If you have prescription drug coverage through a Medicare Part D prescription drug plan or Medicare Advantage Prescription Drug plan, you may be eligible for help with Part D costs. The Medicare Extra Help program offers financial assistance for Medicare beneficiaries who meet certain income and asset criteria and have Medicare Part D.
Also referred to as the Low-Income Subsidy (LIS) program, Extra Help helps pay for expenses like Part D deductibles, premiums, copayments, and/or coinsurance. Individuals enrolled in the program won’t enter the Part D coverage gap (also known as the “donut hole“).
Eligibility for the Low-Income Subsidy
You may be eligible for the Extra Help program if you meet the following requirements:
- You are enrolled in a Medicare prescription drug plan or Medicare Advantage plan that includes prescription drug coverage.
- You live in one of the 50 states or the District of Columbia.
- You meet income and asset requirements, which may change every year.
Individuals who are eligible for Extra Help are given benefits based on their degree of financial need. There are partial and full subsidies available for those who qualify. Items considered when determining income and resource eligibility include:
- Money in checking and savings accounts
Items that aren’t counted include:
- Your home
- Personal possessions
- Burial plots
- Life insurance policies
Other factors that may affect your Extra Help eligibility include whether you or your spouse financially supports other family members who live with you; whether you live in Hawaii or Alaska; and whether you earn income from an employer. Because the income requirements may increase every year, you should still apply even if your income and resources are slightly above the limits. You should also reapply if you’re rejected because of income.
Automatic enrollment in Extra Help
Some individuals automatically qualify for the LIS program. You may automatically be eligible for Extra Help if:
- You’re eligible for both Medicaid and Medicaid (also known as a “dual eligible”).
- You receive Supplemental Security Income (SSI) benefits.
- You’re enrolled in a Medicare Savings Program.
If you automatically qualify for the Low-Income Subsidy program, Medicare will notify you. You do not need to submit an application in this case, although you will need Medicare prescription drug coverage if you don’t already have drug coverage.
Automatic qualification may change on an annual basis depending on your income and resources. Just because you’re eligible one year doesn’t guarantee you’ll qualify for automatic enrollment next year. If your financial situation changes and you’re no longer automatically eligible for Extra Help, Medicare will send you a notice by the end of September. You may still be eligible for the LIS program, but you will need to manually apply for the program.
Medicare also notifies you every fall if the amount of LIS aid you receive changes.
Applying for Extra Help
Extra Help is run by the Social Security Administration. Individuals can apply for the LIS program:
- Online on the Social Security website.
- By calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. Social Security representatives are available Monday through Friday, from 7AM to 7PM.
- In-person at your local Social Security office.
- Through your state’s Medicaid program.
If you don’t qualify for Extra Help
If you don’t qualify for the Low-Income Subsidy program, you can appeal the decision by submitting a form to Social Security. Social Security will re-review your eligibility and notify you of its decision.
You may also be eligible for another state program that helps with prescription drug costs. To learn more about your options, you can contact your local Medicaid office or your State Health Insurance Assistance Program (SHIP) for more information. Remember, if your income and resource levels change, you can always re-apply for the Extra Help program.
You might also consider researching if there’s a lower-cost Medicare Prescription Drug Plan or Medicare Advantage plan that includes drug coverage available. Prescription drug costs can vary widely by plan, even when covering the same medications.