet category.
Learn more
Medicare
If you get Medicare, you may be able to get:
- Employer-sponsored coverage at the same time
- MO HealthNet or Ticket to Work Health Assurance at the same time
- Help paying for Parts A, B, and D
- Parts A, B, and D in a combined plan, or
- A supplement plan to cover more medical expenses.
What 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 qualify for Medicare:
- When you turn 65
- After you get 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 also qualify for Medicare.
If you qualify for Medicare, you can choose from two options:
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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.
- After you get SSDI or CDB for two years, you automatically get Medicare Parts A and B. Otherwise, you may need to sign up, depending on your situation.
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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 or MO HealthNet (including MO HealthNet's Ticket to Work Health Assurance program), having those other benefits may impact your Medicare decisions:
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If you also qualify for MO HealthNet, it may help pay for some medical expenses that Parts A and B don't pay for. MO HealthNet will pay for the Part A and B copayments and deductibles, and it may pay the Part B premium. MO HealthNet will also pay half of your Part D copayments.
- Note: If you are eligible for Medicare, MO HealthNet will not cover your prescription drug cost, even if you choose not to enroll in Part D.
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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 Missouri SHIP.
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 MO HealthNet. 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 $164.90 per month or a bit less, depending on your situation).
However, if you have low income and low resources, you may qualify for a Medicare Savings Program (MSP). Missouri offers three Medicare Savings Programs:
- The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,215 per month or less if you live alone). QMB pays all Medicare cost-sharing, including 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 ($1,458 per month or less if you live alone). SLMB pays for the Part B premium, but does not help with anything else.
- The Qualified Individual (QI) program, also called SLMB-2 in Missouri, helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,641 per month or less if you live alone). QI pays for the Part B premium, but does not help with anything else.
For MSPs, less than half of your earned income is counted. That means you might qualify even if you think your income is over the limits.
| Your Monthly Earned Income | $ |
| Your Monthly Unearned Income (not including SSI) | $ |
| Your Monthly Impairment Related Work Expenses (IRWEs) | $ |
| |
| Your Monthly Countable Income | |
| Your Annual Countable Income | |
| |
| Your Countable Income as a Percent of FPG |
The resource limit for QMB, SLMB, and QI is $9,090 if you live alone and $13,630 if you live with your spouse.
To apply for an MSP, you can:
- Apply online at myDSS.mo.gov
- Visit your local Family Support Division (FSD) office to pick up an application, or
- Call the FSD Information Center at 1-855-373-4636 and ask to have an application mailed to you.
If you have any questions about how to complete the application, call the FSD Information Center at 1-855-373-4636.
Learn more about Medicare Savings Programs in Missouri.
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 Part D Extra Help, also called the Low Income Subsidy (LIS). You automatically get the Low Income Subsidy if you:
- Have both Medicare and SSI
- Have both Medicare and MO HealthNet, or
- Are enrolled in an Medicare Savings Program.
The Low Income Subsidy has two levels:
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The full subsidy is for people who also get MO HealthNet coverage or who are in a Medicare Savings Program. You may also qualify if your countable income is less than $19,683 per year and your resources are less than $9,090 if you are single (the limits are higher for larger households).
- With the full subsidy, you don't have to pay a Part D premium or deductible, and there may be lower copayments.
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The partial subsidy is for people who can’t get the full subsidy, but have less than $21,870 in annual countable income and less than $15,160 in resources, if you are single (the limits are higher for larger households).
- With the partial subsidy, you pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and only have to pay a $104 deductible before you get help paying for drugs. You have to pay co-insurance and copayments for your medications, but they're lower than without the partial subsidy.
Note: 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.
You can also save money by finding a better Part D plan for the medications you take. Use the Medicare Plan Finder to find the right Part D plan for you.
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 don’t cover. For example, a Medicare supplement could cover things like your co-insurance payments for Part B.
You 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 costs, plus an additional amount for extra benefits and prescription drug coverage. A Medicare Savings 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.
