Private health coverage pays for part of your medical costs. These costs can include seeing doctors, having medical tests done, and getting medications. You get private health coverage either by paying a monthly premium directly to an insurance company or by enrolling in a group plan sponsored by your employer or your spouse’s or parent's employer. If you get an individual plan on MNsure, the government may also help pay a portion of your premium.

The details of what medical expenses your private health coverage will pay for depend on how your plan is set up. Different private health coverage plans will pay different amounts for different services in different situations. This means that when you go to the doctor, the hospital, or a pharmacy, your private health coverage will pay part or all of the cost of these services, depending on your plan.

If you don’t have private health coverage right now, these are the most common ways to get it:

1. Private health coverage is often offered as part of your compensation for work. You may also get it through a spouse's or parent's job. This employer-sponsored coverage varies greatly in terms of how much it will cost you and the extent of prescription coverage it includes.
2. Individual health coverage can be purchased for you and your family at MNsure. If you can't get employer-sponsored coverage and don't qualify for Medicare, Medical Assistance, or MinnesotaCare, the government may help you pay your monthly premium through tax subsidies. 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.

For more details, read DB101’s articles on Employer-Sponsored Health Coverage and Buying Individual Health Coverage on MNsure.

Medical Assistance (MA) is Minnesota's Medicaid program. It helps pay medical expenses for people with low income. If you meet eligibility requirements, MA will help pay for your visits to the doctor, hospital stays, prescription drugs, medical equipment, and other medical services.

MA Prescription Benefits

With MA, you don't pay anything when you get a prescription drug (there are no copayments).

Medicare Part D and MA

If you are a senior or the Social Security Administration says you have a disability, you may be able to get disability-based MA and Medicare at the same time. If you are eligible for Medicare Parts A and B, you have to be enrolled in them in order to enroll in disability-based MA.

This is a good deal for you because Medicare Part A is usually free, and disability-based MA will usually pay your Medicare Part B premium (and your Part A premium, if you have one) for you and for Medicare copayments. Since MA covers many services that Medicare does not, by having both you’ll have better health care coverage and will pay less. To learn more about how MA interacts with Medicare Parts A and B, read the DB101's Medicare article.

If you are eligible for Medicare Parts A and/or B, you are also eligible for prescription drug coverage through Medicare Part D. You will automatically be enrolled in a Medicare Part D benchmark plan if you haven't already signed up for a plan on your own and are also:

• On disability-based MA without a spenddown (spenddowns are explained in DB101's disability-based MA article)
• On MA with a spenddown and have met your spenddown, or
• On Medical Assistance for Employed Persons with Disabilities (MA-EPD)

There are different options for benchmark plans. If you do not choose one, you will be given one automatically. To get help finding a plan that covers the medications you need:

• Call the Senior LinkAge Line® at 1-800-333-2433.
• Use the Medicare Prescription Drug Plan Finder.

Being enrolled in disability-based MA or MA-EPD and Medicare at the same time automatically qualifies you for the Part D Low Income Subsidy. This means you won’t have to pay a monthly premium for your Part D or pay any deductibles. If you have the Low Income Subsidy, all you pay for your prescription drugs are copayments that range from $1.60 to $12.15.

Note: If you don’t sign up for Part D coverage, you won’t have any prescription drug coverage. MA cannot pay for your prescriptions if you decline Part D coverage.

The Medical Assistance for Employed Persons with Disabilities (MA-EPD) program lets Minnesotans with disabilities work and earn any level of income, while keeping access to Medical Assistance (MA) coverage. MA-EPD also doesn't have an asset limit (disability-based MA usually does). So, if you get MA due to your disability and start working, you can get MA-EPD and save up more money without losing your health coverage.

Eligibility

To qualify for MA-EPD, you must be:

• A Minnesota resident
• Certified disabled by the Social Security Administration or the State Medical Review Team (SMRT)
• Working
• Paying Medicare and Social Security taxes
• Earning at least $65 per month

To get MA-EPD, you have to pay a monthly premium based on your income and household size.

For detailed eligibility and application information, read DB101’s MA-EPD article.

MA-EPD Prescription Benefits

With MA-EPD, you don't pay anything when you get a prescription drug (there are no copayments).

Medicare Part D and MA-EPD

You do not have to participate in Medicare Part D to qualify for MA-EPD. But, if you refuse Part D coverage, you won't have any prescription drug coverage. MA-EPD will not pay for your prescription drugs if you are also eligible for Medicare. You should definitely enroll in both MA-EPD and Medicare if you can.

