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How Health Benefits Work

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    updated January 6, 2025
    How Health Benefits Work

    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 will introduce the health coverage options that are most likely for you:

    All of these types of coverage have:

    • Clearly defined services they will cover, including most of the physical and mental health needs you may have. For private insurance, all individual plans must cover Essential Health Benefits. Medicare’s coverage is comparable, while Medicaid offers some additional benefits, like personal assistance services if you need them.
    • Payments you must make. Typically, payments for private insurance are highest and the fees for Medicaid are lowest. Your payments may include:
      • Premiums, a monthly payment you must make whether or not you use any medical services. (Medicaid 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 will begin to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
    • 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 will never have to spend more than $9,200 if you’re single or $18,400 for a family on these expenses.
      • Medicare is an exception: There's a a $2,000 annual out-of-pocket maximum for Part D costs (not including premiums) and Medicare Advantage plans have a $9,350 out-of-pocket max. But Original Medicare (Parts A and B) does not have a max.

    None of these types of coverage:

    • 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.

    This article looks at these types of coverage to help you understand which is right for you and how to sign up.

    Get covered

    Don’t assume that coverage is too expensive or that you won’t qualify. You probably will qualify for one of these programs and it may be a lot more affordable 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 has been and will continue to be updated to reflect any changes. For news related to health coverage, visit the Kaiser Family Foundation.

    Learn more

    What Benefits Do I Get?

    How to see which Social Security and state benefits you get.

    Finding the Right Health Coverage For You

    Explore the best health coverage options for you with this interactive tool.

    Supplemental Security Income (SSI)

    SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

    The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

    How Health Benefits Work

    Try It

      How Health Benefits Work

      Income-Based Medicaid

      Look at income-based Medicaid if:

      • You are less than 65 years old

      • You don’t qualify for Medicare

      • You don’t qualify for APA

      • You are a U.S. citizen or eligible immigrant, and

      • Your household has low to moderate income.

      Is Income-Based Medicaid Right for You?

      Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:

      Answer the questions on this page to see if you might qualify for income-based Medicaid. 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 Medicaid covers more services than most private plans. Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on HealthCare.gov.

      Note: Income-based Medicaid is sometimes called MAGI-Category Medicaid, Adult Medicaid, or Medicaid Expansion.

      Do You Meet Income-Based Medicaid’s Basic Requirements?

      To qualify for income-based Medicaid, you must:

      • Be under 65 years old
        • You can be 65 or older if you are the parent or caretaker of a child
      • 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 Medicaid might cover you.

      Medicaid’s rules for immigrants:

      • Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
      • Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid 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 qualify for all of the same programs that U.S. citizens can get.

      Note: You can get Medicaid coverage if you are a Native American born in Canada or Mexico who has rights to cross the border.

      Do You Qualify for Adult Public Assistance (APA)?

      If you have a disability, low income, and low resources, you may qualify for APA. If you already get APA benefits, you automatically get APA-related Medicaid coverage and do not need to apply separately.

      If you do not get APA benefits, income-based Medicaid might cover you.

      Is Your Income Low Enough for Income-Based Medicaid?

      These are the main income rules for income-based Medicaid:

      • If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($2,164 per month for an individual; $4,486 for a family of four), you may qualify.
      • If you are 18 or younger and your family’s income is at or under 208% of FPG ($6,761 per month for a family of four), you may qualify. Income-based Medicaid for children is also called Denali KidCare (DKC).
      • If you are pregnant or gave birth within the last 12 months and your family’s income is at or under 230% of FPG ($7,476 per month for a family of four), you may qualify. The unborn baby is counted as a family member.

      Income-based Medicaid counts most types of earned and unearned income you have. 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 income-based Medicaid eligibility.

      Note: There are no limits to how much money or other resources you can have for income-based Medicaid.

      Health Coverage Income Limits for Your Family

      If your income is low enough and you meet all other requirements, you should sign up for Medicaid.

      Is income-based Medicaid’s income limit 133% or 138% of FPG?

      You may see the income limit for income-based Medicaid listed as 133% of FPG in some places. However, when Medicaid counts your income, they’ll knock 5% of FPG off your income if you make more than 133% of FPG. That's why we say that you can make up to 138% of FPG, because it more accurately shows how much income you could have and still get Medicaid. For children, this means we show 208% of FPG as the limit, instead of 203% and for pregnant women, we show 230% instead of 225%.

      More Ways to Qualify for Medicaid if You Have a Disability

      There are other ways to qualify for Medicaid if you have a disability. You might qualify for APA-related Medicaid if:

      • Get Adult Public Assistance (APA) benefits. If you get APA, you also get APA-related Medicaid automatically.
      • You make more money at work than income-based Medicaid allows. In that case, you could also apply for the Working Disabled Medicaid Buy-In program.
      • You also get Medicare. Usually, Medicaid doesn’t cover people getting Medicare, but APA-related Medicaid does. It may even help pay your monthly Medicare premiums and other Medicare expenses like deductibles and coinsurance.
      • You are 65 years old or older.

