Inside Medicare | What are my options for receiving an expensive Prolia shot?

Janell Sluga Medicare & Individual Health Insurance Account Executive View Bio

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Question:

I changed my insurance for 2026 and I am having trouble with my Prolia shot. What are my options?

Answer:

There is an excellent program that you may be referring to, and it’s called the Medicare Savings Program (MSP). This is a Medicaid benefit administered by your local county’s Department of Social Services (DSS). It’s an income-based program to assist with the cost of your Medicare Part B Premium. To qualify for the MSP, you’ll have to fit into certain income levels. Each year, the income levels change, and the new levels have just released by the Federal Government.

You can pick up an application(s) for the MSP at the DSS office closest to you. They can also be found on the www.mybenefits.ny.gov website. You can also call your local DSS office and request one be mailed to you.

Often our Gross income is different than our Net income (I remember the difference with a rhyme, “Net is what you Get”). Most Americans have their Medicare Part B premium taken out of their Social Security Income payment. If someone’s gross Social Security benefit amount is $2,200 per month, and they pay the standard $202.90 for their Part B Premium, then their net income is probably $1,997. This reduction to their Net income happens because the Part B premium of $202.90 taken out BEFORE you are paid. Something similar can happen with pension payments as well, because you can choose to have your taxes taken out of your pension payment BEFORE you are paid. This can sometimes lead to confusion when people are trying to determine their eligibility for benefits. For most entitlement/benefits that you apply for, you must count your GROSS income – the total amount you are paid before any deductions are removed, NOT what you actually “get.”

There are different assistance levels provided by the MSP. First, there is the QI-1 benefit. This program pays your Medicare Part B premium. This allows you to receive the full gross income from Social Security Payments, minus the Part B Premium. This benefit could also pay your Part D premium, if you have one, and even reduce the cost of your prescription medications. The QI-1 benefit has an income cap (maximum) per household. The monthly income cap for those over age 65 is $2,494 for a one-person household and $3,375 for a couple. This income includes all retiree income, including Social Security, IRA’s, Pensions, Retirement Annuities, VA pension, and more. There is NO resource test for this benefit – that means that money in the bank, investments, and stocks are reviewed in this application process, but NOT included in the calculation of your income.

When determining eligibility for the QI-1 benefit, you are to deduct certain expenses from your Gross income. These expenses include your Health Insurance Premiums, Dental Insurance Premiums, and Long-Term Care Insurance Premiums. This deduction to your Gross income could make a significant difference for whether you qualify or not, as some of these premiums can be a significant cost. For example, Medicare Supplement may cost around $250 monthly. This means that an individual with this monthly premium could make that much MORE in monthly income and still be eligible for the QI-1 benefit ($2,494 + $250 = $2,744). This illustrates that higher income individuals might still be eligible for the QI-1 benefit, depending if they have costs that can be deducted from the calculation of their gross income. You can take your maximum income and review your own insurance premiums and determine if you are close to eligibility.

The next level of benefit is Qualified Medicare Beneficiary (QMB) Medicaid Benefit. The QMB pays your Medicare Part B premium ($202.90) each month. It can also help pay for Health Insurance premiums, including the premiums for your Medicare Advantage plan or Supplement plan – it may even pay these in full. If you still pay copays with your insurance product, this QMB benefit will pay those co-pays as well.

The income cap for this benefit is $1,856 per month and $2,509 per month for a couple. This benefit also does not have a resource test – you must disclose your IRA/401K type of assets, but their value does not disqualify you.

Both the  QI-1 and QMB benefits are what I call “gateway” benefits. Once you are approved for either benefit, you ALSO get the Low Income Subsidy (LIS) for your Part D plan. The LIS pays the premium for your Part D coverage (up to $58.82) and reduces your copays for prescriptions down to $5.10 for generics and $12.65 for brand name medications covered by your plan.

The application for these benefits is generally just 2 pages long. DSS requires proof of income and IRA/401K type of assets. This application and the required proof of income, expenses, and identification can be mailed to DSS or dropped off at your local DSS.

You can apply for this benefit anytime during the year. You can also reapply for this benefit if you have been denied in the past any time, as your income may have changed. These are VERY useful benefits, and I have seen this benefit make a significant difference in the households of many seniors.

Good luck and reach out with questions!

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email jsluga@lawleyinsurance.com.