Extra Help to pay for Medicare prescription drug costs
Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs. You may qualify for Extra Help if your yearly income and resources are below these limits in 2023:
- Single person - yearly income less than $21,876 ($1,823 monthly) and less than $16,660 in other resources per year
- Married person living with a spouse and no other dependents - yearly income less than $29,580 ($2465 monthly) and less than $33,240 in other resources per year
You may qualify even if you have a higher income (like if you still work, live in Alaska or Hawaii, or have dependents living with you). Resources include money in a checking or savings account, stocks, bonds, mutual funds, and Individual Retirement
Accounts (IRAs). Resources don’t include your home, car, household items, burial plot, up to $1,500 for burial expenses (per person), or life insurance policies.
If you qualify for Extra Help and join a Medicare drug plan, you'll:
- Get help paying your Medicare drug plan's costs.
- Have no late enrollment penalty.
You automatically qualify and will receive Extra Help if you have Medicare and meet any of these conditions:
- You have full Medicaid coverage.
- You get help from your state Medicaid program paying your Part B premiums (in a Medicare Savings Program).
- You get Supplemental Security Income (SSI) benefits.
Drug costs in 2023 for people who qualify for Extra Help will be no more than $4.15 for each generic drug and $10.35 for each brand-name drug.
To apply for Extra Help:
- Call SHIIP toll-free at 1-855-408-1212 Monday through Friday from 8am to 5pm and one of our Medicare counselors can assist you.
- Visit socialsecurity.gov/i1020 to apply online.
- Call the Social Security Administration at 1-800-772-1213. TTY users can call 1-800-325-0778.
Medicare Savings Programs to help pay for Medicare health care costs
You can get help from your state paying your Medicare premiums. In some cases, Medicare Savings Programs may also pay Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) deductibles, coinsurance, and copayments if you meet certain conditions. There are four kinds of Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB) Program - helps pay for Part A and/or Part B premiums, and in addition Medicare providers aren't allowed to bill you for services and items Medicare covers like deductibles, coinsurance, and copayments.
- Specified Low-Income Medicare Beneficiary (SLMB) Program - helps pay for Part B premiums.
- Qualified Individual (QI) Program - helps pay for Part B premiums and funding for this program is limited.
- Qualified Disabled and Working Individuals (QDWI) Program - helps pay for Part A premiums only.
If you qualify for a QMB, SLMB, or QI program, you automatically qualify to get Extra Help paying for Medicare prescription drug coverage.
Medicaid is a joint federal and state program that helps pay health care costs if you have limited income and resources and meet other requirements. Some people qualify for both Medicare and Medicaid. All states also have Medicaid programs for people with limited incomes and assets who need nursing home care, long-term care services, and home health care services. Some states also have programs for individual adults who don’t fit any of these categories. Each state uses financial eligibility guidelines to determine whether you are eligible for Medicaid coverage. Generally, your income and assets must be below a certain amount to qualify, but this amount varies from state to state and from program to program. You are eligible for Medicaid if you fall into an eligible group and meet that group’s financial eligibility requirements. If you are eligible for Medicare and Medicaid (dually eligible), you can enroll in both. Medicaid can cover services that Medicare does not, like long-term care. It can also pick up Medicare’s out-of-pocket costs (deductibles, coinsurances, copayments). Some states offer a Medicaid spend-down program or medically needy program for individuals with incomes over their state’s eligibility requirements. A spend-down program allows you to deduct your medical expenses from your income so that you can qualify for Medicaid.
State Pharmacy Assistance Programs (SPAPs)
Many states have SPAPs that help certain people pay for prescription drugs based on financial need, age, or medical condition.
Pharmaceutical Assistance Programs (also called Patient Assistance Programs)
Many drug manufacturers offer assistance programs for people with Medicare drug coverage who meet certain requirements. Visit Medicare.gov/pharmaceutical-assistance-program to learn if there are any programs available for the drugs you are taking.
Programs of All-Inclusive Care for the Elderly (PACE)
PACE is a Medicare and Medicaid program offered in many states that allows people who need a nursing home level of care to remain in the community.
Supplemental Security Income (SSI) Benefits
SSI is a cash benefit paid by Social Security to people with limited income and resources who are blind, 65 or older, or have a disability. SSI benefits aren’t the same as Social Security retirement benefits. You may be able to get both SSI benefits and Social Security benefits at the same time if your Social Security benefit is less than the SSI benefit amount, due to a limited work history, a history of low-wage work, or both. If you’re eligible for SSI, you automatically qualify for Extra Help, and are usually eligible for Medicaid.
To let you know you automatically quality for Extra Help, Medicare will mail you a purple letter that you should keep for your records. You don't need to apply for Extra Help if you get this letter.