      You might qualify for income-based Medicaid, even though you have a disability, if:

      • Your disability does not meet Social Security’s definition of disability. APA-related Medicaid is only for people who have disabilities meeting this standard and for seniors.
      • You have more resources than are allowed by APA-related Medicaid.
      • You make enough money that you would have to pay a monthly premium for the Working Disabled Medicaid Buy-In program.

      Learn more about APA-related Medicaid and the Working Disabled Medicaid Buy-In.

      How to Sign Up

      You can apply for Medicaid:

      If you use an application form, you can also apply for other benefits at the same time, such as Adult Public Assistance (APA), SNAP (formerly Food Stamps), and Alaska Temporary Assistance Program (ATAP). If you apply for Medicaid online, you have to apply for other benefits separately.

      Staying on Medicaid

      Usually, once you are approved for Medicaid, you will continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, you need to report within 10 days of when you know about the change. You can report these changes to the Division of Public Assistance (DPA) by calling 1-800-478-7778, by fax to 1-888-269-6520, by email to hss.dpa.offices@alaska.gov, or in person at any Division of Public Assistance (DPA) office.

      When you report your changes, the DPA will tell you whether you will continue getting Medicaid or if you have new health coverage options, like individual coverage with subsidies or the Working Disabled Medicaid Buy-In program.

      Learn more

      What Benefits Do I Get?

      How to see which Social Security and state benefits you get.

      Finding the Right Health Coverage For You

      Explore the best health coverage options for you with this interactive tool.

      Supplemental Security Income (SSI)

      SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

      The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

      How Health Benefits Work

      Try It

        How Health Benefits Work

        APA-related Medicaid

        Look at APA-related Medicaid if:

        • You are a U.S. citizen or eligible immigrant
        • You have a disability
        • You have low resources, and
        • You have low income.

        Is APA-Related Medicaid Right for You?

        Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:

        If you get Adult Public Assistance (APA) benefits or qualify for SSI’s 1619(b) rule, you automatically get APA-related Medicaid and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI and APA article.

        Otherwise, answer the questions on this page to see if you might qualify for APA-related Medicaid. 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 Medicaid covers more services than most private plans. Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on HealthCare.gov.

        Note: The rules for qualifying for APA-related Medicaid are explained in much greater detail in DB101’s SSI and APA article.

        Medicaid’s rules for immigrants:

        • Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
        • Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid 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 qualify for all of the same programs that U.S. citizens can get.

        Note: You can get Medicaid coverage if you are a Native American born in Canada or Mexico who has rights to cross the border.

        Are you 65 or older or do You Have a Disability That Meets Social Security’s Standards?

        To qualify for APA-related Medicaid, you must either be 65 or older or 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 ($1,620 per month or $2,700 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 a disability benefit like Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards.

        If not, Social Security, in collaboration with Alaska Disability Determination Services (DDS), will check to see if your disability qualifies for Medicaid. Learn more about the disability determination process in DB101's SSI and APA article.

        Note: Learn about Social Security’s definition of disability for children under 18 in DB101’s Benefits for Young People article.

        If you are 65 or older or you already have a disability determination from Social Security or think that your disability will meet Social Security’s standards, APA-related Medicaid might cover you.

        Do You Have Very Low Resources?

        Resources are money and property you own. For APA-related Medicaid, you and your family must have very low resources:

        • If you are single, the most you can have is $2,000 in resources.
        • For couples, the limit is $3,000.

        Some resources don’t count towards APA-related Medicaid’s resource limit, like the home you live in and one car. Learn more about APA-related Medicaid's resource limit and what things don't count as resources in DB101's SSI and APA article.

        Additionally, if your disability began before you turned 26, you can open an ABLE account and the money in your account will not be counted by Medicaid. Learn more about ABLE accounts.

        If your family’s resources are below the limit, APA-related Medicaid might cover you.

        Note: Real property, including the buildings on it, that is owned by an Alaska Native or American Indian is not a countable resource for APA-related Medicaid.

        PLbAcZl78BusloRJ3V0LBYJbq32w7UwDy7

        Do You Have Very Low Income?

        To qualify for APA-related Medicaid, you must have countable income that is $1,795 per month or less if you live on your own ($2,658 or less for couples where both people have a disability or are at least 65 years old).

        For APA-related Medicaid eligibility, not all of your income is counted. For APA-related Medicaid, your income is counted using SSI’s countable income calculation:

        For example, you could make $3,000 per month at work and still qualify for APA-related Medicaid, because more than half of your earned income wouldn’t be counted. Learn more about how your income is counted for APA-related Medicaid and what the income limits are in other situations in DB101's SSI and APA article.

        Try this tool to see the countable income limits for APA and APA-related Medicaid:

        SSI and APA Income Limits

        If your income is low enough and you meet all other requirements, you should sign up for Medicaid. If you qualify for APA-related Medicaid, you may also get a monthly payment from the APA program. Learn more in DB101's SSI and APA article.

        If your income or resources are too high and you have a disability

        If you work, look into the Working Disabled Medicaid Buy-In program if your income or resources are too high for APA-related Medicaid. The Working Disabled Medicaid Buy-In has higher limits. Learn more about the Working Disabled Medicaid Buy-In.

