What Does Medicare Extra Help Cover
Individuals who qualify for the full Extra Help subsidy wont have to pay any premiums or deductibles. They also will only pay $8.95 for each prescription drug that their plan covers. Individuals who only receive partial subsidies may still have premiums and deductibles but they will be substantially less than what they are under Original Medicare.
Eligibility For Medicare Extra Help
To qualify for government help with the costs of your prescription drug coverage, you must have assets and personal resources that fall below specific limits. These limits may change each year. Countable personal resources include stocks, bonds, and money in a checking or savings account. These resources do not include property, vehicles, burial plot and other burial expenses set aside up to $1,500, furniture, and other household items.
You might qualify for Medicare Extra Help automatically
Certain beneficiaries automatically qualify and are enrolled in the Extra Help program. You may automatically qualify if you have Medicare Part A and Part B and meet any of the following conditions:
- You have full Medicaid coverage.
- You get help from your state Medicaid program with paying your Part B premiums.
- You receive Supplemental Security Income benefits.
Once you are determined to be eligible for Medicare Extra Help automatically, you will qualify for the entire year. Even if you stop receiving Medicaid or certain other assistance during the year, you will continue receiving Extra Help for the remainder of the year.
You might have to apply for Medicare Extra Help
If you do not automatically qualify for the Low-Income Subsidy you can apply for it in either of these ways:
- Contact the Social Security Administration, either online, by phone , or by visiting your local Social Security office.
- Ask for a state determination at your state Medicaid agency.
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How Will I Know If I No Longer Qualify For Extra Help Or If There Are Changes To My Copay Costs
Depending on the exact circumstances, there are a few different ways you will be notified about changes to your Extra Help coverage.
For example, if you got Extra Help at one point, but no longer automatically qualify for next year, you will receive a letter in the mail by the end of September. In this case, you may still qualify for some prescription drug cost assistance, but you will have to apply to find out.
If your copays have changed for next year, you will receive a notice in the mail in early October that will inform you of the new amounts.
If you do not receive a notice from Medicare, you can expect your Extra Help benefits to continue as normal for next year.
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Medicare Extra Help Program
The Low-Income Subsidy , also known as the Medicare Extra Help program, is available to beneficiaries who fall below certain income and personal resource limits. This is a federal program that helps pay for costs associated with Medicare prescription drug coverage. This assistance may lower your prescription drug copayment amounts, and decrease or eliminate your Medicare Prescription Drug Plan premiums and deductibles.
If you qualify for the full benefits of Extra Help program, you will pay no more than a small amount for prescription drugs in your planâs formulary . Based on income level, some beneficiaries might qualify for help with a portion of their prescription drug costs . Additionally, if youâre enrolled in the Extra Help program, you will not be subject to a coverage gap, or âdonut hole.â
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See If You Qualify For Extra Help For Part D Prescription DrugsExtra Help Part D income and resource levels
If your income is less than:
If your resources * are less than:
$1,719 per month/$20,625 per year
$2,309 per month/$27,705 per year
*Resources include the value of things you own. Examples of resources: Real estate , bank accounts and cash at home or anywhere else. Resources do not include the home you live in and one car.
Note: If you have income from working, your income could be higher, so we recommend applying to see if you qualify.
Extra Help With Your Medicare Prescription Drug Plan Costs
The Extra Help program assists people with limited resources and lower incomes in paying for Medicare Part D prescription drug coverage.
Receiving Extra Help with your Medicare Part D can:
- Eliminate the Medicare Part D late enrollment penalty
- Reduce your out-of-pocket costs for prescription drugs
- Eliminate your monthly Medicare Part D premiums
- Reduce or eliminate your annual Medicare Part D deductible
- Eliminate the coverage gap, also known as the donut hole
As Extra Help removes the donut hole, your prescriptions will not cost more when you exceed the annual spending limit. The program saves beneficiaries nearly $5,000 in Medicare Part D costs per year.
If you are eligible for Medicaid or any of the following Medicare Savings Programs, you automatically qualify.
- Specified Low-Income Medicare Beneficiary
- Qualifying Individual
With Extra Help, each generic prescription costs no more than $3.95, and each brand-name prescription does not cost more than $9.85.
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If you did not enroll in Medicare Part D when you first became eligible, you do not have to pay the late enrollment penalty if approved for the program. Approval waives this cost if you would otherwise owe the penalty.
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What Are The Income And Resource Limits For Extra Help In 2021
In 2021, the annual income limit for Extra Help for an individual is $19,140. For a married couple who is living together, the limit is $25,860. When your income is calculated, governmental assistance such as food stamps, housing assistance, and home energy assistance arent counted.
