How Health Benefits Work


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:

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:

  • 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.
  • 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.

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 Countable Income:

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:

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:

  • 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.
  • 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.

Finding a cheaper Part D plan that meets your needs

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.

When you can make changes

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