        If you don't work, a Medicaid Qualifying Income Trust (QIT), sometimes called a Miller Trust, may help you get APA-related Medicaid even if your income is over the standard limit. A QIT must be created following certain rules related to how the money is managed and whom it must benefit. For more information about QITs, call the Disability Law Center of Alaska at 1-800-478-1234, Alaska Legal Services, or a private attorney who does these trusts. When you call an attorney, have a list of your regular medical expenses. This list will make it easier to figure out whether a QIT would help you.

        Example: Frida's SSDI benefits are too high for her to get APA-related Medicaid and her Medicare coverage means she can't get income-based Medicaid. She starts putting some of her SSDI benefits into a QIT each month and becomes eligible for APA-related Medicaid. The APA-related Medicaid coverage covers some of her medical expenses that Medicare doesn't cover, like personal assistance services and some prescription drugs.

        More Ways to Qualify for Medicaid if You Have a Disability

        There are other ways to qualify for Medicaid if you have a disability. You might qualify for income-based Medicaid if:

        • Your disability does not meet Social Security’s definition of disability. APA-related Medicaid is only for people who have disabilities meeting this standard.
        • You have more resources than are allowed by APA-related Medicaid.
        • You make enough money that you would have to pay a monthly premium for the Working Disabled Medicaid Buy-In.

        You might qualify for APA-related Medicaid instead of income-based Medicaid if:

        • You also get Medicare. Usually, income-based Medicaid doesn’t cover people getting Medicare, but APA-related Medicaid does. It may even help pay your monthly Medicare premiums and other Medicare expenses like deductibles and coinsurance.
        • You are 65 years old or older.
        • You make more money at work than income-based Medicaid allows. In that case, you might also qualify for the Working Disabled Medicaid Buy-In.

        Learn more about income-based Medicaid and the Working Disabled Medicaid Buy-In.

        How to Sign Up

        You can apply for Medicaid:

        If you use an application form, you can also apply for other benefits at the same time, such as Adult Public Assistance (APA), SNAP (formerly Food Stamps), and Alaska Temporary Assistance Program (ATAP). If you apply for Medicaid online, you have to apply for other benefits separately.

        Staying on Medicaid

        Usually, once you are approved for Medicaid, you will continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, you need to report within 10 days of when you know about the change. You can report these changes to the Division of Public Assistance (DPA) by calling 1-800-478-7778, by fax to 1-888-269-6520, by email to hss.dpa.offices@alaska.gov, or in person at any Division of Public Assistance (DPA) office.

        When you report your changes, the DPA will tell you whether you will continue getting Medicaid or if you have new health coverage options, like individual coverage with subsidies or the Working Disabled Medicaid Buy-In program.

        Learn more

        What Benefits Do I Get?

        How to see which Social Security and state benefits you get.

        Finding the Right Health Coverage For You

        Explore the best health coverage options for you with this interactive tool.

        Supplemental Security Income (SSI)

        SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

        The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

        How Health Benefits Work

        Try It

          How Health Benefits Work

          Working Disabled Medicaid Buy-In

          Look at the Working Disabled Medicaid Buy-In if:

          • You are working
          • You are a citizen or eligible immigrant
          • You have a disability
          • You have low resources, and
          • You don't make too much money.

          Is the Working Disabled Medicaid Buy-In Right for You?

          Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:

          Answer the questions on this page to see if you might qualify for the Working Disabled Medicaid Buy-In. If so, it’s a good option to consider because it lets you earn a lot more money and pay a low monthly premium, low copayments and no deductible to get Medicaid’s comprehensive coverage.

          Note: If you qualify for APA or for SSI’s 1619(b) rule, you automatically get APA-related Medicaid and don’t need to worry about the rules discussed here. Learn more about them in DB101’s SSI and APA article.

          PLbAcZl78Busm37IQGeFHjEeNQGTL6bGq8&si=78gYHul6VFNDW1nY

          Do You Meet the Working Disabled Medicaid Buy-In Program’s Basic Requirements?

          To qualify for the Working Disabled Medicaid Buy-In, you must:

          • Be 18 years old or older
          • Be working and earning too much money to get APA-related Medicaid
          • Be a U.S. citizen or meet specific noncitizen requirements

          If you are working and are either a U.S. citizen or a non-citizen who qualifies, the Working Disabled Medicaid Buy-In might be an option for you.

          Medicaid’s rules for immigrants:

          • Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
          • Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid 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 qualify for all of the same programs that U.S. citizens can get.

          Note: You can get Working Disabled Medicaid Buy-In coverage if you are a Native American born in Canada or Mexico who has rights to cross the border.

          Do You Have a Disability That Meets Social Security’s Standards?

          To qualify for the Working Disabled Medicaid Buy-In, 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 condition has lasted or is expected to last for at least 12 months

          Note: For the Working Disabled Medicaid Buy-In, Social Security’s disability rules related to earned income do not apply.

          If you currently get a disability benefit like SSI or Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards.

          If not, Social Security, in collaboration with Alaska Disability Determination Services (DDS), will check to see if your disability qualifies. Learn more about the disability determination process in DB101's SSI and APA article.

          If you already have a disability determination from Social Security or think that your disability will meet Social Security’s standards, the Working Disabled Medicaid Buy-In might be an option for you.

          Do You Have Low Resources?