Getting Help with Medicare
If you have any problems or questions, trained volunteer counselors at Missouri SHIP offer free Medicare counseling and education to Missouri residents. The SHIP counselors do not sell anything and do not ask for money.
You can only make changes to your Medicare coverage, such as changing your Part D plan, adding a Medicare supplement plan, or switching to Medicare Advantage, during open enrollment, which is from October 15 to December 7 of each year.
If you have any changes you want to make, make sure to do them during this time period, or else you have to wait another year.
Learn more
Employer-Sponsored Coverage
Look at employer-sponsored coverage if:
- Your employer, your parent's employer, or your spouse's employer offers it
- You meet the employer’s requirements, and
- You can't get MO HealthNet.
Is It Right for You?
To get private health insurance, a premium must be paid every month. Many employers offer to pay part, or all, of this monthly premium as a job benefit for employees, their children until they turn 26 years old, and their spouses. Employer-sponsored health coverage is the most common type of coverage in the U.S.
Answer the questions on this page to see if you can get employer-sponsored coverage. If you can, you probably should because you won’t qualify for subsidized individual coverage.
Can You Get MO HealthNet?
If you qualify for MO HealthNet, it is usually your best choice, even if you can get health insurance from an employer. That’s because MO HealthNet usually has no monthly premium and the copayments for services tend to be much lower than private insurance copayments. Also, MO HealthNet may cover some services that employer-sponsored coverage doesn't pay for.
You may qualify for MO HealthNet if you are in one of these situations:
- Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four). The income limits are higher if you are 18 or younger. There are no limits to how much money or other resources you have. Learn more about income-based MO HealthNet.
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You have a disability or are elderly:
- MO HealthNet for people with disabilities and seniors may offer additional services, but it has more eligibility requirements, such as having a disability or being age 65 or older, having low resources, and income limits. Learn more about disability-based MO HealthNet.
- MO HealthNet's Ticket to Work Health Assurance program lets people with disabilities who make more money than the income limits for other types of MO HealthNet get MO HealthNet coverage. However, you may have to pay a monthly premium. Learn more about Ticket to Work Health Assurance.
If you can’t get MO HealthNet, employer-sponsored coverage might be a good option for you.
Does Your Employer, Your Spouse’s Employer, or Your Parent’s Employer Offer Coverage?
Many employers offer health coverage as a job benefit, but they aren't required to. Contact your employer’s Human Resources department to check what benefits are offered.
If an employer offers health coverage as a job benefit for employees, the employer also has to offer the same health coverage to the employees’ children until they turn 26. An employer may also let the employee’s spouse join the plan, but they are not legally required to do so.
If your employer, your parent’s employer, or your spouse’s employer offers health coverage, it might be a good option for you.
Can You Get the Coverage Your Employer Offers?
Employers offer health coverage for employees and their families only if their employees meet certain requirements, such as:
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The employee must work a certain number of hours each week (called the active work requirement).
- Example: Your wife’s employer only gives health benefits to employees who work 30 or more hours per week.
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The employee must have worked for the employer for a certain amount of time (called the waiting period). A waiting period cannot be longer than 90 days.
- Example: Your father’s employer offers health coverage to employees who have worked there for at least 90 days.
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You must sign up during open enrollment.
- Example: After you are hired, you have to sign up for your employer-sponsored coverage during your first month on the job. If you don’t, you have to wait until the next open enrollment period to sign up for coverage.
If your employer, your parent’s employer, or your spouse’s employer offers coverage and you can get that coverage, you probably should.
If you can get employer-sponsored coverage, it may mean you can't get tax credits on Healthcare.gov. It depends on whether the employer-sponsored plan is considered "affordable."
When an employer offers coverage for the employee:
- If it costs less than 9.12% of the employee's household's total income and meets bronze-level standards, it's "affordable." The employee won't qualify for government help through tax subsidies to reduce the premium on an individual plan.
