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How do I qualify for Medicare’s Extra Help?

Louise Norris | March 27, 2023

Reviewed by our health policy panel.

Q: How do I qualify for Medicare’s Extra Help Program?

A: Lower-income Medicare beneficiaries may receive financial assistance through Medicare’s Extra Help program. If you have difficulty paying for prescriptions, the Extra Help program – also known as the Low-Income Subsidy (LIS) – can make prescriptions and plan premiums more affordable than they would be with Medicare Part D alone.

Am I eligible for Extra Help?

Your income (from the prior year) and resources determine the level of help you receive. You’ll automatically receive Extra Help if you have both Medicare and Medicaid, a Medicare Savings Program, or Supplemental Security Income, or Medicare only but also a limited income (note that the levels of Extra Help are different depending on your eligibility category).

To be eligible for Extra Help, your income in 2022 cannot exceed $20,385 for an individual or $27,465 for a married couple living together. In addition, resources must not exceed $15,510 for an individual and $30,950 for married couples (the financial limits are higher if you have dependents living with you, or if you live in Alaska or Hawaii). For 2023, the income limits have increased to $22,166 for a single individual and $29,820 for a couple.

Those are the income and resource limits for partial Extra Help; the limits for full Extra Help are lower. But starting in 2024, under the Inflation Reduction Act, full Extra Help will be available up to the limits that currently apply to partial Extra Help (the dollar amounts are inflation-adjusted each year, so they will be different by 2024). For full Extra Help, the current cap is 150% of the poverty level, while the cap for partial Extra Help is 150% of the poverty level. As of 2024, full Extra Help will be available up to 150% of the poverty level. And the higher resource limits that apply to partial Extra Help will also be used to determine eligibility for full Extra Help as of 2024.

Resources do not include your car or home, but do include stocks, bonds, and bank accounts. A recent law excludes some additional resources, making it easier for more beneficiaries to get Extra Help: life insurance policies don’t count as resources, and financial assistance you receive from friends or relatives to help pay your household expenses is not considered income. (The Social Security Administration has more details about what does and doesn’t count as resources).

Will Extra Help reduce my out-of-pocket costs?

Enrollees who receive full Extra Help in 2023 will pay no more than $4.10 for each generic drug and $10.35 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 $1.45 for generics and $4.30 for brand name drugs.

In addition to having lower copayments, Extra Help enrollees also have their Part D plan deductibles reduced or eliminated altogether (depending on their income). The federal government also pays Part D premiums on behalf of Extra Help enrollees – up to a benchmark amount (this amount is different in each state; you can see which plans have zero premiums in your state for Extra Help enrollees), 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.

Does Extra Help allow me to change my Part D coverage?

Yes. If you qualify for Extra Help, you can switch your Part D coverage up to once per quarter during the first three quarters of the year. There’s no plan change provision during the final quarter of the year, but that’s when Medicare’s normal open enrollment period occurs, allowing anyone with Part D coverage the opportunity to pick a different plan that will take effect January 1.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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