          Resources are money and property you own. For the Working Disabled Medicaid Buy-In, you must have less than $10,000 in resources ($15,000 for couples). Some resources don’t count towards the Working Disabled Medicaid Buy-In’s resource limit, like the home you live in and one car.

          If your resources are below the limit, the Working Disabled Medicaid Buy-In might be an option for you.

          Is Your Income Below the Working Disabled Medicaid Buy-In’s Income Limit?

          The Working Disabled Medicaid Buy-In program is designed so that if you have a disability, you can work without worrying that you’ll lose your Medicaid health coverage. That’s why its income limit is a lot higher.

          For the Working Disabled Medicaid Buy-In, you must:

          Tip: If you live alone and have no unearned income, you could actually have up to $7,923 per month in gross earnings and still qualify for the Working Disabled Medicaid Buy-In. (That's as much as $95,070 per year!)

          If your income is low enough and you meet all other requirements, you should sign up for the Working Disabled Medicaid Buy-In, after making sure it is better than any employer-sponsored coverage you could get.

          The Working Disabled Medicaid Buy-In’s monthly premium

          If you get Working Disabled Medicaid Buy-In coverage, you may need to pay a monthly premium. The amount you pay is based on your income and your family’s income. To learn how much your premium might be, try DB101's Benefits and Work Estimator.

          Example

          Freddy lives alone, has no unearned income, and makes $7,200 per month at his job. He makes way too much money for income-based or APA-related Medicaid, so he applies for the Working Disabled Medicaid Buy-In program.

          When the DPA reviews his application, it says Freddy only has $3,558 in countable income each month, so he easily qualifies for the Working Disabled Medicaid Buy-In. He will have to pay a monthly premium, but it’ll be a lot less than he’d have to pay for private insurance.

          How to Sign Up

          You can apply for the Working Disabled Medicaid Buy-In:

          If you use an application form, you can also apply for other benefits at the same time, such as Adult Public Assistance (APA), SNAP (formerly Food Stamps), and Alaska Temporary Assistance Program (ATAP). If you apply for the Working Disabled Medicaid Buy-In online, you have to apply for other benefits separately.

          Keeping Working Disabled Medicaid Buy-In Coverage

          Usually, once you are approved for the Working Disabled Medicaid Buy-In, you will continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, you need to report within 10 days of when you know about the change. You can report these changes to the Division of Public Assistance (DPA) by calling 1-800-478-7778, by fax to 1-888-269-6520, by email to hss.dpa.offices@alaska.gov, or in person at any Division of Public Assistance (DPA) office.

          When you report your changes, the DPA will tell you whether you will continue getting Working Disabled Medicaid Buy-In coverage and if your premium will change.

          Learn more

          What Benefits Do I Get?

          How to see which Social Security and state benefits you get.

          Finding the Right Health Coverage For You

          Explore the best health coverage options for you with this interactive tool.

          Supplemental Security Income (SSI)

          SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

          The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

          How Health Benefits Work

          Try It

            How Health Benefits Work

            Medicare

            If you get Medicare, you may be able to get:

            • Employer-sponsored coverage at the same time
            • Medicaid at the same time, or
            • Help paying for Parts A, B, and D.

            What Medicare 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 will qualify for Medicare:

            • When you turn 65
            • When you’ve been getting 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 will also qualify for Medicare.

            Medicare coverage includes:

            • 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.

            If you’ve been getting SSDI or CDB for two years, Medicare Parts A and B will start automatically. Otherwise, you may need to sign up, depending on your situation. No matter how you qualify, you need to sign up separately for a Part D plan.

            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. For this reason, nobody is required to get them.

            Answer the questions on this page to see which parts of Original Medicare make sense for you and whether you might qualify for programs that can help you pay your monthly premiums, copayments, co-insurance, and deductibles. If you need more information about Medicare, call the Alaska Medicare Information Office at 1-800-478-6065 or 1-800-770-8973 (TTY).

            Note: In Alaska, there are no Medicare Advantage (Part C) plans. All Medicare coverage is through Original Medicare. If you are 65 or older, you can choose to get private Medicare Supplement Insurance (Medigap), which covers some expenses that Parts A and B do not cover. Learn more about Medicare Supplement Insurance or find a policy in your area.

            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 have employer-sponsored coverage, Medicaid, or Working Disabled Medicaid Buy-In coverage, having those other benefits may impact your Medicare decisions:

            • If you also qualify for Medicaid or the Working Disabled Medicaid Buy-In, they may help pay for some medical expenses that Parts B and D would not pay for. They may also help pay your monthly Medicare premiums and other Medicare expenses like deductibles and coinsurance.
            • 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 Medicaid. 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 $185.00 per month or a bit less).

            If you have both Medicare and Medicaid coverage, Medicaid may help pay for your Part B and Part D expenses.

            If you only have Medicare and don't have Medicaid, a Medicare Savings Program (MSP) might help pay for your Medicare expenses. There are four MSPs that help people with low income and low resources:

            • The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,568 per month or less if you live alone). QMB helps pay for 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 ($1,881 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
            • The SLMB Plus program helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($2,117 per month or less if you live alone). SLMB Plus helps pay for the Part B premium, but does not help with anything else.
            • The Qualified Disabled and Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,620 per month), but have countable income that’s 200% of FPG or less ($3,135 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it will pay for the Part A premium that would otherwise apply.