When you are enrolled in both, you automatically qualify for the Part D Low Income Subsidy. That means that if you enroll in a benchmark plan, you don’t have to pay any Part D premium or deductible. All you'll pay when you get a prescription drug is a $1.60 – $12.15 copayment.

While you work, some of the money you earn automatically comes out of your paycheck and goes into a Medicare fund with other workers’ contributions. If you have to stop working because of a disability, Medicare will take money from this fund and use it to help you pay for your medical costs. Medicare is run by the federal government, though certain aspects of it are operated by private insurance companies, including its prescription drug coverage.

Like any insurance program, there are detailed rules about who can participate in Medicare and limits to what medical costs Medicare will help pay for. Medicare is very complicated because it is actually a set of programs, rather than just a single plan. Each program helps pay for a different aspect of your medical care. The programs are called “parts” and are named by letters. Medicare Part D is the program that helps pay for prescription drugs and is what we will focus on here.

To read a detailed description of all the parts of Medicare, read DB101's Medicare article.

Part D Prescription Drug Coverage

Medicare Part D is also called Medicare Prescription Drug Coverage or MedicareRx. In the Part D program, private companies offer prescription drug coverage to people on Medicare. Each plan has a list of drugs that they will help pay for if you sign up with their plan. This list is called a formulary.

Part D coverage will not supply you with entirely free medications. Generally, you will be responsible for paying these expenses:

• A monthly premium. That means that you will have to pay a certain amount of money each month for your Part D plan, whether or not you purchase any medications.
• A deductible. That means that your Part D plan will not pay for any of your medications until you have spent a certain amount of money on medications yourself.
• Copayments or co-insurance. Copayments are a certain amount of money you have to spend each time you purchase a medication. Co-insurance means you have to spend a certain percent of a medication’s price out of pocket.

There is a $2,000 annual out-of-pocket maximum for Part D costs (not including premiums). The premium, deductible, copayment, and co-insurance levels change each year on January 1. If you qualify for Medicare’s Low Income Subsidy, you may not have to pay all of these expenses. Persons who are enrolled in Part D and are enrolled in Medical Assistance have no cost-sharing for Part D covered drugs.

People who are on a Medicare Savings Program, SSI, or are eligible for both Medical Assistance (MA) and Medicare have special rules for signing up, switching Part D plans, and paying for costs.

Getting Part D Coverage

There are 2 ways to get Part D drug coverage:

1. Enroll in a Stand Alone Prescription Drug Plan that only offers drug coverage. To enroll, you already have to be enrolled in Part A and/or Part B of Original Medicare or in a Medicare Advantage Plan that doesn’t offer drug coverage.
2. Through your Medicare Advantage Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-For-Service Plan, or Special Needs Plan. Most of these plans offer prescription drug coverage as part of their larger package of Medicare benefits. Their drug benefits are called Medicare Advantage – Prescription Drug (MA-PD) plans.

You are not required to sign up for Medicare Part D if you have Medicare. Here are a couple of factors you should consider when you decide whether or not to sign up for Part D:

• If you have prescription drug coverage through your employer, union, retiree, or veterans (VA) coverage, those benefits may be better than Medicare Part D. If you have drug coverage from another source, compare your current policy with a Medicare Part D plan. One way to compare them is to ask your current drug insurance provider if your coverage is “creditable coverage.” Creditable coverage means that it is as good or better than Medicare Part D. Then, ask what happens if you sign up for Part D. Some insurance plans might not allow you to drop prescription coverage without also losing other benefits, and some plans might not let you get coverage back if you change your mind.
• If you don’t sign up for Medicare Part D during your initial enrollment period and change your mind later, there will be a penalty fee for signing up. It may be worth it to sign up for an inexpensive Medicare Part D plan so that you can avoid these penalties. If you currently have creditable coverage through another insurance plan, you can switch to Part D after the initial enrollment period without paying any penalties.

Choosing a Part D Plan

The best Part D Plan for you depends on the medications you need. To choose a Part D plan, make a list that includes the following information:

• All of the medications you are currently taking, including:
  • The dosage amount
  • How often you take them
  • If they are brand name or generic
• Ask your doctor about possible substitutes for the drugs you take
• The pharmacy where you prefer to get your medications and if you prefer mail order

For in-depth, free, personalized assistance with plan selection, Chat with a Hub expert. You should also compare your options online with Medicare’s Prescription Drug Plan Finder.

