Do You Qualify for the Medicare Extra Help Program?

With the rising costs of prescription drugs, more and more people are struggling to pay for their refills. In fact, about five million beneficiaries report not taking recommended medications because they are unable to afford them. The health ramifications of this problem can be severe.

Fortunately, some beneficiaries can get financial assistance for their prescription drugs through a program called Extra Help.

What is Extra Help?

Extra Help is a national program that helps Medicare beneficiaries with limited incomes pay for their prescription drugs. It’s also referred to as the Part D Low-Income Subsidy or LIS. It helps with premiums, deductibles, cost-sharing, and even late-enrollment penalties. 

There are two levels of eligibility: Full or Partial Extra Help. Benefits vary based on eligibility. The benefits below reflect 2023 numbers.

Full Extra Help

• Payment for the Part D monthly premium (up to a state-specific amount)
• The deductible is set at $0
• Cost-sharing maximum of $4.15 for generic drugs
• Cost-sharing maximum of $10.35 for name-brand drugs
• No cost-sharing after the total drug costs reach $7,400

If a person is eligible for the Qualified Medicare Beneficiary (QMB), they pay no more than $4.30 for each prescription.

Partial Extra Help

• Payment for the Part D monthly premium (up to a state-specific amount)
• The deductible is no more than $104
• Cost-sharing of no more than 15% of covered drugs
• Once the total drug costs reach $7,400, costs are limited to the following:
• $4.15 for generic drugs
• $10.35 for name-brand drugs

In addition, both options pay the late-enrollment penalty if one has been incurred. Beneficiaries receive a penalty if they go without drug coverage after the age of 65. Penalties can add up quickly and are added to the Part D premium every month for life.

Lastly, LIS recipients are granted a Special Enrollment Period (SEP) once per quarter for the first nine months of the year. They are allowed to enroll in Part D for the first time or switch their current Part D plans. During the last quarter, they can use the Annual Election Period (AEP) to change their plan for the upcoming year.

Whether you are enrolled in a stand-alone Part D plan or have one included in your Medicare Advantage plan, Extra Help offers assistance with your prescription costs. Of course, your prescriptions must be included in the drug formulary, and beneficiaries need to get their refills at an in-network pharmacy.

Who Qualifies for Extra Help?

There are two ways to qualify for Extra Help; both involve financial means. The limits below reflect 2022 numbers.

Medicare-Only Beneficiaries

Medicare beneficiaries qualify for Partial Extra Help if their income is below $1,719 (or $2,309 for couples) per month and their assets are below $15,510 (or $30,950 for couples).

Beneficiaries qualify for Full Extra Help if their income is up to $1,549 (or $2,080 for couples) per month and their assets are not more than $9,900 (or $15,600 for couples).

Dual-Eligible Beneficiaries (Medicare and Medicaid)

Beneficiaries who are also enrolled in Medicaid and/or the Medicare Savings Program qualify for Full Extra Help benefits if their income is above $1,153 per month. If they are only on Medicaid, they can earn up to $1,153 per month. Cost-sharing in both of these instances varies slightly.

How to Enroll in Extra Help

Some beneficiaries are enrolled in Extra Help automatically, while others need to apply.

Medicare beneficiaries who are enrolled in Medicaid, a Medicare Savings Program, or are receiving Supplemental Security Income, will automatically qualify for Extra Help, regardless of the income requirements. They will not need to apply for Extra Help.

Others can apply online or by calling the Social Security office at 1-800-772-1213 (TTY users call 1-800-325-0778).

If you need help with your prescription drug costs or want to know more about the Extra Help program, call your Local Medicare Specialists and speak with an agent near you! We can review your current drug plan, shop for a new plan, and help you enroll.