How to Afford Healthcare on a Tight Budget (Share with Your Clients) - Western Asset Protection
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How to Afford Healthcare on a Tight Budget (Share with Your Clients)

Many seniors are worried about rising costs and the impact it is having on their retirement budget. As inflation pushes prices higher for basics such as food, gas and housing, are you concerned how you will afford the healthcare coverage you need on your fixed income? Here are some ways you can maximize your coverage and control your costs.

Know How Your Plan Works to Avoid Higher Costs

Whether your plan is Medicare Advantage or Original Medicare with a supplemental plan (Medigap), it’s important to understand how your plan works to avoid higher out of pocket costs and denied claims. Here are some tips to keep in mind:

  • Know your in-network and out-of-network coverage costs. If you want coverage from specific providers and facilities, make sure they are considered in-network with the plan you choose. Some plans offer no out-of-network coverage.
  • Know if you need a referral for certain services. If a referral is required and you don’t get one, your claim could be denied.
  • Take advantage of preventative and routine care, usually covered with zero out-of-pocket costs. These services are important to maintaining your health, and help detect more serious issues sooner, which may ensure better health outcomes and lower costs.
  • Understand the full scope of your out-of-pocket costs (deductible, copays, etc.) for the plan you select. Plans with lower premiums may look appealing but they usually come with higher deductibles and out-of-pocket expense.
  • Know if you are at risk of entering the Medicare prescription “Donut Hole.” There are programs available that can assist with this gap in coverage if you qualify.

How to Save on Your Prescriptions

Prescription medications can be very expensive, and this can be true even for people with Medicare. Most prescription drug plans use formularies, and drugs that are not on the formulary may not be covered. Plans also often use tiers of drugs with different costs, and drugs in the highest tiers can have expensive copays. Ask your Medicare Health Care Broker where your drugs fall on the formulary and what your out-of-pocket costs will be.

In some cases, people may end up paying more for prescriptions with insurance than they would if they purchased the prescription without coverage. When this occurs, it helps to know what options are available.

  • Talk to your doctor. Ask if there are any generic or lower tier drug alternatives.
  • Check online discount pharmacies such as GoodRx, NeedyMeds or WellRX and compare prices.
  • Most major pharmaceutical companies also offer assistance programs to help qualified individuals afford their drugs. Be aware that any drugs purchased outside your insurance usually do not count toward your deductible.
  • Check specific disease funds, which are supported by charitable groups and help to pay for medications and treatments for a specific disease or condition. There are online resources to assist with your search.
  • You may qualify for Extra Help paying for your monthly premiums, annual deductibles, and co-payments related to Medicare prescription drug costs including costs associated with the “donut hole.” People with Extra Help see significant savings (estimated by SSA to be $5100 per year) on their medications. To qualify for Extra Help, you must be receiving Medicare and have limited resources and income.

Additional Programs to Help with Costs

Medicare Savings Programs

There are four Medicare Savings Programs for people with limited income and resources. These programs can help save money on Medicare costs, and if you qualify you are automatically enrolled in Extra Help for prescription drug cost savings. Seniors who may not qualify for full Medicaid may still be able to enroll in the Medicare Savings Programs.


Special Needs Plans

Special Needs Plans (SNPs) cover the same health care services as all Medicare Advantage plans, including Medicare Part A and Part B and are required to provide prescription drug coverage. There are several types of SNPs

  • Dual-Eligible Special Needs Plans (D-SNP): These plans serve people who have both Medicare and Medicaid benefits.
  • Chronic-Condition Special Needs Plans (C-SNP):These types of plans serve beneficiaries with certain severe or disabling chronic conditions such as dementia, chronic health failure, or HIV/AIDS.
  • Institutional Special Needs Plans (I-SNP):These plans serve who are living in an institution such as a nursing home, or who need nursing care at home.

To be eligible to enroll in a Medicare SNP you must meet some requirements. You must be enrolled in Original Medicare Part A and B and live in the service area of the SNP.

If you are struggling with costs and need help finding affordable healthcare coverage, please contact us. Our knowledgeable and experienced team is here to help.