Even if your income is higher than the limits, you should still apply for Extra Help if you think you qualify. Some scenarios where youd still be eligible for Extra Help even though your income is over the limit include if you and/or your spouse:
- Provide financial support for other family members currently living with you
- Earn money by working
- Reside in Alaska or Hawaii
Resource limits also apply when determining your eligibility for Extra Help. Your resources must be equal to or below $14,610 as an individual or $29,160 as a married couple who are living together.
The following examples count as resources:
- Real estate
- Interest on money slated for use as burial expenses
Contact Social Security for a comprehensive list of excluded resources.
How Can I Find A Plan That Helps Me Save On Medicare Part D Costs
Even if you dont qualify for the Extra Help this year, one of the simplest ways you can reduce prescription drug costs is by taking the time to compare and research plan options. Remember, Medicare Part D costs often vary from plan to planeven when the prescription drugs being covered are exactly the same. Each Medicare plan that covers prescription drugs typically places covered medications into different cost tiers, and your copayment and coinsurance costs will depend on which tier your prescriptions fall onto. Typically, medications on higher tiers have higher cost sharing amounts.
The Medicare Advantage and Prescription Drug Annual Election Period runs from October 15 to December 7 each year and is your yearly opportunity to take stock of your prescription coverage and make changes if needed. During this time, you can enroll in Part D coverage, switch plans, or drop your prescription drug coverage entirely.
Would you like to browse plan options now? You can get started by clicking the Compare Plans button on this page simply enter your prescriptions to filter your search and only display plan options that cover your medications.
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How To Apply For Medicare Part D Extra Help Program
Applying for this program is not difficult. You can visit Medicare.gov to get started with an online application for the Extra Help program. The easiest and fastest way to apply is by completing the online application. You should remember, however, that applying for Extra Help does not enroll you in Medicare prescription drug coverage. You will need to enroll in a drug plan separately through the health care insurance provider of your choice. You may even choose to enroll in a Medicare Advantage plan that includes drug coverage.
If you cannot complete your application online, there are other ways that you can apply for this helpful program. You may call the Social Security Administration toll-free at 1-800-772-1213 to complete an application for the Extra Help program. You can call 1-800-Medicare to learn more about your options for prescription drug coverage. Lastly, you can make an appointment at your local Social Security office to complete a paper application in person. Remember that these offices do not accept walk-ins currently, so you will need to call and schedule an appointment first.
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Who Should Complete This Application For Extra Help With Costs Under The Medicare Prescription Drug Coverage
You should complete this online application for Extra Help if:
- You have Medicare Part A and/or Medicare Part B and
- You live in one of the 50 states or the District of Columbia and
- Your income is below $20,625 if you are not currently married or not living with your spouse, or $27,705 if you are currently married and living with your spouse and
- Your combined savings, investments, and real estate are not worth more than $15,510 if you are not currently married or not living with your spouse, or $30,950 if you are currently married and living with your spouse.
If you have more than those amounts, you may not qualify for the Extra Help. However, you can still enroll in an approved Medicare prescription drug plan for coverage.
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Qualifications For Medicare Extra Help Program
To qualify for the Low-Income Subsidy you must meet the following requirements.
- You have Medicare Part A and or Medicare Part B
- LIve in one of the 50 states or the District of Columbia
- As of 2020, you combined savings, investments and real estate are less than $29,160 if you are married or living with your spouse.
- Your income is below $14,610 if you are not married or living with a spouse
- You do not have to count your home, vehicles, personal possessions, life insurance, burial plots, burial contracts, or back payments from Social Security of SSI in those figures.
- If your income exceeds the previous figures you may not qualify for Extra Help, however, you still can purchase a Medicare Part D prescriptions plan to help with the costs of medications
- If you receive Medicare and Supplemental Security Income you should automatically qualify for the program
- Should have both Medicare and Medicaid you should also qualify for the low-income subsidy
How Much Medicare Extra Help Can Save You
Even if you qualify for Medicare Extra Help, your income level, resource level, marital status, and Medicaid eligibility will determine whether you qualify for full or partial Extra Help.
Medicare Extra Help can be understood in relation to Medicare Part D. If you qualify for Extra Help, then it reduces your Part D out-of-pocket costs. In certain circumstances, you’ll pay $0 in Part D premiums and deductibles and heavily reduced copays for prescriptions. The table below explains how Extra Help reduces Part D costs.
If you qualify for both Medicaid and Medicare Extra Help, and are receiving care in an institution, such as an assisted living facility, nursing home, or rehabilitation hospital, or from certain home and community health services, then Extra Help may reduce your Part D costs to nothing.
