Know what pays for Mom's care, and what to do next.
Plain-English answers about Medicare, Medicare Advantage, Medicaid, the VA and long-term care insurance, with the official rule, what the doctor needs to write, and who to call.
Happening right now
Being discharged, or rehab was denied?
You have rights, and some of them expire the day of discharge. Here's what to do in the next hour.
CoCare Management created this free guide to help families find their way through Medicare, Medicaid and care decisions. We don't provide medical or legal advice, we don't sell insurance, and we don't recommend plans.
Lost on what to do next? Send us a question. When we can, we'll reply with general information about where to look and who to call.
1 dayTypical time for a fast hospital discharge appeal decision after the reviewer has the records
72 hoursTime a Medicare Advantage plan usually has for a fast decision when the doctor says waiting could harm health
100 daysMost skilled nursing days Medicare covers per benefit period
Urgent help
They're discharging Mom and insurance denied rehab. What to do in the next hour.
Some of these rights end when she leaves the building. Do the steps in order, and keep the paperwork the hospital hands you.
Read every notice the hospital gives you. Signing a Medicare rights notice shows you received it; it doesn't mean you agree with the discharge.
Ask: is she an inpatient, or "under observation"?
Observation days don't count toward the 3 inpatient days Original Medicare needs before it pays for rehab. If she was under observation for more than 24 hours, the hospital must give you a MOON notice explaining it. If she was admitted as an inpatient and then switched to observation, she may now have the right to a fast appeal of that switch.
"Is my mother an inpatient or an outpatient under observation? On what dates?"
Find the notice with the phone number on it
Leaving the hospital: look for "An Important Message from Medicare about Your Rights." Rehab, home health or hospice ending: look for the "Notice of Medicare Non-Coverage." The phone number for the independent reviewer (called the BFCC-QIO) is printed on it.
Call the reviewer before she leaves
For a hospital discharge, call no later than the day she's scheduled to leave, before she leaves. She can stay while the reviewer decides, and you won't pay for those extra days except normal deductibles and coinsurance. For rehab or home health ending, call by noon the day before services end.
"I'm calling to request a fast appeal of my mother's discharge. I don't believe she is ready to go home safely."
Medicare Advantage said no to rehab? Ask the doctor to request a fast decision
When the doctor says waiting could seriously harm her health, the plan must decide within 72 hours in most cases. Since January 1, 2024, Advantage plans must follow Original Medicare's coverage rules for skilled nursing. If Original Medicare would cover it, the plan generally can't refuse it.
"Please request an expedited reconsideration and ask whether Original Medicare's skilled nursing criteria are met."
Ask the doctor to put the skilled need in writing
Coverage depends on what's documented. See the box below for exactly what helps.
Call for free Medicare help
Call 1-800-MEDICARE or your state's free Medicare counseling program (SHIP). You can also send CoCare a general question.
When the closest facility can't take her
If this applies to your situation, keep this in mind. Not every rehab facility can accept every patient, so the closest available bed may be farther from home than you expected. Common reasons include:
Larger body size or weight, which needs special (bariatric) beds, lifts and wheelchairs, and extra staff
Memory care needs or a risk of wandering
Dialysis, IV antibiotics or complex wound care
Breathing support, such as a ventilator
No open beds
You can ask whether she can move to a facility closer to home later, if a bed opens. Every facility and situation is different.
The official rules
The official rule
Hospital discharge: ask the reviewer no later than the day you're scheduled to be discharged from the hospital. While waiting, you can stay in the hospital while you wait to get the BFCC-QIO's decision.Medicare.gov
The official rule
Rehab, home health or hospice ending: you get a notice at least 2 days before covered services end and must ask no later than noon the day before the termination date listed on the notice.Medicare.gov
The official rule
Medicare Advantage: The plan must give you its decision within 72 hours when the doctor says waiting could seriously jeopardize health. Plans must follow General coverage and benefit conditions included in Traditional Medicare laws (42 CFR 422.101(b)(2), in effect since 2024). Medicare.gov · Regulation
In plain English
You can ask an independent reviewer to stop a discharge that's too early, and Mom can stay while they decide, usually within a day. If she has an Advantage plan, the plan must give a fast answer when the doctor says waiting could seriously harm her health, and the plan can't use stricter rules than regular Medicare for rehab.