MinnesotaCare is a public program that helps pay medical expenses for people with low to middle income. It is for individuals and families who:

• Can’t get affordable insurance through their job, Medical Assistance (MA), or Medicare, and
• Make 200% of the Federal Poverty Guidelines or less ($30,120 or less per year if you're single; $62,400 or less for a family of four).

If you qualify, MinnesotaCare will help pay for your visits to the doctor, hospital stays, prescription drugs, medical equipment, and other medical services. To get MinnesotaCare, you may have to pay a monthly premium ($28 per family member or less).

Generally, if you are 21 years old or older, you pay copayments for medications.

For detailed information on MinnesotaCare, including eligibility and how to sign up, see DB101's MinnesotaCare article.

Drug manufacturers offer programs called Patient Assistance Programs (PAPs) that help low-income people get prescription drugs. Each PAP has its own rules about eligibility and what they will pay for. Before you look for a PAP, write down what drugs you need and make sure you have information about your income handy, such as your most recent paystub.

Here are a few ways to search for PAPs:

• Search PhRMA’s Medicine Assistance Tool (MAT).
• Look at RxAssist’s database of Patient Assistance Programs, with up-to-date information on how to access assistance from nearly 100 companies and more than 700 medications.
• Go to Medicare.gov and check out its list of PAPs. This list is also useful for anybody, not just people on Medicare.

If you are enrolled in a health insurance or drug coverage program that already pays for your medications, you probably won’t be eligible for a Patient Assistance Program. However, insured individuals may be able to obtain a coupon directly from the drug manufacturer or from their doctor’s office that will help to reduce their prescription copayments.

People with HIV/AIDS need to take a lot of expensive prescription medications. Some people have private or public health coverage that helps pay for their medications, but some people don’t have any coverage. And even those who do have health coverage may still have medication costs that their health coverage won’t pay for.

The Program HH AIDS Drug Assistance Program (ADAP) helps pay for HIV/AIDS medications for people who can’t afford to pay their out-of-pocket costs. This program is usually only for people who don't have public or private health coverage or, if they do, whose insurance does not pay for all of their medication expenses.

In Minnesota, ADAP can help pay both for medications and for cost-effective insurance.

Eligibility

To receive ADAP, you must:

• Be HIV positive
• Have income below 400% of the Federal Poverty Guidelines ($5,020 per month if you're single, $6,813 for a couple)
• Be uninsured or insured with a drug co-pay
• Not be on Medical Assistance, Medical Assistance for Employed Persons with Disabilities (MA-EPD), or MinnesotaCare

ADAP Medication Formulary

The ADAP Medication Formulary is the list of medications ADAP pays for. Minnesota’s formulary includes all primary HIV treatment medications, Opportunistic Infection (OI) medications and many medications for treating side effects. See the full list of medications in the Minnesota ADAP Medication Formulary.

How to Enroll

To participate in HIV-related benefit programs administered by the Minnesota Department of Human Services, contact your local social services case worker, or fill out the annual application for Minnesota Department of Human Services, HIV/AIDS Programs.

If you have any questions about HIV resources, call Minnesota's Ryan White Programs Customer Care Line at 1-651-431-2398 or 1-800-657-3761.

Donald’s Story

Donald is a self-employed musician. He has been making a decent living for the last several years and because he was healthy, fit, and not even 30 years old, he only had a catastrophic health plan he got through MNsure.

He recently got tested for HIV and found out that he was HIV-positive. After that, he went to a doctor, who told Donald that he’d have to start taking a lot of prescription medications.

Donald realized that because of his plan's high deductible, he wouldn't be able to afford all of the medications he'd need. And, even if he managed to pay that big deductible, his plan wouldn't pay for all of the medications he needed, because some of them were not on his plan's formulary. But then his doctor's office told him about about the Minnesota AIDS Drug Assistance Program (ADAP).

ADAP supplies HIV/AIDS-related prescription drugs to uninsured and underinsured people living with HIV/AIDS. Donald applied by filling out the annual application for Minnesota Department of Human Services, HIV/AIDS Programs. He qualified for the program because he was HIV positive and earned less than 400% of the Federal Poverty Guidelines ($5,020 a month).