There are several programs available to assist individuals on Medicare. Most of these programs are income-based to assist low-income seniors and disabled Medicare recipients.
The Extra Help Program
The Extra Help program, also known as the Part D Low-Income Subsidy (LIS) program, is a Medicare program designed to help people with limited income and resources pay for their Medicare drug coverage (Part D) costs.
Here’s what the Extra Help program offers:
- Lower Costs: The program helps lower your prescription drug costs, including deductibles and copays. It’s not insurance itself but a subsidy that lowers the cost of your drug coverage in Medicare Part D.
- Automatic Enrollment: Some people automatically qualify for Extra Help. This includes individuals who have full Medicaid coverage, receive help from their state paying their Part B premiums (from a Medicare Savings Program), or receive Supplemental Security Income (SSI) benefits from Social Security.
- Application: If you don’t automatically qualify, you can apply for Extra Help through the Social Security Administration’s website or by calling them directly at 1-800-MEDICARE (1-800-633-4227). The level of help you receive depends on your income and assets.
- No Late Enrollment Penalty: While you’re receiving Extra Help, you won’t have to pay a Part D late enrollment penalty.
- Year-Round Enrollment: Apply for Extra Help at any time before or after you enroll in Part D.
Please note that the Extra Help program is not available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa.
The income limit for the Extra Help program varies depending on your marital status.
- For an individual: Annual income must be limited to $21,870 and resources must be limited to $16,660.
- For a married couple living together: Combined annual income must be limited to $29,580 and combined resources must be limited to $33,240.
These are the limits for 2023, and they may change each year. Also, certain resources are not counted towards these limits. For example, your primary residence and your vehicle(s) are not counted as resources.
There are currently two levels of Extra Help: The Full Subsidy and the Partial Subsidy. Currently, the Full Subsidy is only available to people with income up to 135% of the Federal Poverty Guidelines/Levels (FPL), with a Partial Subsidy available for those up to 150%.
Starting in 2024, the Partial Subsidy will be eliminated and eligibility for the Full Subsidy will be expanded to people with income up to 150% of the FPL. In 2024, most people who qualify for Extra Help will pay:
- No premiums for their drug plan
- No deductibles
- No more than $11.20 in 2024 for each brand-name drug the plan covers and $4.50 for generic.
The eligibility criteria for the Extra Help program are as follows:
- Medicare Enrollment: You must be enrolled in Medicare Part A and/or Part B.
- Residency: You must live in any of the 50 states or Washington, D.C.
- You are not eligible for Extra Help if you are incarcerated.
The approval process for the Extra Help program can take up to 2 weeks. Once approved, your Part D coverage should begin within two months of your enrollment in Extra Help.
If you’re unsure whether you qualify for Extra Help, apply anyway. Many people qualify for these savings and don’t know it.
There are several ways to apply for the Extra Help program.
- Online Application: You can apply online on the Social Security Administration (SSA) website.
- Phone Application: You can call Social Security at 1-800-772-1213 (TTY +1-800-325-0778) to apply over the phone or to request a paper application.
- In-Person Application: You can apply in person at your local Social Security office.
Medicare Savings Programs
Medicare Savings Programs (MSPs) are federally funded, state-administered programs designed to help people with limited income and resources pay for their Medicare costs. These programs can help pay for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums, deductibles, coinsurance, and copayments.
There are four types of Medicare Savings Programs:
Qualified Medicare Beneficiary (QMB) Program: This program helps pay for Part A premiums, Part B premiums, deductibles, coinsurance, and copayments for services and items Medicare covers. The monthly income limit for an individual is $1,235 and the resource limit is $9,090 in 2023. For a married couple, the monthly income limit is $1,663 and the resource limit is $13,630.
The application process for the Qualified Medicare Beneficiary (QMB) Program involves a few steps.
- Check Eligibility: The first step is to find out if you’re eligible for the QMB program. You can do this by checking the income and resource limits, which vary depending on your marital status.
- Get an application: You can request an application for QMB at your local health department, doctor’s office, or hospital social work department. You can also find a QMB program application from your state website.