What the doctor needs to document
For rehab coverage
The dates she was a formal inpatient (Original Medicare needs 3 days in a row; the discharge day doesn't count)
That she needs daily skilled care, such as therapy or nursing, and why it can't safely be done at home
Her current function: walking, transfers, toileting, and fall risk
Improvement isn't required: Medicare covers skilled care necessary to maintain the patient's current condition or prevent or slow further deterioration (the Jimmo settlement)
What rehab costs under Original Medicare in 2026
$0Days 1–20 in skilled nursing, after the hospital deductible
$217Per day for days 21–100
$1,736Part A hospital deductible per benefit period
Medicare Advantage plans set their own copays. Check the plan's Evidence of Coverage.
Medicare pays for medical care: hospital stays, short-term rehab, skilled home health and hospice. It does not pay for long-term help with daily living.
What it doesn't cover
The official rule
Medicare does not provide long-term care coverage or custodial care unless medical care is needed.Medicare.gov
In plain English
Help with bathing, dressing, meals and supervision, whether at home, in assisted living or in a nursing home, isn't paid by Medicare on its own. Medicaid, the VA, long-term care insurance or savings usually pay for that.
Short-term rehab (skilled nursing facility)
Needs a medically necessary inpatient stay of at least 3 days in a row. Observation and ER time don't count.
She generally must enter the facility within about 30 days of leaving the hospital.
Up to 100 days per benefit period: $0 for days 1–20, then $217 a day for days 21–100 in 2026.
Home health
The official rule
For people who are homebound and need part-time or intermittent skilled services.You pay nothing for covered home health services. Medical equipment is 20% after the Part B deductible. Medicare.gov
In plain English
If leaving home takes a lot of effort and she needs a nurse or therapist, Medicare sends one to the house for free. A home health aide is included only while she's also getting skilled care.
What the doctor needs to document
Why she is homebound
The skilled service needed (nursing, physical, occupational or speech therapy)
An in-person visit with the doctor or provider about the reason for home health
Walkers, hospital beds, lift chairs and other equipment have their own rules. See medical equipment.
Hospice
For someone whose doctor certifies a life expectancy of 6 months or less and who chooses comfort care. Hospice care is $0 from a Medicare-approved hospice, with up to a $5 copay per prescription for symptom drugs and 5% of the Medicare-approved amount for inpatient respite care. Nursing home room and board isn't included.
Advantage plans (from private insurers) must cover what Medicare covers, and most add extras that families never think to ask about.
Extras worth asking about
Meals after a hospital stay, for a limited time after discharge
Over-the-counter allowance for items Part D doesn't cover
Rides to doctor visits
Extra help for chronic illness (for members who qualify): food and produce, pest control, rides for groceries, home safety changes
The official rule
Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations. CMS requires chronic-illness extras to have a reasonable expectation of improving or maintaining the health or overall function of the member. CMS
In plain English
These extras change by plan and by year. Call the number on the member card, ask "What extras do I have after a hospital stay?", and ask for the answer in writing. The plan's Evidence of Coverage, sent each fall, lists them.
When the plan says no
The doctor can ask for a fast decision. When waiting could seriously harm health, the plan must answer within 72 hours in most cases (it can take up to 14 more days in some situations).
For rehab and home health, plans must use Original Medicare's coverage rules (since January 1, 2024).
You, a representative, or the doctor can request the decision or the appeal.
Medicaid is the biggest payer of long-term care in the country. It pays for nursing homes and, through waivers, for help at home.
Nursing homes
The official rule
Nursing facility services are required to be provided by state Medicaid programs for individuals age 21 or older who need them. States can't put nursing home care on a waiting list. Medicaid.gov
Care at home: waivers
States can use "home and community-based services" waivers to pay for help at home or in some community settings instead of a nursing home. The person must need a nursing-home level of care. Unlike nursing homes, waivers can have waiting lists.
Money rules
Many states cap income at 300% of the SSI benefit, which is $2,982 a month in 2026 in both Florida and Kentucky.
The asset limit for one person is usually $2,000. A spouse living at home can keep more.
5-year look-back: gifts or transfers made in the 60 months before applying can delay coverage.
