Medicare Extra Help for Low Income Persons

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 ($320 in 2015), though it will leave $66 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.

Once recipients have spent $2,850 in prescription costs, the coverage gap begins; however, individuals who are receiving Extra Help will continue to pay co-payments between $1.20 and $6.35. Individuals who receive partial subsidy will pay 15% of the co-pay for the drugs.

Onece individuals have reached $6,455 in prescription drug costs, they will enter the catstrophic coverage level. Individuals who are receiving Extra Help (either full or partial subsidy pays will pay between $1.20 to $6.35 for generics and name brand drugs or 5% of the drug cost, whichever is greater.

The variable benefits are summarized below:

Beneficiaries Eligible Maximum Income
(2015)
Maximum Resources
(2015)
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
$993/single
$1,331/couple
$8,660/single
$13,750/couple
Deductible-$0
Premium in excess of $28.93
Generics-$1.20
Name Brands-$3.60
Out of pocket-$0
Non-institutionalized
Income > 100% Poverty
or Medicare Savings Program Enrollee
$1,333/single
$1,790/couple
$8,660/single
$13,750/couple
Deductible-$0
Premium in excess of $28.93
Generics-$2.65
Name brands-$6.60
Out of pocket-$0
Non-institutionalized (Partial Subsidy)
Income ≤ 150% Poverty
$1,459/single
$1,966/couple
$13,440/single
$26,860/couple
Deductible-$63.00
Premium in excess of $28.93
Total out of pocket $1,020 (in doughnut hole)
Generics after out of pocket-$2.65
Name brands after out of pocket-$6.60
Out of pocket-$0

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.