            Note: For MSPs, your income is counted using SSI’s countable income calculation, which means 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 SLMB Plus is $9,430 if you live alone and $14,130 if you live with someone else. For QDWI, it’s $4,000 if you live alone and $6,000 if you live with another person.

            Apply for an MSP by filling out the DPA Application for Services and submitting it:

            If you need help with your application, call the Alaska Medicare Information Office at 1-800-478-6065 or 1-800-770-8973 (TTY).

            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 the Low Income Subsidy (LIS), which is also called “Extra Help.” With it, you don't have to pay a Part D premium or deductible, and there may be lower copayments.

            The Low Income Subsidy is for people who also get Medicaid coverage or who are in a Medicare Savings Program. You may also qualify if your countable income is less than $28,215 per year and your resources are less than $17,600 if you are single (the limits are higher for larger households). 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.

            If you get Medicaid or Supplemental Security Income (SSI) benefits, you automatically qualify for the LIS and do not need to apply. Otherwise, you can apply for the Low Income Subsidy online, at your local Social Security office, or by calling the Alaska Medicare Information Office at 1-800-478-6065.

            Note: Before 2024, there used to be a "Partial LIS" that didn't help as much. Now, everybody who qualifies for the LIS gets the full subsidy.

            Changing your Part D plan

            One way to save money is by finding a better Part D plan for the medications you take. You usually can only change your Part D plan during open enrollment, which is from October 15 - December 7. Any changes you make start on January 1 of the following year. Use the Medicare Plan Finder to find the right Part D plan for you.

            Learn more

            What Benefits Do I Get?

            How to see which Social Security and state benefits you get.

            Finding the Right Health Coverage For You

            Explore the best health coverage options for you with this interactive tool.

            Supplemental Security Income (SSI)

            SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

            The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

            How Health Benefits Work

            Try It

              How Health Benefits Work

              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 Medicaid.

              Is Employer-Sponsored Coverage 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 might be able to get employer-sponsored coverage. If you can, you probably should because you probably won’t qualify for subsidized individual coverage.

              Can You Get Medicaid?

              If you qualify for Medicaid, it will always be your best choice, even if you can get health insurance from an employer. That’s because Medicaid usually has no monthly premium and the copayments for services are usually much lower than copayments required by employer-sponsored plans. Also, Medicaid may cover some services that employer-sponsored coverage does not pay for.

              If you can’t get Medicaid, employer-sponsored coverage might be a good option for you.

              You may qualify for Medicaid if you are in one of these situations:

              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 are not 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:

              • 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.
              • 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.
              • 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.

              Employer-sponsored coverage and eligibility for tax credits on HealthCare.gov

              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 9.02% of the employee's household's total income and meets a certain benefits level, 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 9.02% 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 9.02% of the employee's household’s total income and meets a certain benefits level, it's "affordable." Nobody in the family will qualify for subsidies on HealthCare.gov.
              • If it costs more than 9.02% 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 9.02% 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:

              Learn more about Medicare.

              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 and usually there are trade offs between them. For example, one plan may require you to pay a higher monthly premium, while another may require you to pay higher copayments when you visit a doctor.

              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

              COBRA lets most employees and family members keep getting the same health plan they got through an employer after losing employer-sponsored coverage.

              The amount of time you can keep getting coverage through COBRA depends on your situation. No matter what though, you will 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 really 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 about COBRA.

              Learn more

              What Benefits Do I Get?

              How to see which Social Security and state benefits you get.

              Finding the Right Health Coverage For You

              Explore the best health coverage options for you with this interactive tool.

              Supplemental Security Income (SSI)

              SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

              The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

              How Health Benefits Work

              Try It

                How Health Benefits Work

                Individual Coverage on HealthCare.gov

                Look at individual coverage if:

                • You can't get Medicaid
                • You can’t get Medicare, and
                • You can’t get employer-sponsored coverage.

                Is Individual Coverage 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 Medicaid, Medicare, or employer-sponsored coverage, you won’t qualify to get government help paying for an individual plan. That means they are usually a better choice than getting an individual plan, because they’ll cost less.

                Can You Get Medicaid?

                Medicaid 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, Medicaid may cover some services that an individual plan would not.

                If you can’t get Medicaid, individual coverage might be a good option for you.

                You may qualify for Medicaid if you are in one of these situations:

                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 could still buy an individual plan through HealthCare.gov, but you would have to pay the entire premium yourself.

                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 9.02% of your household’s income and that coverage meets a certain benefits level, 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
                • Medicaid, 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 also qualify for a plan with lower expenses, such as smaller copayments, if your family’s income is at or below 250% of the Federal Poverty Guidelines (FPG) ($47,025 for an individual; $97,500 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 will count most types of earned and unearned income you have. 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.

                Try HealthCare.gov's health plan directory.

