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If you have Medicare, you may already be getting Medicare prescription drug coverage. But if you have limited resources, you might be eligible for additional help. The Medicare Extra Help Program can help beneficiaries with limited income afford their medications.
Also known as Medicare Part D Low-Income Subsidy (LIS), the Extra Help Program may cover some to most of your out-of-pocket prescription drug costs. To make sure you aren’t missing out on the opportunity for additional savings, let’s see if you qualify for extra assistance.
Who is Eligible for the Medicare Extra Help Program?
Eligible applicants will meet all of the following requirements:
- You are enrolled in a Prescription Drug Plan (PDP) – Medicare Part D – or a Medicare Advantage Plan that includes a prescription drug benefit (MA-PD).
- You are a resident of one of the 50 states or Washington, D.C.
- Your resources are limited to $14,390 for an individual or $27,720 for a married couple living together. Qualifying resources include bank accounts, stocks, and bonds. Items such as houses, vehicles, life insurance policies, or back payments from Social Security or SSI are not considered resources.
- You have an annual income of less than $18,735 for an individual or $25,365 for a married couple living together.
In some cases, applicants with a higher income may still be eligible for extra help. These situations include the following:
- You or your spouse supports additional family members who live with you.
- You have earnings from work.
- You live in Alaska or Hawaii.
Additionally, you automatically qualify for Extra Help regardless of the above eligibility requirements if you are enrolled in one of the following programs:
- Medicaid
- Supplemental Security Income (SSI)
- Medicare Savings Program (MSP)
In the above situation, you should receive a notice on purple paper from the Centers for Medicare & Medicaid Services (CMS), informing you that you don’t need to apply.
What are the Benefits of the Medicare Extra Help Program?
The Extra Help program, administered by the Social Security Administration (SSA), is estimated to be worth a value of approximately $4,900 per year. It pays for your Medicare Part D premium up to a certain, state-specific amount.
Those eligible for the program will pay less in drug premiums, copayments, coinsurance, annual deductibles, and other Medicare-related costs.
And while you may pay a late penalty if you don’t enroll in a Medicare prescription drug plan when you’re first eligible, you will not pay a penalty if you get Extra Help or another eligible prescription drug plan coverage. Extra Help program participants are covered during the Coverage Gap and do not have to pay a Part D late enrollment penalty.
Extra Help program participants also have a Special Enrollment Period (SEP) to change their prescription drug coverage up to once per month during the first nine months of the calendar year.
The Medicare Annual Enrollment Period (AEP) takes place during the final three months of the year, and you also can change your election, as needed, during this time. You may choose a new, stand-alone Part D drug plan, a Medicare Advantage Plan with prescription coverage, or discontinue your Medicare Advantage Plan and enroll in a stand-alone Part D drug plan with Original Medicare.
The Extra Help program is beneficial because it allows you to change your plan often and easily. If you begin taking a new prescription that your previous plan didn’t cover, you can change to a plan that does cover it. Note though, these changes generally will not take effect until the first day of the following month.
What are the Levels of Coverage?
Not every Medicare Extra Help program participant will be covered 100%. Depending on your eligibility, your monthly plan premium will vary. The Extra Help may not always cover the full amount of your Medicare Part D plan premium.
The four levels of Extra Help coverage, or Low-Income Subsidy, that you may receive are 100%, 75%, 50%, and 25% of your monthly Medicare Part D plan premium.
Please note these additional coverage considerations:
- The Extra Help program is not a plan on its own or a replacement for a Medicare Part D plan.
- Medicare Part D Extra Help will not pay for your monthly Medicare Part B premium.
- If you have a Medicare Advantage Prescription Drug Plan, your Medicare Part C premium will not be lowered.
What is the Medicare Extra Help Enrollment Process?
You should be automatically enrolled in Medicare Extra Help if you are already enrolled in programs such as Medicaid, SSI, or MSP. Reach out to your local Social Security office to confirm.
If you’re not a participant in the above programs and you want to check eligibility, you can contact:
- 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048, 24 hours a day, 7 days a week or visit Medicare’s website.
- The Social Security Administration at 1-800-772-1213 between 7 a.m.-7 p.m., Monday-Friday. TTY users can call 1-800-325-0778. Or, you can visit the Social Security Administration’s website.
- Your state Medicaid office.
When you’re ready to apply, you can do so in person at your local Social Security office, or via print or online form. According to the Social Security Administration, the benefits of applying for Medicare Part D Extra Help program online include:
- A secure, user-friendly interface that takes you step-by-step with self-help screens.
- You can start and stop at any time and save your application for later.
- Your personal information is protected.
- Your application can also be used to start the process for other state-based Medicare Savings Programs, which may find you additional savings.
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