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Extra Help For Prescription Drug Coverage
Extra help for prescription drug coverage is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources a person has.
Full Subsidy Benefits from Extra Help:
- Full premium assistance up to the premium subsidy amount
- Nominal cost sharing up to out-of-pocket threshold
- No coverage gap
Other Low Income Subsidy Benefits from Extra Help:
- Sliding scale premium assistance
- Reduced coinsurance
- No coverage gap
An individual who has Medicare and Medicaid does not need to apply for extra help from Social Security. An individual who is eligible for the Medicare Savings Program does not need to apply for extra help from Social Security. The MSP-eligible individual’s information is sent to CMS automatically for the extra help.
Eligibility specialists ask, “Can I screen you for eligibility for Medicare Savings Program since certification would include eligibility for extra help?”
If the caller does not want to be screened for MSP, refer the caller to the Centralized Benefit Services, 1-800-248-1078, for completion of subsidy application.
If an individual thinks personal information is being misused, call 1-800-MEDICARE .
Apply for extra help or get more information about extra help subsidy by calling Social Security at 1-800-772-1213 or visiting www.socialsecurity.gov.
Benefits Of The Medicare Part D Extra Help/low
The Low-Income Subsidy program helps pay for a portion of Part D prescription drug plan costs, including Part D premiums, deductibles and copayments. Depending on your income and assets, you may qualify for the full subsidy or a partial subsidy. All beneficiaries who qualify for the LIS program are permitted to change Part D plans once a quarter for the first 3 quarters with an effective date of change being the first of the following month. In addition, one change can be made in the last quarter of the year, with the effective date being January 1. Beneficiaries who have been identified as at risk for opioid abuse, may be further restricted from changing plans.
In this section:
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How Medicare Extra Help Works
Once you have a plan, youll have to provide the insurer with documentation to prove that you are receiving Extra Help. The documents that count as proof include
A purple, yellow, or green notice of automatic qualification from Medicare
An Extra Help award notice from the SSA
Your Supplemental Security Income award letter
A copy of your Medicaid card
Once you provide documentation, you will immediately start paying the lower Extra Help drug prices.
Remember that the income and asset limits for Extra Help change every year. Just because you qualify one year does not mean you will qualify the next. Youll receive a notice from Medicare around the end of September if the SSA believes you no longer automatically qualify for Extra Help.
In this case, you will need to reapply for the program through SSA.gov or your local Medicaid office.
Senior Editor & Personal Finance Expert
Derek is a former senior editor and personal finance expert at Policygenius, where he specialized in financial data, taxes, estate planning, and investing. Previously, he was a staff writer at SmartAsset.
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Find Out If You Qualify
You might be eligible if you have an annual income under $20,000 and have less than $15,000 in assets. However, there are some exceptions.
Your assets may include bank accounts, savings bonds, mutual funds, Individual Retirement Accounts , and any other cash at home or anywhere else. Include the things you own by yourself, with your spouse, or with someone else. Do not count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts, or back payments from Social Security or SSI.
Find out if you might be eligible for benefits below.
DISCLAIMER: This quiz does not replace the official enrollment process and uses Partial Extra Help numbers to qualify the results. Those that may be eligible for Full Extra Help will need to contact their State Health Insurance Program Center. Eligibility does not guarantee enrollment into the program.
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Will Extra Help Reduce My Out
Enrollees who receive full Extra Help in 2022 will pay no more than $3.95 for each generic drug and $9.85 for brand-name drugs. This is a valuable benefit that the Social Security Administration estimates is worth an average of about $5,000 per year. For Extra Help enrollees with lower incomes who are also enrolled in Medicaid, copays are limited to $1.35 for generics and $4.00 for brand name drugs.
In addition to having lower copayments, Extra Help enrollees also have their Part D plan deductibles reduced or eliminated altogether . The federal government also pays Part D premiums on behalf of Extra Help enrollees up to a benchmark amount , and eliminates the Part D late enrollment penalty for beneficiaries who would otherwise have to pay it.
Some beneficiaries, with income on the higher end of the eligible range, receive partial Extra Help, which reduces but does not fully cover the premiums and deductible for Part D. Partial Extra Help also reduces other out-of-pocket costs under Part D, but not as much as full Extra Help. As noted above, these beneficiaries will be eligible for full Extra Help as of 2024, under the terms of the Inflation Reduction Act.
CMS estimates that up to 2 million Medicare enrollees may be eligible for Extra Help but not enrolled. If you think you might be eligible, apply online or call Social Security at 1-800-772-1213.