Some Medicare assistance program eligibility requirements and premium costs depend on your income and resources. Special rules apply to American Indian and Alaska Native people’s income. Other rules also apply.
If you are Native American or an Alaska Native, you can access the Indian Health Service (IHS), which provides many (but not all) healthcare services.
Older adults who are eligible for IHS coverage may also be eligible for Medicare, which can offer access to a more comprehensive range of services, including preventive care.
If you have joint eligibility, you can use Medicare alongside the IHS.
Medicare’s eligibility requirements for individuals who also use the IHS are the same as the requirements for people who do not.
IHS eligibility
To be eligible for IHS coverage, you must:
- be an American Indian, Alaska Native, or both
- be a member of or enrolled in a federally recognized tribe
- live on or own tax-exempt or restricted land
Additionally, the following groups may also be eligible for IHS coverage:
- dependent children of an eligible person, if the child is under 19 years old
- spouses of an eligible person
- pregnant people in situations where the other parent is an American Indian or Alaska Native
Medicare eligibility
Medicare services are available if you:
- are age 65 years or over
- have end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS)
- are under age 65 years, have a disability, and have received disability benefits for 2 years or more
Joint eligibility
The IHS is not medical insurance and does not always offer all of the services or treatments you may need. In these instances, Medicare may be able to help.
If you use the IHS and become eligible for Medicare, consider enrolling as soon as possible to ensure you get the best coverage for your healthcare needs.
The IHS covers many services, although not all of those listed are available at every IHS facility. Services may include:
- inpatient care that requires you to stay in a hospital for more than 24 hours
- outpatient care, including hospital stays under 24 hours
- pharmacy
- radiology, like X-rays
- lab work
- dental
- optical
- hearing
Original Medicare is made up of Part A and Part B.
Part A covers inpatient care, and Part B covers outpatient medical services.
You can purchase a stand-alone Part D prescription drug plan for take-home medications. Private insurers administer these plans on behalf of Medicare.
Alternatively, Medicare Advantage (Part C) plans are available, also administered by private insurers. These plans bundle the benefits of parts A and B. They also typically include the prescription drug coverage from Part D and extra benefits, like dental, fitness, optical, and hearing.
Services you receive through the IHS are not subject to monthly costs in the form of premiums, deductibles, copayments, or coinsurance.
If you have Original Medicare, depending on your work and tax history, you may be eligible for premium-free Part A coverage. If not, monthly premiums cost either $285 or $518.
Part B monthly premiums start at $185 but can increase depending on how much you earn.
Because private insurers administer Medicare Part D and Medicare Advantage plans, costs can vary by plan, plan provider, and location, although many plan premiums start at $0.
For some people, their income will determine what they pay for Medicare.
Your modified adjusted gross income (MAGI) from 2 years ago is what the government uses to determine your income-related monthly adjustment amount (IRMAA).
This determines how much you will pay for Part B or Part D premiums.
Your income includes:
- alimony from divorces and separations finalized before January 1, 2019
- capital gains
- excluded (untaxed) foreign income
- federal taxable wages (from your job)
- investment income
- rental and royalty income
- retirement or pension income
- self-employment income
- Social Security
- Social Security Disability Income (SSDI)
- tips
- unemployment compensation
However, there are special rules for calculating MAGI for American Indian and Alaska Native communities, and the following are typically excluded from tax calculations:
- payments from Alaska Native Claims Settlement Act (ANCSA) corporations and settlement trusts
- payments from trust and reservation property
- income from property and rights related to hunting, fishing, and natural resources
- income from the sale and use of cultural and subsistence property
- income that falls within the IRS General Welfare Doctrine
- any other income that is non-taxable according to federal law or IRS guidance
If you need more specific information about what income is exempt from determining your MAGI, you can contact your tribe.
If you have limited income and resources, you may be eligible for a Medicare savings program (MSP). The four different MSPs are:
- Qualified Medicare Beneficiary (QMB) program
- Specified Low-Income Medicare Beneficiary (SLMB) program
- Qualifying Individual (QI) program
- Qualified Disabled & Working Individual (QDWI) program
These plans can help pay for some of Medicare’s associated costs, such as monthly premiums, deductibles, copayments, and coinsurance.
Each has different eligibility criteria, but with all programs except the QWDI program, you will also get Extra Help, which is a program that can help you with the costs of take-home prescription medications.
You do not need to have an MSP to qualify for Extra Help, but your income and resources must not exceed specific amounts:
| Individual income | Individual resources | Married income | Married resources |
|---|---|---|---|
| $23,475 | $17,600 | $31,725 | $35,130 |
To qualify for Extra Help, you need to meet the above income and resource limits. But some income and resource items do not count toward the overall limit.
In addition to the income and resource list given by the Social Security Agency (SSA), the following are not counted:
- specific money received by an Alaska Native from an Alaska Native Regional and Village Corporation
- land held in trust by the United States for an American Indian or tribe
- money held in trust for tribes by the Secretary of the Interior and allocated per capita to tribe members
- up to $2,000 each year, money that an American Indian receives from individual interests in trusts or
restricted lands - federally legislated payments to members of specific tribes
As of January 2019, many people will no longer need an exemption certificate, but this can vary by state.
Between 2014 and 2019, every U.S. citizen was required to either have healthcare coverage or get a healthcare coverage exemption, or else they would pay a tax penalty if they filed an income tax return.
If your only healthcare coverage is through the IHS, you may need to file for an exemption to avoid paying any penalties unless you have any other health insurance, such as through:
- your employer
- the Health Insurance Marketplace
- Medicare
- Medicaid
- Veterans Affairs (VA)
You can complete an application for an exemption, which should provide you with an exemption certificate number. You can use this number when completing Form 8965 to avoid a tax return penalty.
Some states no longer charge penalty fees and no longer require exemption certificates, so it’s best to check with your state, local tax office, or the person who helps prepare your taxes.
While the IHS offers many different healthcare services, it may not cover everything. In these instances, you can use both the IHS and Medicare for your healthcare needs.
Some income and resource limit rules apply to American Indian and Alaska Native communities when deciding Medicare costs and additional support eligibility.
If you only receive services from IHS, you may need to apply for an exemption certificate number to avoid penalty fees for lack of healthcare coverage, but this can vary by state.