Part 2: 'Extra Help' Paying for Prescriptions

En español l "Extra Help" is a special part of Medicare drug coverage that gives much more assistance to people with limited incomes than the regular program does. If you qualify, you can save a lot of money.

If you qualify for “full” Extra Help, you receive coverage throughout the year (no doughnut hole), pay no premium or deductible, pay very little for your prescriptions. If you qualify for “partial” Extra Help, you receive coverage throughout the year and pay a reduced premium and deductible and up to 15 percent of the cost of your drugs.

Will I qualify for Extra Help and what benefits would I get?

Here are the current income limits and benefits under the four levels of Extra Help for 2015 through early 2017:

Level 1: If you receive full Medicaid benefits and live in a nursing home, you automatically qualify for full Extra Help and pay nothing for your prescription drugs coverage – no premiums, deductibles or copays.

Level 2: If you receive Medicaid or Supplemental Security Income (SSI) or if your state pays your Medicare premiums, you automatically qualify for full Extra Help. You pay no premium or deductible for Medicare drug coverage. Depending on your income, your copays for each prescription in 2016 are: $1.20 or $3.60 for generics; $3.60 or $7.40 for brand names and nothing for catastrophic coverage. In 2017, copays are $1.20 or $3.70 for generics; $3.70 or $8.25 for brand names and nothing for catastrophic coverage.  

Level 3: If your current income is no higher than $1,336 a month (single) or $1,802 a month (for a married couple living together), and your assets (mainly savings) are no more than $8,780 (single) or $13,930 (married), you pay no premium or deductible. Your copays for each prescription are: $2.95 for generic drugs, $7.40 for brand-name drugs and nothing for catastrophic coverage.

Level 4: If your current income is no higher than $1,485 a month (single) or $2,002 a month (for a married couple living together), and your assets (mainly savings) are no more than $13,640 (single) or $27,250 (married), you pay a percentage of your plan’s premium depending on income. You also pay: an annual deductible ($74 in 2016; $82 in 2017); and no more than 15 percent of the cost of each prescription. At the catastrophic level of coverage you pay $2.95 for generics and $7.40 for brand-name drugs in 2016 ($3.30 and $8.25 respectively in 2017) or 5 percent of the cost, whichever is greater. (The asset limits above include $1,500 per person for intended funeral expenses, whether or not you’ve set aside money for this purpose.

Note:  You automatically qualify for the catastrophic level of coverage when your total drug costs (what you’ve paid and your plan has paid) reach a certain limit ($4,850 in 2016; $4,950 in 2017) since the beginning of the calendar year.

What counts as income?

It includes money you receive from Social Security, wages, dividends, alimony and rental property. It does not include funds acquired through loans or a reverse mortgage.

What counts as assets?

Assets include bank accounts, IRAs and the value of investments, and extra real estate. They do not include your home, vehicles, personal possessions, burial plots or up to $1,500 in savings intended for funeral expenses.

What if I’m married but we live apart?

You count as single for the income and asset tests. You also count as single if your spouse’s stay in a nursing home is likely to be permanent. Check with the Social Security Administration if you’re not sure.

What if my income is a little too high?

It’s still worth applying. The income limit is higher if you live in Alaska or Hawaii, have dependent relatives living with you or have certain earnings that don’t count. Also, remember that the limits go up slightly every year. The Social Security Administration announces the new limits each February or March.

What if my assets are a little too high?

Social Security Administration rules do not prevent you from spending down or giving away some of your savings to reduce assets below the limit. Only what you have at the time you apply counts as assets. But be aware that spending down might affect your eligibility for other programs (such as Medicaid and SSI) should you need them within a few years.

How do I know if I qualify?

If you receive Medicaid or SSI or your state pays your Medicare premiums, you qualify automatically, and Medicare should notify you of this. Otherwise, you can apply to the Social Security Administration at 1-800-772-1213 or online at the Social Security website or in person at your local SSA office. If you’re new to Medicare, you will probably receive an Extra Help application form in the mail. After receiving your application, SSA will notify you whether or not you qualify. You have the right to appeal that decision.

Can my spouse and I apply for Extra Help together?

Yes. You can use the same application form if both of you apply at the same time. Even if only one of you is applying, you must still give details of your spouse’s income and assets and your spouse must also sign the form.

Can anyone else apply for me?

Yes. Anyone — including a family member, friend, caregiver, legal representative, social worker or a counselor at your state health insurance assistance program (SHIP) — can complete a printed or online application and even sign it on your behalf. There is less red tape in applying for Extra Help than most assistance programs.

Do I have to fill out the application form in English?

You must fill out the application in either English or Spanish. However, you can get detailed printed instructions on how to fill out the form in these other languages: Arabic, Armenian, Chinese, Farsi, French, Greek, Haitian-Creole, Italian, Korean, Polish, Portuguese, Russian, Spanish, Tagalog and Vietnamese. You can download these instructions from Social Security’s website. Or call Social Security at 1-800-772-1213 and ask for form SSA-1020B-INST to be mailed to you in the language you need. When calling Social Security, you can also ask for an interpreter who speaks your own language, free of charge.

What if I don’t qualify?

You may be able to get similar or better help from a state pharmacy assistance program, if there is one in your state. (Go here for details and contact information.) Most have higher income limits than Extra Help and some don’t count assets. Your state health insurance assistance program (SHIP) can tell you more. Otherwise, you can sign up for regular Medicare drug coverage.

How will I get my drugs?

By enrolling in a Medicare drug plan. If you qualify for Extra Help automatically but don’t enroll in a plan, Medicare will enroll you in one. But be aware that this plan may not meet your needs. You have the right to switch to a plan of your own choosing at any time.

What plan choices will I have?

You will have many plans to choose from. But to guarantee a zero premium, you must choose a plan with a premium that is below the regional average cost. If you choose a more expensive plan, you must pay the difference between the regional average and that plan’s premium. (To find out which plans are available to you at a zero premium, call Medicare at 1-800-633-4227 or compare plans on Medicare's website.)

What if Medicare doesn’t cover all the drugs I now get through Medicaid, or I can’t afford the costs?

Medicaid programs in some states continue to supply drugs that a Medicare drug plan doesn’t cover. Some state pharmacy assistance programs pay all or some out-of-pocket costs. Some charities, patient support groups and other assistance programs may be able to help. Go here for information on many of these.

Can I get a 90-day supply of my drugs?

Yes—usually by choosing the plan’s mail order option. (Most, but not all, plans offer mail order.) You may also be able to get 90-day supplies at a local pharmacy in your plan’s network. To find out, ask the pharmacist or call the plan. People who receive Extra Help pay only one copay for each 90-day supply.

Will Extra Help affect other benefits I get?

Food stamps and housing assistance may decrease, but your savings on drugs will still leave you better off. Heating assistance and SSI are not affected.

Once eligible for Extra Help, can I lose it?

It’s possible if your circumstances change. Certain marital events may affect eligibility. If your spouse dies, you separate or get divorced, you get back together after being separated or you marry someone else, you must report these changes to Social Security immediately so that your eligibility can be reviewed. (These events won’t necessarily result in your losing Extra Help—in some situations, they may mean that you qualify for more Extra Help than you had before.)