Q & A: "Extra Help" with Paying for Medicare Part D Prescription Drug Costs

Related topics: Medications, Insurance, Financial

The National Council on Aging shares information to help qualifying seniors save money on their prescription drugs.

Q: What is Medicare Part D?

Medicare Part D helps consumers with Original Medicare (and sometimes those in Medicare Advantage plans that do not cover prescriptions) pay for prescription drugs.

Q: Do I have to pay anything for my prescription drugs under the Medicare Part D benefit? What if I cannot afford these costs?

In 2014, the average monthly premium of a standard Part D plan is $31, and Medicare Part D drug plans can also charge an initial deductible of $310 before your Part D savings begin. You will also have to pay, throughout your benefit, part of the cost of each drug on your plan's formulary that you purchase. The amount you pay for plan-covered drugs will change, depending on where you are at in the benefit. However, if your income and resources (or assets) are limited, you may qualify for Extra Help, or the low-income subsidy (LIS), in paying for these costs.

Q: How do I know if I am eligible for Extra Help?

In general, you may qualify for Extra Help in 2014 if:

Your monthly income is $1,459 or less if you are single ($17,505 annual income), or $1,966 or less if you are married and living with your spouse ($23,595 annual income). You might qualify even if you have slightly higher income if you provide at least half of the financial support for other relatives living in your household, if you have earnings from work, or if you live in Alaska or Hawaii.


Your resources or assets (such as savings accounts or investments) are $13,440 or less if you are single, or $26,860 if you are married and living with your spouse. (All asset eligibility limits include a $1,500 per person burial allowance.)

Q: How do I apply for Extra Help with my prescription drug costs?

You have the option of applying for Extra Help using the forms and process established by the Social Security Administration (SSA) or through a process set up by your state's Medical Assistance (Medicaid) office.

You can complete SSA's application form and mail it to:

Social Security Administration
Wilkes-Barre Data Operations Center,
P.O. Box 1020
Wilkes-Barre, PA 18767-9910.

You can also apply online at www.BenefitsCheckUp.org or www.socialsecurity.gov. Some people don't have to apply to get Extra Help. See the next question to find out who doesn't have to apply.

Q: What does the term "deemed eligible" mean?

If you are "deemed eligible," it means that you will automatically qualify for a benefit even though you have not officially applied for it. In the case of the Medicare Part D, you will be "deemed" automatically eligible for the Extra Help/LIS program if:

  • You are enrolled in both Medicare and Medicaid, or
  • You are enrolled in Medicare and receive Supplemental Security Income (SSI), or
  • You are enrolled in a Medicare Savings Program (MSP), and your state pays your Medicare Part B premiums and maybe some other Medicare costs.

If you are automatically deemed eligible, you should get a letter from the Centers for Medicare & Medicaid Services (CMS) telling you that you do not have to apply for this Extra Help.

Q: If I am eligible for Extra Help, will I also be eligible for Medicare Savings Program (MSP)?

Not necessarily, but as of 2010, Social Security sends your completed Extra Help application (once they have determined your Extra Help eligibility) to your state Medicaid agency to start the application process for Medicare Savings Programs. Each state has its own eligibility rules for the MSPs. This means you may have to provide more information to be eligible for an MSP.

Unless you tell them not to, Social Security will send your completed application to start the MSP application process, regardless of whether your application was accepted or denied for Extra Help. This is because in some states you may qualify for MSP even if you are denied Extra Help for financial reasons.

Q: Which kinds of documentation must I submit with my Extra Help application form?

You do not need to provide copies of any documents (such as checking account statements, tax returns, or paycheck stubs) as proof of eligibility for Extra Help. Your declaration of income and resources is accepted for the Extra Help application process. Social Security will compare your answers on the application with other federal agencies' records to confirm your information.

Q: Do I need to report in-kind support (things I am given to help me get food or shelter) or the cash value of my life insurance policy?

As of 2010, the Social Security Administration no longer counts in-kind maintenance or support as income on the Extra Help application. This means that you do not need to report the monetary value of shelter and food help you get from family members or caregivers as income. Also, you no longer have to report the cash surrender value of your life insurance policy (the amount you could have gotten if you cashed in your life insurance).

Note: Some states still count life insurance cash value and in-kind support as income and resources in determining Medicare Savings Program (MSP) eligibility. Knowing the rules in your state will help you gather the information your state Medicaid eligibility office needs to make a decision about your eligibility for Medicare Savings Programs.

Q: Is there any place I can go to talk with someone about my situation?

Yes. Visit www.centerforbenefits.org to find out about local resources you can call on. You can also call Social Security at 1-800-772-1213 or visit your local Social Security Office.

Finally, every state has a State Health Insurance Assistance Program (called SHIP). You can find the telephone number of the program in your area by calling the Centers for Medicare & Medicaid Services (CMS) at 1-800-633-4227 or the ElderCare Locator at 1-800-677-1116.

Q: My mother does not speak English. Can she fill out the application form in her own language?

Applications for the Extra Help are available in Spanish, as well as English. In addition, instruction sheets are available in 14 different languages for side-by-side comparisons with the English version of the applications and interactions with your clients. These languages include: Arabic, Armenian, Chinese, Farsi, French, Greek, Haitian-Creole, Italian, Korean, Polish, Portuguese, Russian, Tagalog, and Vietnamese. Answers to questions on application forms must be submitted in English, however. You can visit Social Security's website at http://socialsecurity.gov/prescriptionhelp/eh_otherlanguages.htm to access these instruction sheets.

Q: What happens if I do not answer every question on the application form?

Social Security will accept incomplete paper applications. (Online applications must be complete in order to be accepted.) If you submit an incomplete paper application, Social Security will then contact you—or the contact person you listed in the application—by phone or in writing (if they are unable to make contact by phone) to help you complete the form. But be sure to put at least your name, Social Security number, and telephone number on the application so that they know where to contact you.

Q: If someone calls me and says they are from the Social Security Administration, how do I know it's a legitimate call?

If someone calls you for more information necessary to complete the form, be sure this person is actually from the Social Security Administration. An SSA employee will not ask for your Social Security Number (unless the number you have given is incorrect). If you are at all suspicious about a call from someone claiming to be from SSA, hang up and call SSA at 1-800-772-1213 to find out if the call was legitimate.

Q: What happens after I submit the application to the Social Security Administration?

After the Social Security Administration processes your Extra Help application, they will do the following things:

  • Send a notice telling you they received your application
  • Contact you with additional questions (if application is incomplete or if income information does not match up with other federal records)
  • Determine whether you are eligible for Extra Help
  • Notify you about whether you are or are not eligible for the Extra Help
  • Send your application information to your state Medicaid agency to start your application for a Medicare Savings Program (unless you tell them not to)

It's important that you do not complete multiple Extra Help applications. This can cancel out your original application and delay the process. If you are awaiting confirmation or a decision on your eligibility, call Social Security at 1-800-772-1213 to find out the status of your application.

Q: If the Social Security Administration says I do not qualify for the Extra Help, can I appeal?

Yes. If SSA determined that you are not eligible for the Extra Help, you may appeal the decision within 60 days. You can file an appeal request any SSA office in person, by mail, by fax, or by phone (1-800-772-1213).

Source: The National Council on Aging (www.ncoa.org) is a nonprofit service and advocacy organization whose mission is to improve the lives of millions of older adults, especially those who are vulnerable and disadvantaged. NCOA is a national voice for older Americans and the community organizations that serve them, and works with thousands of organizations across the country to help seniors find jobs and benefits, improve their health, live independently, and remain active in their communities.