Public Health Coverage

Many people with disabilities have public health coverage. Here we’ll describe the most common public health care coverage programs and explain how they may change when you begin to work.

Medicare

Medicare is the federal health insurance program for people over age 65 and people with disabilities who are on Social Security Disability Insurance (SSDI). People on SSDI benefits usually start to get Medicare after they’ve been getting SSDI for more than 2 years (24 months). Medicare is actually made up of 3 main programs: Medicare Part A, Medicare Part B, and Medicare Part D.

Medicare Part A

Medicare Part A helps pay for hospital stays. If you’re on SSDI benefits, you won’t have to pay a premium for Medicare Part A, but there may be other expenses. If you’re admitted to the hospital, for example, you may have to pay a $1,340 deductible each benefit period before Part A will begin paying your hospital costs. And if you’re in the hospital for more than 60 days, you may be charged $335 – $670 per day or more.

Note: If you have Medicare and you also have MO HealthNet coverage, MO HealthNet will pay the Part A costs for you.

To learn more about Part A, click here.

Medicare Part B

Medicare Part B helps pay for the medical care you get when you are not staying in a hospital, such as when you go to see a doctor. Medicare Part B is optional and you may have to pay a monthly premium for it. However, many people with low income and resources do not have to pay a premium for Part B because it is paid for them by the MO HealthNet program.

To qualify for MO HealthNet payment of the Part B premium, you must have countable income below 135% of the Federal Poverty Guidelines (FPG) ($1,366 per month if you’re single, $1,852 for couples) or be a MO HealthNet recipient getting SSI benefits, Supplemental Aid to the Blind (SAB), or a Supplemental Nursing Care cash grant.

The Part B monthly premium for most people who do have to pay a premium is $134.00 or a bit less, depending on your situation. You may also have to pay a yearly deductible of $183 and 20% co-insurance. If you’re on SSDI benefits and have to pay a Medicare Part B premium, it will be automatically deducted from your monthly SSDI benefits amount.

To learn more about Part B, click here.

Medicare Part D

Medicare Part D helps pay for prescription drugs. There are many different Part D plans and to get Part D coverage, you need to sign up for a plan. For some Part D plans, you’ll have to pay a $405 yearly deductible. You may also have to pay for 25% of your drug costs until your total drug costs equal $3,750. Then you’ll have to pay for all of the costs of your drugs until your total drug costs equal $7,509. This is called the donut hole. While you are in the donut hole, you will get a 65% discount on the price of brand-name drugs and a 56% discount on the price of generic drugs.

Note: You may qualify for a Low Income Subsidy (also called Extra Help) to help pay for the Medicare Part D premium, deductible, and other costs. With the Low Income Subsidy, all you have to pay for your medications is a copayment of $1.25 – $8.35 per prescription. You will not have to pay the yearly deductible or other Part D costs and you won’t have to pay for your drugs when you’re in the donut hole. If you’re enrolled in MO HealthNet, you automatically qualify for the Low Income Subsidy, and MO HealthNet will pay half of your prescription copayments. If you are not enrolled in MO HealthNet, you can apply for the Low Income Subsidy online or by calling Social Security at 1-800-772-1213 or 1-800-325-0778 (TTY).

To learn more about Part D, click here.

Medicare Advantage

Medicare Advantage is another way to get your Medicare benefits, instead of getting Original Medicare. Medicare Advantage is also known as Medicare Part C. Its plans are approved by Medicare but run by private companies. You can sign up for a Medicare Advantage (Part C) plan during the month when you become eligible for Medicare. You can also sign up during the 3 months before or after you become eligible for Medicare. Your monthly premium, other expenses, such as deductibles and copayments, the services that are covered, and the medical providers you can go to may all be different than Original Medicare. To read more about Medicare Advantage, click here.

Medicare and Work

When you work and get SSDI benefits, you keep your Medicare – plain and simple. If your SSDI benefits stop because of work, you can keep your Medicare for at least 8.5 years after you return to work, as long as your disabling condition still meets Social Security’s definition of disability. This is called Extended Medicare.

MO HealthNet

MO HealthNet is a health care program that pays medical expenses for people who have low income and low resources, including people who are disabled, blind, elderly, young, or pregnant. It is Missouri’s Medicaid program. If you qualify, it will pay for most of your medical expenses with only small copayments. For a list of the services MO HealthNet will pay for, click here.

Standard MO HealthNet

Eligibility for MO HealthNet is based on factors such as your income, your resources, your disability status, your family situation, your age, and citizenship/immigration status.

  • If you are disabled, your countable income must be less than 85% of the Federal Poverty Guidelines (FPG) ($860 per month if you are single) and your resources must be below $3,000.
  • If you are blind, your countable income must be less than 100% of FPG ($1,012 per month if you are single) and your resources must be below $3,000.

If you work and your countable income and your resources are below these levels, you should be able to keep MO HealthNet. But that’s not a lot of money to live on every month. And what if you want to save money to buy a car or a house or go on vacation?