- If it costs more than 9.12% of the household’s total income, it's not affordable and the employee may qualify for tax subsidies to get a plan on Healthcare.gov.
When an employer offers coverage for the employee and the employee's spouse and children:
- If the coverage for the entire family costs less than 9.12% of the employee's household’s total income and meets bronze-level standards, it's "affordable." Nobody in the family will qualify for subsidies on Healthcare.gov.
- If it costs more than 9.12% of the household’s total income, it's not affordable and the spouse and children may qualify for subsidies on Healthcare.gov. However, the employee will not qualify for subsidies unless the cost of insurance for the employee alone is more than 9.12% of the household’s total income.
Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on Healthcare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023.
Getting Medicare and Employer-Sponsored Coverage at the Same Time
If you get Medicare and also have employer-sponsored coverage, you should learn how your benefits work together.
If you get Original Medicare coverage, you can get Medicare Part A, which usually has no monthly premium, and both Parts B and D, which do have monthly premiums.
If you have private coverage that covers the same things Parts B and D cover, you can choose not to get them so that you don't have to pay their premiums. But it's important to make sure you won't have problems later:
- 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 Missouri SHIP.
How to Sign Up
Talk to the employer’s Human Resources department to learn how to sign up. An employer may offer more than one plan. Every option must cover the Essential Health Benefits, but usually there are other trade-offs between plans. For example, you may have to pay a higher monthly premium for one plan and higher copayments when you visit a doctor for another plan.
Sign up for coverage when it is first offered; otherwise, you may have to wait until the annual open enrollment period, which is usually near the end of the year. Certain changes in family or coverage status may trigger a special enrollment period. For example, if you get married or have a child, your new spouse or baby will be able to sign up with your employer-sponsored coverage without waiting until open enrollment.
If You Have to Stop Working Temporarily
In certain situations, you may be able to leave your job for a while, but keep getting your employer-sponsored coverage until you return to work.
If you work for any government agency or for a private employer with 50 or more employees, the Family and Medical Leave Act (FMLA) lets you take up to 12 weeks of unpaid leave per year for certain family and medical reasons, such as the birth of a child or to care for a sick family member. During this leave, your employer must continue to offer the same health coverage at the same cost as you would get while working. Learn more about the FMLA.
If you serve in the uniformed services, the Uniformed Services Employment and Reemployment Rights Act (USERRA) protects your job and health coverage for up to 24 months while you are serving. Learn more about USERRA.
COBRA and Missouri Continuation Coverage
COBRA and Missouri Continuation Coverage let most employees and family members keep getting the same health plan they got through an employer after losing employer-sponsored coverage.
COBRA is a federal law that says that companies with 20 or more employees have to let ex-employees keep getting the same health coverage they had as employees. Missouri Continuation Coverage is a state "mini-COBRA" law giving the same coverage to ex-employees of companies with fewer than 20 employees. The rules are the same for COBRA and Missouri Contiuation Coverage.
How long you can get coverage through COBRA depends on your situation. No matter what though, you have to pay the entire premium for COBRA, including any amount that your employer paid in the past. Your plan could be a lot more expensive than you realize.
COBRA used to be important because it was so hard for individuals, especially people with disabilities, to get an individual insurance plan. Now, Healthcare.gov makes that much easier and often much cheaper. That said, there are times when COBRA might make sense, like if you’ve already paid the full deductible or out-of-pocket maximum for the year with your employer-sponsored coverage.
The bottom line: Do not sign up for COBRA without comparing it with your other options.
Learn more
Individual Coverage on Healthcare.gov
Look at individual coverage if:
- You can't get MO HealthNet
- You can’t get Medicare, and
- You can’t get employer-sponsored coverage.
Is It Right for You?
With individual coverage, an individual or family pays a monthly premium and the plan agrees to pay some of the costs of approved medical services when needed, including preventive care, lab tests, surgery, or prescription drugs. If you have low to moderate income, the government may help you pay for your monthly premium and get a plan with lower copayments.