In plain English
Don't give money or property away to "qualify" without advice first. A penalty can start right when care is needed most. An elder law attorney can show legal ways to plan.
PACE: an all-in-one option
PACE covers medical and social care for people 55 or older who need a nursing-home level of care but can live safely at home, in areas with a PACE program. It's available in parts of Florida and Kentucky.
What the doctor needs to document
Diagnoses and how they limit daily activities (bathing, dressing, eating, toileting, moving)
Memory or thinking problems, and safety risks like falls or wandering
Wartime veterans and surviving spouses who need help with daily living may get extra money every month on top of a VA pension.
Aid and Attendance
The official rule
Paid with a VA pension if at least one is true: You need another person to help you perform daily activities, like bathing, feeding, and dressing; You have to stay in bed—or spend a large portion of the day in bed—because of illness; You're a patient in a nursing home due to the loss of mental or physical abilities related to a disability; or eyesight is limited to 5/200 or less in both eyes, even with glasses or contacts. VA.gov
Maximum yearly pension with Aid and Attendance (from Dec 1, 2025)
$29,093Veteran, no dependents
$34,488Veteran with one dependent
$18,697Surviving spouse
In plain English
These are maximums. The VA subtracts countable income, and medical and care costs can lower countable income. The money can help pay for home care or assisted living.
What the doctor needs to document
VA Form 21-2680, the exam for housebound status or need for aid and attendance, completed by a doctor
Which daily activities she or he needs help with, and why
VA home and community programs
Homemaker and Home Health Aide care
Adult Day Health Care and respite care
Home Based Primary Care and Skilled Home Health Care
Veteran-Directed Care, a flexible budget to hire your own helpers
If Mom or Dad bought a long-term care policy years ago, find it now. Many families forget it exists.
The official rule
Most policies pay when you need help with two or more of six ADLs (activities of daily living) or have a cognitive impairment. Payments start after an elimination period, often 30, 60 or 90 days. ACL.gov
In plain English
If she needs help with things like bathing and dressing, or has dementia, the policy likely kicks in. You usually pay for the first month or few months yourself, so start the claim right away.
How to start a claim
Find the policy, or call the insurer with her name, date of birth and Social Security number.
Ask for a claim packet and the "elimination period" for her policy.
Have the doctor document which daily activities she needs help with, or the cognitive diagnosis.
Keep receipts for all care from day one.
Last checked October 28, 2026.
State guide
Florida: what pays for care
Florida's Medicaid long-term care program can pay for help at home and for assisted living services. Getting in starts with a phone screening, and there's often a waitlist, so call early.
Does Medicaid pay for assisted living in Florida?
The official rule
Florida's Statewide Medicaid Managed Care Long-Term Care program lists Assisted Living among its covered services, along with personal care, adult day care, hospice and nursing facility care. All of these services are available based on medical necessity.Florida Elder Affairs
In plain English
Yes for the care services, but generally not for rent and meals (room and board). The program's services also include home accessibility adaptation and personal care at home. Florida's Optional State Supplementation can add a small monthly payment toward assisted living for people with low income.
How to get in: 3 steps
Phone screening: call the Elder Helpline. The screening takes about 45 minutes to an hour and gives a priority score for the waitlist. Ask to be rescreened if her health changes.
Medical check (CARES): Elder Affairs confirms she needs a nursing-home level of care, at no cost.
Money check (DCF): apply for Medicaid through the Department of Children and Families.
2026 limits for one person
$2,982Monthly income limit
$2,000Asset limit
$160Monthly personal needs allowance
Other Florida programs
Community Care for the Elderly: for people 60 and older who need help, with services like adult day care, case management and home-delivered meals.
Home Care for the Elderly: a $160 monthly subsidy for people 60 and older living with a family caregiver at home, for those who qualify.
PACE: available in parts of Florida for people 55 and older.
What the doctor needs to document
Diagnoses and how they limit daily activities
Memory problems, fall risk and supervision needs
Recent hospital stays or decline. A change in condition can raise the waitlist priority score.
Kentucky Medicaid doesn't pay for assisted living, but its home care waiver, the state Homecare Program and personal care home supplements can fill the gap.
Does Medicaid pay for assisted living in Kentucky?
