What Medicare Plans Cost If You Receive SSI Disability
If you receive Supplemental Security Income (SSI) for disability, you are enrolled in Medicare Part A (hospital insurance) automatically, and Part A has no monthly premium for you. Medicare Part B (medical insurance) normally costs a monthly premium, but if your income is low enough, your state may pay your Part B premium through a program called Medicaid Buy-In or a similar state program. This means your out-of-pocket cost for Part B could be zero.
Beyond Part A and Part B, you can choose between two ways to receive your Medicare benefits: Original Medicare (Parts A and B together) paired with a Medigap or Part D plan, or Medicare Advantage (Part C), which is an all-in-one plan offered by private insurers. The cost difference between these two routes is significant, and which one costs less depends on your specific situation, your state, and which plans are available to you.
Key Takeaways
- If your SSI income is low enough, your state may pay your Medicare Part B premium through Medicaid, making your Part B cost zero.
- Medicare Advantage plans often have zero or low monthly premiums for people on SSI, but charge copays when you use care.
- Original Medicare has no copays for hospital stays (Part A), but you pay 20 percent of doctor visits and tests after you meet your deductible.
- Medicaid covers costs that Medicare does not, so if you have both Medicare and Medicaid, your total out-of-pocket cost is usually lowest.
- Your state determines which plans are available to you and whether it will pay your Part B premium, so costs vary by location.
Medicare Advantage Plans and Their Costs for SSI Recipients
Many Medicare Advantage plans (Part C) charge zero monthly premium if you are on SSI, because your state Medicaid program pays the premium. These plans are offered by private insurance companies like UnitedHealthcare, Humana, and Anthem, and they bundle hospital care, doctor visits, and prescription drugs into one plan.
The trade-off is that Medicare Advantage plans charge copays — a fixed dollar amount you pay each time you see a doctor, go to the emergency room, or fill a prescription. A typical copay might be $5 to $15 for a doctor visit, $50 to $150 for an emergency room visit, or $0 to $10 for a generic prescription drug. These copays add up if you use care frequently. Some Medicare Advantage plans also limit which doctors and hospitals you can use, so you must stay in their network to avoid higher costs.
The advantage of Medicare Advantage for someone on SSI is that the premium is often covered by Medicaid, and if you also have full Medicaid coverage, Medicaid pays the copays you cannot afford. This combination — Medicare Advantage plus Medicaid — can result in very low out-of-pocket costs.
Original Medicare and What You Pay Out of Pocket
Original Medicare consists of Part A (hospital) and Part B (doctor and outpatient care). Part A covers hospital stays with no copay after you meet a deductible (the amount you pay before Medicare starts paying). For 2024, the Part A deductible is $1,632 per hospital stay, but if you have Medicaid, Medicaid pays this deductible for you.
Part B covers doctor visits, lab tests, and outpatient procedures. You pay 20 percent of the cost after you meet your Part B deductible (which is $240 for 2024). If you have Medicaid, it covers the 20 percent coinsurance and the deductible, so your out-of-pocket cost is zero.
Original Medicare does not cover prescription drugs, so you must enroll in a separate Part D plan (prescription drug coverage). Part D plans charge a monthly premium, a deductible, and copays or coinsurance for each drug. If your income is very low, you may receive a subsidy that reduces or eliminates your Part D premium and copays. Your state Medicaid program can tell you whether you may have access to.
How Medicaid Affects Your Total Medicare Cost
If you receive SSI, you are usually dual may be able to access — meaning you have both Medicare and Medicaid. Medicaid is the state program that covers costs Medicare does not, including the Part B premium, deductibles, and coinsurance. This is why your actual out-of-pocket cost is often much lower than the official Medicare cost.
Your state Medicaid program determines exactly what it covers. Some states cover the Part B premium and all deductibles and coinsurance. Other states cover less. A few states have waiting lists for Medicaid, so you may have Medicare but not Medicaid for a period of time. You can contact your state Medicaid office to find out what your state covers.