- Complete the Application: Fill out the application form with all the necessary information.
- Submit the Application: You can apply in person or by mailing the application to your local department of social services. Some states also allow you to apply online or by phone.
- Wait for Approval: After you submit your application, your state will review it and determine if you qualify for the QMB program.
For more information, please visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227)
Specified Low-Income Medicare Beneficiary (SLMB) Program: This program helps pay for Part B premiums. You must have both Part A and Part B to qualify. The monthly income limit for an individual is $1,478 and the resource limit is $9,090 in 2023. For a married couple, the monthly income limit is $1,992 and the resource limit is $13,630.
The Specified Low-Income Medicare Beneficiary (SLMB) Program is a state-sponsored program that provides financial assistance to help pay for Medicare Part B premiums. It is one of the four Medicare Savings Programs.
Key details about the SLMB Program:
What it covers: The program helps pay for Part B premiums only.
Eligibility: To qualify for SLMB benefits, you must meet certain income and resource requirements. These limits change from year to year. As of 2023, the limits are:
- Individual monthly income limit: $1,478
- Married couple monthly income limit: $1,992
- Individual resource limit: $9,090
- Married couple resource limit: $13,630
How to apply: You can apply for this program through your state Medicaid Program. Even if your income or resources are higher than the amounts listed here, it’s important to call or fill out an application as you could still qualify for savings.
In the Specified Low-Income Medicare Beneficiary (SLMB) Program, resources are considered as part of the eligibility criteria. Here are some examples of what may be considered resources:
- Money in a checking or savings account
- Stocks
- Bonds
However, certain items do not count as resources. These include:
- Your primary home
- A vehicle
- A burial plot
- Furniture and other household or personal items
- Up to $1,500 for burial expenses (if you’ve put that money aside)
If you have questions about any specific items or accounts that might be counted, it’s recommended to contact your state Medicaid office.
Qualifying Individual (QI) Program and Qualified Disabled & Working Individuals Program are two other types of MSPs. Please contact your state Medicaid office for details on these programs.
The Donut Hole
There are several ways to get help with prescription costs during the Medicare coverage gap, also known as the “donut hole”.
- Discuss switching to generics or other lower-cost drugs with your doctor. There may be generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now.
- You might be able to lower prescription costs by using mail-order pharmacies.
- Choose a Medicare drug plan that offers additional coverage during the gap. There are plans that offer additional coverage during the Medicare drug coverage gap, however, plans with additional gap coverage may charge a higher monthly premium.
- Pharmaceutical Assistance Programs. Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare drug coverage (Part D).
- State Pharmaceutical Assistance Programs: Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs.
- Apply for Extra Help. If you qualify for Extra Help, you could pay no more than $4.15 for each generic covered drug in 2023 ($4.50 in 2024) and $10.35 for each brand-name covered drug in 2023 ($11.20 in 2024).
State Health Insurance Assistance Program (SHIP)
The State Health Insurance Assistance Program (SHIP) is a national program that offers free, unbiased help to Medicare beneficiaries, their families, and caregivers. Here are some key details about SHIP:
- Mission: SHIP’s mission is to empower, educate, and assist Medicare-eligible individuals through objective outreach, counseling, and training.
- Services: SHIP provides one-on-one assistance, counseling, and education to help beneficiaries make informed decisions about their care and benefits. This includes help with understanding Medicare benefits, plans, and options; assistance with enrollment; and help with resolving problems related to Medicare.
- Network: SHIP oversees a network of more than 2,200 local sites and over 12,500 team members, including staff, in-kind professionals, and volunteers.
- Eligibility: SHIP services support people with limited incomes, Medicare beneficiaries under the age of 65 with disabilities, and individuals who are dually eligible for Medicare and Medicaid.
- Contact: To partner with SHIP in your community or to get help, you can visit www.shiphelp.org or call 877-839-26752.
The above information is based on information currently available on the internet. Please verify directly with Medicare or the agency indicated to ensure the most current information.
Dawn Levitt, Author 