The official rule
Assisted Living Communities in Kentucky are social models and do not provide health services. Residents may still get Medicare or Medicaid coverage for health care from outside licensed agencies. Kentucky DAIL
In plain English
No, Medicaid won't pay the assisted living bill. But a home health nurse or therapist can still visit her there and bill Medicare or Medicaid.
Help at home: the HCB waiver
Who: age 65 or older, or with a physical disability, who needs a nursing-home level of care and meets Medicaid's money rules.
Covers: adult day health care, attendant care, home changes like grab bars and ramps, home-delivered meals, and respite.
Waitlist: yes, in order of when the completed application arrives, so apply early.
Choose your helpers: with Participant Directed Services, you can hire people you know.
How to apply: first qualify for Medicaid (kynect or DCBS), then apply for the waiver on kynect or at an Aging and Disability Resource Center.
Personal care homes: State Supplementation
A monthly payment for people who are aged, blind or disabled and live in a licensed personal care home or family care home, or receive caretaker services at home. It makes up the difference between the person's income and the standard.
$1,610Monthly standard, personal care home (2026)
$1,166Monthly standard, family care home (2026)
$2,000Asset limit
Personal care home residents can't use waiver services at the same time.
Kentucky Homecare Program
For people 60 and older who can't do 2 daily activities (like bathing) or 3 household tasks (like cooking) on their own: personal care, home-delivered meals, respite, home repair and case management. It's run through Area Agencies on Aging, and some areas may have waiting lists.
2026 Medicaid long-term care limits for one person
$2,982Monthly income limit
$2,000Asset limit
PACEAvailable in parts of Kentucky, age 55+
What the doctor needs to document
Diagnoses and which daily activities she needs help with
Memory problems and safety risks
That she needs a nursing-home level of care (for the waiver)
Enter the plan number from your member card, or pick your state, county and plan. We'll show what your plan filed with Medicare for rehab, home health, meals, rides and other help at home, plus who to call and what to tell the doctor.
or
Monthly premium (2027)
Most you'd pay in a year, in network
Member services
Care benefits in this plan
Tap any benefit to see what it means, who to call and what to tell the doctor. Missing something? Tap "Which plans have this?"
Insurance company
Plan
Plan number
Monthly premium
Member services
If you want to switch
We don't recommend plans. Talk to a licensed insurance agent or your free state Medicare counselor (SHIP) about your options. You can change plans October 15 to December 7 each year, and Medicare Advantage members can make one switch January 1 to March 31. Some situations allow a change at other times. Special needs plans are only for people who qualify.
Source: Medicare's 2027 plan benefit and landscape data (CMS, October 2026). This shows what each plan filed with Medicare. The plan's Evidence of Coverage has the full rules, and plans can make limited changes. Not affiliated with any insurance company.
Program guide
Medical equipment at home
Walkers, wheelchairs, hospital beds, lift chairs and oxygen are covered when a doctor orders them and the person meets Medicare's rules. Each item has its own rules, and a few common items aren't covered at all.
The basics
The official rule
Part B covers medically necessary DME if your doctor or other health care provider orders it for use in your home. After the Part B deductible, you pay 20% of the Medicare-approved amount (if your supplier accepts assignment).Medicare.gov
In plain English
The doctor orders it, a Medicare-enrolled supplier delivers it, Medicare pays 80%, and you pay 20%. The Part B deductible is $283 in 2026. Use a supplier that is enrolled in Medicare and accepts assignment, or you may pay more. Some items are rented, some are bought, and some become yours after a number of rental payments.
Medicare Advantage: the plan sets its own cost share, uses its own network of suppliers, and often needs to approve items first. Look up your plan to see its equipment costs.
Good to know, item by item
Lift chairsLift part only
In plain English
Medicare covers the lifting mechanism, not the chair. Most people buy a complete lift chair from a Medicare-enrolled supplier. The supplier bills Medicare for the lift part, and you pay for the chair itself plus your 20% share of the lift. Ask the supplier how they split the bill before you buy. Spring-loaded seats that push you up aren't covered.