Answer the questions on this page to see if it might make sense for you to get individual health coverage. If it does, sign up using Healthcare.gov, the easiest place to comparison shop for an individual plan and the only place where you might be able to get help from the government to pay for your private insurance.
Do You Have Any Better Options?
If you can get MO HealthNet, Medicare, or employer-sponsored coverage, you don’t qualify for government help to pay for an individual plan. That means they are usually a better choice than getting an individual plan, because they cost less.
Can You Get MO HealthNet?
MO HealthNet is a government health program for people with low income. It’s a great program that usually has no monthly premium and copayments for services that are usually much lower than copayments required by individual plans. Also, MO HealthNet may cover some services that an individual plan doesn't cover.
You may qualify for MO HealthNet if you are in one of these situations:
- Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four). The income limits are higher if you are 18 or younger. There are no limits to how much money or other resources you have. Learn more about income-based MO HealthNet.
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You have a disability or are elderly:
- MO HealthNet for people with disabilities and seniors may offer additional services, but it has more eligibility requirements, such as having a disability or being age 65 or older, having low resources, and income limits. Learn more about disability-based MO HealthNet.
- MO HealthNet's Ticket to Work Health Assurance program lets people with disabilities who make more money than the income limits for other types of MO HealthNet get MO HealthNet coverage. However, you may have to pay a monthly premium. Learn more about Ticket to Work Health Assurance.
If you can’t get MO HealthNet, individual coverage might be a good option for you.
Can You Get Medicare?
Medicare is a government health program for seniors (65 years old or older) and people with disabilities. To get Medicare coverage, you or a family member must have worked for a certain number of years and met other eligibility rules.
If you get Medicare, you cannot get government help to pay for an individual health plan. You can still buy an individual plan through Healthcare.gov, but you have to pay the entire premium yourself. Note: If you get Medicare and want more coverage than it offers, look into Medicare Advantage or Medicare supplement policies. Healthcare.gov does not offer these.
If you can’t get Medicare, individual coverage might be a good option for you.
Can You Get Employer-Sponsored Coverage?
Many employers offer private health coverage as a job benefit for employees, their children until they turn 26, and their spouses. If your employer offers you health coverage that would cost you less than 9.12% of your household’s income and that coverage meets bronze-level standards, you won't qualify for government help paying for an individual plan. If you can get employer-sponsored coverage, but sign up for an individual plan anyway, you will have to pay the full premium.
Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on Healthcare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on Healthcare.gov.
If you can’t get employer-sponsored coverage, individual coverage might be a good option for you.
When an Individual Plan Is Your Best Option
You should get an individual plan through Healthcare.gov if you cannot get health coverage from:
- Your job
- Your spouse’s job
- Your parent’s job
- MO HealthNet, or
- Medicare.
The government may make your individual plan more affordable if you cannot get health coverage from any of the above options:
- You may get a tax subsidy to help pay your monthly premium.
- You may qualify for a plan with lower expenses, such as smaller copayments, if your family’s income is at or below 250% of FPG ($33,975 for an individual; $69,375 for a family of four).
Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.
When Healthcare.gov looks at your income, they count most of your earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.
To compare plans, look at Healthcare.gov's health plan directory.
| Your family size: | |
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Income limits for your family: | |
| Income-based MO HealthNet, adults (138% FPG) | |
| MO HealthNet for Kids, free (150% FPG) | |
| MO HealthNet for Kids, premium (300% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Notes:
| |
Carefully compare your options when you get an individual plan. All plans must cover the Essential Health Benefits. However, the amount you have to pay for your premium and other fees, such as copayments, co-insurance, and deductible depends on your exact plan.
There are four levels of plan:
- Platinum plans have the highest monthly premiums and the lowest fees when you get medical care.
- Gold plans have slightly lower premiums and slightly higher fees when you get medical care.
- Silver plans have lower premiums. The fees for medical services depend on your family’s income. If your income is at or below 250% of FPG, the fees may be as low as a gold or platinum plan.
