For individuals who receive Part D prescription drug coverage and are low-income, there is assistance available for the costs of deductibles and co-pays. This Extra Help is also known as the Low Income Subsidy (or LIS).
Who is eligible?
To receive Extra Help, persons must be eligible for Medicare Part D and have income less than 100% of the Federal Poverty Level for a full benefit or less than 150% of the Poverty Level for a partial benefit.
What are the benefits?
Benefits vary based on the recipient’s income and on living situation. In general, Extra Help will pay for a person’s monthly drug plan premium for an Extra Help approved plan. It will also pay the annual deductible amount ($480 in 2022), though it will leave $99 deductible for partial subsidy recipients to pay out of pocket. Extra Help will also cover all drugs in the coverage gap, or doughnut hole, or 85% of drug costs for partial subsidy recipients. Individuals will pay $3.95/generic or multi-source drug and $9.85 for other drugs.
In the standard benefit, when Medicare beneficiaries have spent $4,430 in 2022 in prescription costs, the coverage gap begins; however, individuals who are receiving Extra Help will continue to pay co-payments between $3.95 for generic or multisource drugs with a retail price under $79 and 5% for those with a retail price greater than $79. For brand-name drugs, beneficiaries would pay $9.85 for those drugs with a retail price under $197 and 5% for those with a retail price over $197.
Getting Extra Help with your Part D can
- Reduce your out-of-pocket costs for prescriptions
- Eliminate your monthly Part D premiums
- Reduce or eliminate your annual Part D deductibles
- Eliminate the coverage gap, also known as the donut hole. This means your prescriptions won’t cost more just because you went over a spending limit in a particular year.
On average, Extra Help is estimated to save beneficiaries $5000 in prescription drug costs per year.
The variable benefits are summarized below:
| Beneficiaries Eligible | Maximum Income (2021 Federal Poverty Levels) | Maximum Resources (2021) | Benefits (Deductibles, Co-pays, Out of pocket) |
| Institutionalized for more than 30 days in an assisted living, nursing home or hospital and receiving Medicaid. | Deductibles and Co-pays $0.00 | ||
| Non-institutionalized Income ≤ 100% Poverty | $1,094/single $1,472/couple | $9,470/single $14,960/couple | Deductible-$0 Premium in excess of $35.02 Generics-$1.35 Name Brands-$4.00 Out of pocket-$0 |
| Non-institutionalized Income > 135% Poverty or Medicare Savings Program Enrollee | $1,499/single $1,959/couple | $9,470/single $14,960/couple | Deductible-$0 Premium in excess of $35.02 Generics-$3.95 Name brands-$9.85 Out of pocket-$0 |
| Non-institutionalized (Partial Subsidy) Income ≤ 150% Poverty | $1,595/single $2,155/couple | $14,790/single $29,520/couple | Deductible-$92.00 Total out of pocket 15% (in doughnut hole) Generics after doughnut hole-$3.95 Name brands after doughnut hole-$9.85 |
Individuals who in addition to Medicare, receive Medicaid, Supplemental Security Income or a Medicare Savings Program (Qualified Medicare Benefit – QMB, Qualified Individual 1 – QI-1, or Special Low Income Medicare Beneficiary – SLIM-B) will be automatically enrolled in Extra Help. Auto-enrollees may be asked for verification documentation of lawful presence, income and resources by their county department of social services.
Individuals who are not auto-enrolled must apply through the Social Security Administration or individuals can enroll over the phone (1-800-772-1213). To talk to a counselor about completing an application, call 303-333-3482.