                Health Coverage Income Limits for Your Family
                Choosing a plan

                Carefully compare your options when you get an individual plan. All plans must cover the Essential Health Benefits. However, the amount you’ll 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:

                1. Platinum plans have the highest monthly premiums and the lowest fees when you get medical care.
                2. Gold plans have slightly lower premiums and slightly higher fees when you get medical care.
                3. 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.
                4. 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

                Anybody who wants to sign up for an individual plan can do so now, until open enrollment ends.

                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 will cover you during 2025, you must sign up between November 1, 2024 and January 15, 2025.
                • If you do not sign up during that time, you will not usually be 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 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 and Alaska Natives do not have these restrictions on enrollment.

                Learn more

                What Benefits Do I Get?

                How to see which Social Security and state benefits you get.

                Finding the Right Health Coverage For You

                Explore the best health coverage options for you with this interactive tool.

                Supplemental Security Income (SSI)

                SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

                The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

                How Health Benefits Work

                Try It

                  How Health Benefits Work

                  Frequently Asked Questions

                  How you sign up depends on the type of coverage you get:

                  • For Medicare, you automatically get coverage if you’ve been getting SSDI for two years. Otherwise, you may need to sign up.
                  • For employer-sponsored coverage, talk to your employer’s Human Resources department.
                  • For individual coverage, apply at HealthCare.gov. HealthCare.gov will first check whether you qualify for Medicaid and, if not, will let you compare individual plans and see whether the government will help with tax credits.

                  For Medicaid or the Working Disabled Medicaid Buy-In, you can apply:

                  If you use an application form, you can also apply for other benefits at the same time, such as Adult Public Assistance (APA), SNAP (formerly Food Stamps), and Alaska Temporary Assistance Program (ATAP). If you apply online, you have to apply for other benefits separately.

                  You can qualify for Medicaid if your family’s income qualifies, even if your job offers insurance.

                  You cannot get subsidies for purchasing an individual health plan through HealthCare.gov if your job offers you affordable insurance.

                  In most cases, no. The actual medical coverage you get from Medicaid will be the same, no matter how you qualified. Generally speaking, the big difference is that people with disabilities get extra ways to qualify and if you have a disability and start working, you can earn a lot more while still getting Medicaid coverage through the Working Disabled Medicaid Buy-In.

                  Note: If you qualify for APA-related Medicaid, you may also get a monthly payment from the APA program. Learn more in DB101's SSI and APA article.

                  For income-based Medicaid, the main income rules are:

                  • If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($2,164 per month for an individual; $4,486 for a family of four), you may qualify.
                  • If you are 18 or younger and your family’s income is at or under 208% of FPG ($6,761 per month for a family of four), you may qualify. Income-based Medicaid for children is also called Denali KidCare (DKC).
                  • If you are pregnant or gave birth within the last 12 months and your family’s income is at or under 230% of FPG ($7,476 per month for a family of four), you may qualify. The unborn baby is counted as a family member.

                  Income-based Medicaid counts most types of earned and unearned income you have. 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 income-based Medicaid eligibility.

                  If you have a disability, you may be able to get Medicaid coverage if your income is a lot higher than this, thanks to the Working Disabled Medicaid Buy-In program. With the Working Disabled Medicaid Buy-In, the exact income limit depends on your living situation. If you live alone and don't have any unearned income, you could make as much as $7,923 per month and still qualify. (That's as much as $95,070 per year!) Learn more about the Working Disabled Medicaid Buy-In program.

                  Health Coverage Income Limits for Your Family
                  • Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
                  • Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid 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 qualify for all of the same programs that U.S. citizens can get.

                  Note: You can get Medicaid coverage if you are a Native American born in Canada or Mexico who has rights to cross the border.

                  There are different health coverage options as your income goes up:

                  • Depending on how much your income goes up, your Medicaid may continue, unchanged.
                  • If you got Supplemental Security Income (SSI) before you started earning more, you can usually keep Medicaid thanks to SSI’s 1619(b) rule.
                  • If you have a disability and work, you can also consider the Working Disabled Medicaid Buy-In. With the Working Disabled Medicaid Buy-In, if you live alone, you can work, earn up to $7,923 per month, and pay a monthly premium to get Medicaid coverage. The income limit is higher if you live with others. Note: The amount of earned income you can have for the Working Disabled Medicaid Buy-In depends on how much unearned income you have.
                  • If your employer offers it, you may be able to get employer-sponsored coverage.
                  • If your employer does not offer coverage, you should consider private individual coverage. You may get government help to pay for an individual plan on HealthCare.gov. 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.

                  The bottom line: There is a coverage option for almost everybody. Do not worry that getting a job will leave you without health coverage.

                  To qualify for the Working Disabled Medicaid Buy-In, you must:

                  • Be 18 or older
                  • Be a U.S. citizen or a qualified immigrant
                  • Be working or have a spouse who is working
                  • Have a disability that meets Social Security’s medical standards.
                    • Note: For the Working Disabled Medicaid Buy-In, SSA’s disability rules related to income do not apply.
                  • Have unearned income at or below the APA RC limit ($1,795 per month). If you are married, the limit is $2,658 and your spouse's deemed unearned income is also counted.
                    • Note: The APA RC limit is also called the "Expanded Refused Cash Income Limit." What it means is that you may qualify for APA-related Medicaid even if you don't qualify for APA cash benefits.
                  • Have household countable income at or below 250% of the Federal Poverty Guidelines (FPG), including other members of your family you live with. That’s $3,919 per month if you live alone.
                    • Not all of your earned income is counted. If you live alone and have no unearned income, you could actually earn up to $7,923 per month and still qualify for the Working Disabled Medicaid Buy-In. (That's as much as $95,070 per year!)
                  • Have less than $10,000 in resources ($15,000 for couples). The house you live in and one car are not counted.