The official rule
All of these must be true: severe arthritis of the hip or knee or ... a severe neuromuscular disease; the person is completely incapable of standing up from a regular armchair or any chair in their home (difficulty alone isn't enough); and once standing, the beneficiary must have the ability to ambulate. When the lift is built into a chair, the supplier bills the lift mechanism to Medicare and the chair as a non-covered item. Medicare coverage rule · Billing article
What the doctor needs to document
The diagnosis: severe hip or knee arthritis, or a severe neuromuscular disease
That she can't stand up from any chair in her home, and can walk once standing
That other treatments, like medication or physical therapy, were tried and didn't work
A written order sent to the supplier before the claim
Hospital bedsCovered if rules met
The official rule
A standard hospital bed is covered when the person has at least one of these: a condition that requires body positioning in ways that can't be done with an ordinary bed; needs positioning to relieve pain; needs the head of the bed raised more than 30 degrees most of the time because of congestive heart failure, chronic lung disease or aspiration; or needs traction that only attaches to a hospital bed. A semi-electric bed also needs frequent or immediate changes in position. CMS
In plain English
Wanting a more comfortable bed isn't enough. The doctor has to show a medical reason a regular bed won't work.
What the doctor needs to document
The medical condition and how severe and frequent the symptoms are
Which positioning or attachment is needed, and why an ordinary bed can't do it
WalkersCovered if rules met
The official rule
Covered when The patient has a mobility limitation that significantly impairs their ability to take part in 1 or more mobility-related daily activities in the home, The patient can safely use the walker, and Using a walker can resolve the functional mobility deficit.CMS
What the doctor needs to document
Which daily activities at home she can't do safely (getting to the bathroom, the kitchen, the bedroom)
That she can use a walker safely and it solves the problem
Power wheelchairs and scootersCovered if rules met
The official rule
You must have a face-to-face examination and a written prescription from a treating provider. The mobility problem must keep her from daily activities at home, and it cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. She also can't propel a manual wheelchair at home, must be able to operate the device safely, and the home must have room to use it. The exam must be within 6 months before the order. Medicare.gov · Medicare coverage rule
In plain English
Medicare looks at whether she needs it to get around inside her home, not for trips out. A cane, walker or manual wheelchair has to be ruled out first.
What the doctor needs to document
An in-person exam about her mobility, within 6 months before the order
Why a cane, walker or manual wheelchair won't work
That she can operate the device safely
Bedside commodesCovered if rules met
The official rule
A commode is covered when the beneficiary is physically incapable of utilizing regular toilet facilities, for example when confined to a single room, confined to one level of the home with no toilet on that level, or confined to a home with no toilet. Medicare coverage rule
What the doctor needs to document
Why she can't get to or use the regular toilet, such as being limited to one room or one floor
Home oxygenCovered if rules met
The official rule
The main test: an arterial oxygen saturation at or below 88%, taken at rest, breathing room air (or an arterial oxygen level, PO2, of 55 mm Hg or below). Some people at 89% qualify with other conditions, such as swelling from heart failure. For hospital patients, the test must be within 2 days of discharge, and the equipment supplier can't do the test. CMS
What the doctor needs to document
The oxygen test result, the date, and the conditions (at rest, during exercise or during sleep)
For a hospital patient, a test within 2 days of discharge
Medicare's equipment list marks bathtub seats as comfort or convenience item; hygienic equipment; not primarily medical in nature, and grab bars as a self-help device; not primarily medical in nature. Raised toilet seats and bathtub lifts are also listed as not covered. Medicare national coverage rule
In plain English
Original Medicare won't pay for these. But some Medicare Advantage plans include home and bathroom safety items (look up your plan), Medicaid home care programs may help for people who qualify: Kentucky's HCB waiver covers minor home adaptations (Kentucky guide), and Florida's long-term care program lists home accessibility adaptation (Florida guide).
Who to call
The doctor's office: ask them to send the order and notes to the supplier.
The supplier: ask, "Are you enrolled in Medicare, and do you accept assignment?" If she has an Advantage plan, ask if they're in the plan's network.
1-800-MEDICARE (1-800-633-4227) to find enrolled suppliers, or the plan's member services for Advantage plans.
Every Medicare drug plan has its own list of covered drugs and its own rules for the expensive ones. Here's what those rules mean, what the doctor needs to send, and where families sometimes find help with the cost.
