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Reminder: You may now qualify for Medicare Part D financial Extra Help

Category: Medicaid, LIS, & Extra Help
Published: Mar, 08 2023 01:03:25

If you are eligible for Medicare and having difficulties paying for your prescription drugs, you may want to learn more about the Medicare Part D Extra-Help program by calling or visiting a local state Medicaid office or calling the Social Security Administration at 1-800-772-1213.

Extra Help or the Low Income Subsidy (LIS) is a government program that helps Medicare beneficiaries pay all or part of their monthly Medicare Part D drug plan premiums, deductibles, and may cover a significant portion of their prescription drug costs.

If you already qualify for Medicaid, you will automatically qualify for the Medicare Part D Extra Help and do not need to apply.

However, even if you do not meet the financial qualifications for your state Medicaid program, you may still qualify for at least partial Extra Help benefits based on your annual income and financial resources (or assets) - and still save money on your prescription drugs. 

No change in 2023 finances?
With changes in annual qualification requirements, you may now qualify for Extra Help.

Extra Help qualification limits change each year - and the 2023 income and resource limits for the Medicare Part D “Extra Help” program have recently been increased, so you may now be eligible for the “Extra Help” program --- even if you have not experienced changes in your financial situation.

Did the January increases in your 2023 Social Security benefits make you lose your Extra Help status?
You can reapply now for 2023 Extra Help.

Some people may have lost their Part D Extra Help benefits this past January when their monthly Social Security benefits increased pushing them above the Extra Help income limits, but these people are urged to re-apply for 2023 Extra Help now based on the newly released Extra Help qualification limits.

Partial or Full Extra Help based on Income and Assets

The income limits for Extra Help are based on the government's 2023 Federal Poverty Level (FPL) Guidelines that are adjusted each year and include the following information:
  • If your annual income is at or below 135% of FPL ($19,683 if you are single or $26,622 for married couples), you could qualify for the "full" Low-Income Subsidy (resource or asset limits also apply).

  • If your annual income is at or below 150% of FPL ($21,870 if you are single or $29,580 for married couples), you may qualify for "partial" Extra Help (resource limits also apply).
Important:  Again, even if you did not qualify for Extra Help last year, you may now qualify based on the new FPL Guidelines.

2023 Full Low-Income Subsidy Income Requirements (135% of FPL)
in Family
48 Contiguous
States & D.C.
Alaska Hawaii
1 $19,683 $24,584 $22,640
2 $26,622 $33,264 $30,618
3 $33,561 $41,945 $38,597
4 $40,500 $50,625 $46,575
5 $47,439 $59,306 $54,554
6 $54,378 $67,986 $62,532

Learn more in our article, 2023 Federal Poverty Level Guidelines (FPL): 2023/2024 LIS Qualifications and Benefits.

Your tax return and changing financial status

Typically, the Extra Help application uses the most recent tax return information sent to Social Security from the IRS.  This would currently be your 2022 tax return (reporting 2021 income).  However, if you have had significant changes in your income in comparison to your tax return, you can appeal to Social Security to use more recent income figures.  Please see: How to appeal the decision Social Security made on your application for Extra Help.

Qualifying for Medicaid and Medicaid Spend-down

As a reminder, Medicaid “Spend down” allows you to subtract your medical expenses (for example, what you pay for your prescription medications) from your annual income so that you might become eligible for your state’s Medicaid program based on the cost of healthcare.  In other words, you may be eligible for your state’s Medicaid program based on the principle of “Spend-Down”, even if you would otherwise earn too much to qualify for Medicaid.  You can click here to read more about Medicaid Spend Down.

Extra Help status and changing 2023 Medicare Part D or Medicare Advantage plans.

If you qualify for Extra Help, you are granted a Special Enrollment Period (SEP) allowing you to change your Medicare plan once per quarter during the first nine (9) months of the plan year.  You can telephone a Medicare representative at 1-800-Medicare (1-800-633-4227) for assistance finding the most economical health and prescription drug coverage.

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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.
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  • 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.