                  If you get Working Disabled Medicaid Buy-In coverage, you may need to pay a monthly premium. The amount you pay is based on your income and your family’s income. To learn how much your premium might be, try DB101's Benefits and Work Estimator.

                  Medicare has three main parts:

                  • Medicare Part A helps pay for medical care you get while you’re in a hospital.
                  • Medicare Part B helps pay for medical care you get outside of a hospital.
                  • Medicare Part D helps pay for prescription drugs.

                  If you or your spouse worked enough time while paying Medicare taxes, you will qualify for Medicare Parts A and B:

                  • When you turn 65
                  • When you’ve been getting 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).

                  Note: If you have had a disability since before you were 22 years old, you will start getting Medicare if you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record.

                  No. Medicare will only help pay for care that it considers reasonable and necessary. If you need a service that Medicare doesn’t cover, you’ll have to pay for it yourself, unless you have other coverage, such as Medicaid or employer-sponsored coverage.

                  For certain services, you’ll pay a deductible, copayment, or co-insurance before Medicare will begin to help pay for that service. For Medicare Part B and Part D, you may have to pay a monthly premium.

                  You may qualify to get help paying for your Medicare premiums, copayments, and deductibles if you have low income. Medicare Savings Programs help pay for Part B coverage and the Low Income Subsidy (LIS) helps pay for Part D coverage.

                  Learn more about MSPs and the LIS.

                  Yes. Other types of coverage that you can have with Medicare include:

                  Learn more about how Medicare interacts with other types of coverage.

                  You may be responsible for no cost, a percentage of the cost, or the amount of the cost of the coverage that is above what the employer agrees to pay.

                  Employers are supposed to offer plans that cost the employee, for the employee’s policy alone, less than 9.02% of the employee’s family income for the monthly premium. Also, that coverage must meet a certain benefits level for copayment, co-insurance, and deductible expenses.

                  If your employer offers a plan that does not meet these standards, you may qualify for government help through tax subsidies to reduce the premium on an individual plan.

                  Note: The coverage your employer offers must meet affordability standards for the employee, but not for the family. It may be very expensive for family members to join an employer-sponsored health plan. 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.

                  Yes, if you are under 26, you can be covered by your parent's insurance plan. Employers who offer coverage to their employees must also offer it to their children under the age of 26.

                  Employers do not have to offer coverage to the spouses of employees, but many do.

                  Note: While employers must offer this coverage to children, the employee may be required to pay for all of it.

                  Yes. Plans cannot deny people coverage. When you apply for insurance, they cannot reject your application and they cannot say that they won’t cover medical needs related to your disability. They also cannot charge you more because you have a disability.

                  Depending on your situation, you may qualify to have the government help pay for your individual health plan through tax credits. Here's how it works:

                  1. When you sign up at HealthCare.gov, you give details about your family's situation. HealthCare.gov reviews that information instantly. If your family qualifies for government help to pay for individual coverage, HealthCare.gov tells you and lists insurance options for you.
                  2. Your insurance options list the full cost of the monthly premium, how much of that premium the government will pay each month, and how much you will pay each month. The way the government helps pay for the premium is by giving you a tax credit every month, so you don't have to think about it during the year. All you have to do is make sure you keep paying your part of the premium.
                  3. In January or February, the government will send you a form listing how much your total health coverage tax credits were for the previous year. You will need this form at tax time, because it is possible the government paid more or less than it should have for your health coverage. If so, this will be sorted out when you file your taxes.

                  No, but depending on your income, you may get more help from the government if you get a silver-level plan:

                  • The government may help pay for your premium through tax credits. That means you would pay less each month. You might get this help no matter what metal your plan is.
                  • If you make 250% of the Federal Poverty Guidelines (FPG) or less and get a silver plan, the government also pays to reduce your copayments, co-insurance, deductible, and out-of-pocket maximum. That means you’ll pay less each time you need medical services. If you get this help, your silver plan might actually be as good or better than many platinum or gold plans. If you do not get a silver plan, the government will not help you with these expenses.

                  When HealthCare.gov looks at your income, they will count most types of earned and unearned income you have. 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.

                  Health Coverage Income Limits for Your Family

                  Usually, when you sign up for a plan through HealthCare.gov, you need to stay on the plan for the entire calendar year. So, if you are signed up for 2025, then you can’t leave that plan until 2026.

                  However, there are certain situations when you may be able to change plans mid-year:

                  • If your income changes and you gain or lose eligibility for government help paying for your coverage
                  • If you move, or
                  • In other life-changing circumstances, such as having a child or getting married.

                  The first one is the key. If your income goes down and you can’t afford your plan anymore, report your change in income to HealthCare.gov. You may qualify to get Medicaid or to have the government increase how much it pays for your current insurance (meaning that you have to pay less).

