The Medicare “Extra Help” Program

Extra Help, also known as the Low-Income Subsidy, is a program to help people with limited income and resources pay their Medicare prescription drug costs. Through this program, Medicare helps pay your Part D monthly premium, any yearly deductible, coinsurance and copayments. If you qualify, you pay $0 or very low premiums for your prescription drug coverage, and you have low copayments for your drugs when you go to the pharmacy.

Do I Qualify?

If your monthly income is under $1,630 or $2,198 for couples, then you may qualify for Extra Help. If you are enrolled in Medicaid, Supplemental Security Income or a Medicare Savings Program (MSP), then you automatically qualify for Extra Help.

If you receive Extra Help but are unsure if you’re paying the right amount, contact your drug plan provider. More information may need to be provided in order to check the level of help you should be getting.
Medicare Pie chart

Documentation

Documentation is required for proof that you qualify for Extra Help. Examples of documents you can provide include:

A purple notice from Medicare that says you automatically qualify for Extra Help.
A yellow or green automatic enrollment notice from Medicare.
An Extra Help "Notice of Award" from the Social Security Administration (SSA).

An orange notice from Medicare that says your copayment amount will change next year.
If you have Supplemental Security Income (SSI), you can use your award letter from Social Security as confirmation that you have SSI.

You can use the following documents as proof you have Medicaid and live in an institution or get home- and community-based services:

A bill from an institution (i.e. a nursing home)
A copy of a state document showing Medicaid paid for your institution stay for at least a month.

A print-out from your state’s Medicaid system showing you lived in the institution for at least a month.
A document from your state that shows you have Medicaid and are getting home- and community-based services.

Other proof you have Medicaid includes:

A copy of your Medicaid card (if you have one).
A copy of a state document that shows you have Medicaid.

A print-out from a state electronic enrollment file that shows you have Medicaid.
A screen print from your state's Medicaid systems that shows you have Medicaid.
Any other document from your state that shows you have Medicaid.

If you don’t have or are unable to find any of these documents, reach out to your plan administrator for help.

Costs

There are various cost mechanisms used to determine what you pay for your drug costs once you enroll in Extra Help.

Most of those who qualify for the program pay nothing for their monthly premium or yearly deductible.
If approved for Extra Help, the cost for generic drugs in 2021 should be no more than $3.70 and no more than $9.20 for any other brand-name drug.
If you have a higher income and qualify for partial Extra Help, which entails reduced monthly premiums, deductibles and copayments, then you’ll pay no more than 15% of the costs of the drugs on your drug list until you reach the out-of-pocket limit. If you have Medicaid and live in a nursing home, for example, or receive home-and-community-based services, you should be paying nothing for your covered drugs.

Medicare Extra Help In New York

New York excludes the cost of certain health insurance premiums from your income. Sometimes a portion of your Part D premium can also be deducted from your income.

If you enroll for a Medicare Savings Program, you will automatically receive Extra Help.
If you meet income limits and live in New York, the Medicare Rights Center can help you apply for a Medicare Savings Program. Call 800-333-4114 for more information or to apply.

If your plan administrator doesn’t correct a problem to help you pay the right amount, doesn’t respond to your request for help or takes longer than expected to get back to you, call 1-800-MEDICARE to file a complaint.

The Medicare “Extra Help” Program

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With a wide variety of Medicare plans to choose from it can be difficult to know if you are getting the best coverage for the lowest cost based on your needs. Fortunately, help is just a phone call away!