Note: If your disability began before you turned 26, you can open an ABLE account where you can save up to $15,000 each year and not have it counted as resources by MO HealthNet. Learn more about ABLE Accounts.

MO HealthNet and Work

If you have a disability, there are a few ways you can keep your MO HealthNet while working and earning more than these limits:

  1. You can get MO HealthNet with a spend down
  2. You can get MO HealthNet through the Supplemental Security Income (SSI) 1619(b) rule
  3. You can get MO HealthNet through a program called the Ticket to Work Health Assurance (TWHA) program

As with any type of MO HealthNet, to qualify through these you must:

  • Have or apply for a Social Security number
  • Live in Missouri and intend to remain
  • Be a United States citizen or an eligible noncitizen
  • Have limited resources
    • For most MO HealthNet programs, including the spend down and TWHA, you must have less than $3,000 in available resources ($6,000 for couples).
    • For people who get MO HealthNet through 1619(b), the resource limit is the same as SSI’s, $2,000 for an individual, $3,000 for a couple.

The amount of money you can make and whether you have to pay a monthly premium or spend money of your own for care depends on your situation. Here we’ll explain the differences between these 3 rules.

Note: When you apply for MO HealthNet, you don’t have to tell them you are applying for the spend down or the Ticket to Work Health Assurance program. They’ll look at your application and figure out which is the best MO HealthNet program for you. If you are in 1619(b) status, you need to tell your local Family Support Division (FSD) office, because they do not get notice from Social Security.

MO HealthNet with a Spend Down

If you make more than MO HealthNet’s income limit for people with disabilities, you may qualify for MO HealthNet with a spend down. A spend down is like an insurance deductible or an insurance premium. With a spend down, you are responsible for part of your medical expenses each month before MO HealthNet coverage will start paying for them.

Every month when you pay the spend down, you will get MO HealthNet coverage. When you don’t meet the spend down, you won’t get MO HealthNet coverage. If you do not have health care expenses every month, you may choose to pay the spend down in some months but not pay it in other months.

To see some common questions people ask about how the MO HealthNet spend down works, click here.

SSI’s 1619(b) Program

For people on SSI, the 1619(b) program lets you work and keep MO HealthNet, even if you make too much money to get SSI cash benefits. If you are on this program, you will not have to pay a premium.

In addition to the eligibility requirements listed earlier for all MO HealthNet programs, to qualify for MO HealthNet based on 1619(b) you must:

  • Be found eligible for 1619(b) status by Social Security
  • Have gotten MO HealthNet (Medicaid) in the month prior becoming eligible for 1619(b) status.

To be eligible for 1619(b) status you must:

  • Have been eligible for SSI cash benefits for at least 1 month
  • Be working and have gross earnings below $37,188 per year
  • Not be getting SSI benefits because you earn too much
  • Still be considered disabled or blind by SSI
  • Need MO HealthNet to be able to work
  • Not make enough money to pay for the services you get with MO HealthNet benefits
  • Respond to all Social Security requests for information

Note: When your income is counted, Social Security won’t count all of your income, thanks to various SSI work incentives. So you may be making more than $37,188 per year and still qualify for 1619(b).

MO HealthNet Ticket to Work Health Assurance (TWHA) Program

If you have a disability and are working, you may be able to get MO HealthNet through the Ticket to Work Health Assurance (TWHA) program, even if you have too much income to be eligible for the regular MO HealthNet program or to get Social Security disability payments. TWHA covers the same services that standard MO HealthNet covers, including visits to the doctor, hospital stays, medical equipment, home care services, and mental health services. The program encourages you to work and enjoy the benefits of working without having to worry that you’ll lose your health benefits.

In addition to the eligibility requirements listed earlier for all MO HealthNet programs, to qualify for TWHA you must:

  • Be age 16 – 64
  • Be working and paying Social Security and Medicare taxes
  • Get Social Security disability benefits or be considered disabled by the Missouri Department of Social Services (DSS) Family Support Division (FSD)
  • Have gross income of $3,035 per month or less for an individual, $4,115 or less for a couple.
  • Also meet countable net income limits. Your countable net income is calculated by the Family Support Division and includes various deductions from your gross income.

Depending on your gross income, you may have to pay a monthly premium for this type of MO HealthNet coverage. Premiums range from a minimum of $40 per month to a maximum of $206 per month, depending on your situation.

If you don't qualify for MO HealthNet or Medicare

If your income goes up so much that you no longer qualify for MO HealthNet and you can't get Medicare or employer-sponsored coverage, the government may help you pay for a private health coverage plan on Healthcare.gov. To get this help, your family’s income has to be between 100% and 400% of the Federal Poverty Guidelines ($48,560 per year for an individual; $100,400 for a family of four).

For more information, visit Healthcare.gov.

How Does Your Income Compare to FPG?