Medicare Extra Help Program
The Low-Income Subsidy (LIS), also known as the Medicare Extra Help program, is available to beneficiaries who fall below certain income and personal resource limits. This is a federal program that helps pay for costs associated with Medicare prescription drug coverage. This assistance may lower your prescription drug copayment amounts, and decrease or eliminate your Medicare Prescription Drug Plan premiums and deductibles.
In 2016, if you qualify for the full benefits of Extra Help program, you will pay no more than a $2.95 copayment for generic drugs and no more than a $7.40 copayment for brand-name drugs covered under your plan's formulary (list of covered prescription drugs). Based on income level, some beneficiaries might qualify for help with a portion of their prescription drug costs (called "partial" Extra Help). Additionally, if you're enrolled in the Extra Help program, you will not be subject to a coverage gap, or "donut hole."
The coverage gap ("donut hole")
The Medicare Part D coverage gap occurs if you and your Medicare Prescription Drug Plan spend a certain amount on covered prescription drug costs during a calendar year. In 2016, this amount is $3,310. Once you and your plan reach that total, you typically get less coverage for your prescription drugs for the remainder of the year: you'll pay up to 58% of the costs of generic drugs and up to 45% of brand-name drug costs. Once you've spent $4850 (in 2016) in out-of-pocket costs, you'll leave the coverage gap and pay only a small copayment or coinsurance for your prescriptions for the rest of the year.
Eligibility for Medicare Extra Help
To qualify for government help with the costs of your prescription drug coverage, you must have assets and personal resources that fall below specific limits. These limits may change each year. Countable personal resources include stocks, bonds, and money in a checking or savings account. These resources do not include property, vehicles, burial plot and other burial expenses set aside up to $1,500, furniture, and other household items.
You might qualify for Medicare Extra Help automatically
Certain beneficiaries automatically qualify and are enrolled in the Extra Help program. You may automatically qualify if you have Medicare Part A and Part B and meet any of the following conditions:
- You have full Medicaid coverage.
- You get help from your state Medicaid program with paying your Part B premiums.
- You receive Supplemental Security Income(SSI) benefits.
Once you are determined to be eligible for Medicare Extra Help automatically, you will qualify for the entire year. Even if you stop receiving Medicaid or certain other assistance during the year, you will continue receiving Extra Help for the remainder of the year.
Please note: Although you may automatically qualify for the LIS one year, the income and resource limits change annually, so you may not qualify in another year. If you don't automatically qualify in the upcoming year, you will receive a notice regarding this change. This does not mean that you don't qualify for Medicare Extra Help at all, but that you must complete a redetermination form to find out. The Social Security Administration or Medicaid will send you this form if you need to fill it out.
You might have to apply for Medicare Extra Help
If you do not automatically qualify for the Low-Income Subsidy (LIS) you can apply for it in either of these ways:
- Contact the Social Security Administration, either online, by phone (1-800-772-1213; TTY users can call 1-800-325-0778, Monday through Friday, 7AM to 7PM), or by visiting your local Social Security office.
- Ask for a "state determination" at your state Medicaid agency.
If you find that you don't qualify for federal assistance (Medicare Extra Help) with your prescription drug costs, there may be other options available to you. You may contact your local Medicaid office or your State Health Insurance Assistance Program (SHIP) for more details. If you find that you no longer qualify for federal or state assistance, you can try any of the following ways to lower your Medicare Part D Prescription Drug Plan costs:
- See if you can trade a high-cost brand-name prescription drug for an equally effective generic drug, which may cost less. Talk to your doctor about this first.
- Ask your doctor about lower-cost brand-name drugs.
- Consider taking advantage of mail-order pharmacies.
- Compare available Part D Prescription Drug Plans in your area to see whether you'd be able to save money with a different plan. You can just enter your zip code where indicated on this page to start comparing plans.
This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
eHealthInsurance is operated by eHealthInsurance Services, Inc., a licensed health insurance agency certified to sell Medicare products.
The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.
Last Updated Date: 11/5/2016