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Tips for completing the application for extra help

 Here are some tips to help you complete the application. Following these tips will help us process your application as quickly as possible.
  • Computers read your application when you send it back to Social Security. Use only a pen with black ink to complete the application. The computer cannot read ink of any color other than black and this could cause a delay in getting you an answer about your application for Extra Help.

  • Many questions on the application ask you to mark an “X” in a “Yes” or “No” box. Please remember that you cannot mark an “X” in both the “Yes” and “No” boxes.

  • Your Social Security number or Railroad Retirement Board number must be included on the application. In order to receive a quick response from us, please be sure you enter your name and number exactly as they appear on your Social Security card or Railroad Retirement Board card.

  • If you are single, widowed, divorced or not living with your spouse, do not complete question 2 (marital information), and do not write in any boxes anywhere on the form that ask for information about your spouse.

  • When you file your application for Extra Help, you also can start your application process for the Medicare Savings Programs — State programs that provide help with other Medicare costs. Social Security will send information to your State unless you tell us not to on the Extra Help application. Your State will contact you to help you apply for a Medicare Savings Program. Do not complete question 15 if you want help from the Medicare Savings Programs.

  • Please send the entire application package back to us — not just the page that you signed. If you are unable to answer all the questions, send your application and we will help you complete it.

  • There is no need to send us anything other than your completed application. We do not need to see doctor bills, prescription lists, Internal Revenue Service (IRS) forms or other documents.

  • Apply online at www.socialsecurity.gov or complete an original paper application. Please do not complete a photocopied, faxed or downloaded copy of the application. Anything other than the online or original paper application could cause a delay in getting you an answer about your application for extra help. If you need a paper application, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visit a Social Security office and ask for an application for extra help. Social Security representatives are available to help you complete your application.

  • If relatives, neighbors or friends want an application, have them visit Social Security online or call us to ask for an application. Please do not share your application with them.

Also see:

(Source: Social Security Administration: Understanding The Extra Help With Your Medicare Prescription Drug Plan publication 10508, January 2011. Additional examples and links from Q1Group LLC)


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Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
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    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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