Check a drug in a 2027 plan
Florida and Kentucky plans, from Medicare's official 2027 drug lists. Pick the plan, then type the medicine.
or
Source: Medicare Prescription Drug Plan Formulary files, October 2026 release for 2027 plans. Plans can change their lists during the year; confirm with the plan before filling.
What the special rules mean
Next to a drug on a plan's list (on the plan's website, in the welcome packet, or on Medicare Plan Finder) you may see these letters. Each one means a step has to happen before the plan pays.
PA · Prior authorizationApproval first
In plain English
The doctor has to send the plan proof that the person meets the plan's rules for this drug before the pharmacy can fill it. The rules are different for every drug and every plan. For expensive specialty drugs, they usually cover the exact diagnosis, test results, other drugs already tried, and which kind of specialist is prescribing.
What helps
Get the plan's written criteria for the drug before the doctor submits, so nothing is missing
Make sure the doctor's note answers every item on the list, with dates and test results
Ask the doctor's office to tell you the day it's sent, and call the plan two days later to check
ST · Step therapyTry another first
In plain English
The plan wants the person to try a different, usually cheaper, drug first. If that drug was already tried and didn't work, caused side effects, or can't be used for a medical reason, the doctor can ask the plan to skip the step.
What the doctor needs to show
Which drug was tried, the dates, and what happened
Or the medical reason the first drug can't be used
QL · Quantity limitLimit per month
In plain English
The plan covers only a set amount, for example 30 tablets every 30 days. If the doctor prescribes more, the doctor can ask the plan for an exception and explain why the higher amount is needed.
TiersSets the copay
In plain English
Plans sort drugs into tiers. Lower tiers (usually generics) cost the least. The highest tier, often called specialty, is where most cancer, multiple sclerosis and arthritis drugs sit, and it usually costs a percentage of the price instead of a flat copay. The yearly out-of-pocket cap below still applies.
If the plan says no
The official rule
You, your representative, or the prescriber can ask the plan for a coverage determination, including an exception to its drug list or rules. The plan must decide within 72 hours after it gets the doctor's supporting statement, or 24 hours if waiting could seriously harm the person's health. If it still says no, you can appeal (a redetermination) within 65 days of the written denial. Medicare.gov · CMS appeals chart
In plain English
A "no" is often a missing piece of paperwork, not a final answer. Ask the plan for the denial in writing and the exact reason, give it to the doctor, and have the doctor resend with the missing item. If the person is waiting on a cancer drug or anything urgent, ask for the fast (expedited) decision. The doctor's statement that waiting could harm the person's health is what qualifies it.
What the doctor needs to send for an exception
A supporting statement saying why the drug is medically necessary
For a drug not on the list: why the covered alternatives won't work or would cause harm
For a lower copay (tiering exception): why the cheaper-tier drugs won't work
Chart notes, test results and the history of drugs already tried
Drugs given at the doctor's office or infusion center, like many IV chemotherapy drugs, are usually covered under the medical side (Part B or the Medicare Advantage medical benefit), not the drug plan. They have different approval rules. Ask the doctor's office which side the drug is billed under.
Specialty drugs: what the plan wants to see
For expensive drugs, each plan publishes the exact approval rules. Below are real examples from Medicare drug plans, rewritten as checklists. Your plan's rules may be different, so ask the plan for its criteria for the drug (member services can send them) and give them to the doctor before the request goes in.
Ibrance (palbociclib) · breast cancerApproval first
Checklist: all of these, from one 2026 Medicare plan
Tumor testing confirms the breast cancer is hormone receptor-positive and HER2-negative
Ibrance will be taken together with a hormone pill (an aromatase inhibitor such as letrozole) or fulvestrant injections
For women who could become pregnant, pregnancy status is documented
Prescribed by a cancer specialist (oncologist); patient is 18 or older
Not taken with certain drugs that interfere with it (the doctor checks the medication list)
If the cancer has stopped responding to hormone therapy, that plan also covers it when a PIK3CA mutation is confirmed and Ibrance is paired with inavolisib. Approval lasts 1 year, then renews.