                  Note: American Indians and Alaska Natives do not have these restrictions and can change up to once a month.

                  Learn more

                  What Benefits Do I Get?

                  How to see which Social Security and state benefits you get.

                  Finding the Right Health Coverage For You

                  Explore the best health coverage options for you with this interactive tool.

                  Supplemental Security Income (SSI)

                  SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

                  The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

                  How Health Benefits Work

                  Try It

                    How Health Benefits Work

                    Common Pitfalls

                    Not getting health coverage because you think it will be too expensive

                    Almost everyone has a health coverage option, even if you have a disability. The exact coverage that’s right for you depends on things like your family’s income, whether you can get employer-sponsored coverage, your age, where you live, and whether you have a disability.

                    If you can get employer-sponsored coverage or public health coverage, like Medicare or Medicaid, they are probably your best options.

                    If you can’t, you should look into getting an individual plan through HealthCare.gov, where the government may help you pay a plan's expenses. 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.

                    Note: It is very important to have health coverage, but starting in 2019 there is no tax penalty if you don't have coverage.

                    Getting an individual plan without using HealthCare.gov

                    HealthCare.gov is the best way to get an individual plan. There are four big reasons it is best to use HealthCare.gov:

                    1. It’s the only place where you can get government help paying for your premiums and other health expenses.
                    2. It will automatically check if you or your family might qualify for a public health coverage program like Medicaid and will let you know how to apply for it instead of an individual plan.
                    3. HealthCare.gov has customer services representatives available over the phone at 1-800-318-2596 or 1-855-889-4325 (TTY). You can also get local help.
                    4. It’s totally free – there are no commissions and no hidden fees.

                    Not understanding the expenses involved with private health coverage

                    When making decisions about health coverage and comparing different plans, make sure you understand all of a plan’s costs, which can include:

                    • Premiums, a monthly amount that has to be paid whether or not you use medical services. If you have employer-sponsored coverage, your employer pays part or all of the premium and you pay whatever the employer doesn’t pay. If you have individual coverage, you pay the entire premium, though the government may help you pay through tax subsidies if your income is low enough.
                    • Copayments, a set amount you have to pay for a medical visit or service. The exact amount of the copayment depends on the service you get: Medications, visits to specialists, lab tests, X-rays, emergency room visits, and other services can all have different copayment amounts.
                    • 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 will begin to pay for certain services, including hospital care, emergency room visits, and brand-name prescription drugs. Once you have paid the deductible, you do not have to pay it again until the next calendar year.

                    Not looking into Medicaid because you think you won’t qualify

                    Medicaid used to be mainly for people with disabilities, seniors, children, and pregnant women. Now, it is for anybody with low income (at or below 138% of the Federal Poverty Guidelines (FPG), $2,164 per month for an individual; $4,486 for a family of four). No matter how much money you have in the bank or what your health situation is, you could qualify.

                    Not working because you think you’ll lose Medicaid coverage

                    In the past, people feared that if they got a job while they were on Medicaid, they’d lose their coverage, because they would no longer have low enough income to qualify.

                    Now, if you lose one health coverage option, there should be another one you can get. If you lose your Medicaid coverage, you may become eligible for the Working Disabled Medicaid Buy-In program, employer-sponsored coverage, or private individual coverage. And, if you can’t afford individual coverage, the government may help you pay for it.

                    The bottom line: There is a coverage option for most people. Do not worry that getting a job will leave you without health coverage.

                    Learn more

                    What Benefits Do I Get?

                    How to see which Social Security and state benefits you get.

                    Finding the Right Health Coverage For You

                    Explore the best health coverage options for you with this interactive tool.

                    Supplemental Security Income (SSI)

                    SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.

                    The BasicsIncome-Based MedicaidAPA-Related MedicaidWorking Disabled Medicaid Buy-InMedicareEmployer-Sponsored CoverageIndividual Coverage on HealthCare.govFAQsPitfallsNext Steps

                    How Health Benefits Work

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                      How Health Benefits Work

                      Next Steps

                      Learn more about Medicaid

                      Apply for Medicaid or Working Disabled Medicaid Buy-In coverage

                      You can apply for Medicaid or the Working Disabled Medicaid Buy-In:

                      If you use an application form, you can also apply for other benefits at the same time, such as Adult Public Assistance (APA), SNAP (formerly Food Stamps), and Alaska Temporary Assistance Program (ATAP). If you apply for Medicaid online, you have to apply for other benefits separately.

                      Learn more about Medicare

                      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

                      Benefits Planning Services

                      If you're currently on SSI, SSDI, or CDB benefits, and you're looking for a job, a trained benefits planner 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 or 1-866-833-2967 (TTY) Monday through Friday from 8:00 a.m. - 8:00 p.m. EST.

                      View DB101's full list of experts who can help you understand different benefits.

                      Learn more

                      What Benefits Do I Get?

                      How to see which Social Security and state benefits you get.

                      Finding the Right Health Coverage For You

                      Explore the best health coverage options for you with this interactive tool.

                      Supplemental Security Income (SSI)

                      SSI and Adult Public Assistance (APA) give cash benefits to people with disabilities and seniors who have low income and low resources.