Are you a Medicare beneficiary with a lower income? If so, you might be eligible for Extra Help, a program that can significantly reduce your expenses for monthly premiums, yearly deductibles, and copays related to Part D prescription drug coverage. Keep reading to discover the ins and outs of Extra Help, including eligibility criteria, application procedures, and avenues for appeals. Your path to potential assistance starts here.
Table of contents
What is Extra Help?
Extra Help is a program that helps lower-income Medicare beneficiaries pay Part D costs. Applying for assistance doesn’t automatically sign you up for a Part D plan.
If you’re eligible for Extra Help, you won’t be subject to a late enrollment penalty when joining a Part D plan. Those qualifying should check with their drug plan to ensure it has the correct Extra Help applied to coverage.
Medicare beneficiaries who qualify for Extra Help get assistance from Medicare to pay Part D coverage such as monthly premiums, annual deductibles, coinsurances, and copays.
Do I qualify for Extra Help with Medicare?
Income Limit
Individual below $1,843
Couples below $2,485
Asset Limit
Single up to $16,660
Couples up to $33,240
To be eligible for Extra Help, you must have Medicare, be low-income, and have limited assets. Extra Help is only available to those residing in one of America’s 50 states or the District of Columbia.
You must enroll in a Medicare-approved prescription drug plan for benefits to start. However, you don’t need to be enrolled in a plan to file for benefits.
If you already have Medicare and Medicaid, don’t apply for extra help because you already have those benefits. Those participating in Programs of All-Inclusive Care for the Elderly (PACE), Medicare Savings Programs, and Supplemental Security Income (SSI) benefits automatically qualify for Extra Help.
If you believe you should be receiving benefits and are not, contact your local Social Security or Medicaid office. Even if you don’t qualify automatically, we suggest you apply.
Medicare Extra Help income limits
In 2023, the combined income limit for married couples living together is $29,820. For singles or those not living with a spouse, the income limit is $22,116.
You can still apply if your income is slightly higher than the limits. It’s just possible the application will be denied.
Resource limits will affect eligibility. Examples of resources include funds in bank accounts, stocks, bonds, mutual funds, real estate, Individual Retirement Accounts, and cash.
Your primary residence doesn’t count toward real estate resource limits. Cars, burial expenses, and personal belongings don’t count as resources.
For beneficiaries with Medicare only
| Income Limit – Monthly | Asset Limit | Program | Co-pay/Coinsurance costs |
|---|---|---|---|
| Individuals below $1,843 Couples below $2,485 |
Individuals up to $16,660 Couples up to $33,240 With a qualifying income level |
Partial Extra Help Premiums will lower based on income and state up to a $104 deductible |
Full Extra Help $0 premium and deductible |
| Individuals below $1,660 Couples below $2,239 |
Individuals up to $10,590 Couples up to $16,630 |
Full Extra Help $0 premium and deducitble |
$4.15 – generic $10.35 brand. No copay once the out-of-pocket reaches $7,400 |
If you have Medicare and Medicaid and/or a Medicare Savings Program (MSP)
| Program Enrolled | Income Limit -Monthly | LIS Program | Co-pay/Coinsurance |
|---|---|---|---|
| Medicaid and/or a Medicare Savings Program | Individuals above $1,235 Couples above $1,663 |
Full Extra Help $0 premium and deductible |
$4.15 generic copay $10.35 brand-name copay No copay after $7,400 in out-of-pocket drug costs |
| Medicaid | Individuals up to$1,235 Couples up to $1,663 |
Full Extra Help $0 premium and deductible |
$1.45 generic copay $4.30 brand-name copay No copay after $7,400 in out-of-pocket drug costs |
Levels of Extra Help?
Your eligibility for Extra Help can vary based on your income and assets, potentially entitling you to either full or partial assistance. These programs are designed to help cover the expenses of your medications. To access this support, it’s important that your prescribed medications are listed on your plan’s formulary, and that you utilize pharmacies within your plan’s approved network.
What does Medicare Extra Help cover?
Medicare Extra Help will contribute to paying the cost of your Part D premiums, deductibles, copayments, and coinsurances. Also, Extra Help waives late enrollment penalty fees.
In 2023, you won’t pay more than $4.15 for generic medications and $10.35 for brand-name prescriptions when you have Extra Help.
Extra Help waives the coverage gap for beneficiaries who otherwise fall into the Medicare donut hole. It’s estimated that Extra Help saves beneficiaries a little over $5,000 annually.
What happens when I start receiving Extra Help?
Once you receive Extra Help, you must enroll in a Part D plan if you don’t already have one. The cost of your prescription coverage will be lower.
You can expect lower premiums, deductibles, coinsurances, and copayments. You’ll need to complete a review of eligibility periodically to ensure your benefits-to-income ratio is accurate.
Remember to compare Part D plans each year to ensure your policy continues to provide you with the most value.
What happens if I no longer qualify for Extra Help?
If you no longer qualify for Extra Help due to increased income and/or assets, you’ll be responsible for your drug plan premium and may want to find a different policy. You should get notified in the fall before the new year if you’re no longer eligible for Extra Help.
For those who miss the Annual Enrollment Period, you may be able to change plans during the Open Enrollment Period for Medicare Advantage. Be sure to choose the policy that saves you the most annually.
Sometimes, mail-order prescriptions can help lower your out-of-pocket costs.
FAQs
How do I apply for extra help with Medicare?
Many Medicare beneficiaries apply for Extra Help online. To apply over the phone, call Social Security. You can apply via a paper application or schedule a face-to-face appointment at your local Social Security office.
What are the income limits for Extra Help with Medicare?
In 2023, the combined income limit for married couples living together is $29,820. For singles or those not living with a spouse, the income limit is $22,116.
How long does it take to get Extra Help with Medicare?
Once you apply for Extra Help, your request can take anywhere from a few to 14 days to process. The length of time a response takes depends on your circumstances.
What if I’m wrongfully denied Extra Help?
Suppose you believe your application for Extra Help should be approved, but you’re denied coverage. In that case, you can file an Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs.
Follow the instructions for filing an appeal to determine your eligibility.
How do I find the best Medicare plans to complement Extra Help
Those with Extra Help may find Medicare Advantage plans appealing since the premiums are so low. But a Medicare Supplemental plan could save you money in the long run.
Working with a licensed insurance agent is a great way to determine which options make the most sense for you and your situation. Our agents’ time and knowledge are free to you!
Give us a call to get a personalized Medigap quote. Or fill out the online rate form to get the best rates in your area now.
