Fact Sheet: 2016 Medicare Part D Extra Help Program

What is Extra Help?Helping Hands

Extra Help is a program within Medicare that assists individuals with the cost of Part D prescription drug plan. Part D prescription drug coverage is available for any Medicare beneficiary. Some Medicare beneficiaries with limited resources and income are eligible for the Extra Help program.

What does Extra Help cover?

Extra Help assists eligible beneficiaries with paying for costs associated with their Medicare Part D prescription drug plan like annual deductibles, monthly premiums, and prescription co-payments or coinsurance.

How Much Will You Pay In Extra Help?

With the full Extra Help benefit in 2016, an eligible beneficiary should pay no more than $2.95 for a generic drug (or a brand-name drug treated as a generic) and $7.40  for any other brand-name drug.  For those qualifying for partial Extra Help, an eligible beneficiary should pay no more than 15 percent of the cost of drugs on your plan’s formulary (or list of covered drugs) until you reach the out-of-pocket maximum. Most people who qualify for Extra Help also pay nothing or a reduced amount for their monthly premium or annual deductible.

Medicare enrollees who have Medicaid, live in an institution like a nursing home, or receive home and community based services should not be paying anything out-of-pocket for their drugs.

How to Qualify for Extra Help

Many Medicare beneficiaries qualify for Extra Help and don’t even know it. To qualify for Extra Help:

  1. You must be enrolled in a Medicare Part D prescription drug plan.
  2. You must reside in one of the 50 states or the District of Columbia.
  3. Your annual income must be less than $17,655 for an individual or $23,895 for a married couple living together. Even those individuals or couples with incomes exceeding the threshold may still be eligible for assistance (For example, if you or your spouse support other family members who live with you, have work-related earnings or live in Hawaii or Alaska).
  4. Your resources cannot exceed $13,640 for an individual or $27,250 for a married couple who live together. (This includes: bank accounts, stocks and bonds. This does not include: home, car or life insurance policies.)

How to Apply for Extra Help

To apply for Extra Help, you must complete Social Security’s Application for Extra Help with Medicare Prescription Drug Plan Costs (SSA-1020). You can apply in the following ways:

  • Apply online at www.socialsecurity.gov/extrahelp;
  • Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) to apply over the phone or to request an application; or
  • Apply at your local Social Security office.

Once you’ve submitted your application, Social Security will review and send a determination letter to inform you whether or not you’ve qualified. As soon as you receive your eligibility determination, you can choose a Medicare Part D prescription drug plan.

Being deemed eligible for Extra Help does not automatically enroll you in a Medicare prescription drug plan. While some beneficiaries with the full Extra Help benefit may be automatically enrolled in a Part D prescription drug plan, it is still important to follow up to ensure that you are enrolled once your Extra Help application is approved. If you are automatically enrolled but do not choose a plan for yourself, the Centers for Medicare and Medicaid Services (CMS) will randomly assign you to a plan.

What If You Don’t Qualify for Extra Help?

If you are not eligible for Extra Help, but are eligible for Medicare you are still able to enroll in a Medicare Part D prescription drug plan.

How to Ensure You’re Paying the Right Amount in Extra Help

If you think you’re paying the wrong amount, call your Medicare Part D drug plan. Your plan may ask you to provide information to help them verify if the level of Extra Help you are receiving is correct. Here is a list of documents you can use to help prove you qualify for Extra Help:

  • 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 Social Security.
  • 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 proof that you have SSI.

Medicare Shared Savings Program

In addition to Extra Help, Medicare has a program called the Medicare Shared Savings Program (MSSP). These are state programs that help with other Medicare-associated costs (ex: Medicare Part B’s medical insurance premiums). By filling out an Extra Help application, you are automatically beginning the application process for MSSP as well. Your state will contact you in order to complete the MSSP application process. If you would like to opt-out of applying for MSSP, there is a place to indicate that on your Extra Help application.

Further Information

For more information on Extra Help or assistance applying to the program, go to www.socialsecurity.gov/extrahelp or call Social Security at 1-800-772-1213 TTY 1-800-325-0778.

For more information on the Medicare Shared Savings Program, Medicare Part D prescription drug plans, enrollment periods or other Medicare-related concerns, go to www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048.

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