What the doctor's paperwork should show
The pathology or biomarker report (ER/PR and HER2 results)
Xtandi (enzalutamide) · prostate cancerApproval first
Checklist: the questions one Medicare plan's form asks
The cancer is one of these: it has spread but still responds to hormone therapy; it keeps growing despite hormone therapy; or the PSA is rising after surgery or radiation, it hasn't spread, and the risk of spread is high
And (except the rising-PSA case) the patient is also getting a testosterone-lowering shot, like Lupron or Eligard, or has had surgery to remove the testicles
What the doctor's paperwork should show
Scans showing whether the cancer has spread
PSA history and the dates of earlier treatment
The name and dates of the hormone shot, or the surgery record
Adalimumab (Humira biosimilars) · rheumatoid arthritis and moreApproval first
Checklist for rheumatoid arthritis: both of these, from Humana's 2026 drug plan
Diagnosis is moderate to severe active rheumatoid arthritis
Has already tried at least one standard arthritis pill, like methotrexate, sulfasalazine, hydroxychloroquine or leflunomide, and it didn't work or wasn't tolerated, or can't safely take any of them
Patient is 18 or older
Other conditions (Crohn's, psoriasis, ankylosing spondylitis, uveitis and others) each have their own "tried first" rule. Approval lasts through the end of the plan year. The plan's list names the biosimilar versions (adalimumab-adaz and adalimumab-adbm), so ask whether brand-name Humira is covered.
What the doctor's paperwork should show
Chart notes with the diagnosis and how active the disease is
The earlier drug's name, dates taken and why it was stopped, or the medical reason none can be used
These are possible options to look into, not a promise that anyone qualifies. Each program decides on its own.
The 2027 numbers
The "donut hole" is gone. In 2027 a Medicare drug plan's deductible is at most $700, and once you've paid $2,400 out of pocket for covered drugs, you pay nothing for covered drugs the rest of the year. Optum
Also new in 2027: Medicare negotiated lower prices on 15 more drugs, including Ibrance and Xtandi, starting January 1, 2027. Kiplinger
Medicare Prescription Payment PlanAnyone with a drug plan
In plain English
Instead of a big bill at the pharmacy, the plan spreads your drug costs into monthly payments with no interest. It doesn't lower the total, but it stops a $2,400 hit in January. Sign up with your plan (call member services). Medicare.gov
Extra HelpLimited income
In plain English
Medicare's own program that lowers drug plan premiums, deductibles and copays for people with limited income and savings. People who get Medicaid or a Medicare Savings Program qualify automatically. Apply at ssa.gov/extrahelp or call Social Security at 1-800-772-1213.
Medicare Savings Programs and MedicaidLimited income
In plain English
State programs that can pay Medicare premiums and, for some people, deductibles and copays. You apply through the state Medicaid office. See our Florida and Kentucky guides. Medicare booklet
Charity copay foundationsFunds open and close
In plain English
Independent charities help Medicare patients pay copays for specific diseases. Each fund opens and closes during the year as money comes in, so check often and apply the day it opens.
Blood Cancer United (formerly the Leukemia & Lymphoma Society): for blood cancers
Drug company assistance programsVaries
In plain English
Many drug makers run programs that can give the drug free to people who qualify. Their coupon or copay cards can't be used with Medicare (federal law), but their separate assistance programs sometimes can. Call and ask whether Medicare patients are accepted.
Ibrance: Pfizer RxPathways, 1-844-989-7284. Accepts some Medicare patients; asks them to join the Prescription Payment Plan first.
This page is general information, not medical, legal or insurance advice. Plans change their drug lists and rules during the year. Always confirm with the plan, using the member services number on the card, before the doctor submits. CoCare doesn't sell insurance and doesn't recommend plans or drugs.
The free guide
What pays for care
Pick a program or a state. Each page shows the official rule, a plain-English version, what the doctor needs to document, and who to call.
Each state guide covers its Medicaid long-term care programs, free help lines, and where to file complaints.
Tell us what's happening and what you're trying to figure out. When we can, we reply by email with general information about where to look and who to call. We can't advise on individual medical or legal situations, and we can't promise a reply to every message. It's free.
Prefer email? Write to help@cocaremanagement.com
We share general information only, not medical or legal advice. For medical questions, talk to the doctor. For legal questions, talk to an elder law attorney. In an emergency, call 911.