What is Medicare Extra Help?

A federal assistance program that helps low-income Medicare beneficiaries afford prescription drug coverage

Derek Silva

Derek Silva

Published October 14, 2019

KEY TAKEAWAYS

  • Medicare Extra help can save eligible beneficiaries about $4,900 each year on Medicare prescription drug coverage

  • The Social Security Administration (SSA) oversees Medicare Extra Help

  • Income and asset limits for the Medicare Extra Help program change every year

  • You cannot use Extra Help with a Medicare Advantage plan

Medicare provides health insurance to seniors and those with certain disabilities. It comes in four parts. Medicare Part A and B make up Original Medicare, which covers hospital insurance and visits to a doctor. Original Medicare doesn’t cover prescription drugs, though.

To get prescription drug coverage, Medicare recipients need to pay for a Part D Medicare Prescription Drug plan, which means a monthly premium and copays or coinsurance.

If you can’t afford a Medciare Part D plan, you may qualify for Medicare Extra Help. The program, which is run by the Social Security Administration (SSA), reduces or eliminates the monthly premiums and annual deductibles. It also decreases the cost of your copays and coinsurance. You cannot use it with Medicare Advantage plans (Part C).

The amount of assistance varies by income, but Medicare Extra Help coverage saves eligible beneficiaries about $4,900 each year, according to the Social Security Administration.

In this article:

Who qualifies for Medicare Extra Help?

You will automatically qualify for Medicare Extra Help if you have Medicare and also meet any of these conditions:

  • You have full Medicaid coverage.
  • You use a Medicare Savings Program (MSP) to help pay your Part B premiums.
  • You get Supplemental Security Income (SSI) benefits.

To learn more about whether or not you qualify for Medicaid, check our state-by-state guide to Medicaid.

If you are a part of any Medicare Savings Programs, or MSPs, to help pay for your Medicare Part A and B costs, you will automatically receive Medicare Extra Help.

If you don’t qualify for Extra Help based on the criteria above, you may still qualify if you are at least 65 years old, live in the U.S., have Medicare Part A and Part B, and your annual income is within the annual income and total asset limits.

Income and asset limits are based on the federal poverty guidelines (also known as the federal poverty level or FPL). The poverty guidelines change each year, so make sure to check again around February or March. Below are the Medicare Extra Help income and asset limits for 2019.

Medicare Extra Help income limits 2019

Filing statusAnnual incomeTotal assets
Single$18,735$14,390
Married$25,365$28,720

What assets are included?

Your assets include money that you have across all types of savings accounts, checking accounts, and investment accounts. Make sure to consider your retirement accounts like an IRA or 401(k), as well any stocks or bonds you own. Real estate that you own other than your primary residence also counts toward your total assets in most cases.

Your assets do not include your home, a car, a burial plot, furniture, or any other personal items. Life insurance policies are excluded and you can subtract $1,500 per person for burial expenses. You don’t have to include any advance tax credits you get, such as for the earned income tax credit, or money you received for housing assistance. You can find a complete list of exemptions on the SSA website.

How much Medicare Extra Help costs

Even if you qualify for Medicare Extra Help, your income level will determine whether you qualify for full or partial Extra Help.

Anyone who receives Medicaid or a Medicare Savings Plan will receive full Extra Help. You also receive full extra help if you have Medicare and earn less than $1,425 per month in 2019 ($1,922 for joint filers). Below are the full Medicare Extra Help prices:

  • $0 premiums, up to your state benchmark limit
  • $0 deductible
  • Between $1.25 and $3.40 for generic drug copays
  • Between $3.80 and $8.50 for brand-name drug copays
  • No copay after paying $5,100 out-of-pocket for covered prescriptions

The 2019 state benchmarks for Medicare Extra Help premiums run between about $22 and $40.

If you have Medicare and earn up to $1,581 per month ($2,134 for joint filers) in 2019, you will receive partial Extra Help. Below are the partial Medicare Extra Help prices:

  • Premiums of 25%, 50%, or 75% of your state’s benchmark premium, depending on your income
  • Deductible of up to $85
  • You will pay your plan’s full generic drug copays or coinsurance of 15%, whichever is less, until you spend $5,100 out of pocket. Then generic drug copays are $3.40. Brand-name drug copays are $8.50 or 5% of the drug cost, whichever is more.

The cost of Medicare Extra Help in 2019

If you have Medicaid or MSPsMedicare only and monthly income of $1,425 or lessMedicare only and monthly income of $1,581 or less
Premiums$0$025%, 50%, or 75% of local benchmark
Deductible$0$0up to $85
Generic drug copay$1.25 to $3.40$3.40Full plan copays or 15% coinsurnace; $3.40 after you spend $5,100
Name-brand drug copay$3.80 to $8.50$8.50Full plan copays or 15% coinsurnace; $8.50 or 5% of drug cost after you spend $5,100

How to apply for Medicare Extra Help

You automatically qualify for Extra Help and do not need to apply if you receive full Medicaid benefits, you’re enrolled in a Medicare Savings Program, or you receive Supplemental Security Income (SSI) benefits.

In all other scenarios, you can apply online for Medicare Extra Help through the Social Security Administration site. You can also apply in person at your local Social Security office or call 1-800-722-1213 to apply over the phone. You can also call to request a physical application by mail.

Once you apply, the SSA will review your application and send a letter saying whether or not you were approved. If you do qualify for Extra Help, you need to enroll in a Medicare Part D prescription drug plan. You can do so right away because approval for Extra Help qualifies you for a Medicare special enrollment period. Compare plans in your state on the Medicare website, which will help you apply for one directly through the insurer.

How Medicare Extra Help works

Once you have a plan, you’ll have to provide the insurer with documentation to prove that you are receiving Extra Help. The documents that count as proof include

  • A purple, yellow, or green notice of automatic qualification from Medicare
  • An Extra Help award notice from the SSA
  • Your Supplemental Security Income award letter
  • A copy of your Medicaid card

Once you provide documentation, you will immediately start paying the lower Extra Help drug prices.

Remember that the income and asset limits for Extra Help change every year. Just because you qualify one year does not mean you will qualify the next. You’ll receive a notice from Medicare around the end of September if the SSA believes you no longer automatically qualify for Extra Help.

In this case, you will need to reapply for the program through SSA.gov or your local Medicaid office.

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