How “Extra Help” Can Lower Your Drug Cost

Filling prescriptions may be your most significant medical expense if you take many drugs or even a few costly ones. The Part D prescription drug program helps up to a point, but premiums, deductibles, copays, and the higher costs of the coverage gap (“doughnut hole”) can add up to outlays many people cannot afford.

If you were receiving Medicaid before joining Medicare, your drug coverage may now come from the Part D Extra Help program instead of Medicaid, even if you still qualify for Medicaid.

If you have full Medicaid coverage, receive Supplemental Security Income (SSI), your state pays your Medicare premiums, or you qualify for a Medicaid medical spend-down program, you are automatically eligible for full Extra Help.

If you do not qualify for full Extra Help, you may still qualify for partial Extra Help, which provides lower costs than the standard Medicare Part D program.

Extra Help is easier to apply for than many assistance programs, but you must provide details about your income and assets.

Everyone who qualifies—whether for full or partial assistance—receives full drug coverage throughout the year and does not have to deal with the coverage gap. Those with Extra Help can also switch to a different Part D plan at any time during the year.

Qualifying for Extra Help

• Level 1: Full Medicaid benefits and living in an institution such as a nursing home.
• Level 2: Full Medicaid benefits and income no higher than $1,025 per month.
• Level 3: Full Medicaid benefits with income above Level 2 limits, or receiving SSI, or the state pays your Medicare premiums.
• Level 4: Income no higher than $1,377 per month and savings under $8,890.
• Level 5: Income no higher than $1,528 per month and savings under $13,820.

Applying for Extra Help

• Online
• By phone
• In person
• By mail

What Counts as Income

• Pretax wages or earnings from self-employment
• Social Security or railroad benefits before deductions
• Veterans benefits
• Annuities and pensions
• Workers’ compensation
• Alimony
• Net income from rental property

What Counts as Assets

• Bank accounts, including checking, savings, and certificates of deposit
• Loan proceeds saved beyond the month received
• Cash kept at home or elsewhere
• Individual retirement accounts (IRAs) and 401(k)s
• Stocks, bonds, and mutual funds
• Real estate (excluding your primary residence, depending on guidelines)

Who Can Help Me Apply?

• A trusted friend or family member
• Free expert personal assistance programs
• Social Security
• Community organizations

What Happens After I Apply?

Social Security will send a notice confirming receipt of your application and begin processing it.

• You may be contacted by mail or phone if additional information is needed.
• You may receive a pre-decisional notice if your application is likely to be denied.

Social Security will determine whether you are eligible for Extra Help.

What If I Am Turned Down?

• Request a telephone hearing
• Ask for a case review

How Long Does Extra Help Last?

You may lose Extra Help next year if:

• Your income exceeds the program limits.
• Your savings or other countable assets rise above the limit.
• You no longer qualify for a program that grants automatic eligibility.

Choosing a Drug Plan with Extra Help

Qualifying for Extra Help is only one step. You must still enroll in a Medicare Part D drug plan to receive prescription coverage. If you qualify automatically and do not enroll yourself, Medicare may enroll you in a plan to ensure continued coverage.

Understanding Zero Premiums

Your premium may be waived if you join a drug plan that charges a premium below a specific dollar amount. To determine which plans in your area offer zero premiums and what you would pay for your prescriptions, you can:

• Use the Medicare online plan finder tool.
• Call the Medicare helpline.
• Contact your state Health Insurance Assistance Program (SHIP).