- Bronze plans have the lowest monthly premiums and the highest fees when you get medical care.
You may see these plans listed with percentage ratings (60%, 70%, 73%, 80%, 87%, or 90%). The higher the percentage rating, the lower the fees you have to pay when you get medical care.
The bottom line: If your income is at or below 250% of FPG, sign up for a silver plan. Otherwise, think about how much you typically spend on medical care to decide which metal plan is best.
How to Sign Up
Healthcare.gov is a one-stop shop where you can compare plans and figure out which is right for you. And it is the only place where you can get government help to pay for your individual plan.
Start out by comparing your options so that you can make an informed decision when you are ready. If you find Healthcare.gov confusing or think there is a mistake, get help by calling Healthcare.gov at 1-800-318-2596 or 1-855-889-4325 (TTY) or get local help.
Open Enrollment
Open enrollment for individual plans has ended for this year. People in certain situations can still sign up for a health plan under special enrollment rules.
Usually, you can only sign up for an insurance plan through Healthcare.gov during a specific time called open enrollment:
- To get an individual plan that covers you during 2023, you must sign up between November 1, 2022 and January 15, 2023.
- If you do not sign up during that time, you are not usually allowed to sign up for an individual plan through Healthcare.gov until another year has passed.
Special Enrollment
You can sign up for an individual plan through Healthcare.gov even though it is not the usual open enrollment period if:
- Your household income is at or below 150% of FPG
- You lose other health coverage you had
- Your health coverage is not meeting its obligations
- Your income changes and you gain or lose eligibility for government help paying for your coverage
- You become a legal resident of the U.S.
- You move
- There was a mistake in your enrollment, or
- In other life-changing circumstances, such as having a child or getting married.
Note: American Indians do not have these restrictions on enrollment.
Learn more
Next Steps
Learn more about MO HealthNet
- Visit the MO HealthNet website.
- Visit or call your local Family Support Division (FSD) office.
If you have questions or need help, talk to a Benefits Specialist.
Apply for MO HealthNet or Ticket to Work Health Assurance
To apply for MO HealthNet or MO HealthNet's Ticket to Work Health Assurance program:
- Apply online at MyDSS.mo.gov; you can also apply at the same time for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance, or other benefits
- Download and print an application (also available in Spanish) and mail it to the address on the form
- Call the Family Support Division Information Center at 1-855-373-4636 to have an application mailed to you, or
- Call or visit your local Family Support Division (FSD) office
If you need help filling out an application, talk to a Benefits Specialist.
Learn more about Medicare
- Visit Medicare.gov.
- Use the Medicare Plan Finder to compare Part D and Medicare Advantage plans.
- See how Medicare interacts with private health coverage in How Medicare works with other insurance.
- Learn more about Medicare Savings Programs in Missouri.
- Call Missouri SHIP at 1-800-390-3330 for free Medicare counseling and education.
- Call Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY). The line is open 24 hours a day, 7 days a week.
- Read Medicare & You, Medicare’s official handbook, which explains benefits, costs, services, health plans, and prescription drug plans.
Learn more about employer-sponsored coverage
To learn more about employer-sponsored coverage, talk to your employer’s Human Resources department. It will know about the specifics of the health coverage options it offers.
Learn more about individual coverage
- Visit Healthcare.gov, which has a lot of great information introducing your options.
- Call Healthcare.gov at 1-800-318-2596 or 1-855-889-4325 (TTY).
- Get local help from Healthcare.gov.
- To get an idea of what your premium might be, check out Healthcare.gov's health plan directory.
Benefits Planning Services
If you're currently on SSI, SSDI, or CDB benefits, and you're looking for a job, a trained Benefits Specialist can help you avoid complications when you are working on a job plan for your future. For questions or guidance specific to your situation, you can speak to someone at the Ticket to Work Help Line at 1-866-968-7842 (1-866-833-2967 TTY/TDD) Monday through Friday from 8:00AM - 8:00PM EST.