If you have both Medicare and Medicaid, the cheapest route is usually Original Medicare (not Medicare Advantage), because Medicaid covers the coinsurance and deductibles that would otherwise come out of your pocket. Medicare Advantage copays are sometimes higher than the 20 percent coinsurance in Original Medicare, and Medicaid may not cover them in full.
Comparing Costs Between Original Medicare and Medicare Advantage
| Cost Element | Original Medicare + Part D | Medicare Advantage |
|---|---|---|
| Monthly Premium (Part B) | Usually paid by Medicaid | Often $0 if Medicaid pays |
| Hospital Deductible | $1,632 (paid by Medicaid if may be able to access) | Varies by plan, often $0 |
| Doctor Visit Copay | 20% after deductible (paid by Medicaid if may be able to access) | $5–$25 per visit |
| Emergency Room | 20% after deductible (paid by Medicaid if may be able to access) | $50–$150 copay |
| Prescription Drug Coverage | Separate Part D plan with premium and copays | Included in plan |
| Out-of-Pocket Maximum | No limit in Original Medicare | $7,550 for 2024 (varies by plan) |
The table above shows the official costs, but remember: if you have Medicaid, it covers most or all of these costs. The real difference between the two routes depends on whether your state Medicaid program covers the copays in Medicare Advantage plans.
State Variations in Premium information and Plan Availability
Your state determines which Medicare plans are available in your area and whether the state will pay your Part B premium. Some states offer many Medicare Advantage plans with zero premium; others offer only a few. Some states pay the Part B premium for all SSI recipients; others have income limits or other restrictions.
For example, California, New York, and Texas each have different Medicaid programs and different lists of available Medicare plans. A plan that costs nothing in one state may not be available in another. You can see which plans are available to you by visiting Medicare.gov and entering your zip code, or by calling 1-800-MEDICARE.
Your state Medicaid office can tell you whether your state pays your Part B premium and what other costs Medicaid covers. You can find your state Medicaid office through the Centers for Medicare & Medicaid Services (CMS) website or by calling your local social services office.
When to Choose Original Medicare vs. Medicare Advantage
Choose Original Medicare if you want to see any doctor or specialist without restrictions, if you use many different providers, or if you have Medicaid that covers the coinsurance. Original Medicare has no network limits, so you can go to any hospital or doctor that accepts Medicare.
Choose Medicare Advantage if you prefer a plan with a zero or very low premium, if you do not mind using doctors within a specific network, or if you want prescription drugs included in one plan. Medicare Advantage works well if you use care regularly and your copays are low, or if you have Medicaid that covers the copays.
The best choice depends on your health, which doctors you see, which medications you take, and what your state Medicaid program covers. There is no single cheapest option for everyone on SSI.
Frequently Asked Questions
Does SSI automatically give me Medicare?
Yes. If you receive SSI for disability, you are enrolled in Medicare Part A automatically after you have been on SSI for 24 months. Part A has no monthly premium. You are also enrolled in Part B, but Part B normally has a monthly premium unless your state Medicaid program pays it for you.
Will my state pay my Medicare Part B premium?
Most states pay the Part B premium for people on SSI, but the rules vary. Some states have income limits or other restrictions. Contact your state Medicaid office or call 1-800-MEDICARE to find out whether your state will pay your premium.
Can I switch from Medicare Advantage to Original Medicare?
Yes, but only during certain times of the year. You can switch during the Annual Enrollment Period (October 15 to December 7 each year), or if you have a may have access to life event like moving to a new state. If you miss the enrollment period, you may have to wait until the next one.
What happens to my copays if I have both Medicare and Medicaid?
If you have both, Medicaid usually covers the copays and deductibles that Medicare does not. However, what Medicaid covers varies by state. Some states cover all copays; others cover only some. Your state Medicaid office can tell you exactly what is covered.
Do I have to choose a Medicare plan, or is it automatic?
If you do nothing, you stay in Original Medicare with Part B. If you want to switch to Medicare Advantage or change your Part D plan, you must enroll during the Annual Enrollment Period or within 60 days of becoming may be able to access for Medicare. If you miss the important date, you may pay a penalty when you do enroll.