- If you aren't already in a Medicare drug plan, you must join one to use this Extra Help.
- If you're not enrolled in a Medicare drug plan, Medicare may enroll you in one so that you'll be able to use the Extra Help. If Medicare enrolls you in a plan, you'll get a yellow or green letter letting you know when your coverage begins, and you'll have a Special Enrollment Period to change plans.
- Different plans cover different drugs. Check to see if the plan you're enrolled in covers the drugs you use and if you can go to the pharmacies you want.
- If you have Medicaid and live in certain institutions (like a nursing home) or get home and community based services, you pay nothing for your prescription drugs.
If you don’t want to join a Medicare drug plan (for example, because you want only your employer or union coverage), call the plan listed in your letter, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Tell them you don’t want to be in a Medicare drug plan (you want to “opt out”). If you continue to qualify for Extra Help or if your employer or union coverage is creditable prescription drug coverage, you won’t have to pay a penalty if you join later. Important: If you have employer or union coverage and you join a Medicare drug plan, you may lose your employer or union coverage (for you and your dependents) even if you qualify for Extra Help. Call your employer's benefits administrator before you join a Medicare drug plan.
Drug costs in 2023 for people who qualify for Extra Help will be no more than $4.15 for each generic drug and $10.35 for each brand-name drug. Look on the Extra Help letters you get, or contact your plan to find out your exact costs.
NOTE: When you apply for Extra Help, you can also start your application process for the Medicare Savings Programs. These state programs provide help with other Medicare costs. Social Security will send information to your state unless you tell them not to on the Extra Help application.
There are 4 kinds of Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB) Program: If you’re eligible, the QMB Program helps pay for Part A and/or Part B premiums. In addition, Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments (except outpatient prescription drugs). If you get a bill for these charges tell your provider or the debt collector that you’re in the QMB Program and can’t be charged for Medicare deductibles, coinsurance, and copayments. If you’ve already made payments on a bill for services and items Medicare covers, you have the right to a refund. Note: To make sure your provider knows you’re in the QMB Program, show both your Medicare and Medicaid or QMB card each time you get care. You can also give your provider a copy of your “Medicare Summary Notice” (MSN). Your MSN will show you’re in the QMB Program and shouldn’t be billed. Log in to your MyMedicare.gov account at any time to view your MSN or sign up to get your MSNs electronically. If your provider won’t stop billing you, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Medicare can confirm that you’re in the QMB Program and can also ask your provider to stop billing you, and refund any payments you’ve already made.
- Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums only.
- Qualifying Individual (QI) Program: Helps pay Part B premiums only. Funding for QI benefits is limited, and the applications are granted on a first come, first-served basis.
- Qualified Disabled and Working Individuals (QDWI) Program: Helps pay Part A premiums only. You may qualify for this program if you have a disability and are working.
In most cases, to qualify for a Medicare Savings Program, you must have income and resources below a certain limit. States have different limits and ways of counting your income and resources, so you should check with your state Medicaid office to see if you qualify, or call SHIIP toll-free at 1-855-408-1212 Monday through Friday from 8am to 5pm and one of our Medicare counselors can assist you.
What does Medicaid cover?
- If you have Medicare and full Medicaid coverage, most of your health care costs are covered. You can get your Medicare coverage through Original Medicare or a Medicare Advantage Plan.
- If you have Medicare and/or full Medicaid coverage, Medicare covers your Part D prescription drugs. Medicaid may still cover some drugs that Medicare doesn’t cover.
- People with Medicaid may get coverage for services that Medicare doesn’t cover or only partially covers, like nursing home care, personal care, transportation to medical services, home- and community-based services, anddental, vision, and hearing services.
PACE is a Medicare and Medicaid program offered in many states that allows people who otherwise need a nursing home-level of care to remain in the community. To qualify for PACE, you must meet these conditions:
- You’re 55 or older.
- You live in the service area of a PACE organization.
- You’re certified by your state as needing a nursing home-level of care.
- At the time you join, you’re able to live safely in the community with the help of PACE services.
PACE covers all Medicare- and Medicaid-covered care and services, and other services that the PACE team of health care professionals decides are necessary to improve and maintain your health. This includes prescription drugs, as well as any other medically necessary care, like doctor or health
care provider visits, transportation, home care, hospital visits, and even nursing home stays when necessary. If you have Medicaid, you won’t have to pay a monthly premium for the long-term care portion of the PACE benefit. If you have Medicare but not Medicaid, you’ll be charged a monthly premium to cover the long-term care portion of the PACE benefit and a premium for Medicare Part D drugs. However, in PACE, there’s never a deductible or copayment for any drug, service, or care approved by the PACE team of health care professionals. Detailed information regarding this program can be found at the NC PACE website.