If you are a Medicare beneficiary enrolled in a Medicare Part D prescription drug plan, you may qualify for Extra Help to cover the cost of your prescription drugs.
When you have limited assets, income, and resources, programs are available to help offset your Medicare Part D costs. Social Security and the Centers for Medicare & Medicaid Services (CMS) work together to provide this low-income subsidy to Medicare beneficiaries who qualify.
What is Medicare Part D Extra Help?
Extra Help is a low-income subsidy for Medicare enrollees with limited resources. The program helps offset the cost of Medicare Part D premiums and coinsurances. Whether you receive full or partial benefits depends on your income, assets, and resources.
Most people who qualify for Extra Help will receive coverage for their drug plan’s entire premium, either the whole or partial deductible (depending on the level they receive), and a limit for out-of-pocket spending on individual drugs.
In addition to these benefits, those who qualify for Extra Help will also be exempt from paying the Medicare Part D late enrollment penalty if they delaye Medicare Part D without creditable coverage.
Lastly, those who qualify for Extra Help will receive a quarterly Special Enrollment Period. This allows beneficiaries to change Medicare Part D plans up to four times per year.
Who Qualifies for Medicare Part D Extra Help?
If you have both Medicare and Medicaid coverage, receive Supplemental Security Income (SSI), or qualify for a Medicare Savings Plan, you will automatically enroll in Medicare Part D Extra Help. Thus, you do not need to apply for Extra Help, as it will automatically factor into your premiums as well as copayments at the pharmacy.
If you do not already have another form of Medicare assistance, you will need to apply for Extra Help benefits. To qualify for full or partial benefits, you must meet specific income and resource criteria.
Extra Help Income Limits in 2023
Below is the annual and monthly income and asset limitations for Extra Help benefits in 2023.
| Full Extra Help Benefits | ||||||
|---|---|---|---|---|---|---|
| Beneficiary Group | Annual Income Eligibility Requirement | Monthly Eligibility Requirement | Need to Apply? | Monthly Premium | Annual Deductible | Copay |
| Dual Medicare and Medicaid benefits: Institutionalized | Meet state Medicaid financial eligibility | Meet state Medicaid financial eligibility | No | Covered in full | Covered in full | None |
| Dual Medicare and Medicaid benefits: Income less than Federal Poverty Limit | Meet state Medicaid/MSP financial eligibility | Meet state Medicaid/MSP financial eligibility | No | Covered in full | Covered in full | Generic: $1.35 Brand: $4.00 |
| Dual Medicare and Medicaid benefits: Income greater than Federal Poverty Limit | Meet state Medicaid/MSP financial eligibility | Meet state Medicaid/MSP financial eligibility | No | Covered in full | Covered in full | Generic: $3.95 Brand: $9.85 |
| Non-dual benefits: Less than 135% Federal Poverty Limit | Single: $1,549 Couple: $2,080 | Single: $9,900 Couple: $15,600 | No, if receiving SSI. Yes, if not receiving SSI. | Covered in full | Covered in full | Generic: $3.95 Brand: $9.85 |
If you do not meet the income limits to receive full Extra Help benefits, you may still qualify for partial Extra Help benefits. The chart below shows the income and asset limits to qualify for partial Extra Help for Medicare Part D.
| Partial Extra Help Benefits | |||||||
|---|---|---|---|---|---|---|---|
| Beneficiary Group | Annual Income Eligibility Requirement | Monthly Eligibility Requirement | Asset Eligibility Requirement | Need to Apply? | Monthly Premium | Annual Deductible | Coinsurance/copay |
| Non-dual benefits: Income greater than 135% Federal Poverty Limit | Single: $18,587 Couple: $24,959 | Single: $1,549 Couple: $2,080 | Single: $15,510 Couple: $30,950 | Yes | No | $99 | Catastrophic Copay: $3.95-$9.85 |
| Non-dual benefits: Income between 135-150% Federal Poverty Limit | Single: $20,625 Couple: $27,705 | Single: $1,719 Couple: $2,309 | Single: $15,510 Couple: $30,950 | Yes | Yes, Sliding scale | $99 | Coinsurance: 15% Catastrophic Copay: $3.95-$9.85 |
How to Apply for Medicare Part D Extra Help
You can apply for Medicare Part D Extra Help online through the Social Security Administration website or by calling your local Social Security office. Keep in mind, you do not need to enroll in a Medicare Part D plan before applying for Extra Help.
If your application for Extra Help is denied and you believe you should still qualify, you can submit a decision appeal. However, you may need to provide supporting documentation and there is no time frame in which a decision must be made.
